Impact of high-volume, intermediate-volume and low-volume bowel preparation on colonoscopy quality and patient satisfaction: An observational study.

Background: Although optimal bowel preparation is essential for high-quality screening colonoscopy, documentation of preparation quality, patient satisfaction and adherence is scarce. Aim: The aim of this article is to compare low-volume (LV, 300 ml sodium picosulfate), intermediate-volume (IV, 2 l polyethylene glycol, PEG + ascorbic acid and sodium ascorbate), and high-volume (HV, 4 l PEG) purgatives. Results: A total of 5000 individuals (50.5% women) were enrolled between March 2015 and July 2017 (LV:IV:HV = 3.61:1.54:1). Overall sex- and age-adjusted adenoma detection rate was 25.4% (LV 23.8%, IV 25.4%, HV 29.8%), median age was 59.6 years, and cleansing was successful in 96.8%. Success rates of bowel cleansing were highest with HV (97.6%), followed by LV (97.2%) and IV (95.3%) with OR 2.04 (CI 95% 1.20-3.45, p = 0.008) and OR 1.79 (CI 95% 1.27-2.50, p = 0.001), respectively, compared to IV. A total of 93.5% of the LV group would use the same purgative in the future, 73.2% of IV and 69.4% of HV. A total of 84.4% would prefer overnight preparation, 12.1% same-day preparation. Conclusion: All purgatives investigated showed good bowel cleansing quality results, patient satisfaction and compliance. Improvement in patient information might lead to even higher participation rates in screening colonoscopy since one in five patients stated that bowel preparation worried him or her most prior to colonoscopy.

Circadian profiling reveals higher histamine plasma levels and lower diamine oxidase serum activities in 24% of patients with suspected histamine intolerance compared to food allergy and controls.

BACKGROUND: Histamine intolerance is thought to trigger manifold clinical symptoms after ingesting histamine-rich food due to reduced activity of diamine oxidase (DAO). No study has hitherto systematically assessed daily fluctuations of histamine levels and DAO activities in symptomatic patients. The aim of the study was to investigate the presence of histamine intolerance, to therefore establish day profiles of histamine levels and DAO activities, and to compare the results between patients with suspected histamine intolerance, food allergy and healthy controls. METHODS: We determined day profiles of histamine plasma levels and DAO serum activities in 33 patients with suspected histamine intolerance, in 21 patients with proven food allergy and in 10 healthy control patients. Clinical symptoms, food intolerances and further clinical and laboratory chemical parameters were evaluated. RESULTS: Twenty-four percent (8 of 33) suspected histamine-intolerant patients showed elevated histamine levels during the day. That might be caused by constantly and significantly reduced DAO activities in these patients compared to food-allergic and control patients. The remaining 25 patients presented normal histamine levels and DAO activities, but an increased prevalence of multiple food intolerances compared to the other subgroup of suspected histamine-intolerants. There was no correlation between subjective complaints and serological histamine parameters in patients with suspected histamine intolerance. CONCLUSIONS: We determined by daily profiling that decreased DAO activities correlated with elevated histamine levels in a subgroup of suspected histamine-intolerants. This finding discriminates these patients from food intolerant individuals with similar clinical symptoms and strongly suggests the presence of histamine intolerance.

Sinus surgery postpones chronic Gram-negative lung infection: cohort study of 106 patients with cystic fibrosis.

BACKGROUND: In patients with cystic fibrosis (CF) the sinuses are a bacterial reservoir for Gram-negative bacteria (GNB). From the sinuses the GNB can repeatedly migrate to the lungs. In a one-year follow-up study, endoscopic sinus surgery (ESS) with adjuvant therapy reduced the frequency of pulmonary samples positive for GNB. We investigated whether the effect is sustained. METHODOLOGY: We report the effect of ESS and adjuvant therapy three years postoperatively in a CF cohort participating in this prospective clinical follow-up study. The primary endpoint was the lung infection status defined by Leeds criteria. RESULTS: One hundred and six CF patients underwent ESS; 27 had improved lung infection status after three years. The prevalence of patients free of lung colonization with GNB significantly increased from 16/106 patients (15%) preoperatively to 35/106 patients (33%) after three years. The total cohort had decreasing lung function during follow-up; however, in 27 patients with improved lung infection status lung function was stable. Revision surgery was performed in 31 patients (28%). CONCLUSION: ESS with adjuvant therapy significantly improves the lung infection status for at least three years in our cohort of patients with CF and may postpone chronic lung infection with GNB and thus stabilize lung function.

Hydrothermally modified slow release corn starch: a potential new therapeutic option for treating hypoglycemia in autoimmune hypoglycemia (Hirata's disease).

We report the successful treatment of autoimmune hypoglycemia in an 82-year-old non-diabetic Caucasian male with hydrothermally modified slow release corn starch, a product which is used in other conditions associated with hypoglycemia, most typically glycogen storage disease type I. An 82-year-old-Caucasian male presented with recurrent spontaneous hypoglycemia as low as 30 mg/dl following in-patient treatment for community acquired pneumonia. During a fasting-test, symptomatic hypoglycemia occurred. Plasma concentrations of c-peptide and insulin were considerably elevated. Autoimmune hypoglycemia was confirmed by the presence of insulin autoantibodies. While dietary restriction alone did not result in sufficient glucose control in this patient with autoimmune hypoglycemia, treatment with hydrothermally modified slow release corn starch led to stable euglycemia. This easy, well tolerated and non-invasive treatment may constitute a new therapeutic option for hypoglycemia in patients with autoimmune hypoglycemia who do not achieve sufficient control of hypoglycemia by dietary restriction alone.

Effects of lipoprotein apheresis on PCSK9 levels.

BACKGROUND: PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) increases LDL cholesterol (LDL-C) levels by stimulating the degradation of Low Density Lipoprotein receptors (LDL-r). This protein is now of high interest because antibodies which inhibit its effect on LDL-r are being developed. A severe hypercholesterolemia and / or an elevation of lipoprotein(a) can be treated with lipoprotein apheresis (LA) in high-risk patients. METHODS: We measured serum PCSK9 levels in patients eligible for the extracorporeal treatment: in 40 patients (Cohort I) who were treated with different systems before and after apheresis sessions and in the intervals between sessions. 10 patients (Cohort II) who were eligible but did not start LA yet served as controls. RESULTS: Patients' baseline serum PCSK9 levels were elevated relative to healthy volunteers and LA sessions acutely reduced the mean PCSK9 concentrations by 51%. Comparison of the effectiveness of the different LA methods demonstrated the DSA and HELP were more effective than the DALI system. After 24 h PCSK9 levels had returned to baseline compared to 8 days for the LDL-C concentrations to return to its pre-apheresis levels. In Cohort II baseline PCSK9 levels were similar to those in Cohort I. CONCLUSION: The acute reductions of PCSK9 by apheresis may be beneficial with respect to increasing the effectiveness of lipid-lowering drugs and with respect to an anti-atherosclerotic effect. In the future, antagonists to PCSK9 will probably be combined with or possibly replace LA in patients with a very high cardiovascular risk.

Attenuation of catecholamine-induced immunosuppression in whole blood from patients with sepsis.

Studies performed on healthy volunteers have revealed that catecholamines down-regulate the lipopolysaccharide (LPS)-induced production of tumor necrosis factor (TNF)alpha, interleukin (IL)-6, and IL-1beta. We extended this observation and show that this effect is based on changes in the mRNA concentration of these cytokines. Catecholamines are increased in severe sepsis due to endogenous production and have to be administered exogenously when the disease has proceeded to the state of prolonged hypotension. We here investigated whether the immunomodulating effect of catecholamines could also be demonstrated in the blood of patients with prolonged severe sepsis and of those in prolonged septic shock. Blood was stimulated ex vivo with LPS in the presence and absence of epinephrine and the cytokine protein concentration was determined. In blood of healthy volunteers, epinephrine reduced the LPS-stimulated synthesis of TNFalpha by 62.5% (P< 0.0001), of IL-6 by 39% (P< 0.0001), and of IL-1beta by 40% (P= 0.015), and increased the LPS-stimulated IL-10 production by 77.8% (P < 0.0001). Correspondingly, in blood of patients with prolonged severe sepsis, TNFalpha was reduced by 67.2% (P < 0.0001) and IL-6 was reduced by 32.9% (P < 0.0001); IL-1beta and IL-10 were not modulated by catecholamines in these patients. In blood samples of patients in prolonged septic shock, epinephrine did not modulate cytokine levels of IL-6 and IL-10, and decreased TNFalpha only by 36.4% (P < 0.0001). Interestingly, epinephrine suppressed the IL-1beta production by 73% (P < 0.0001) in blood of patients in prolonged septic shock, which was twice as much as in blood samples of healthy volunteers. The altered response of septic blood to catecholamines might be due to an altered reactivity of leukocytes in the prolonged disease although an additional role of preexisting catecholamines cannot be completely excluded.

Improvement of cardiac output and liver blood flow and reduction of pulmonary vascular resistance by intravenous infusion of L-arginine during the early reperfusion period in pig liver transplantation.

BACKGROUND: The release of liver arginase after orthotopic liver transplantation (OLT) causes a deficiency of L-arginine and nitrite in the plasma. This deficiency is possibly related to pulmonary hypertension and reduced hepatic blood flow, which are commonly observed in the immediate reperfusion period. The aim of this study was to evaluate the impact of L-arginine supplementation on metabolic and hemodynamic parameters during liver reperfusion after OLT in pigs. METHODS: Thirteen pig OLTs (control group, n=6; arginine group, n=7) were performed by a standard technique. Cold ischemic time was 20 hr. L-Arginine was infused at a dosage of 500 mg/kg body weight into the donor pigs (30 min before liver explantation) and also into the recipients (over a period of 3 hr from the beginning of the reperfusion period). At the end of the experimental study, the pigs were killed with an overdose of potassium. RESULTS: In the control group, liver revascularization increased plasma arginase concentrations (+615%) and reduced plasma levels of L-arginine (-87%), nitrite (-82%), and nitrate (-53%). Infusion of L-arginine increased plasma levels of L-arginine from 94+/-21 micromol/L to 1674+/-252 micromol/L (P<0.001), L-ornithine from 46+/-8 micromol/L to 2215+/-465 micromol/L (P<0.001), and L-citrulline from 58+/-8 micromol/L to 116+/-34 micromol/L (P<0.001), but had no effect on plasma levels of nitrite and nitrate. Administration of L-arginine in the donor pigs did not produce any systemic or organ-specific hemodynamic alterations. Infusion of L-arginine into the recipient pigs improved cardiac performance (increase in heart rate [+61%, P=0.017] and cardiac index [+53%, P=0.005], reduction in pulmonary capillary wedge pressure [-54%, P=0.014]). Moreover L-arginine infusion increased oxygen consumption (+65%, P=0.003), reduced pulmonary vascular resistance index (P=0.001), stimulated portal venous blood flow (P=0.014), and elevated body temperature during the reperfusion period (P=0.007). CONCLUSIONS: From these data, we conclude that the infusion of L-arginine during OLT improves the hemodynamic performance of the heart, lung, and liver.

Silent myocardial ischemia in glaucoma and cataract patients.

BACKGROUND: Glaucoma and cataract are multifactorial diseases. They have been described to be associated with cardiovascular risk factors. METHODS: Twenty-four-hour ECG monitoring was done in 22 normal-tension glaucoma patients, 27 open-angle glaucoma patients, 25 cataract patients, and 20 normal controls. The frequency of silent myocardial ischemia (SMI) as well as that of ventricular extrasystoles (VES) was evaluated. RESULTS: At least one episode of significant asymptomatic ST-T segment depression occurred in 45% of the normal-tension glaucomas, in 25.9% of open-angle glaucomas, in 12% of cataract patients, and in 5% of normal controls. The frequency of VES was not significantly different among the groups. CONCLUSIONS: Glaucoma, especially normal-tension glaucoma, is significantly associated with the occurrence of episodic asymptomatic myocardial ischemias. Cataract patients, however, had only a slightly, statistically not significantly increased frequency of both SMI and VES compared with normals.

Somatization among Chinese depressives in general practice.

Depressive illness was a common clinical syndrome found in general practice in Hong Kong. The phenomenon of somatization among Chinese depressives in general practice was investigated. Patients clinically identified as depressed were compared with organic patients in terms of their presenting complaints and responses to a symptom checklist. Sleep disturbances, general malaise, pains and aches, dizziness, and menopausal symptoms were the most frequent distrubances that prompted Chinese depressives to seek help in general practice. When directly asked, these patients admitted having various psychological features including dysphoric mood, self-reproach, loss off interest in social activities and in sex. Subgroup comparisons showed little sex difference in initial complaints and admitted symptomatology among the depressives. Some age differences were observed in the presenting complaints. The discrepancy between the pattern of presenting complaints and admitted symptoms suggest that patients were aware of their emotional disturbance even though they tended to express these distrubances in somatic terms in their help-seeking processes. Distinction between the expression mode and the recognition mode of somatization was discussed.

Skeletal maturation of Hong Kong Chinese children in the first five years of life.

This report describes the skeletal maturity during the first five years of life of 492 Chinese children in Hong Kong in a longitudinal study. Hand-wrist radiographs taken half-yearly were assessed by the Tanner-Whitehouse method and rated according to the TW1 20-bone self-weighting maturity score. Skeletal age was in advance of chronological age in both sexes, but significantly more so in females, especially between 18 months and three years. The relationship of the skeletal maturation of these children to various socioeconomic factors is discussed, including the effect of preferential child rearing in favour of males.

Coccidioidal pericarditis.

A 26-year-old man developed coccidioidomycosis which resulted in myocarditis associated with congestive heart failure. A pericardial effusion developed and progressed to constrictive pericarditis. A pericardiectomy was performed and revealed that the pericarditis was due to Coccidioides immitis. The patient was subsequently treated with amphotericin B and showed marked improvement.

Catecholamine-secreting paraganglioma. The problem of classification.

Sudden catecholamine release, associated congestive heart failure, acute injury changes on ECG, and elevation of cardiac enzyme levels were observed after biopsy of a mediastinal mass. Five months later, a normal ECG and coronary arteriogram were recorded. Initial severe avoid unexpected catecholamine release, we recommend that all paragangliomas be evaluated for catecholaime production.