A double-blind placebo controlled trial of oral midazolam as premedication before flexible sigmoidoscopy.

OBJECTIVE: We aimed to determine the efficacy of oral midazolam as premedication to improve tolerance of flexible sigmoidoscopy. METHODS: Ninety-nine patients were randomized to receive 7.5 mg of oral midazolam solution mixed with apple juice or placebo (apple juice), 20 min before sigmoidoscopy. Patients' anxiety and pain experienced before sedation, before the procedure, and during the procedure were assessed using a 10-cm visual analog scale (VAS) by both patients and physicians (0 = no pain, anxiety, 10 = severe pain, anxiety). Extent of sedation, amnesia, overall tolerance, adequacy of sedation, and willingness to repeat the procedure were assessed, and changes in vital signs and oximetries were recorded. RESULTS: Fifty-one patients received midazolam and 48 patients received placebo. Patients reported less pain and anxiety (VAS 2.56, 1.64) compared with placebo (VAS 4.62, 4.16) during the procedure (p < 0.005, p < 0.0005). Physicians observed less pain and anxiety (VAS 2.19, 1.52) with midazolam than placebo (VAS 5.00, 3.97) during the procedure (p < 0.0001, p < 0.0001). A significantly greater number of patients judged tolerance of the procedure to be "excellent" using midazolam (p < 0.005) compared with placebo. A majority of patients in both groups was willing to repeat the procedure if recommended. Two patients in the midazolam group had transient asymptomatic hypotension during sigmoidoscopy, but no patients were observed to have desaturation by oximetry. CONCLUSIONS: Oral midazolam significantly reduces anxiety and pain during flexible sigmoidoscopy as assessed by both patients and physicians. Oral midazolam is a safe and effective premedication before flexible sigmoidoscopy in patients who require or prefer sedation.

Both massive upper and lower gastrointestinal hemorrhage secondary to tuberculosis.

We report a case of gastrointestinal tuberculosis, presenting with both massive upper and lower gastrointestinal bleeding that required two emergency operations. Massive bleeding is rare in gastrointestinal tuberculosis because of associated obliterative endarteritis. Tuberculosis should be considered in the differential diagnosis of massive gastrointestinal bleeding in the appropriate clinical setting even in an immunocompetent patient.

Troglitazone-induced hepatic failure leading to liver transplantation. A case report.

BACKGROUND: Troglitazone is a new drug for the treatment of type 2 diabetes. Although mild liver injury occurred in 1.9% of participants in controlled trials, the U.S. Food and Drug Administration has received reports of five postmarketing cases of severe liver disease that resulted in death or liver transplantation. OBJECTIVE: To report the clinical and histopathologic characteristics of a patient with troglitazone-associated severe liver injury leading to transplantation. DESIGN: Case report. SETTING: Two university hospitals. PATIENT: A 55-year-old woman taking troglitazone, 400 mg/d, and insulin, 120 U/d. INTERVENTION: Discontinuation of troglitazone therapy, pretransplantation liver biopsy, and liver transplantation. RESULTS: Early nonspecific symptoms were attributed to other causes and were not evaluated. After the patient had used troglitazone for 3.5 months, massive loss of liver parenchyma and symptoms of liver failure developed, necessitating liver transplantation. CONCLUSION: Troglitazone may cause subfulminant liver failure.