Chronic Abdominal Wall Pain: An Under-Recognized Diagnosis Leading to Unnecessary Testing.

Chronic abdominal wall pain (CAWP) refers to a condition wherein pain originates from the abdominal wall itself rather than the underlying viscera. According to various estimates, 10% to 30% of patients with chronic abdominal pain are eventually diagnosed with CAWP, usually after expensive testing has failed to uncover another etiology. The most common cause of CAWP is anterior cutaneous nerve entrapment syndrome. The diagnosis of CAWP is made using an oft-forgotten physical examination finding known as Carnett's sign, where focal abdominal tenderness is either the same or worsened during contraction of the abdominal musculature. CAWP can be confirmed by response to trigger point injection of local anesthetic. Once diagnosis is made, treatment ranges from conservative management to trigger point injection and in refractory cases, even surgery. This review provides an overview of CAWP, discusses the cost and implications of a missed diagnosis, compares somatic versus visceral innervation, describes the pathophysiology of nerve entrapment, and reviews the evidence behind available treatment modalities.

Measurement of Fractional Exhaled Nitric Oxide as a Marker of Disease Activity in Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Definitive diagnosis of IBD requires endoscopic and pathologic confirmation. These tools are also used to classify disease activity. Our aim was to determine if the fractional exhaled nitric oxide (FeNO) could be utilized to screen for IBD and assess for disease activity. METHODS: We matched weighted IBD cases and controls from the 2009-2010 NHANES dataset. All subjects underwent measurement of FeNO using standardized techniques. We assessed for potential confounders for FeNO measurement including age, height, and asthma. For IBD subjects, we used the presence of diarrhea, fatigue, and weight loss as a proxy for IBD activity. Laboratory parameters examined to estimate disease activity included anemia (≤ 10 g/dl), iron deficiency (ferritin ≤ 20 ng/ml), hypoalbuminemia (≤ 3.2 g/dl), and CRP (≥ 1.1 mg/dl). RESULTS: The weighted sample represented 199,414,901 subjects. The weighted prevalence of IBD was 2,084,895 (1.0%). IBD subjects had nearly the same FeNO level as those without IBD (17.0 ± 16.2 vs. 16.7 ± 14.5 ppb). The odds of a FeNO > 25 ppb was half (OR=0.501; 95% CI 0.497-0.504) for subjects with IBD compared to those without IBD after controlling for confounders. The AUROC curve for FeNO was 0.47 (0.35-0.59). FeNO levels were not higher in patients with laboratory values suggestive of active disease. FeNO levels were higher in IBD patients with diarrhea, rectal urgency, and fatigue but were lower in those with unintentional weight loss. CONCLUSION: Measurement of FeNO does not appear to be useful to screen for IBD or assess disease activity.

The effect of calcium supplementation on blood pressure in non-pregnant women with previous pre-eclampsia: An exploratory, randomized placebo controlled study.

BACKGROUND: Epidemiological findings suggest that the link between poverty and pre-eclampsia might be dietary calcium deficiency. Calcium supplementation has been associated with a modest reduction in pre-eclampsia, and also in blood pressure (BP). METHODS: This exploratory sub-study of the WHO Calcium and Pre-eclampsia (CAP) trial aims to determine the effect of 500mg/day elemental calcium on the blood pressure of non-pregnant women with previous pre-eclampsia. Non-pregnant women with at least one subsequent follow-up trial visit at approximately 12 or 24weeks after randomization were included. RESULTS: Of 836 women randomized by 9 September 2014, 1st visit data were available in 367 women of whom 217 had previously had severe pre-eclampsia, 2nd visit data were available in 201 women. There was an overall trend to reduced BP in the calcium supplementation group (1-2.5mmHg) although differences were small and not statistically significant. In the subgroup with previous severe pre-eclampsia, the mean diastolic BP change in the calcium group (-2.6mmHg) was statistically larger than in the placebo group (+0.8mmHg), (mean difference -3.4, 95% CI -0.4 to -6.4; p=0.025). The effect of calcium on diastolic BP at 12weeks was greater than in those with non-severe pre-eclampsia (p=0.020, ANOVA analysis). CONCLUSIONS: There is an overall trend to reduced BP but only statistically significant in the diastolic BP of women with previous severe pre-eclampsia. This is consistent with our hypothesis that this group is more sensitive to calcium supplementation, however results need to be interpreted with caution.

Administrative Database Research Overestimates the Rate of Interval Colon Cancer.

GOALS: Our study reexamines the prevalence of interval colorectal cancer (I-CRC) by manually reviewing CRC cases at a single institution. BACKGROUND: In 2% to 8% of patients with CRC, diagnosis occurs during the interval 6 to 36 months after a cancer-free colonoscopy. Rates are often determined by linking the date of colonoscopy with cancer registry information. STUDY: We examined all colonoscopies from 1993 to 2011. These examinations were linked with Pennsylvania Cancer Registry data. Matched charts were manually reviewed. We determined whether the CRC was "prevalent" or, for patients with a previous colonoscopy, whether they were interval or noninterval based on time from last colonoscopy. For interval cases, we identified "administrative errors" that could falsely increase the number of reported I-CRC. RESULTS: Over the study period, 43,661 colonoscopies were performed, with 1147 (2.6%) positive for CRC after excluding cases (n=52) in which patients had IBD, previous surgery, or nonadenocarcinoma malignancy. Prevalent CRCs totaled 1062 (92.6%). Noninterval CRCs (diagnosed over 36 mo from index colonoscopy) were present in 40 (3.5%). There remained 45 (3.9%) potential I-CRC cases. However, after manual review, 21 cases were found to be administrative errors. Therefore, the accurate proportion of colonoscopies that found an I-CRC was 2.1% (95% confidence interval, 1.5%-3.2%). CONCLUSIONS: The prevalence of I-CRC at our institution before adjustment was comparable with previously reported rates. This proportion was 47% lower after adjusting for administrative errors placing our figure at the lower end of reported I-CRC incidence. Reported rates of I-CRC may be falsely elevated due to errors unique to merging administrative databases.

The influence of race on symptom severity and quality of life in gastroparesis.

BACKGROUND: The majority of clinical studies for gastroparesis have primarily included white women. Our aim was to compare the etiology, clinical characteristics, healthcare utilization, symptom profile, and quality of life (QOL) in white and nonwhite patients with gastroparesis. METHODS: Newly referred patients with gastroparesis completed: (1) a comprehensive demographic profile, (2) the Patient Assessment of Upper Gastrointestinal Disorder Symptoms (PAGI-SYM), and (3) the Patient Assessment of Upper Gastrointestinal Disorders QOL (PAGI-QOL). All patients had confirmed delayed gastric emptying as measured by 4-hour scintigraphy. RESULTS: A total of 255 patients were enrolled; mean age was 42.5 years and 83.3% were females. There were 44 (17%) nonwhites (33 African American and 11 Hispanic) and 211 (83%) whites. The proportion of nonwhite patients with gastroparesis secondary to diabetes was 55% compared with 19% of white patients (P<0.001). The total PAGI-SYM score was higher in nonwhite patients. Nonwhite patients had higher PAGI-SYM subscale scores for nausea/vomiting, upper abdominal pain, and lower abdominal pain. The 2 groups differed in health care utilization: 49% of nonwhite patients reported ≥4 gastroparesis-related emergency department visits and 42% reported more ≥4 gastroparesis-related hospitalizations, as compared with 20% and 14% of white patients, respectively. Total PAGI-QOL scores were lower in nonwhite patients. Linear regression showed that nonwhite race, sex, age, and age of onset were independently associated with symptom scores, whereas etiology of gastroparesis and gastric emptying times were not. CONCLUSIONS: Nonwhite patients with gastroparesis had more severe symptoms, poorer QOL, and utilized more health care resources than white. Nonwhites were more likely to have diabetes as the etiology.

Conversion of municipal solid waste to carboxylic acids using a mixed culture of mesophilic microorganisms.

Waste biomass was anaerobically converted to carboxylate salts by using a mixed culture of acid-forming microorganisms. Municipal solid waste (MSW) was the energy source (carbohydrates) and sewage sludge (SS) was the nutrient source (minerals, metals, and vitamins). Four fermentors were arranged in series and solids and liquids were transferred countercurrently in opposite directions, which allows both high conversions and high product concentrations. Fresh biomass was added to Fermentor 1 (highest carboxylic acid concentration) and fresh media was added to Fermentor 4 (most digested biomass). All fermentations were performed at 40 degrees C. Calcium carbonate was added to the fermentors to neutralize the acids to their corresponding carboxylate salts. Iodoform was used to inhibit methane production and urea was added as a nitrogen source. Product concentrations were up to 25 g/L, with productivities up to 1.4 g total acid/(L liquid d). Mass balances with closure between 93% and 105% were obtained for all systems. Continuum particle distribution modeling (CPDM) was applied to correlate batch fermentation data to countercurrent fermentation data and predict product concentration over a wide range of solids loading rates and residence times. CPDM for lime-treated MSW/SS fermentation system predicted the experimental total acid concentration and conversion within 4% and 16% respectively.

Conversion of municipal solid waste into carboxylic acids by anaerobic countercurrent fermentation: effect of using intermediate lime treatment.

Municipal solid waste (MSW) and sewage sludge (SS) were combined and anaerobically converted into carboxylate salts by using a mixed culture of acid-forming microorganisms. MSW is an energy source and SS is a source of nutrients. In this study, MSW and SS were combined, so they complemented each other. Four fermentors were arranged in series for a countercurrent fermentation process. In this process, the solids and liquid were transferred in opposite directions, with the addition of fresh biomass to fermentor 1 and fresh liquid media to fermentor 4. An intermediate lime treatment of solids exiting fermentor 3 before entering fermentor 4 was applied to improve the product acid concentration from the untreated MSW/SS fermentations. All fermentations were performed under anaerobic conditions at 40 degrees C. Calcium carbonate was added to neutralize the carboxylic acids and to control the pH. Iodoform was used as a methanogen inhibitor. Carboxylic acid concentration and gas composition were determined by gas chromatography. Substrate conversion was measured by volatile solids loss, and carboxylic acid productivity was calculated as the function of the total carboxylic acids produced, the amount of liquid in all fermentors, and time. The addition of intermediate lime treatment increased product concentration and conversion by approx 30 and 15%, respectively. The highest carboxylic acid concentrations for untreated MSW/SS fermentations with and without intermediate lime treatment were 22.2 and 17.7 g of carboxylic acid/L of liquid, respectively. These results confirm that adding a treatment step between fermentor 3 and fermentor 4 will increase the digestibility and acid productivity of the fermentation.

Leiomiosarcomas uterinos: 10 años de experiencia (1992-2002) en el Hospital Carlos Van Buren / Leiomiosarcomas uterine: 10 years of experience (1992-2002) in the Hospital Carlos Van Buren

Objetivo: Analizar retrospectivamente los factores pronósticos y los resultados de la cirugía exclusiva o con radioterapia adyuvante de leiomiosarcomas uterinos. Material y Métodos: Desde 1992 a 2002, 18 pacientes con leiomiosarcomas uterinos fueron tratados en el servicio de oncología del Hospital Van Buren. Según FIGO: 61,1 por ciento estaba en etapa I, 5,5 por ciento en etapa II, 11,1 por ciento en etapa III y 22,2 por ciento en etapa IV. 17 por ciento presentaban metástasis al diagnóstico. La edad promedio fue de 54,5 años. 33,3 por ciento de las pacientes fueron operadas con el diagnóstico de leiomiosarcoma y 66,7 por ciento con otro diagnóstico, principalmente leiomioma. 61,1 por ciento de las pacientes recibieron radioterapia adyuvante. Resultados: La mediana de sobrevida global fue 13 meses. Las sobrevida global, libre de enfermedad y libre de recurrencia loco-regional fueron a 5 años de 27,8 por ciento, 22,2 por ciento y 81,4 por ciento, respectivamente. Solamente 5,5 por ciento de las pacientes recidivaron exclusivamente en pelvis y 38,8 por ciento desarrolló metástasis a distancia exclusivas. Los factores pronósticos de sobrevida global fueron: la etapa FIGO, la cito reducción quirúrgica y la edad de las pacientes. La radioterapia adyuvante no aumentó la sobrevida global, la sobrevida libre de enfermedad, ni la sobrevida libre de recurrencia loco-regional comparado con el grupo de observación. Conclusiones: Concluimos que la histerectomía abdominal total con o sin salpingo-ooforectomía bilateral permanece como tratamiento de elección en leiomiosarcomas uterinos. La radioterapia adyuvante no tuvo impacto en resultados de tratamiento.

Pharmaceutical services in an Army field hospital in Haiti during Operation Uphold Democracy.

The pharmaceutical services provided by an Army field hospital in Haiti during Operation Uphold Democracy are described. In January 1995, 155 soldiers of the 47th Field Hospital from Ft. Sill, Oklahoma, were deployed to Haiti to provide medical care for 2400 U.S. troops and 7000 multinational troops and police officers. The pharmacy staff (one pharmacist and two technicians) provided patient counseling, drug information, staff consultation, and clinical support to the intensive and intermediate care wards and emergency medical tent of the field hospital. Other responsibilities were providing nonprescription drugs to outpatients, interpreting and evaluating drug orders, participating in drug selection, and ordering supplies. A 30- to 60-day drug supply was maintained. The formulary was designed by the pharmacist and an internist and was based on the mission requirements and conditions in Haiti. Of the 10 oral medications most commonly dispensed to outpatients, 6 were antibacterials and 1 was an antimalarial. An average of two patients were admitted to the hospital daily. Some 240 inpatients were recorded in the pharmacy computer during the hospital's six-month deployment, and more than 5000 were treated in the emergency tent. The pharmacy service of the 47th Field Hospital met the challenge of supporting U.S. and multinational troops in Haiti during Operation Uphold Democracy.

Cuidado integral y continuo del paciente (resumen) / Education for continuity of care

Journal of Medical Education 20, nov. 1954 (English)