Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data.

BACKGROUND: Simple endoscopic retrograde cholangiopancreatography (ERCP) outcome measures such as success and complication rates may not allow direct comparisons among endoscopists or centers because procedure degree of difficulty can vary tremendously from case to case. We propose a new grading scale designed to objectively quantify ERCP degree of difficulty. METHODS: A 1 to 5 scale was devised to grade ERCPs according to their level of technical difficulty. A retrospective pilot study was performed to assess ERCP outcomes at our institution according to difficulty grade. The scale was then prospectively applied to all ERCPs during a 1-year period. RESULTS: In the pilot study, 209 of 231 (90%) ERCPs were technically successful, and 8 (3%) were followed by complications. Grade 1 to 4 procedures were more likely to succeed (94% vs. 74%, p< 0.05) and less likely to have associated complications (2% vs. 10%, p< 0.05) than grade 5/5B ERCPs. Of 187 ERCPs assessed prospectively, 166 (89%) were successful and 10 (5%) were followed by complications; 132 of 138 (96%) grade 1 to 4 procedures succeeded compared with 30 of 46 grade 5 to 5B ERCPs (65%, p<0.001), but complications were not significantly more frequent in grade 5 to 5B ERCPs (8.7% vs. 4.3%, p = not significant). CONCLUSIONS: Technical success was dependent on ERCP degree of difficulty, but complications were not. Outcome data that incorporate degree of difficulty information may be more meaningful, allowing endoscopist-to-endoscopist and center-to-center comparisons.

The effects of meal composition on subsequent craving and binge eating.

This study investigated the effects of meals differing in macronutrient composition on subsequent food craving, bingeing, nutrient intake, and mood. Nine women who had prospectively demonstrated episodes of craving received one each of a high-protein, high-carbohydrate, and mixed meal on three separate days. Appetite and mood ratings were taken before and at four intervals up to 150 min after meal consumption. Subsequent ad libitum food intake was recorded in diaries. Premeal hunger, appetite and mood ratings were similar across meal type. After the protein-rich meal, craving for sweet, carbohydrate-rich foods was significantly higher than after the carbohydrate and mixed meals. Elevated negative mood state after the protein-rich meal and reduced vigor after the carbohydrate meal were not statistically significant. The first ad libitum eating episodes after the protein meal contained significantly higher absolute and proportional amounts of total carbohydrate and sucrose and were more likely to be categorized as a binge than were those after the carbohydrate and mixed meals. Those ad libitum eating episodes classified as a craving/binge were characterized by a higher energy and absolute carbohydrate, fat, and sucrose content. Evidence of macronutrient compensation after a protein-rich meal suggests that carbohydrate intake regulation may exist in certain individuals. Possibly via the effects of sensory-specific satiety, serotonergic function, or cognitive factors, a protein-rich meal may induce craving for sweet-tasting, palatable foods in susceptible individuals.

Urinary catecholamines and plasma hormones predict mood state in rapid cycling bipolar affective disorder.

Over the course of 1 year, a patient with a rapid cycling bipolar affective disorder was followed at weekly intervals to examine whether plasma hormones and urinary catecholamines could predict current or future mood. Higher cortisol levels were found to predict depressed mood 3 days after blood sampling, higher urinary dopamine predicted a manic mood 3 days after blood sampling, urinary norepinephrine was associated with severity of current mood and prolactin was lower with concurrent depressed mood. In multivariate analyses of mood against cortisol, prolactin and three urinary catecholamines, > 50% of the variance in mood state in 3 days was explained by combinations of these biologic measures, especially cortisol and urinary dopamine, while all five biologic variables contributed to explaining 50% of the variance in current mood state. Based on the interrelationships between urinary dopamine, norepinephrine and mood, we postulate the existence of an overcompensating mechanism which is reflected in opposing correlations between urinary dopamine and norepinephrine with mood, despite the two urinary catecholamines being positively correlated.

Endocrine and behavioral responses to methylphenidate in normal subjects.

Methylphenidate (0.3 mg/kg) was administered intravenously to 20 normal subjects. Behavioral responses varied considerably among individuals. Both cortisol and growth hormone showed significant increases (p less than 0.001). The adrenocorticotrophic hormone (ACTH) response seemed insufficient to explain the increase in cortisol. For men only, the increase in cortisol correlated positively with the increase in epinephrine (r = 0.77, p less than 0.05) and correlated negatively with baseline cortisol (r = -0.70, p less than 0.05), with increase in growth hormone (r = -0.70, p less than 0.05), and with the increase in "energy" (r = -0.83, p less than 0.01). The growth hormone response varied between the sexes, and for men, the growth hormone correlated with both an increase in "energy" (r = 0.70, p less than 0.05) and "friendliness" (r = 0.68, p less than 0.05). For all subjects, baseline heart rate correlated with the increase in "energy" (r = -0.69, p less than 0.002). In a separate study, six male subjects received, on different occasions, saline and a lower dose of methylphenidate. Together, these studies show that the increases in cortisol, growth hormone, and epinephrine, and the decrease in prolactin are dose-dependent.

Endocrine and behavioural responses to methylphenidate in depression.

Twenty patients with a major depressive disorder and 20 control subjects were subjected to a 1 mg dexamethasone suppression test (DST) and a challenge with intravenous (IV) methylphenidate (MP)(0.3 mg/kg). None of the controls, but 9 depressives, were DST non-suppressors. Among the depressives there were correlations between DST-cortisol and baseline (4 p.m.) levels of cortisol, growth hormone, prolactin and adrenaline. Compared with the controls the depressives had a decreased cortisol response and an enhanced adrenaline response to the MP challenge. The decreased cortisol response was not related to either DST-cortisol or baseline cortisol, but was correlated with the mood response to MP.

Overwhelming pneumococcal septicaemia in a patient with ulcerative colitis and splenic atrophy.

This report describes a young woman with ulcerative colitis who developed rapidly fatal pneumococcal septicaemia. Necropsy revealed splenic atrophy. This case supports the hypothesis that splenic atrophy might contribute to the morbidity of ulcerative colitis. The occurrence of splenic atrophy in ulcerative colitis is now well established. Splenic atrophy from other causes has been associated with severe bacterial infections, often pneumococcal. It has been suggested that splenic atrophy is most severe when ulcerative colitis is active and may contribute to postoperative morbidity. This case documents overwhelming septicaemia in a patient with splenic atrophy whose colitis was in remission.