A pharmacy-based approach to cholesterol management.

OBJECTIVE: To determine the clinical and economic impact of a pharmacy-based cholesterol management program in patients with cardiovascular disease. STUDY DESIGN: Demonstration project. PATIENTS AND METHODS: From January 1, 1999, through June 30, 1999, 300 patients with a documented history of cardiovascular disease were enrolled in a pharmacy-based cholesterol program. A similar group of 150 randomly selected patients receiving usual care during the same period served as the comparator group. The following were collected for both groups: patient demographics, comorbidities, fasting lipid profiles, cholesterol medication, cost of medication, and cardiovascular events. The McNemar symmetry chi2 test was used to compare appropriate laboratory monitoring, receipt of cholesterol medication, and achievement of target low-density lipoprotein cholesterol levels at baseline and 1 year for both groups. Kruskal-Wallis analysis of variance was used to compare the cost of therapy for both groups at baseline and follow-up. RESULTS: Mean +/- SD age of program and usual care patients was 67 +/- 10 and 69 +/- 11 years, respectively. At 1 year, >95% of program patients were receiving appropriate laboratory monitoring. In 1 year, the percentage of patients reaching target low-density lipoprotein cholesterol levels increased from 45% to 72% (P< .01) and from 33% to 43% (P = .26) in program and usual care patients, respectively. Despite increased medication use among program patients, their cost per patient per month was lower at 1-year follow-up vs baseline. CONCLUSION: Regular patient interaction and close patient monitoring allowed the pharmacy-based lipid management program to improve cholesterol management in patients with cardiovascular disease.

Chest pain: overlooked manifestation of unsuspected esophageal foreign body.

Two cases of unsuspected esophageal foreign body ingestion with chest pain as the main symptom are reported. Both patients had extensive cardiac evaluation to rule out myocardial ischemia. They were discharged home with continuing chest pain and odynophagia. Both patients were denture wearers, and further questioning revealed the coincidence of chest pain with taking meals. Further evaluation revealed an impacted esophageal foreign body in one patient and an esophageal perforation with a mediastinal abscess in the other. These cases illustrate the importance of considering esophageal foreign bodies as factors in chest pain.

Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry (SOM).

OBJECTIVE: Sphincter of Oddi manometry (SOM) is a useful diagnostic procedure when evaluating patients with unexplained biliary pain or idiopathic recurrent pancreatitis. Acute pancreatitis is a recognized complication of SOM whose pathogenesis appears to be multifactoral. We conducted this study to determine the incidence of pancreatitis in patients after SOM and to identify any variables that may lead to an increased incidence of pancreatitis. METHODS: A retrospective review of 100 consecutive patients who underwent SOM between 1992 and 1996 at two university-affiliated hospitals was done. SOM was performed using a triple lumen catheter with each lumen perfused at a rate of 0.25 cc/min using an Arndorfer pneumohydraulic capillary perfusion system. The following data were recorded: age, gender, clinical type of sphincter of Oddi dysfunction, length of procedure, doses of medications used, duct cannulated, sphincter of Oddi pressure, whether endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy was performed, and the number of patients developing pancreatitis. Statistical analysis was performed using a T test, chi2, and multiple regression analysis. RESULTS: The overall incidence of pancreatitis was 17%. Six patients with type II SO dysfunction and 11 patients with type III SO dysfunction developed pancreatitis. The incidence of pancreatitis was significantly lower in those patients who only had SOM, compared with those patients who had SOM and ERCP (9.3% vs 26.1%, p < 0.026). There was no significant correlation between age, gender, duration of procedure, dose of midazolam used, sphincter of Oddi pressure, or type of SO dysfunction with the development of SOM-induced pancreatitis. Multiple regression analysis showed that sphincterotomy added no additional risk, beyond that associated with ERCP, for the development of pancreatitis. CONCLUSIONS: The results of this study indicate that the incidence of pancreatitis was highest when SOM was followed by ERCP. A potential method of decreasing the incidence of pancreatitis after SOM is performing ERCP with or without sphincterotomy at another session, separated from the SOM by at least 24 h. Before this can be definitely recommended, the results of this study must be validated by others or by a prospective study.

Evidence of gender bias in patients undergoing flexible sigmoidoscopy.

Some studies have revealed gender bias against women in various aspects of medical care. There is no substantial evidence of gender bias in patients undergoing cancer evaluations, specifically colorectal cancer screening and diagnosis of colorectal complaints. This study was designed to examine the role of gender bias related to patients undergoing flexible sigmoidoscopy. At the University of South Florida, we conducted a retrospective study of 1910 patients at three distinct flexible sigmoidoscopy clinics over several years, through 1992. The proportions of male and female patients who underwent the procedure for indications of either screening for colorectal cancer or the diagnosis of colorectal complaints were determined. These proportions were compared with the respective male and female patient proportion from the total number of currently active patients at each site who were eligible to have the procedure for an appropriate indication. At all three sites, a significantly smaller proportion of women (p < 0.01) underwent the procedure than expected. This was true for both screening and diagnostic indications. Conversely, at all sites significantly more men (p < 0.01) underwent the procedure for both indications. The results of this study suggest gender bias against women for patients undergoing flexible sigmoidoscopy for both screening and diagnosis. This bias may adversely affect the lethality of colorectal cancer in women. It is important to determine if such biases are influenced by the physician's recommendation or mainly due to patient attitudes.

Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful adjunct to laparoscopic cholecystectomy. Preoperative ERCP is indicated if there is a high degree of suspicion for common duct stones, when severe gallstone-induced pancreatitis is present, or when there is uncertainty regarding the diagnosis. The best indicators of common duct stones preoperatively are an elevated bilirubin, a dilated common bile duct (CBD) on sonography, or stones visualized in the CBD on sonography. Mild gallstone pancreatitis and transient mild elevations in liver enzymes are not predictive of CBD stones and are not indications for ERCP. Postoperative ERCP is highly effective in clearing CBD stones. It has the advantage of being more readily available as compared to laparoscopic CBD exploration, and preserves all the advantages of the laparoscopic approach. Post-operative ERCP is indicated for retained CBD stones, evaluation and therapy of biliary injuries, and persistent biliary symptoms or abnormal liver enzymes and bilirubin. ERCP is the procedure of choice for the evaluation of laparoscopic biliary injuries. Major biliary injuries will generally require surgical therapy. Bile duct strictures are sometimes amenable to endoscopic therapy with dilation and stents. Biliary leaks are readily treatable with endoscopic therapy. Small cystic duct stump leaks and leaks from a duct of Lushka close within a few days with nasobiliary drainage. Larger leaks may require more prolonged drainage with stents and early supplemental percutaneous drainage of an accompanying biloma. Bilious ascites should be treated with nasobiliary drainage using low suction to be prevent contamination of the peritoneal cavity with intestinal flora, and simultaneous percutaneous ascites drainage. Biliary leaks, unless associated with major bile duct injuries, rarely require surgical therapy.

A prospective trial of transjugular intrahepatic portasystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices.

OBJECTIVE: The authors compare transjugular intrahepatic portasystemic stent shunts (TIPS) to small-diameter prosthetic H-graft portacaval shunts (HGPCS). SUMMARY BACKGROUND DATA: Transjugular intrahepatic portasystemic stent shunts have been embraced as a first-line therapy in the treatment of bleeding varices due to portal hypertension, although they have not been compared to operatively placed shunts in a prospective trial. METHODS: In 1993, the authors began a prospective, randomized trial to compare TIPS with HGPCSs. All patients had bleeding varices and had failed nonoperative management. Shunting was undertaken as definitive therapy in all. Failure of shunting was defined as an inability to accomplish shunting despite repeated attempts, unexpected liver failure leading to transplantation, irreversible shunt occlusion, major variceal rehemorrhage, or death. Mortality and failure rates were analyzed at 30 days (early) and after 30 days (late) using Fischer's exact test. RESULTS: There were 35 patients in each group, with no difference in age, gender, Child's class, etiology of cirrhosis, urgency of shunting, or incidence of ascites or encephalopathy between groups. In two patients, TIPS could not be placed despite repeated attempts. Transjugular intrahepatic portasystemic stent shunts reduced portal pressures from 32 +/- 7.5 mmHg (standard deviation) to 25 +/- 7.5 mmHg (p < 0.01), whereas HGPCS reduced them from 30 +/- 4.6 mmHg to 19 +/- 5.3 mmHg (p < 0.01; paired Student's test). Irreversible occlusion occurred in three patients after placement of TIPS. Total failure rate after TIPS placement was 57%; after HGPCS placement, it was 26% (p < 0.02). CONCLUSIONS: Both TIPS and HGPCS reduced portal pressure. Placement of TIPS resulted in more deaths, more rebleeding, and more than twice the treatment failures. Mortality and failure rates promote the application of HGPCS over TIPS.

Does fluoroscopic guidance for Maloney esophageal dilation impact on the clinical endpoint of therapy: relief of dysphagia and achievement of luminal patency.

BACKGROUND: Use of fluoroscopy for Maloney esophageal dilation is controversial. We designed this prospective, randomized, single-blinded study to determine whether fluoroscopic guidance has an impact on relief of dysphagia and achievement of luminal patency. METHODS: Patients with benign esophageal strictures were randomized to undergo Maloney dilation with or without fluoroscopic guidance. Strictures were dilated to size 48F. Dysphagia scores were obtained before and 1 week after dilation. RESULTS: Eighty-three patients underwent 100 dilation sessions with fluoroscopic guidance being used for 50 sessions (156 dilations) and blinded technique for 50 (161 dilations). A 12.5 mm barium pill passed after dilation following 62.0% of the fluoroscopic dilation sessions and 42.0% of the blinded dilations (p = 0.045). Dysphagia was improved in 93.0% of patients receiving fluoroscopic dilations and 69.0% of patients receiving blinded dilations (p = 0.006). The mean improvement in dysphagia score was -2.10 points for the fluoroscopic group versus -1.50 points for the blinded group (p = 0.057). Differences in these parameters between techniques were even greater in 12 patients re-randomized to both techniques at different sessions. CONCLUSIONS: The use of fluoroscopic guidance impacts favorably on the efficacy of Maloney dilation, resulting in greater relief of dysphagia and increased luminal patency compared to the blinded technique. Based on these results, use of fluoroscopy is recommended when Maloney esophageal dilation is performed.

Surgical clips as a nidus for biliary stone formation: diagnosis and therapy.

Two cases in which a cystic duct stump clip migrated into the common bile duct and formed the nidus for a stone are reported. In one case, the diagnosis was made before ERCP, on the basis of CT findings. In the second case, a retrospective review of plain abdominal films showed evidence of clip migration. Both patients were treated successfully with endoscopic sphincterotomy, as have most such patients reported in the literature. Although clip migration can occur after both open and laparoscopic cholecystectomy, there is some evidence that this complication may be more common after the laparoscopic procedure. Clip migration can be diagnosed before cholangiography by carefully reviewing plain abdominal films and CT scans. ERCP confirms the diagnosis, and sphincterotomy with clip and stone removal is the therapeutic procedure of choice. Additional surgical procedures only rarely are required.

Prolonged evaluation of epinephrine and normal saline solution injections in an acute ulcer model with a single bleeding artery.

BACKGROUND: Animal studies of epinephrine or normal saline solution injection for bleeding ulcers do not consistently demonstrate local tamponade effect. METHODS: We studied the change of bleeding rates of 28 acute gastric ulcers with a single bleeding artery in 10 dogs. Four injections of 1 mL epinephrine 1:10000 at 1 mm from the spurting artery (n = 7) were compared to four injections of normal saline solution 1 to 5 mL (n = 12) and to four dry needle sticks (n = 9). Bleeding rates were measured at initial arterial incision and at minutes 1, 5, 10, 15, 20, 25, and 30 after treatment. RESULT: Reductions in early blood loss to 24.3% +/- .05 of baseline occurred with saline solution, to 17.7% +/- .03 with epinephrine, and to 66.0% +/- 1.8 in controls (p < .05 for epinephrine and saline solution vs control). A tendency for saline solution injected ulcers to resume bleeding was identified, with late blood loss increasing to 26.9% +/- .05 of baseline, (saline solution vs control) compared to 7.7% +/- .02 in epinephrine injected ulcers (p < .05 vs control). CONCLUSIONS: The early acute hemostatic effect of injection therapy depends on local tamponade. The prolonged hemostatic effect is a combination of tamponade and vasoconstriction, with advantage of epinephrine over saline solution.

The role of ERCP in patients after laparoscopic cholecystectomy.

OBJECTIVES: The goal of this study was to evaluate the feasibility of endoscopic management of complications encountered in patients undergoing laparoscopic cholecystectomy. Special attention was given to establishing the optimal timing, success rate, and complications of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic cholecystectomy. METHODS: Fifty-six consecutive patients referred from two major medical centers were evaluated with ERCP after laparoscopic cholecystectomy. The patient population included 22 men and 34 women 16-87 yr of age. Indications included common bile duct stones seen on operative cholangiography or ultrasound, persistently elevated liver enzymes and abdominal pain, evidence of biliary injury, and other, All endoscopic procedures were carried out by experienced endoscopists using standard ERCP techniques and equipment. Endoscopic papillotomy was performed with 2- to 2.5-cm cutting wire papillotomes and all biliary stones were removed with 8.5- to 14-mm balloons. Small biliary leaks were first treated with 3-7 days of nasobiliary drainage, and if persistent with 10-Fr internal stents for 1 month. One patient with a biliary stricture was dilated with placement of progressively larger biliary stents over 9-month period. RESULTS: ERCP was performed within 6 h to 2 yr after laparoscopic cholecystectomy (LC). In 12 patients, it was performed within the first 24 h after LC. A cholangiogram was obtained in all patients. No complications were encountered. Thirty patients underwent therapeutic endoscopy. Common bile duct stones were found and were successfully removed from 23 patients. One patient required an emergent ERCP and sphincterotomy for gallstone pancreatitis 3 days after LC. Fourteen patients had common bile duct injuries, cystic duct stump leaks, or leakage from ducts of Luschka (one patient). All leaks were successfully treated with temporary stenting. Six patients with bile duct transection or complete obstruction by clips required surgical therapy. One patient with a common bile duct stricture was managed with endoscopic stents alone. Two patients had unsuspected malignancies, one each with ampullary and pancreatic carcinoma. Fourteen patients had a normal ERCP. CONCLUSIONS: Diagnostic and therapeutic ERCP can be done within 24 h of LC with safety and a high degree of success. Delay in removal of CBD stones may lead to complications. Cystic duct stump leaks are easily corrected with nasobiliary drainage, and some post-LC strictures may be amenable to therapy with biliary stents. Finally, malignancy must be excluded in patients with unexplained recurrent symptoms.