Ischemic colitis revisited: a prospective study identifying hypercoagulability as a risk factor.

BACKGROUND: Although causes for ischemic colitis have been identified, many cases are deemed idiopathic. Some reports suggest an association between ischemic colitis and coagulation disorders. Our purpose was to explore the relationship of ischemic colitis and clotting abnormalities. METHODS: Eighteen patients consented to undergo a hypercoagulability evaluation. Tests included protein C, protein S, activated protein C resistance, factor V Leiden, anticardiolipin antibodies, antineutrophil cytoplasmic antibodies, rheumatoid factor, antithrombin III, anti-smooth muscle antibody, lupus anticoagulant panel, and prothrombin 20210G/A mutation (in women undergoing hormone replacement therapy). RESULTS: Five of 18 patients tested positive for coagulation abnormalities, including factor V and activated protein C resistance, protein S deficiency, prothrombin 20210G/A mutation, and anticardiolipin antibody. CONCLUSION: To our knowledge, this is the largest series of patients with ischemic colitis studied for coagulation defects in the United States. The prevalence of clotting disorders in our study (28%) was higher than that in the general population (8.4%). Coagulation disorders should be considered in some cases of ischemic colitis that are thought to be idiopathic.

Effectiveness of screening and treatment for depression in ambulatory indigent patients.

OBJECTIVE: To determine the effectiveness of screening and treatment for depression among ambulatory indigent patients visiting resident physicians. DESIGN: Two-group randomized trial (N = 33 intervention, N = 28 usual care) with baseline, 6-month, and 12-month outcome measurements. SETTING: Internal Medicine Residency Clinic. PATIENTS: Clinic patients over 18 years of age who screened positive for depression on the PRIME-MD during a visit to their resident physician. Patients were not receiving treatment nor seeking care for any emotional problems. All patients were either enrolled in Medicaid or had income below the poverty line. INTERVENTION: Resident physicians were educated to follow AHCPR (AHRQ; Agency for Healthcare Research and Quality) guidelines for diagnosis and treatment of depression in a primary care setting. For the intervention group patients, a screening nurse advised residents regarding the positive screen, handed them a standardized protocol outline, and attempted to arrange behavioral care. The patients in the usual care group were provided the results of the screen by the screening nurse before their visit with the resident, and advised to seek care for their symptoms. MAIN RESULTS: Results for the primary outcome of depression symptoms measured with the Beck Depression Inventory (BDI) demonstrated that intervention was successful in reducing symptoms relative to usual care (difference = -4.9 BDI points, P =.05, 95% confidence interval [CI], -9.8 to -0.005 effect size = -0.41). During the 12-month follow-up, 70% of intervention patients were treated for depression (of these, 91% with antidepressants), while 15% of usual care patients were treated with antidepressants for depression. Another 18% of the usual care group had depression noted, but no treatment was identified. BDI differences between intervention and control groups were similar at the 6- and 12-month measures. Quality of life and costs were also measured, but differences between the groups were not significant in this regard. CONCLUSION: Screening and treatment for depression by resident physicians was successful in reducing symptoms relative to usual care in an indigent population. Almost twice as many intervention patients as usual care controls demonstrated a substantial reduction (10 BDI points) in symptoms related to depression.

One-day quadruple therapy compared with 7-day triple therapy for Helicobacter pylori infection.

BACKGROUND: Eradication of Helicobacter pylori infection has had an impact on the treatment and recurrence rates of peptic ulcer disease and malignancies such as mucosa-associated lymphoid tissue lymphoma. Treatment options are cumbersome, expensive, and associated with side effects. METHODS: Randomized, prospective, open-labeled equivalence trial with a parallel-group design to compare eradication rates of H pylori with a 1-day, 4-drug regimen with a 7-day, 3-drug regimen. A total of 160 patients with dyspepsia and a Glasgow Dyspepsia Severity Score of at least 3 had a urea breath test labeled with carbon 14. Patients who tested positive were randomized to 1 of the 2 study groups. The study was designed to test the therapeutic equivalence of 1-day and 7-day regimens based on the percentage of H pylori eradication in each group at 5 weeks. RESULTS: The 1-day treatment group (n = 80) had a slightly higher eradication percentage (95%) than the 7-day group (90%). The possible inferiority of the 1-day treatment relative to the 7-day treatment, a 15% difference in the number of patients whose infection was not eradicated at 5 weeks, was rejected (P<.001; 90% confidence interval, 2.7%-11%). Both groups demonstrated a mean decrease of 7.5 points in the Glasgow Dyspepsia Severity Score. The 2 groups showed no significant differences in side effects. Patients whose treatment failed (4 in the 1-day treatment group and 7 in the 7-day treatment group) were re-treated for 10 days. One patient from the 7-day treatment group still tested positive after the second treatment. CONCLUSIONS: The 1-day treatment proved to be statistically similar to the 7-day treatment for the eradication of H pylori in patients with dyspepsia and a positive urea breath test. Further evaluation will be necessary to determine whether the 1-day regimen is adequate for patients with peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, or gastric adenocarcinoma.

Effectiveness of a group exercise program in a long-term care facility: a randomized pilot trial.

OBJECTIVE: The purpose of this pilot was to determine whether a strength and flexibility program in frail long-term care facility (LTC) residents would result in improved function. DESIGN: A prospective, randomized, controlled, semicrossover trial was designed with participants assigned either to group exercise (EX) or recreational therapy (C). In the EX group, the intervention continued for 1 year. In the C group, recreation continued for 6 months; these controls were then crossed over to the same exercise intervention as the EX group and followed for an additional 6 months. Functional outcomes were measured at baseline and 3, 6, 9, and 12 months for both groups. SETTING: A LTC facility, which included both assisted living (AL) and nursing home (NH) residents. PARTICIPANTS: Twenty frail residents (5 from NH, 15 from AL) aged 75 to 99 years at one LTC facility. INTERVENTION: After random group assignment, the EX group met 1 hour three times per week. An exercise physiologist and LTC staff conducted sessions which included seated range of motion (ROM) exercises and strength training using simple equipment such as elastic resistance bands (therabands) and soft weights. The C group met three times per week and participated in activities such as painting during the first 6 months, before crossing over to exercise. MEASUREMENTS AND METHODS: Objective measures of physical and cognitive function were obtained at baseline and 3, 6, 9, and 12 months using the timed get-up-and-go test (TUG), Berg balance scale, physical performance test (PPT), and mini-mental status exam (MMSE). Because we were interested in the impact of exercise on multiple endpoints and to protect the type I error rate, a global hypothesis test was used. RESULTS: There was a significant overall impact across the four measures of the exercise intervention (P = 0.013). Exercise benefit as indicated by the difference between exercise and control conditions showed exercise decreased TUG by 18 seconds, which represents an effect size (in standard deviation units) of 0.50, increased PPT scores by 1.3, with effect size = 0.40, increased Berg scores by 4.8, with effect size of 0.32, and increased MMSE by 3.1, with effect size = 0.54. Except for the Berg, 90% confidence intervals on these exercise effects excluded 0. CONCLUSION: Frail elderly in a LTC facility were able to participate and benefit from a strength training program. The program was delivered with low-cost equipment by an exercise physiologist and LTC staff. The advantage of such a program is that it provides recreational and therapeutic benefits.