Xanthine oxidase mediates chronic stress-induced cerebrovascular dysfunction and cognitive impairment.

Xanthine oxidase (XO) mediates vascular function. Chronic stress impairs cerebrovascular function and increases the risk of stroke and cognitive decline. Our study determined the role of XO on stress-induced cerebrovascular dysfunction and cognitive decline. We measured middle cerebral artery (MCA) function, free radical formation, and working memory in 6-month-old C57BL/6 mice who underwent 8 weeks of control conditions or unpredictable chronic mild stress (UCMS) with or without febuxostat (50 mg/L), a XO inhibitor. UCMS mice had an impaired MCA dilation to acetylcholine vs. controls (p < 0.0001), and increased total free radical formation, XOR protein levels, and hydrogen peroxide production in the liver compared to controls. UCMS increased hydrogen peroxide production in the brain and cerebrovasculature compared to controls. Working memory, using the y-maze test, was impaired (p < 0.05) in UCMS mice compared to control mice. However, blocking XO using febuxostat prevented the UCMS-induced impaired MCA response, while free radical production and hydrogen peroxide levels were similar to controls in the liver and brain of UCMS mice treated with febuxostat. Further, UCMS + Feb mice did not have a significant reduction in working memory. These data suggest that the cerebrovascular dysfunction associated with chronic stress may be driven by XO, which leads to a reduction in working memory.

Diagnosis of Alcoholic Liver Disease: Key Foundations and New Developments.

Alcoholic liver disease is a spectrum of conditions that include alcoholic fatty liver disease, alcoholic hepatitis, and chronic alcoholic liver disease. The diagnosis of alcoholic liver disease remains founded in an accurate patient history and detailed physical examination. Concurrent with the physical examination, objective data from laboratory, imaging, and histologic studies are helpful to confirm a diagnosis of alcoholic liver disease. Novel biomarkers, scoring systems, and imaging modalities are improving the ability to diagnose and manage alcoholic liver disease, but for most practicing clinicians, these have not been adopted widely because of their cost, but also because of limitations and uncertainty in their performance characteristics.

The role of a nurse telephone call to prevent no-shows in endoscopy.

BACKGROUND AND AIMS: Preventing missed appointments, or "no-shows," is an important target in improving efficient patient care and lowering costs in gastrointestinal endoscopy practices. We aimed to investigate whether a nurse telephone call would reduce no-show rates for endoscopic appointments, and to determine if hiring and maintaining a nurse dedicated to pre-endoscopy phone calls is economically advantageous. Our secondary aim was to identify predictors of no-shows to endoscopy appointments. METHODS: We hired and trained a full-time licensed nurse to make a telephone call to patients 7 days before their scheduled upper endoscopy or colonoscopy. We compared this intervention with a previous reminder system involving mailed reminders. The effect of the intervention and impact of other predictors of no-shows were analyzed in 2 similar preintervention and postintervention patient cohorts. A mixed effects logistic regression model was used to estimate the association of the odds of being a no-show to the scheduled appointment and the characteristics of the patient and visit. An analysis of costs was performed that included the startup and maintenance costs of the intervention. RESULTS: We found that a nurse phone call was associated with a 33% reduction in the odds of a no-show visit (odds ratio, 0.67; 95% confidence interval, 0.50-0.91), adjusting for gender, age, partnered status, insurer type, distance from the endoscopy center, and visit type. The recovered reimbursement during the study period was $48,765, with net savings of $16,190 when accounting for the maintenance costs of the intervention; this resulted in a net revenue per annum of $43,173. CONCLUSIONS: We found that endoscopy practices may increase revenue, improve scheduling efficiency, and maximize resource utilization by hiring a nurse to reduce no-shows. Predictors of no-shows to endoscopy included unpartnered or single patients, commercial or managed care, being scheduled for colonoscopy as opposed to upper endoscopy, and being scheduled for a screening or surveillance colonoscopy.

Practice patterns of sedation for colonoscopy.

BACKGROUND: Sedative and analgesic medications have been used routinely for decades to provide patient comfort, reduce procedure time, and improve examination quality during colonoscopy. OBJECTIVE: To evaluate trends of sedation during colonoscopy in the United States. SETTING: Endoscopic data repository of U.S. gastroenterology practices (Clinical Outcomes Research Initiative, CORI database from 2000 until 2013). PATIENTS: The study population was made up of patients undergoing a total of 1,385,436 colonoscopies. INTERVENTIONS: Colonoscopy without any intervention or with mucosal biopsy, polypectomy, various means of hemostasis, luminal dilation, stent placement, or ablation. MAIN OUTCOME MEASUREMENTS: Dose of midazolam, diazepam, fentanyl, meperidine, diphenhydramine, promethazine, and propofol used for sedation during colonoscopy. RESULTS: During the past 14 years, midazolam, fentanyl, and propofol have become the most commonly used sedatives for colonoscopy. Except for benzodiazepines, which were dosed higher in women than men, equal doses of sedation were given to female and male patients. White patients were given higher doses than other ethnic groups undergoing sedation for colonoscopy. Except for histamine-1 receptor antagonists, all sedative medications were given at lower doses to patients with increasing age. The dose of sedatives was higher in colonoscopies associated with procedural interventions or of long duration. LIMITATIONS: Potential for incomplete or incorrect documentation in the database. CONCLUSION: The findings reflect on colonoscopy practice in the United States during the last 14 years and provide an incentive for future research on how sex and ethnicity influence sedation practices.

Family history of inflammatory bowel disease among patients with ulcerative colitis: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Despite numerous shared susceptibility loci between Crohn's disease and ulcerative colitis, the prevalence of family history among ulcerative colitis patients is not well-established and considered to be less prevalent. A systemic review and meta-analysis were conducted to estimate the prevalence of family history of inflammatory bowel disease in ulcerative colitis patients, and its effect on disease outcomes. METHODS: PubMED was searched to identify studies reporting the prevalence of family history of inflammatory bowel disease among ulcerative colitis patients. Definitions of family history, study type, and subtypes of family history prevalence were abstracted, as were disease outcomes including age at ulcerative colitis diagnosis, disease location, surgery and extraintestinal manifestations. Pooled prevalence estimates were calculated using random effects models. RESULTS: Seventy-one studies (86,824 patients) were included. The prevalence of a family history of inflammatory bowel disease in ulcerative colitis patients was 12% (95% confidence interval [CI] 11 to 13%; range 0-39%). Family history of ulcerative colitis (9%; 22 studies) was more prevalent than Crohn's disease (2%; 18 studies). Patients younger than 18years of age at time of diagnosis had a greater family history of inflammatory bowel disease (prevalence 15%, 95% CI: 11-20%; 13 studies). There were no differences in disease location, need for surgery, or extraintestinal manifestations among those with a family history, although very few studies reported on these outcomes. CONCLUSIONS: Overall, 12% of ulcerative colitis patients have a family history of inflammatory bowel disease, and were more likely to have a family history of ulcerative colitis than Crohn's disease. Pediatric-onset ulcerative colitis patients were more likely to have a family history of inflammatory bowel disease.

Heart failure with transient left bundle branch block in the setting of left coronary fistula.

Coronary arterial fistulas are rare communications between vessels or chambers of the heart. Although cardiac symptoms associated with fistulas are well described, fistulas are seldom considered in the differential diagnosis of acute myocardial ischemia. We describe the case of a 64-year-old man who presented with left shoulder pain, signs of heart failure, and a new left bundle branch block (LBBB). Cardiac catheterization revealed a small left anterior descending (LAD)-to-pulmonary artery (PA) fistula. Diuresis led to subjective improvement of the patient's symptoms and within several days the LBBB resolved. We hypothesize that the coronary fistula in this patient contributed to transient ischemia of the LAD territory through a coronary steal mechanism. We elected to observe rather than repair the fistula, as his symptoms and ECG changes resolved with treatment of his heart failure.