Association between triglyceride levels and cardiovascular disease in patients with acute pancreatitis.

Conventional wisdom supports prescribing "fibrates before statins", that is, prioritizing treatment of hypertriglyceridemia (hTG) to prevent pancreatitis ahead of low-density lipoprotein cholesterol to prevent coronary heart disease. The relationship between hTG and acute pancreatitis, however, may not support this approach to clinical management. This study analyzed administrative data from the Veterans Health Administration for evidence of (1) temporal association between assessed triglycerides level and days to acute pancreatitis admission; (2) association between hTG and outcomes in the year after hospitalization for acute pancreatitis; (3) relative rates of prescription of fibrates vs statins in patients with acute pancreatitis; (4) association of prescription of fibrates alone versus fibrates with statins or statins alone with rates of adverse outcomes after hospitalization for acute pancreatitis. Only modest association was found between above-normal or extremely high triglycerides and time until acute pancreatitis. CHD/MI/stroke occurred in 23% in the year following AP, supporting cardiovascular risk management. Fibrates were prescribed less often than statins, defying conventional wisdom, but the high rates of cardiovascular events in the year following AP support a clinical focus on reducing cardiovascular risk factors.

Screening for hepatitis B in patients with lymphoma.

Chronic hepatitis B virus (HBV) infection can be reactivated during lymphoma chemotherapy, specifically with rituximab. In 2008, the Centers for Disease Control and Prevention and, in 2010, the American Society of Clinical Oncology made recommendations that anyone who received cytotoxic or immunosuppressive therapy should be tested for serologic markers of HBV infection. In our study, we wanted to determine the screening rates for HBV infection at our institution and if simply adding a checkbox onto the rituximab order would improve HBV screening. We performed a retrospective chart review of two cohorts of lymphoma patients at Scott & White Health Clinic. Cohort 1 included patients from 1993 to 2008. Cohort 2 included patients who received rituximab after an institutionwide protocol (rituximab order checkbox) was initiated in 2011. A total of 452 patients treated for lymphoma were reviewed. Only 15 of the 404 Cohort 1 patients received HBV screening (3.7%; 95% confidence interval, 2.1%-6.1%). Screening rates were statistically higher if baseline liver laboratory values were elevated (P < 0.0001). HBV was also checked more frequently if patients' liver function tests became elevated while on chemotherapy, 85.7% (12/14). Of the 48 patients in Cohort 2, 33 patients (68.7%) received HBV screening. No patients in either cohort had a positive HBV surface antigen or developed reactivation of HBV during chemotherapy. The addition of a checkbox on the rituximab order form significantly increased our screening for HBV infection in lymphoma patients initiating chemotherapy.

Effects of the no interruption zone on distraction levels, withdrawal times, and adenoma detection rates of colonoscopy.

BACKGROUND: The creation of no interruption zones (NIZs) reduces medical errors by reducing distraction levels on hospital wards. To date, the effect of a NIZ during colonoscopy has not been evaluated. AIMS: Assess the effects of a NIZ during colonoscopy, on distraction levels, withdrawal times, and adenoma detection rates (ADRs). METHODS: This was a non-randomized prospective study of screening colonoscopies at a teaching hospital. The intervention, a NIZ, was created by limiting conversations to the care of the patient undergoing the procedure and posting a "do not disturb" sign during the withdrawal phase of colonoscopy. Distraction levels, withdrawal times, and ADRs were analyzed at baseline and after the NIZ. RESULTS: The implementation of the NIZ leads to a significant reduction of high-distraction-level environments (13.1 vs. 5.1 %; p < 0.0001). There was a significant decrease in withdrawal time with NIZs; (10.6 vs. 9.9 min, p = 0.0038). There was no significant difference in ADRs (38 % baseline vs. 36 % NIZs, respectively; p = 0.33). CONCLUSIONS: Creation of a NIZ was associated with a significant decrease in high-distraction environments and shorter withdrawal times with no significant change in ADRs. Further studies are needed to evaluate whether lower distraction levels in an endoscopy suite translate to improved quality measures.

Birth cohort screening for chronic hepatitis during colonoscopy appointments.

OBJECTIVES: More than 70% of infections with hepatitis C viruses (HCV) occur among people born between 1945 and 1965 (baby boomers). The US Centers for Disease Control estimate that 70% of people with chronic hepatitis are not aware that they are infected with a virus. We performed a prospective trial to determine whether people born during this time period would accept testing for chronic viral infection (hepatitis B virus (HBV) and HCV) during routine colonoscopies. We also evaluated acceptance and efficacy of screening for immunity to hepatitis A (HAV) and B viruses. METHODS: During a 3-month period, 500 people, 50-65 years old, who received a colonoscopy were offered a test for viral hepatitis. Patients answered questions about vaccination, exposure, diagnoses, and risk factors related to viral hepatitis, and blood samples were collected. Patients who tested positive for antibodies to HCV or hepatitis B surface antigen (HBsAg) were contacted for further testing and possible therapy. Patients without immunity to HAV or HBV were offered vaccinations. RESULTS: Three hundred and seventy-six people (158 men) agreed to be tested. Four were found to have antibodies against HCV and one had detectable virus. None of the patients tested positive for HBsAg; 136 (36%) had at least one risk factor for chronic hepatitis and 31 (8%) had multiple risk factors. Three hundred and fifteen patients (84%) were not immune to HAV, HBV, or both viruses. CONCLUSIONS: It is possible to screen patients for viral hepatitis during visits for routine colonoscopy. This approach can identify individuals with undiagnosed chronic HBV and HCV infections who could benefit from education, vaccination, or therapy.

Frequency and clinical outcome of capsule retention during capsule endoscopy for GI bleeding of obscure origin.

BACKGROUND: Capsule endoscopy is now commonly performed for GI bleeding of obscure origin. Regional transit abnormality refers to slowed capsule movement during capsule endoscopy. The frequency and clinical outcome of capsule retention and regional transit abnormalities are unknown. METHODS: Initial capsule endoscopies performed at a single institution in 52 patients with GI bleeding of obscure origin were reviewed retrospectively. For patients with capsule retention or regional transit abnormality, preprocedural characteristics, and post-procedural outcomes were recorded. OBSERVATIONS: Capsule retention occurred in 7 patients, all of whom remained asymptomatic. Regional transit abnormality was noted in 3 patients. Sources of bleeding were localized in all cases. Seven patients underwent surgery. Stricture induced by non-steroidal anti-inflammatory drugs was the major cause of retention. In all patients, anemia resolved during follow-up. CONCLUSIONS: Capsule retention and regional transit abnormality occurred in almost 20% of patients who had capsule endoscopy for GI bleeding of obscure origin. These capsule movement abnormalities led to the diagnosis of bleeding sources and thereby influenced patient management. A history of non-steroidal anti-inflammatory drugs use may be associated with an increased risk of capsule retention.