A retrospective study of the Framingham cardiovascular risk scores in a liver transplant population.

OBJECTIVE: Evaluate the relationship between Framingham cardiovascular risk scores (FRS) and transplant-related factors, particularly renal function, in a stable liver transplant population. METHODS: Single-center retrospective study of 54 post-liver transplant patients followed in one outpatient clinic. Demographics and laboratory data were assessed using the modified FRS (2009). Standard statistical analyses were performed between FRS and transplant-related factors; patient demographics, new-onset diabetes after transplant (NODAT), immunosuppressives, and estimated glomerular filtration rate (eGFR) measured by isotope dilution mass spectrometry (IDMS) and Cockcroft-Gault (CG) equations. RESULTS: Forty percent of patients were classified as low FRS, 29.6% as moderate FRS, and 29.6% as high FRS (of whom 50% had NODAT). Immunosuppressant use was similar between the high- and low-risk groups. FRS inversely correlated with eGFR (P = .0001) measured by either equation. eGFR measured by IDMS in the high-risk group (60.4 ± 22.1 mL/min/1.73 m(2)) was significantly lower than that in the low-risk group (97.1 ± 54 mL/min/1.73 m(2); P = .0001). In the multivariate analysis, age, eGFR and NODAT were significantly different between the low- and high-risk FRS groups. Receiving operational characteristic (ROC) analysis identified eGFR measured by IDMS at 42.7 mL/min/1.73 m(2) with a sensitivity of 92%, specificity of 19%, and positive predictive value of 72% to identify high-risk patients. Box-plot analysis of variance between eGFRs in the three risk groups showed a P value of .001. CONCLUSIONS: In this study one-third of liver transplant patients had a high FRS, and 14.8% had an eGFR below 40 mL/min/1.73 m(2). Low eGFR predicts those with high FRS. Liver transplant patients particularly those with NODAT, with low eGFR should undergo close management of cardiovascular risk factors.

The Second Canadian Consensus Conference on the Management of Patients with Gastroesophageal Reflux Disease.

The Second Canadian Consensus Conference on the Management of Patients with Gastroesophageal Reflux Disease (GERD) was organized by the Canadian Association of Gastroenterology to address major advances in the understanding of the pathophysiology of GERD, to review the new methods of investigation and therapy introduced since the first conference in 1992 and to examine the issue of relevant health economics. The changes that have taken place over the past four years have been sufficiently dramatic to necessitate reassessment of the recommendations made following the first conference. The second conference dealt with the investigation and treatment of uncomplicated GERD and the complex issues of esophageal and extraesophageal complications such as chest pain, Barrett's esophagus, and reflux-related pulmonary and laryngeal disorders. The role of laparoscopic surgery was also discussed. A decision tree for investigation and treatment of patients with GERD was developed. The 38 participants represented a broad spectrum of experience, location of practice and special interests. The distribution of participants conformed to the recommendations of the Canadian Medical Association guidelines for consensus documents in that there should be input from all possible interested parties. A list of the state-of-the-art lectures presented during the conference, the small group sessions, the session chairpersons and participants are appended to this document. CONCLUSIONS. UNCOMPLICATED GERD: GERD with alarm symptoms must be investigated immediately. There was no consensus about when to investigate uncomplicated GERD, ie, whether to perform endoscopy immediately or after initial therapy fails. There was controversy regarding 'step up' (H2 receptor antagonist [H2RA] or prokinetic [PK] first therapy) versus 'step down' therapy (proton pump inhibitor [PPI] first therapy). The majority decision was for short term 'step up' therapy and investigation if symptoms do not improve or recur. Maintenance therapy should be carried out with the initial therapy that was effective. H2RAs and PKs may suffice for maintenance therapy in milder GERD; however, for severe esophagitis, PPIs should be used. SURGERY: Indications for laparoscopic surgery should be the same as for conventional antireflux operations. NONCARDIAC ANGINA-LIKE CHEST PAIN: After exclusion of nonesophageal causes, the majority decided that eight weeks of therapy with a PPI should be performed, while some suggested work-up before a therapeutic test. In the absence of response or recurrence, esophagogastroduodenoscopy (EGD) and, depending on the circumstances, 24 h ambulatory pH/motility may be indicated. BARRETT'S ESOPHAGUS: Only patients who, in case of future discovery of cancer or dysplasia, are able or willing to undergo therapy should have surveillance. In the absence of dysplasia EGD should be performed every two years, and in the presence of mild dysplasia every three to six months. All agreed that for severe dysplasia, esophagectomy or poor risk patients, esophageal mucosal ablation is indicated. ESTRAESOPHAGEAL COMPLICATONS (EECs): Asthma, chronic cough and posterior laryngitis were considered EECs. Although PPIs may decrease symptoms, improvement alone is not diagnostic of the presence of EEC. Ambulatory pH studies with two pH probes or ambulatory pH/motility may be useful in establishing causation. HEALTH ECONOMICS: There are limited data for an economic comparison among the different drugs or between medical and surgical therapy.

Is the Mayo model for predicting survival useful after the introduction of ursodeoxycholic acid treatment for primary biliary cirrhosis?

Treatment of patients with primary biliary cirrhosis (PBC) using ursodeoxycholic acid (UDCA) leads to a reduction in serum bilirubin. The first objective of this study was to assess the performance of certain prognostic indicators for PBC after the introduction of treatment with UDCA. Serum bilirubin is an important prognostic indicator for PBC and an important component of the Mayo model for grading patients into risk categories. In an analysis of patients enrolled in the Canadian multicenter trial, the Mayo score was calculated before and after treatment with UDCA. After treatment, the Mayo score continued to divide patients with PBC into groups with varying risk. In addition, the serum bilirubin alone was shown to do the same even after the introduction of treatment with UDCA. A second objective was to establish whether UDCA had an effect on long-term (2- to 6-year) survival in patients with PBC.

Acute hereditary coproporphyria induced by the androgenic/anabolic steroid methandrostenolone (Dianabol).

Acute attacks of porphyria can be induced by certain drugs. We report a case of acute coproporphyria induced by methandrostenolone. This is the first report of acute porphyria induced by an androgenic, anabolic steroid.

The effect of ursodeoxycholic acid therapy on gallstone formation in the morbidly obese during rapid weight loss.

UNLABELLED: Obesity is a significant risk factor for cholesterol gallstone formation, particularly when patients are morbidly obese and rapidly losing weight. Our objective, in a double-blind, placebo-driven trial of ursodeoxycholic acid, was to study the prevention of gallstone development in 29 morbidly obese subjects after bariatric surgery. These subjects included 20 women and nine men, ages 43 +/- 7.3 yr, weight 142.5 +/- 31 kg (mean +/- SD), representing 224% +/- 28.2% of their ideal body weight. Gallbladders were free of stones according to preoperative ultrasound and palpation at surgery. Microscopy of aspirated gallbladder bile revealed cholesterol crystals present in only one patient. After recovery from vertical-band gastroplasty, 13 patients received ursodeoxycholic acid 1000 mg/day. Ten patients completed the 3-month study: two were noncompliant, one experienced heartburn. Fourteen of 16 subjects on matching placebo also were compliant; two were not. There were no differences in clinical characteristics or bile composition between these two groups on entry into the study. The cholesterol saturation index in these obese patients at 1.62 +/- 0.46 was definitely supersaturated, and higher than that in 10 non-obese patients without stones (0.96 +/- 0.29) or 10 with pigment stones (1.01 +/- 0.28) (p < 0.05). At 3 months, the two obese groups had similar weight loss (17% of preoperative weight) and had repeat ultrasounds. Six of the 14 placebo-treated patients (43%) developed gallstones: two became symptomatic, requiring cholecystectomy. There was no correlation between the risk of developing gallstones and pretreatment bile composition or the degree of weight loss. None of 10 patients or ursodeoxycholic acid formed gallstones. CONCLUSIONS: Morbid obesity is associated with gallbladder bile supersaturated with cholesterol. A high percentage will develop gallstones following gastroplasty. This can be prevented by ursodeoxycholic acid therapy.

Effect of moderate exercise on esophageal function in asymptomatic athletes.

It has been thought that upper intestinal symptoms of heartburn, regurgitation, belching, and chest pain experienced during exercise may represent esophageal dysfunction. The aim of this study is to examine esophageal function during moderate exercise in asymptomatic healthy athletes. Six healthy male athletes were exercised for 2 h on a treadmill set at a workload of 50% of their maximum oxygen uptake. Esophageal motility studies were performed immediately before, immediately after, and 1 h after the exercise. The mean lower esophageal sphincter pressure increased from a base line of 24 to 32 mm Hg immediately postexercise (p less than .01), reducing to 27 mm Hg after 1 hour rest. The mean amplitude and duration of esophageal peristalsis remained unchanged throughout the study. The significance of the lower esophageal sphincter pressure increase with moderate exercise is unknown but may relate to the observed exercise-induced increase in serum motilin, gastrin, and catecholamines.

Gastrointestinal symptoms during exercise in Enduro athletes: prevalence and speculations on the aetiology.

A study of the prevalence of gastrointestinal symptoms during exercise was carried out on athletes who participated in the recent Enduro event in Dunedin. Of 119 competitors, 70 (59%) responded to our questionnaire and demonstrated a prevalence of gastrointestinal symptoms of 81%. Upper gastrointestinal symptoms were noticed in 58% with lower gastrointestinal symptoms, tending to be more severe and significant to the athlete, noticed in 61%. Speculations on the aetiology of these symptoms are included. The demonstrated high prevalence of symptoms during exercise and the relative lack of knowledge in this area provides a fertile ground for further objective research.

Hemobilia after percutaneous liver biopsy: role of endoscopic retrograde cholangiopancreatography and sphincterotomy.

Hemobilia is a rare complication of percutaneous liver biopsy. We present such a case that demonstrates the usefulness of endoscopic retrograde cholangiopancreatography in establishing the diagnosis, the importance of localization of the bleeding site by angiography, and the therapeutic usefulness of arterial embolization for the control of persistent bleeding. Also, we propose a possible indication for endoscopic sphincterotomy in the rare case where retained intrabiliary blood clot causes progressive obstructive jaundice complicated by severe pain and sepsis.

Effect of Morphine and butorphanol on gallbladder emptying.

In the search for the most appropriate analgesic for patients with biliary tract and pancreatic pain, the authors compared the effect of morphine and the opiate agonist-antagonist butorphanol on gallbladder contraction and emptying stimulated by cholecystokinin octapeptide. Morphine markedly inhibited gallbladder emptying while butorphanol only slightly delayed it. Compared with morphine, the effect of butorphanol was minimal; the latter, therefore, seems to be a suitable analgesic for the treatment of pain of biliary tract or pancreatic origin.