Ulcerative Colitis: Rapid Evidence Review.

Ulcerative colitis is a relapsing and remitting inflammatory bowel disease of the large intestine. Risk factors include recent Salmonella or Campylobacter infection and a family history of ulcerative colitis. Diagnosis is suspected based on symptoms of urgency, tenesmus, and hematochezia and is confirmed with endoscopic findings of continuous inflammation from the rectum to more proximal colon, depending on the extent of disease. Fecal calprotectin may be used to assess disease activity and relapse. Medications available to treat the inflammation include 5-aminosalicylic acid, corticosteroids, tumor necrosis factor-alpha antibodies, anti-integrin antibodies, anti-interleukin-12 and -23 antibodies, and Janus kinase inhibitors. Choice of medication and method of delivery depend on the location and severity of mucosal inflammation. Other treatments such as fecal microbiota transplantation are considered experimental, and complementary therapies such as probiotics and curcumin have mixed data. Surgical treatment may be needed for fulminant or refractory disease. Increased risk of colorectal cancer and use of immunosuppressive therapies affect the preventive care needs for these patients.

A novel quantitative approach to the measurement of abdominal aortic calcification as applied to the Canadian Multicenter Osteoporosis Study (CaMOS).

BACKGROUND AND AIMS: Lateral spine radiographs provide an inexpensive resource for characterizing abdominal aortic calcification (AAC). A widely accepted measurement of AAC is the semi-quantitative technique generated by the Framingham Heart Study (F-AAC-24). We sought to develop an analytical method to quantify ACC (QAAC) on lateral spine radiographs and compare the finding to conventional subjective measurements. METHODS: Severity of AAC was quantified by measuring pixel intensities in the user-defined region of the aorta with internal standardization to the vertebral endplates and background calibration to the density of the vertebral body. The association between bone mineral density (BMD) measured by dual energy X-ray absorptiometry (DXA) and AAC measured by QAAC, F-AAC-24 and a modified Framingham score (F-AAC-12) was determined in 110 participants of the Canadian Multicenter Osteoporosis Study (CaMOS). RESULTS: The inter-observer reliability for the QAAC was slightly higher than with the visual and semi-quantitative Framingham method and the pseudo-colored images illustrate the potential to meaningfully resolve severity of calcification. There was a significant negative association between QAAC and BMD measures of the hip and spine. This association remained significant after adjustment for age, sex, estimated glomerular filtration rate, phosphate and hypertension. Significant predictors of F-ACC-12 and 24 included age and hypertension. CONCLUSIONS: The QAAC is a reproducible approach to measuring AAC. Whether it is capable of monitoring subtle calcific changes over time requires further study. This technique could be applied to large studies that seek to determine the impact of interventions that modify bone density as a treatment for vascular calcification and cardiovascular disease in the general population.

Sudden infant death syndrome.

Sudden infant death syndrome (SIDS) is the sudden unexpected death of a child younger than one year during sleep that cannot be explained after a postmortem evaluation including autopsy, a thorough history, and scene evaluation. The incidence of SIDS has decreased more than 50% in the past 20 years, largely as a result of the Back to Sleep campaign. The most important risk factors relate to the sleep environment. Prone and side sleeping positions are significantly more dangerous than the supine position. Bed sharing with a parent is strongly correlated with an increased risk of SIDS, especially in infants younger than 12 weeks. Apparent life-threatening events are not a risk factor for SIDS. Parents should place infants on their backs to sleep, should not share a bed, and should avoid exposing the infant to tobacco smoke. Other risk-reducing measures include using a firm crib mattress, breastfeeding, keeping vaccinations up to date, avoiding overheating due to overbundling, avoiding soft bedding, and considering the use of a pacifier during sleep once breastfeeding is established. One consequence of the Back to Sleep campaign is a significant increase in the incidence of occipital flattening. Infants who develop a flat spot should be placed with the head facing alternating directions each time he or she is put to bed. Supervised prone positioning while the infant is awake, avoiding excessive use of carriers, and upright positioning while awake are also recommended.

Ulcerative colitis.

Ulcerative colitis is a chronic inflammatory disease of the colon. The etiology is unknown. Risk factors include a history of recent infection with Salmonella or Campylobacter, living in Western industrialized nations and at higher latitudes, and a family history of the disease. The incidence peaks in early adulthood, but patients can develop the disorder from early childhood through adulthood. Ulcerative colitis often presents with abdominal pain, diarrhea, and hematochezia. It is important to exclude infectious etiologies. Anemia and an elevated erythrocyte sedimentation rate or C-reactive protein level may suggest inflammatory bowel disease, but the absence of laboratory abnormalities does not rule out ulcerative colitis. The diagnosis is suspected clinically and confirmed through endoscopic biopsy. First-line treatment is therapy with 5-aminosalicylic acid. Corticosteroids may be added if 5-aminosalicylic acid therapy is ineffective. Infliximab can be added to induce and sustain remission. Patients with severe or nonresponsive ulcerative colitis should be hospitalized, and intravenous corticosteroids should be given. If medical management has been ineffective, surgical intervention is indicated for severe disease. Patients with ulcerative colitis have an increased risk of colon cancer and should have periodic colonoscopy beginning eight to 10 years after diagnosis.

Impact of hypertension, aging, and antihypertensive treatment on the morphology of the pudendal artery.

INTRODUCTION: Aging and hypertension increase the risk of erectile dysfunction (ED) and cardiovascular disease. Arterial insufficiency is likely a primary factor in hypertension-related ED. Given the dominance of internal pudendal arteries in controlling penile vascular resistance, pathological changes in this vessel would be critical for inducing ED in aged hypertensives. AIM: We assessed the age-related impact of hypertension and its treatment on erectile function and pudendal artery structure in young and old spontaneously hypertensive rats (SHRs). METHODS: Erectile responses were monitored in 15- and 77-week-old SHR and Wistar Kyoto (WKY) rats using apomorphine (80 mg/kg). At sacrifice, the vasculature was perfusion-fixed and aorta, renal, mesenteric, and internal pudendal arteries assessed morphometrically using light and electron microscopy. A separate group of 15-week SHR were treated with enalapril and hydrochlorothiazide (30 mg/kg/day, 2 weeks) followed by 2 weeks off treatment, after which the same vessels were assessed morphometrically. Arterial pressures were determined using radiotelemetry. MAIN OUTCOMES MEASURED: Erectile function, vessel morphology (lumen diameter, wall thickness, cross-sectional area, extracellular matrix [ECM]) and arterial pressure. RESULTS: Erectile responses were similar in young SHR and WKY (1.7 ± 0.80 vs. 1.4 ± 0.85) but declined significantly in aged SHR (0.3 ± 0.49). Vascular aging in SHR was associated with striking pudendal remodeling, characterized by marked neointimal proliferation and disruptions of the internal elastic lamina. This remodeling involved thickening of the medial layer (35 ± 6.0 µm vs. 81 ± 3.5 µm, P < 0.01), decreased lumen diameter (282 ± 6.3 µm vs. 250 ± 12.4 µm, P < 0.05) and increased ECM (10 ± 2.0 µm² vs. 26 ± 10.6 µm², P < 0.001). In old pudendals, there were significantly more round synthetic smooth muscle cells bordering the intima and in the neointima. Antihypertensive treatment decreased the wall:lumen ratio in young SHR pudendal arteries (-17%). CONCLUSIONS: Vascular aging in SHR with ED involved distinctive pathogenic remodeling in the internal pudendal artery. In young SHR, brief antihypertensive therapy was able to regress this abnormal morphology.

Morphological and functional evidence for the contribution of the pudendal artery in aging-induced erectile dysfunction.

INTRODUCTION: Aging increases the risk of both erectile dysfunction (ED) and cardiovascular disease. These conditions have similar etiologies and commonly coexist. One unifying concept is the role of arterial insufficiency which is a primary factor in the onset of age-related ED. AIM: Based on the novel finding that the pudendal arteries contribute 70% of the total penile vascular resistance, our objective was to morphometrically and functionally characterize this vessel in young and old normotensive rats. METHODS: Erectile function was monitored in 15- and 77-week Sprague-Dawley rats using the apomorphine bioassay (80mg/kg, s.c.). Anesthetized animals were perfusion-fixed, aortic, renal, and internal pudendal arteries were excised, embedded, sectioned, stained, and morphometrically assessed using light microscopy. Hearts were excised, separated, and weighed prior to perfusion. Contractile and relaxation responses to acetylcholine (ACh) and phenylephrine (PE) were assessed by wire myograph. MAIN OUTCOME MEASURES: Erectile function, morphological measurements, concentration response curves to ACh and PE. RESULTS: With age, there were marked decreases in erectile responses compared to younger rats (2.8±0.87 vs. 0.3±0.58). The pudendal arteries had a relatively small lumen (303±13.8µm) and a thick medial layer (47±2.2µm). In aged pudendal arteries, the lumen diameter did not change, and yet the medial layer, cross sectional area, and extracellular matrix were markedly increased. In contrast, the lumen diameter and wall thickness of the aorta and renal arteries in aged rats increased proportionally. An increase in small, round, smooth muscle cells was seen in aged pudendal arteries. Functionally, there were no differences in contractile responses to PE; however, ACh-induced relaxation decreased with age. CONCLUSIONS: In aged rats, erectile function was severely diminished when pudendal arteries had undergone marked phenotypic changes. Specifically, there was endothelial dysfunction and pathological remodeling of this vessel with age, characterized by medial thickening, impaired vasodilation and significantly reduced capacity for penile blood flow.

Urine drug screening: a valuable office procedure.

Urine drug screening can enhance workplace safety, monitor medication compliance, and detect drug abuse. Ordering and interpreting these tests requires an understanding of testing modalities, detection times for specific drugs, and common explanations for false-positive and false-negative results. Employment screening, federal regulations, unusual patient behavior, and risk patterns may prompt urine drug screening. Compliance testing may be necessary for patients taking controlled substances. Standard immunoassay testing is fast, inexpensive, and the preferred initial test for urine drug screening. This method reliably detects morphine, codeine, and heroin; however, it often does not detect other opioids such as hydrocodone, oxycodone, methadone, fentanyl, buprenorphine, and tramadol. Unexpected positive test results should be confirmed with gas chromatography/mass spectrometry or high-performance liquid chromatography. A positive test result reflects use of the drug within the previous one to three days, although marijuana can be detected in the system for a longer period of time. Careful attention to urine collection methods can identify some attempts by patients to produce false-negative test results.

Sudden infant death syndrome.

Sudden infant death syndrome is the leading cause of death among healthy infants, affecting 0.57 per 1,000 live births. The most easily modifiable risk factor for sudden infant death syndrome is sleeping position. To reduce the risk of sudden infant death syndrome, parents should be advised to place infants on their backs to sleep and avoid exposing the infant to cigarette smoke. Other recommendations include use of a firm sleeping surface and avoidance of sleeping with soft objects, bed sharing, and overheating the infant. Pacifier use appears to decrease the risk of sudden infant death syndrome, but should be avoided until one month of age in infants who are breastfed. The occurrence of apparent life-threatening events does not increase the risk of sudden infant death syndrome, and home apnea monitoring does not lower the risk of sudden infant death syndrome. Supine sleeping position has increased the incidence of flattening of the occiput (deformational plagiocephaly), but this condition can be prevented and treated by encouraging supervised "tummy time," meaning that when awake, infants should spend as much time as possible on their stomachs. All apparent deaths from sudden infant death syndrome should be carefully investigated to exclude other causes of death, including child abuse. Families who have an infant die from sudden infant death syndrome should be offered emotional support and grief counseling.

Pharmacologic management of adult depression.

Major depression is a common and treatable disease. Many patients benefit from pharmacologic treatment and, because there is little variation in antidepressant effectiveness, medication choices should be made based on patient characteristics, safety, and anticipated side effects. Most patients respond favorably to treatment, but many do not have complete symptom relief. Changing medications or augmenting with a second medication is helpful for some partial or nonresponders. All antidepressants are capable of producing harmful side effects, and some are particularly prone to dangerous drug-drug interactions. The risk of suicide is always a concern in depression and this risk is not necessarily reduced by the use of antidepressants. Some persons may have an increase in suicidal thoughts with antidepressant treatment. Close follow-up is required when initiating therapy and adjusting dosages.

Evaluation of a first seizure.

Seizure is a common presentation in the emergency care setting, and new-onset epilepsy is the most common cause of unprovoked seizures. The patient history and physical examination should direct the type and timing of laboratory and imaging studies. No single sign, symptom, or test dearly differentiates a seizure from a nonseizure event (e.g., syncope, pseudoseizure). Electroencephalography is recommended for patients presenting with a first seizure, and neuroimaging is recommended for adults. Neuroimaging also should be performed in children with risk factors such as head trauma, focal neurologic deficits, or a history of malignancy. Magnetic resonance imaging is preferred over computed tomography except when acute intracranial bleeding is suspected. The most common laboratory findings associated with a seizure are abnormal sodium and glucose levels. Patients with a normal neurologic examination, normal test results, and no structural brain disease do not require hospitalization or antiepileptic medications. Treatment with antiepileptic medications reduces the one- to two-year risk of recurrent seizures but does not reduce the long-term risk of recurrence and does not affect remission rates. Regardless of etiology, a seizure diagnosis severely limits a patient's driving privileges, although laws vary by state.

What should we eat? Evidence from observational studies.

Observational studies provide a wealth of important correlations between diet and disease. There is a clear pattern of dietary habits that is associated with reduced rates of a multitude of common illnesses, including heart attack, cancer, stroke, diabetes, and hypertension. In some cases, interventional studies have proven the benefits of dietary change; in others, there is insufficient evidence to prove causation. Based on the existing evidence, the optimal diet should emphasize fruits and vegetables, nuts, unsaturated oils, whole grains, and fish, while minimizing saturated fats (especially trans fats), sodium, and red meats. Its overall calorie content should be low enough to maintain a healthy weight.

Antidepressant medication use in palliative care.

Depression and other mood disorders occur in approximately 25 percent of terminal patients. Untreated, depression and mood disorders can have a significantly negative impact on patients and families. Screening for depression can be done as easily as asking one question: "are you depressed?" A positive response to this question can be followed with one of the more extensive screening tools. Anxiety disorders can also have a negative effect on patients and their families. These can be identified by also using one of the validated screening tools. Use of the antidepressant medications for treating depression and, in some cases, anxiety disorders has not been well studied in hospice and palliative care. Some of the antidepressants can also serve as adjuvant therapy in pain management.

Alcohol consumption: an overview of benefits and risks.

Published health benefits of regular light-to-moderate alcohol consumption include lower myocardial infarction rates, reduced heart failure rates, reduced risk of ischemic stroke, lower risk for dementia, decreased risk of diabetes and reduced risk of osteoporosis. Numerous complimentary biochemical changes have been identified that explain the beneficial effects of moderate alcohol consumption. Heavy alcohol consumption, however, can negatively affect neurologic, cardiac, gastrointestinal, hematologic, immune, psychiatric and musculoskeletal organ systems. Binge drinking is a significant problem even among moderate drinkers and is associated with particularly high social and economic costs. A cautious approach should be emphasized for those individuals who drink even small amounts of alcohol. Physicians can apply the research evidence describing the known risks and benefits of alcohol consumption when counseling their patients regarding alcohol consumption.