Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study.

BACKGROUND AND STUDY AIMS: Capsule endoscopy may play a role in the evaluation of patients presenting with acute upper gastrointestinal hemorrhage in the emergency department. PATIENTS AND METHODS: We evaluated adults with acute upper gastrointestinal hemorrhage presenting to the emergency departments of two academic centers. Patients ingested a wireless video capsule, which was followed immediately by a nasogastric tube aspiration and later by esophagogastroduodenoscopy (EGD). We compared capsule endoscopy with nasogastric tube aspiration for determination of the presence of blood, and with EGD for discrimination of the source of bleeding, identification of peptic/inflammatory lesions, safety, and patient satisfaction. RESULTS: The study enrolled 49 patients (32 men, 17 women; mean age 58.3 ±â€†19 years), but three patients did not complete the capsule endoscopy and five were intolerant of the nasogastric tube. Blood was detected in the upper gastrointestinal tract significantly more often by capsule endoscopy (15 /18 [83.3 %]) than by nasogastric tube aspiration (6 /18 [33.3 %]; P = 0.035). There was no significant difference in the identification of peptic/inflammatory lesions between capsule endoscopy (27 /40 [67.5 %]) and EGD (35 /40 [87.5 %]; P = 0.10, OR 0.39 95 %CI 0.11 - 1.15). Capsule endoscopy reached the duodenum in 45 /46 patients (98 %). One patient (2.2 %) had self-limited shortness of breath and one (2.2 %) had coughing on capsule ingestion. CONCLUSIONS: In an emergency department setting, capsule endoscopy appears feasible and safe in people presenting with acute upper gastrointestinal hemorrhage. Capsule endoscopy identifies gross blood in the upper gastrointestinal tract, including the duodenum, significantly more often than nasogastric tube aspiration and identifies inflammatory lesions, as well as EGD. Capsule endoscopy may facilitate patient triage and earlier endoscopy, but should not be considered a substitute for EGD.

The use of Pillcam Colon in assessing mucosal inflammation in ulcerative colitis: a multicenter study.

BACKGROUND AND STUDY AIM: Treatment of ulcerative colitis should be tailored to the severity of colonic inflammation, which in the past has been gauged mainly by clinical features and biochemical parameters. Recently, mucosal healing has been proposed as a standard to guide therapy. The aim of this multicenter study was to test whether mucosal appearance, as reported by colon capsule endoscopy (CCE), can be used to differentiate active from inactive ulcerative colitis. PATIENTS AND METHODS: Adult patients from Hong Kong, Singapore, and Taiwan who were suspected or known to have ulcerative colitis were included in this prospective study. CCE and conventional optical colonoscopy were offered to these patients on the same day after receiving standard bowel preparation. The primary endpoint was the accuracy of CCE in assessing colonic inflammation (defined as the presence of ulcers, erythema, erosions, edema, exudates in mucosa), using optical colonoscopy as the gold standard. RESULTS: At total of 100 patients (42 females; median age 50 years; range 22 - 68 years) were enrolled. Four cases were excluded from the analysis due to technical failure or slow transit of the capsule. In nine patients, the capsule was not excreted within 8.5 hours and required retrieval during colonoscopy. The sensitivity of CCE to detect active colonic inflammation was 89 % (95 % confidence interval [CI] 80 - 95) and specificity was 75 % (95 %CI 51 - 90). The positive and negative predictive values of CCE for colonic inflammation were 93 % (95 %CI 84 - 97) and 65 % (95 %CI 43 - 83), respectively. No serious adverse event related to the CCE procedure or preparation was reported. CONCLUSION: CCE is a safe procedure to monitor mucosal healing in ulcerative colitis. However, at this stage, CCE cannot be recommended to replace conventional colonoscopy in the management of this condition.

Diabetes prevention program in a Mediterranean environment: individual or group therapy? An effectiveness evaluation.

INTRODUCTION: Diabetes as a multifactorial disorder requires prevention measures based upon the modification of several risk factors simultaneously; otherwise, there is insufficient potential for prevention. Following the success of the American Diabetes Prevention Program (DPP), we implemented an intervention program in a large Israeli healthcare organization with an emphasize on Mediterranean Diet (MedDiet) and physical activity. The objective was to evaluate the effectiveness of two types of intervention, individual and group therapies, in reducing risk factors and in preventing or delaying the development of type 2 diabetes. METHODS: Out of 180 primary care physicians, 85 who agreed to participate, were randomly assigned, between the years 2005 and 2006, into two groups: those who would refer pre-diabetes adult patients for individual therapy and those who would refer for group therapy. The two groups of patients consisted of 111 and 112 in each group. The intervention lasted for 6 months and discussed: the benefits of MedDiet, planning nutritional behavior and mindful eating, and the importance of physical activity. All patients were invited to participate in walking groups. Follow up lasted for 24 months and logistic, mixed models, and Cox regressions were employed. RESULTS: No statistically significant differences were detected between the two intervention groups in age; gender and clinical measurements at recruitment. Thirty nine percent of both groups developed diabetes (entered the DR by 2012), including 38.7% from the individual therapy and 39.3% from the group therapy (P=0.933). The mean time from 2005 until entry to the Diabetes Registry (DR) was 2.9 and 2.5 years for the individual and group therapy respectively (P=0.542). CONCLUSION: Both interventions were equally effective in achieving the desired outcomes and time until entry to the DR. For large health organizations with a high number of pre-diabetes patients and scarce resources, group therapy, where 12 people are reached out by one team member are preferable and more costly effective, than a one on one therapy.

Bariatric surgery in morbidly obese sleep-apnea patients: short- and long-term follow-up.

Forty-seven obese sleep-apnea patients were investigated in the sleep laboratory before and after a massive weight reduction achieved by bariatric surgery. The first postoperative sleep investigations were performed approximately 1 y after surgery and revealed a highly significant decrease in the number of apneic episodes per hour of sleep and a significant improvement in all sleep-quality-related measures. A second postoperative sleep study was performed approximately 7 y postoperatively and revealed that regaining of weight was associated with the reappearance of sleep apnea syndrome, although the great majority of the patients still felt, subjectively, that they were well and did not suffer from recurrence of the sleep apnea syndrome.

Paroxysmal awakenings from sleep associated with excessive daytime somnolence: a form of nocturnal epilepsy.

We describe 14 hypersomniac patients whose polysomnographic recordings revealed abnormal EEG patterns consisting of paroxysmal epileptic discharges during stages 2 and 3 of NREM sleep, associated with arousals, fragmentation of sleep, and reduction in sleep efficiency, particularly REM sleep. Three patients who received anticonvulsants showed clinical and polysomnographic documented improvement in sleep patterns. These patients probably had a unique form of nocturnal epilepsy-related sleep disorder, manifested by paroxysmal wakenings from sleep.

Speech arrest and supplementary motor area seizures.

A right-handed man had recurrent episodes of speech arrest that were focal epileptic seizures. A metastatic adenocarcinoma was identified and removed from the left supplementary motor area. The similarity of these rare seizures to transient ischemic attacks may lead to an erroneous and hazardous misdiagnosis.

Auditory brainstem evoked potentials during sleep apnea.

Auditory brainstem evoked potentials (ABEPs) were recorded from seven subjects with predominantly central sleep apnea. ABEPs were recorded during: (1) waking, (2) non-REM sleep between apneic episodes, (3) first half of apneas, and (4) second half of apneas. Latencies of vertex positive peaks III, V, and VI as well as the V-III interpeak latency difference were determined, and the effect of apnea phase on these measures were evaluated. The measures studied did not reveal chronic or acute functional abnormality of auditory brainstem, which may result from or cause apneic episodes during non-REM sleep. The normality and stability of ABEPs during apneic sleep indicate effective compensatory mechanisms in auditory brainstem. Brainstem functional changes associated with central apneas may not be reflected in the ABEP measures studied, unless they are part of a more extensive dysfunction.

Localized pontine lesion: nearly total absence of REM sleep.

Eight whole-night polysomnographic recordings were conducted in a 33-year-old man with a localized pontine lesion inflicted by a shrapnel fragment. Sleep recordings revealed no rapid eye movement (REM) sleep in 3 nights, and markedly reduced REM sleep in 5 nights; non-rapid eye movement (NREM) sleep was normal. In spite of marked reduction of REM sleep, the patient conducted a normal life and had none of the typical symptoms of REM-sleep deprivation.

Periodic leg movements in sleep: effect of clonazepam treatment.

Periodic leg movements in sleep were diagnosed in 8 patients with insomnia and in 12 patients with hypersomnia. Polysomnography did not reveal any difference in the number of leg movements in these groups, the mean duration of a leg movement, or the number of activity epochs. Those with insomnia, however, had a shorter intermovement interval than those with hypersomnia, with more leg movements in each activity epoch. Treatment with 0.5 to 2 mg clonazepam improved subjective complaints and decreased the number of leg movements without affecting the intermovement interval or movement duration.

Time domain analysis of VEPs. Detection of waveform abnormalities in multiple sclerosis.

Visual evoked potentials (VEPs) are a useful tool in the diagnosis of multiple sclerosis. To improve their diagnostic power in the early stages of the disease, the VEP shape, as well as its latency, were considered. The Karhunen-Loeve expansion (KLE) was used because it affords an unique advantage in classifying the VEPs by their shape, and gives a well-defined criterion based on similarity to the normative prototype. Using this criterion, it was possible to quantitatively define normative limits of waveform. We were also able to detect early changes in VEPs recorded from suspected multiple sclerosis patients. KLE promises to enable classification of waveforms in early stages of the pathology, when peak-latency comparisons are the least effective.

Narcolepsy-cataplexy in Israeli Jews is associated exclusively with the HLA DR2 haplotype. A study at the serological and genomic level.

Narcolepsy is a very rare disease among Israeli Jews with a frequency of 7/3 X 10(6). An investigation of the association of narcolepsy with the human leukocyte antigen system was conducted in Israeli Jews at the serologic and genomic levels. The human leukocyte antigen class I and class II antigen typing of 7 clinically diagnosed narcoleptics, 3 individuals suffering from sleep disorders other than narcolepsy, and 11 healthy matched controls revealed that all narcoleptic patients (100%) investigated in the present study carried the HLA-DR2 haplotype, whereas patients with other sleep disorders did not. The HLA-B7 and DR2 occurred jointly in 57% (4/7) of the narcoleptic patients, as compared to 2% in randomly selected Israeli healthy controls. Restriction fragment length polymorphism analysis was performed with several restriction enzymes and three cDNA probes for DQ alpha, DQ beta, and DR beta genes on genomic DNAs obtained from narcoleptics and patients with other sleep disorders, matched controls, and 3 homozygous typing cells representing the DR2 subtypes Dw2, Dw12, and DwAZH. The restriction fragment length polymorphism analysis showed that all narcoleptics (7 of 7) shared virtually identical restriction fragment length polymorphisms with one of the homozygous typing cells (GSO), which defines DR2,Dw2. The frequency of the DR2,Dw2 haplotype in the healthy Israeli population is 3.2%. Other non-narcoleptic patients did not share these restriction fragment length polymorphisms. These findings indicate that narcolepsy is associated worldwide with the HLA-DR2,Dw2 haplotype.

HLA class II analysis in Jewish Israeli narcoleptic patients.

HLA class II was investigated in eight Jewish narcoleptic patients, representing the total of such patients known in Israel at present, and in three patients suffering from sleep disturbances other than narcolepsy. All (11 out of 11) patients carried the serologic specificities DR2, DQ6 (DQ1). At the DNA level, all narcoleptics were found to be DRB1*1501, DQA1*0102, DQB1*0602 which indicates that the susceptibility gene may be located within the HLA class II region, DR, and/or DQ. As for the nonnarcoleptic patients with idiopathic hypersomnia, they carried different alleles of DR2 and DQ6, namely DRB1*1502, DQA1*0103, DQB1*0601. This study confirms that the incidence of narcolepsy in Israel is extremely low and that HLA class II genes or a gene(s) tightly linked to them are involved in the disease.

Kleine Levin syndrome (KLS) in young females.

During the years 1982-1998, we encountered 7 adolescents and one young woman suffering from KLS. In 4 patients, hypersomnolence was accompanied by hyperphagia and hypersexuality, while in the remaining 4, recurrent hypersomnia was the only symptom. Mean age at onset of hypersomnolent attacks was 15.1+/-3.5 yrs. The mean duration of a hypersomnolent attack was 9.9+/-5.4 days, and the number of attacks per patient was 6.2+/-3.4. Polysomnographic recordings from 3 patients inbetween attacks, and from one patient during an attack, showed relatively normal sleep structure with decreased sleep efficiency due to numerous awakenings from sleep stage 2. Besides the recurrent hypersomnia, all patients enjoyed good health, with no evidence of behavioral or endocrine dysfunction. Similarly aged males with KLS from our clinic and previously reported females, had similar clinical features.

Mortality in sleep apnea patients: a multivariate analysis of risk factors.

During 1976-1988 we diagnosed sleep apnea syndrome (SAS) in 1,620 adult men and women monitored in the Technion sleep laboratories. Their age at the time of diagnosis ranged between 21 and 79 years. Fifty-seven patients (53 men and 4 women) had died by 1990, 53% due to respiratory-cardiovascular causes. The observed/expected (O/E) mortality rates, calculated for men only, revealed excess mortality of patients under 70 years old. Excess mortality was significant in the fourth and fifth decades (3.33, p < 0.002; 3.23, p < 0.0002, respectively). In patients older than 70 O/E was 0.33 (p < 0.0007). Hierarchical multivariate analysis with four fixed variables [age, body mass index (BMI), hypertension and apnea index] and four additional variables added manually one at a time (heart disease, lung disease, diabetes, apnea duration) was used to determine the predictors of death from all causes, cardiopulmonary causes and from myocardial infarction (MI). All four major variables were found to be significant predictors of mortality from all causes, in addition to lung disease and heart disease. Only age and BMI were significant predictors of cardiopulmonary deaths in addition to lung disease. Age, BMI and hypertension predicted MI deaths in addition to lung disease. These results were interpreted to suggest that SAS affects death indirectly, most probably by being a risk factor for hypertension.

Recurrence of sleep apnea without concomitant weight increase 7.5 years after weight reduction surgery.

In this study we report on a long-term follow-up of 14 morbidly obese sleep apneic patients, 11 of whom were male and 3 female. The mean age was 46 +/- 8.5 years. These patients had undergone weight reduction surgery. Before surgery, body mass index (BMI) and apnea index (AI) were 45 +/- 7.2 kg/m2 and 40 +/- 28.8 (SD) h-1, respectively. Four and a half months after surgery (range, 2 to 7 months), both BMI and AI significantly decreased to 33 +/- 7.5 kg/m2 and 11 +/- 16.4 h-1, respectively. Seven and half years after surgery (range, 5 to 10 years), BMI increased only slightly to 35 +/- 6.0 kg/m2 (p > 0.2), while AI increased significantly to 24 +/- 23 h-1 (p < 0.05). There were poor and insignificant correlations between changes in BMI and AI prior to 4.5 months after operation (r = 0.23; p > 0.4). and 4.5 months to 7.5 years after operation (r = 0.41; p > 0.1). We conclude that morbid obesity is not the only causative factor in the sleep apnea syndrome for these patients. Weight reduction surgery alone does not "cure" their sleep apnea, and they are still at risk.

The relationship between the severity of sleep apnea syndrome and 24-h blood pressure values in patients with obstructive sleep apnea.

Automated ambulatory 24-h BP monitoring was made in 38 patients with obstructive sleep apnea syndrome. Stepwise multiple regression analysis revealed that diastolic, systolic, and mean BP values during sleep as well as during wakefulness were significantly related to apnea/hypopnea index and age. Minimal arterial O2 saturation and total sleep time also significantly contributed to diastolic and mean BP values during sleep. Body mass index did not significantly contribute to any of the BP values. These results support a causal relationship between the severity of sleep apnea syndrome and systemic hypertension.

Melatonin improves evening napping.

Twelve young adults were treated with either melatonin, 3 mg or 6 mg, or placebo, at two different times before an early evening nap (18.00-20.00 h) according to a balanced double-blind Latin square design. Polysomnographic monitoring revealed that both dosages of melatonin significantly shortened sleep latency and increased total sleep time in comparison to placebo, irrespective of the time of administration. Subjects also tended to assess their sleep as 'deeper' after melatonin treatment. Based on previous data and the present results, it was concluded that exogenous melatonin exerts hypnotic effects only when circulating levels of endogenous melatonin are low.

Prior antihypertensive treatment and admission blood pressure correlated with clinical outcome and early morning presentation in hypertensive ischaemic stroke patients.

Blood pressure (BP) reduction of 5-6 mm Hg reduces the relative risk of stroke by 30-40%. This effect does not appear to depend on the antihypertensive agent used to bring about the required reduction in BP. Patients with acute ischaemic stroke often exhibit an elevated BP. These patients, who previously suffered from hypertension, have significantly higher levels of BP readings on admission with increased incidence of stroke immediately after arising. The aim of this study was to compare antihypertensive agents, especially short and long acting drugs with the measurement of BP on admission, the time of the ischaemic stroke and its clinical severity. This was studied retrospectively in 109 patients (55 females and 54 males). The mean age was 69.7 +/- 10.4 years. All the patients admitted between 1 July 1996 and 30 June 1997 for ischaemic stroke as established by brain CT scan, were studied. Of the stroke subjects not treated or treated with short acting calcium blockers, 40.8% and 44.4% of them respectively appeared to have an ischaemic stroke in the early morning hours in contrast to 20% of those treated with long acting calcium blockers (P < 0.05). The last group of patients also experienced less clinical severity. These results emphasise the need for proper 24-h control of BP and by comparison to other antihypertensive agents, the long acting calcium blockers with these subjects may prevent a sudden early morning rise in BP, which is instrumental in stroke prevention.

Increased incidence of diabetes mellitus in the patients with transitional cell carcinoma of urinary bladder.

The progression of bladder cancer to invasive disease is highly dependent on its ability to penetrate basement membrane of urothelium. Studies on diabetic nephropathy have shown a reduction in proteoglycan content of the glomerular basement membrane. Based on the well-known fact that proteoglycans are one of the main components of basement membrane and extracellular matrix we assessed the relationship between diabetes mellitus, bladder cancer incidence and its behavior. These studies include 252 patients with microscopically confirmed transitional cell carcinoma of bladder, and 549 patients with other urological disorders who served as controls. The prevalence of diabetes mellitus in each group was assessed. The group of patients suffering from transitional cell carcinoma was divided according to etiological risk factors such as cigarette smoking, diabetes and patients that were non-smokers and did not suffer from diabetes mellitus. We assessed the features of bladder cancer behavior in each group. Logistic regression model estimation for statistical analysis was used, with transitional cell carcinoma as a dependent binary variable and age, sexes smoking and diabetes as independent variables. Statistical significance was considered at two levels: p

A hypernychthemeral sleep-wake syndrome: a treatment attempt.

The wake and sleep-onset times of a patient with a sleep-wake cycle longer than 24 hr were recorded by the patient for 4 years. During this time, the patient found himself unable to maintain a 24-hr sleep-wake schedule. When treated with 1-2 mg clonazepam, taken nightly, he was able to become entrained to a 24-hr day. Despite entrainment of his sleep-wake cycle, the patient reported depression, lack of motivation and fatigue and chose not to continue taking the drug.