ASAP: A pharmacy-level intervention to increase nonprescription syringe sales to reduce bloodborne illnesses.

BACKGROUND: Pharmacy syringe sales are effective structural interventions to reduce bloodborne illnesses in populations, and are legal in all but two states. Yet evidence indicates reduced syringe sales in recent years. This study was designed as a feasibility test of an intervention to promote syringe sales by pharmacies in Arizona. METHODS: A four-month pilot among three Arizona pharmacies measured feasibility and acceptability through monthly surveys to 18 enrolled pharmacy staff members. RESULTS: Pharmacy staff reported increased ease of dispensing syringes across the study. Rankings of syringe dispensing as 'easiest' among 6 measured pharmacy practices increased from 38.9 % at baseline to 50.1 % post intervention module training, and to 83.3 % at pilot conclusion. The majority (72.2 %) of pharmacy staff agreed that intervention materials were easy to use. Over 70 % indicated that the intervention was influential in their "being more open to selling syringes without a prescription to someone who might use them for illicit drug use," and 61.1 % reported that in the future, they were highly likely to dispense syringes to customers who would use them to inject drugs. A vast majority (92 %) reported being likely to dispense subsidized naloxone if available to their pharmacy at no cost. CONCLUSIONS: An education-based intervention was found to be feasible and acceptable to pharmacy staff and had an observed impact on perceptions of ease and likelihood of dispensing syringes without a prescription to people who may use them to inject drugs.

Intestinal absorption of magnesium from food and supplements.

The purpose of this study was to measure magnesium absorption over the wide range of intakes to which the intestine may be exposed from food and/or magnesium-containing medications. Net magnesium absorption was measured in normal subjects after they ingested a standard meal supplemented with 0, 10, 20, 40, and 80 mEq of magnesium acetate. Although absorption increased with each increment in intake, fractional magnesium absorption fell progressively (from 65% at the lowest to 11% at the highest intake) so that absorption as a function of intake was curvilinear. This absorption-intake relationship was almost perfectly represented by an equation containing a hyperbolic function plus a linear function. Our results are statistically compatible with a magnesium absorption process that simultaneously uses a mechanism that reaches an absorptive maximum, plus a mechanism that endlessly absorbs a defined fraction (7%) of ingested magnesium. Compared to previous studies of calcium absorption, much less magnesium that calcium was absorbed at intakes above 8 mEq/meal, apparently due to greater restriction of intestinal permeability to magnesium. We also found that magnesium from a high magnesium-containing food source, almonds, was just as bioavailable as from soluble magnesium acetate. In contrast, magnesium absorption from commercially available enteric-coated magnesium chloride was much less than from magnesium acetate, suggesting that enteric coating can impair magnesium bioavailability.

Carbohydrate malabsorption. Its measurement and its contribution to diarrhea.

The major purpose of this research was to gain insight into the effect of carbohydrate malabsorption on fecal water output. To do this we measured daily fecal output of total carbohydrate, reducing sugars, and organic acids (a product of bacterial fermentation). Normal subjects were studied in their native state and when diarrhea was induced by mechanisms that did and did not involve carbohydrate malabsorption. Patients with malabsorption syndrome were also studied. We concluded that: (a) Excretion of carbohydrate and its breakdown products can be expressed as a single number by converting organic acids to their monosaccharide equivalents. (b) Diarrhea per se causes only a trivial increase in fecal carbohydrate excretion. (c) The molar output of osmotic moieties in feces due to unabsorbed carbohydrate can be determined by adding fecal reducing sugars to organic acids and their obligated cations. This expression parallels almost exactly the effect of increasing doses of lactulose (a nonabsorbable sugar) on fecal water output; one excreted millimole obligates 3.5 g of stool water. This relationship can be used to predict the effect of carbohydrate malabsorption on stool water output in patients with diarrhea. (d) 12 of 19 patients with malabsorption syndrome due to various diseases had excessive fecal excretion of carbohydrate and its breakdown products; of the diseases that cause malabsorption syndrome, combined small and large bowel resection is most likely to result in excessive fecal excretion of carbohydrate and monosaccharide equivalents. In 6 of these 19 patients carbohydrate malabsorption appeared to be the major cause of diarrhea.

Defining the limitations of transcutaneous bilirubin measurement in late preterm newborns.

OBJECTIVE: The objective of this study is to determine the impact of postnatal age on the bias between transcutaneous (TcB) and total serum bilirubin (TSB), and evaluate a TcB screening protocol. STUDY DESIGN: Preterm and term infants had paired TcB and TSB performed on days 1 to 3 of life; a subset of preterm infants had measurements on days 4 to 7. Sensitivity and specificity of TcB (plotted on an age-specific TSB nomogram) for prediction of high-intermediate (HIR) or high-risk TSB were calculated. RESULTS: Median TcB bias was 2.6 and 2.5 mg dl-1 for term and preterm infants in the first 3 days of life, respectively. However, median bias was 2.2 mg dl-1 for preterm infants at 4 to 7 days of life. TcB in preterm infants predicted HIR or high-risk TSB with 94% sensitivity and 56% specificity. CONCLUSION: TcB screening protocols developed for term infants can be used for late preterm infants in the first 3 days of life.

Colonic histopathology in untreated celiac sprue or refractory sprue: is it lymphocytic colitis or colonic lymphocytosis?

Colonic histopathology in some patients with untreated celiac sprue and refractory sprue has been said to be indistinguishable from lymphocytic colitis, but there have been no objective comparisons on which this is based. The purpose of this study was to determine the prevalence and to characterize the nature of colonic histopathology at the time of diagnosis in patients with celiac or refractory sprue. Colonoscopic biopsy specimens obtained at the time of diagnosis from 16 patients with celiac sprue, six patients with refractory sprue, nine patients with lymphocytic colitis, and five normal controls were analyzed blindly by histological and morphometric methods, quantitating the number and specific subtypes of inflammatory cells within the lamina propria and epithelium. Immunoperoxidase staining of intraepithelial lymphocytes with a monoclonal antibody to CD8 also was performed. Three of 16 patients with untreated celiac sprue (19%) were thought to have colonic histological abnormalities, which by morphometry consisted of slightly increased numbers of lymphocytes in the surface epithelium and lamina propria, many of which were CD8-positive. These abnormalities were distinguishable from lymphocytic colitis by the lack of increased overall lamina propria cellularity and surface epithelial abnormalities, and by fewer intraepithelial lymphocytes. In refractory sprue, colonic histological abnormalities were more frequent than in celiac sprue, occurring in four of six patients (67%), more pronounced, and identical to those in the lymphocytic colitis syndrome. However, colonic intraepithelial lymphocytes in lymphocytic colitis were mostly CD8-positive, whereas those in the colitis of refractory sprue rarely were. Mild colonic lymphocytosis in patients with untreated celiac sprue should be distinguished from lymphocytic colitis by the lack of surface epithelial abnormalities, the lack of increased cellularity of the lamina propria, and the lack of ongoing watery diarrhea after treatment with a gluten-free diet. In contrast, colonic histopathology in refractory sprue is indistinguishable from lymphocytic colitis, although immunohistochemical differences do exist.

A new method of quantitative fecal fat microscopy and its correlation with chemically measured fecal fat output.

Fecal fat microscopy using the Sudan stain has suffered from a relative lack of specificity, and results are "qualitative." Therefore, we developed a quantitative fecal fat microscopic method with hopes of improving diagnostic accuracy. One hundred eighty patients with chronic diarrhea collected stools for 1 to 3 days, and fecal fat output was measured by a standard chemical method, and microscopy was performed by the old qualitative and new quantitative methods. There was a highly statistically significant linear correlation between quantitative fecal fat microscopy and chemically measured fecal fat output. The quantitative microscopic method had a sensitivity of 94% and a specificity of 95%; the traditional method had a sensitivity and specificity of 76% and 99%, respectively. Fecal fat Sudan microscopy performed by a dedicated approach to counting and size measurement of fat globules can yield a quantitative result that correlates well with chemically measured fecal fat output and has a high diagnostic accuracy.

Regulatory changes following kainic acid-induced striatal lesions.

Kainic acid-induced lesions (KAL) of the striatum produce body weight and regulatory deficits in the rat. Unlike lateral hypothalamic rats. KAL rats drink more during food deprivation and eat more afterwards as compared to both baseline conditions and control rats. The present study investigated these effects further. As in previous studies, food deprivation was found to cause polydipsia and increased postdeprivational food intake in the KAL animal. Urination and defecation, often used as an index of emotionality, were also found to increase under these conditions. When the antidiuretic hormone vasopressin was injected, all of these differences remained with the exception of postdeprivational feeding--KAL rats no longer ate more than controls. These findings suggest that psychogenic factors--but not hormonal influences--may play a primary role in the regulatory peculiarities seen in the KAL rat.

The prevalence of occult gastrointestinal bleeding in celiac sprue.

BACKGROUND: Iron deficiency complicating celiac sprue is usually attributed to the malabsorption of dietary iron or the loss of iron from the intestinal mucosa. There has been little investigation of the role of intestinal loss of blood in patients with this condition. The purpose of this study was to determine the prevalence of occult gastrointestinal bleeding in patients with celiac sprue. METHODS: We tested one 48- or 72-hour stool collection from each of 8 patients with partial villous atrophy and 28 patients with total villous atrophy using a guaiac-impregnated card (Hemoccult). Serving as controls were 18 normal subjects, each studied before and during laxative-induced diarrhea; 17 patients with idiopathic chronic diarrhea; 63 patients with microscopic colitis; 23 patients with pancreatic steatorrhea; and 7 patients with treated celiac sprue who had normal intestinal histologic features. All the patients underwent a diagnostic workup that included esophagogastroduodenoscopy, colonoscopy, and barium radiography of the small bowel. RESULTS: Positive Hemoccult tests were infrequent in each of the control groups, occurring in 0 to 8 percent of the subjects, whereas 2 of the 8 patients with partial villous atrophy (25 percent) and 15 of the 28 patients with total villous atrophy (54 percent) had positive tests. When the patients with total villous atrophy were classified according to their subsequent responses to a gluten-free diet, 7 of the 17 who were responsive to gluten withdrawal (41 percent) were Hemoccult-positive, as compared with with 8 of the 11 who did not respond to the diet (73 percent). CONCLUSIONS: Occult gastrointestinal bleeding can be detected in about half of patients with celiac sprue and should be added to the list of factors that can contribute to iron deficiency in patients with this disorder.

The effect of diarrhea on fecal fat excretion.

To determine whether diarrhea increases fecal fat excretion, fecal fat output was measured during three consecutive days in normal subjects and in normal subjects in whom diarrhea was purposefully induced. Mean fecal fat output in normal subjects was 3.4 g/day; the upper limit of normal was 6.4 g/day. Twenty-one percent of subjects with mild to moderate diarrhea (fecal weight 200-800 g/day) and 58% of subjects with severe diarrhea (fecal weight greater than 800 g/day) had fecal fat excretion above the upper limit of normal, with values as high as 13.6 g/day. It is concluded that (a) diarrhea itself can induce mild secondary steatorrhea, and (b) when the quantitative fecal fat test is used in patients with diarrhea, mild abnormalities (up to 14 g/day) are not specific for a primary defect in fat digestion or absorption, i.e., they may represent false-positive results.

Alpha-heavy chain disease, Mediterranean lymphoma, and immunoproliferative small intestinal disease: a review of clinicopathological features, pathogenesis, and differential diagnosis.

There are a number of clinical syndromes associated with chronic diarrhea, malabsorption, and lymphoplasmacytic proliferation of the small intestine. In Middle-Eastern and Mediterranean countries immunoproliferative small intestinal disease is endemic, whereas in other parts of the world (including Northwestern Europe and North America) celiac sprue, and other sprue-like syndromes refractory to dietary gluten withdrawal, predominate. All of these syndromes appear to involve chronic stimulation of intestinal mucosa-associated lymphoid tissue and are associated with a heightened risk of malignant transformation. The clinicopathological features of these diseases, and distinction of the Middle Eastern syndromes from those more common in the Western hemisphere, have been reviewed.

AGA technical review on the evaluation and management of chronic diarrhea.

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 27, 1998.

Efficacy of open-label bismuth subsalicylate for the treatment of microscopic colitis.

BACKGROUND & AIMS: The pathogenesis of the microscopic colitis syndrome is unknown but may involve bacteria, an intestinal luminal antigen, and/or autoimmunity. It was hypothesized that bismuth subsalicylate would resolve both diarrhea and colonic inflammation in microscopic colitis because it possesses antidiarrheal, antibacterial, and anti-inflammatory properties. METHODS: Thirteen patients with microscopic colitis (7 with subepithelial collagen deposition and 6 without) were treated with eight chewable 262-mg bismuth subsalicylate tablets per day for 8 weeks. Patients recorded the frequency of bowel movements daily. Forty-eight-hour stool collections and flexible sigmoidoscopy with 24 biopsies were performed before and after treatment in each patient. RESULTS: Twelve patients completed the trial. Eleven patients had a resolution of diarrhea and a reduction in fecal weight. The average time to respond was 2 weeks. In 9 patients, colitis resolved. When present before treatment, subepithelial collagen thickening disappeared. Those completing the trial experienced no side effects. Posttreatment follow-up for 7-28 months shows that 9 patients remain well having undergone no further treatment, 2 are well but required retreatment, and 1 has continued diarrhea. CONCLUSIONS: Bismuth subsalicylate treatment for 8 weeks is safe and well tolerated. This regimen appears to be efficacious for the treatment of microscopic colitis and is worthy of further study in a controlled trial.

Disseminated rhabdomyosarcoma of the urinary bladder in an adult.

A rare case of alveolar rhabdomyosarcoma of the urinary bladder, manifested as a systemic disease in a 51-year-old woman, was diagnosed at necropsy. Diffuse lytic bone lesions and extensive bone marrow involvement with a leukoerythroblastic blood picture led to an initial clinical diagnosis of a hematologic malignancy.

Tibial chondral fissures associated with the lateral meniscus.

This article describes a relatively common lesion of the lateral tibial plateau that has not been reported in the literature. This lesion is a fissure of the articular cartilage parallel to the lateral meniscal rim. Sometimes asymptomatic, this articular fissure was noted in 10 of 61 consecutive patients (16%) undergoing knee arthroscopy in an outpatient surgery unit. This chondral fissure often demarcates an abrupt transition between firm and healthy articular cartilage, which is covered by the lateral meniscus, and exposed articular cartilage, which is soft and fibrillated. Progressive articular degeneration of knees with this lesion has not been documented; therefore, the clinical significance of these chondral fissure is not yet known.

The prevalence and causes of chronic diarrhea in patients with celiac sprue treated with a gluten-free diet.

BACKGROUND & AIMS: The majority of patients with celiac sprue experience diarrhea before diagnosis. There have been no studies of the prevalence or causes of chronic diarrhea in these patients after treatment with a gluten-free diet. METHODS: Seventy-eight patients with celiac sprue (59 women and 19 men) treated with a gluten-free diet for at least 12 months were surveyed about their bowel habits. Those with chronic diarrhea, defined as passage of loose stools three or more times per week for 6 months, underwent an extensive diagnostic evaluation to determine its cause. RESULTS: Sixty-two of the 78 patients (79%) experienced diarrhea before treatment, and 13 (17%) had chronic diarrhea (of lesser severity) after treatment. The causes of diarrhea in 11 patients consenting to this study were microscopic colitis, steatorrhea secondary to exocrine pancreatic insufficiency, dietary lactose or fructose malabsorption, anal sphincter dysfunction causing fecal incontinence, and the irritable bowel syndrome. Only 1 patient had antigliadin antibodies detected in serum or small intestinal villous atrophy. CONCLUSIONS: After treatment of celiac sprue with a gluten-free diet, chronic diarrhea persists in a substantial percentage of patients. Although ongoing gluten ingestion is one possible cause, other causes may be more frequent. Therefore, diagnostic investigation of diarrhea in celiac sprue after treatment seems warranted.

The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhea.

BACKGROUND: The prevalence of chronic diarrhea from a colonic disease and the optimal method of its diagnosis have not been ascertained. METHODS: Eight hundred nine patients with chronic non-bloody diarrhea unassociated with human immunodeficiency virus (HIV) infection underwent colonoscopy with biopsy specimen taken from throughout the colon and, if reached, the terminal ileum. The prevalence and anatomic distribution of ileocolonic histopathology and whether flexible sigmoidoscopy or colonoscopy represents the safest and most cost-effective test for diagnosis were determined. RESULTS: 122 of 809 patients (15%) had colonic histopathology (microscopic colitis in 80 patients, Crohn's disease in 23, melanosis coli in 8, ulcerative colitis in 5, other forms of colitis in 5, and nodular lymphoid hyperplasia in 1). A correct assessment of colonic histology (normal or abnormal) could have been made from biopsies of the distal colon in 99.7% of patients. CONCLUSION: In a referral setting, colonic histopathology occurs in 15% of patients with chronic diarrhea without HIV infection. According to this prevalence and the nearly universal diffuse anatomic distribution of colonic disease in these patients, a diagnostic investigation for chronic colonic diarrhea using a 60 cm flexible sigmoidoscope is highly efficient and cost-effective.

Rat platelet prostaglandin, cyclic AMP and lipid response to variations in dietary fat.

Diets supplying 20 or 40% of the calories as fat with linoleate to saturated fatty acid ratios of 0.4, 0.8 and 5.5 were fed to male weanling rats for 8 and 11 weeks. Recalcification clotting time was not affected by dietary treatment. Concentration of cAMP in the platelets was significantly elevated at the highest level of dietary linoleate. Cyclic AMP was negatively correlated with concentration of dihomo-gamma-linolenic acid in platelet phospholipids and positively correlated with prostaglandin E1, suggesting that dihomo-gamma-linolenic acid is rapidly converted to prostaglandin E1 causing a rise of cAMP due to stimulation of adenylate cyclase. Dietary treatment did not markedly change the composition of the platelet phospholipid fatty acids and, therefore, resulted in no change in synthesis of the proaggregatory prostaglandin by platelets during clotting. Although the fatty acid composition of the platelet phospholipids remained constant, dietary treatment did affect the total amount of phospholipid fatty acid present in the platelet. Serum concentrations of cholesterol were significantly higher in rats fed the 20% fat diet than in rats fed the 40% fat diet. Platelet cholesterol followed the same trend as serum cholesterol indicating that the cholesterol content of platelets appears to reflect the lipid environment of the plasma.

Successful treatment of chronic severe neutropenia with weekly recombinant granulocyte-colony stimulating factor.

Daily treatment for symptomatic chronic neutropenia with recombinant granulocyte-colony stimulating factor (rhG-CSF) filgrastim is costly and sometimes causes neutrophillia. We report the use of weekly filgrastim in a 40-year-old man with life-long symptomatic neutropenia. Baseline neutrophil counts were < 1 x 10(9)/l 60% of the time, and fell below 0.5 x 10(9)/l for 7d periods every 22 d. Following 1 year of weekly filgrastim treatment, the absolute neutrophil count was maintained > 1 x 10(9)/l (averaging 2 x 10(9)/l) and the frequency and severity of symptoms were reduced by 85%. Therefore the benefits of filgrastim for the treatment of at least one form of chronic severe neutropenia can be derived from weekly rather than daily doses.

Celiac sprue: another autoimmune syndrome associated with hepatitis C.

OBJECTIVE: Celiac sprue is being diagnosed with increasing frequency by screening individuals with epidemiologically associated autoimmune syndromes. We sought to test our hypothesis that hepatitis C also may predispose to celiac sprue because it can trigger autoimmune reactions. METHODS: Two hundred fifty-nine consecutively evaluated patients with chronic hepatitis C infection, 59 with autoimmune liver disease, 137 with other hepatic diseases, 356 with various GI syndromes, and 221 normal volunteers underwent serologic screening for celiac sprue. Patients with antigliadin, antiendomysial, and antitissue transglutaminase antibodies in serum underwent duodenoscopy and biopsy. RESULTS: There was a statistically significantly higher prevalence of antigliadin antibody in all groups of patients with liver disease compared with GI controls and normal controls. However, only patients with hepatitis C (n = 3; 1.2%) or autoimmune liver disease (n = 2; 3.4%) had antiendomysial/antitissue transglutaminase antibody in serum. One of 221 normal volunteers (0.4%) was antigliadin, antiendomysial, and antitissue transglutaminase positive; this individual also was found to have hepatitis C (previously undiagnosed). Each of these six individuals had mild intestinal symptoms, duodenal histopathology consistent with celiac sprue, and the celiac-associated HLA-DQ2 allele. Five of the six followed a prescribed gluten-free diet and experienced symptomatic improvement. CONCLUSION: Celiac sprue is epidemiologically associated with chronic hepatitis C infection and with autoimmune liver disease. Because hepatitis C is much more frequently encountered than autoimmune liver disease, hepatitis C appears to be the most common hepatic disease associated with the development of celiac sprue.