Patient satisfaction with on-demand sedation for outpatient colonoscopy.

BACKGROUND AND STUDY AIM: To reduce the costs of colonoscopy the feasibility of unsedated procedures has been explored. The aims of our study were to assess patient satisfaction with on-demand sedation and identify factors related to painful colonoscopy. PATIENTS AND METHODS: The Norwegian Gastronet quality assurance documentation tools consist of endoscopy reports (completed on site) and a patient satisfaction questionnaire (completed by the patient on the day after colonoscopy). Data were collected from January 1 2004 to December 31 2006. Colonoscopies reported to be moderately or severely painful were defined as "painful colonoscopy." RESULTS: Nine endoscopy centers representing 86 endoscopists reported 14 915 examinations and 12 354 patient reports were returned (83 % response rate). Patient satisfaction with service and information given was greater than 95 % for all centers. Mean rate of painful colonoscopy was 34 % and mean sedation rate 34 %. Odds ratio (OR) for painful colonoscopy was 2.2 ( P < 0.001) when sedation was given. The ORs for painful colonoscopy were similar for all but one center (no. 4) with OR 1.6 ( P = 0.04), while the OR for giving sedation was higher for all but one center (no. 1) compared with the reference center (ORs 2.2 to 7.5, all P-values < 0.001). CONCLUSION: A surprisingly high rate of painful colonoscopy was found. High sedation rates were not associated with low rates of painful colonoscopy. Recommending increased sedation rates as the only intervention to improve suboptimal performance might not lead to lower rates of painful colonoscopy.

Long-term prognosis of patients with alcoholic liver cirrhosis: a 15-year follow-up study of 100 Norwegian patients admitted to one unit.

BACKGROUND: Most follow-up studies in patients with alcoholic liver cirrhosis have been for a 5-year period or less. The aim of this study was to assess the long-term mortality and causes of death among patients with alcoholic liver cirrhosis and to identify predictors of mortality. METHODS: One hundred patients with alcoholic liver cirrhosis, consecutively admitted to one medical department, were included in the study from May 1984 until December 1988. All patients had a history of alcohol abuse of at least 100 g ethanol daily for several years. The study comprised 65 men and 35 women with a median age of 58 years (range 34-82). Percutaneous liver biopsies and/or autopsies were obtained on 89 patients. Sixty-seven had ascites at admission and 34% had bleeding oesophageal varices. All patients were followed prospectively until death or until October 2000. RESULTS: During the follow-up period 90% of the patients died, 68 of whom (76 %) had been autopsied. The cumulative actuarial mortality after 1, 3, 6 and 12 months was 18%, 28%, 36% and 49%, respectively and after 5, 10 and 15 years 71%, 84% and 90%, respectively. None of the patients underwent liver transplantation during the study. The causes of death were bleeding, liver failure or a combination of these two conditions in 52 of 90 patients (58%), while 9 (11%) died of hepatocellular carcinoma 0.5 to 73 months after inclusion in the study. Using the Cox regression analysis, age, alcohol abuse and alkaline phosphatase were independent and significant predictors of mortality, but Child-Pugh class was not. CONCLUSIONS: The mortality in a group of patients with advanced alcoholic cirrhosis was extremely high with 5 and 15 years' mortality in 71% and 90%, respectively. Independent predictors of a poor prognosis were high age, continuous alcohol consumption of more than 10 g ethanol per day and high levels of alkaline phosphatase.

Relation between food provocation and systemic immune activation in patients with food intolerance.

We found that food provocation in food intolerant patients was characterised by a general and systemic immune activation accompanied by an increase in systemic symptoms. Our findings might be important for the understanding of the mechanisms involved in the pathogenesis of food intolerance.

Adverse reaction to food: assessment by double-blind placebo-controlled food challenge and clinical, psychosomatic and immunologic analysis.

Double-blind placebo-controlled food challenge (DBPCFC) with food items applied in capsules was performed in a prospective study of 17 selected patients and 34 age- and sex-matched healthy controls in the interdisciplinary clinical setting. Protein immunoblotting showed no differences in antigenicity between foods in the capsules and the corresponding fresh foods. All patients reacted to one or more food substances during DBPCFC, with a doubtful reaction to placebo in 2 patients. Agreement between diet history and provocation was seen in 53 of 85 individual food challenges, 36 being positive with both examinations. In 22 (38%) of the 58 positive provocations, the reactions were not expected from the patients' histories. No reaction to food or placebo occurred in the control group. Related to diet history, sensitivity and specificity of provocation were 62 and 63%, respectively, with a positive predictive value of 78%. Allergy, previous gastroenterologic and infectious diseases among first-degree relatives, immunologic abnormalities and elevation of total IgE were significantly more common for the patients than controls. A positive skin prick test correlated well with diet history, but both prick test and food antibodies correlated poorly with DBPCFC. Assessment by the General Health Questionnaire showed a significant difference towards the controls. After 3-4 months of follow-up on an individually based diet, 11 of 15 patients reported general improvement of their condition. DBPCFC may be a valuable diagnostic test in addition to dietary history as a basis for elimination diet on food-intolerant patients. The effect of the elimination diet on the symptoms may also suggest a therapeutic effect or provocation.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of gastric anacidity on the release of cobalamins from food and their subsequent binding to R-protein.

Rabbit liver homogenate, labelled in vivo with 57Co, was used to investigate the effect of anacid gastric juice on the release of cobalamins from food and on the cobalamin binding to proteins in humans. The cobalamin release was investigated in vitro by incubating the liver homogenate with native and neutralized gastric juice. The cobalamin release and the amount of cobalamins bound to R-protein were significantly higher with native than with neutralized gastric juice. To investigate the effect of anacidity on cobalamin release in vivo, 14 healthy volunteers were given omeprazole or placebo in a double-blind crossover fashion. 57Co-labelled liver-bound cobalamins were given orally, and aspirates were collected from the stomach and the upper jejunum. After omeprazole gastric anacidity (pH greater than 6.0) was obtained in 11, 12, and 10 individuals after 5, 30, and 60 min, respectively. In the gastric aspirates obtained after omeprazole there was a slight inhibition in cobalamin release after 5 and 30 min (p less than 0.05). In the jejunal aspirates the cobalamin release was close to 90% in both the placebo and the omeprazole experiment, and there was no significant difference in the percentage of cobalamins bound to R-protein in the two groups. The percentage of cobalamins bound to R-protein was much lower in the jejunal aspirates (26.6% and 23.7% in omeprazole and placebo, respectively) than in the gastric aspirates (65.8% and 68.6%).

The effect of omeprazole on gastric acidity and the absorption of liver cobalamins.

The effect of gastric anacidity on the absorption of food-bound cobalamins is uncertain. Omeprazole, an inhibitor of the enzyme H-K-ATPase in the parietal cell, is the most potent inhibitor of gastric acidity known so far. In 17 healthy male volunteers the absorption of liver-bound cobalamins was assessed after a single intravenous dose of omeprazole (80 mg) or placebo in a double-blind, crossover manner. The effect of omeprazole on pH, gastric acidity, and intrinsic factor (IF) concentration was measured in aspirates of gastric juice 5 min before and 30 and 60 min after the administration of liver homogenate containing 0.74 nmol of 57Co-labelled cobalamins. Omeprazole treatment resulted in anacidity (pH values above 6.0) in 14 individuals 30 min after the liver dose and in 15 individuals after 60 min. The IF concentration was unchanged in the omeprazole experiment as compared with the placebo experiment. The absorption of liver-bound cobalamins was 310 pmol (189-501 pmol) in the omeprazole experiment as compared with 415 pmol (150-549 pmol) in the placebo experiment (median values and range, p = 0.5228). We suggest that anacidity induced by omeprazole does not reduce the absorption of liver-bound cobalamins.

Cystic fibrosis: protease activity in saliva evaluated with chromogenic substrates.

The protease activities in saliva from individuals with cystic fibrosis (CF) were studied using four different chromogenic substrates. In the CF-group a significantly decreased protease activity in the range 50-70% was found, compared to an age- and sex-matched control group, but with considerable overlap between the CF-patients and the control patients. The trypsin-like activity found in CF-patients without chronic colonisation with Pseudomonas aeruginosa was significantly decreased and without overlap compared to the control patients. The results indicate that determination of salivary protease activity using chromogenic substrates may give additional information in patients with suspected cystic fibrosis, and indicate the possibility of an additional diagnostic test.

The effect of ranitidine on the absorption of food cobalamins.

The effect of the histamine H2-receptor antagonist ranitidine on the absorption of food cobalamins was investigated in 20 healthy volunteers randomized to treatment with ranitidine or placebo for 1 week. Liver homogenates containing cobalamins labelled in vivo with cobalt-57 was obtained by repeated injections of 57Co-labelled cyanocobalamin in rabbits. Test doses (0.37 nmol) of the 57Co-labelled liver cobalamins were administered orally together with 51CrCl3 and carmine red, and the absorption of 57Co-labelled cobalamins was assessed from the ratio of the two isotopes in the stool collection that had been coloured by the carmine red. There was no significant difference in the mean absorption before (47.4%) and after (50.7%) the treatment.

Effect of omeprazole on the secretion of intrinsic factor, gastric acid and pepsin in man.

The effect of an intravenous infusion of omeprazole (0.35 mg/kg) and placebo on basal and stimulated (pentagastrin 1.0 microgram/kg/h) secretion of gastric acid, intrinsic factor and pepsin was studied in 10 healthy male subjects. Omeprazole caused a marked inhibition of basal and stimulated acid output. The inhibition of pepsin output was less marked, but also significant. The output of intrinsic factor, however, showed no significant change. The results indicate that acid and intrinsic factor might have different secretory mechanisms within the parietal cell.

Determination of the R-protein and the R-protein-vitamin B12-complex in saliva and gastrointestinal juice by FPLC Mono S cationic chromatography.

The binding of vitamin B12 to the two vitamin B12 binding proteins--intrinsic factor and R-protein--in gastrointestinal juice is pH dependent. It is therefore of importance that binding studies are carried out at pH values near the physiological pH of the gastric juice. In the present study the vitamin B12 complexes of the two vitamin B12 binders were separated at a pH of 1.8 using the cationic exchange chromatograph Mono S attached to the fast protein liquid chromatography (FPLC) system. The R-protein concentration was measured in saliva and gastric juice with high accuracy and with highly significant correlation compared to the serum-coated charcoal method of Gottlieb. The method showed a decreased recovery in duodenal juice and in samples with high bile content.

Absorption of food cobalamins assessed by the double-isotope method in healthy volunteers and in patients with chronic diarrhoea.

To make a food preparation containing radioactively labelled cobalamins, rabbits were given repeated injections with 57Co-labelled cyanocobalamin. The liver was removed, homogenized, and fried for 1 min or boiled for 30 min. Of the radioactivity in the fried homogenate 41.7% was recovered in the centrifuged supernatant compared with 50.8% in the boiled homogenate. The radioactivity in the supernatants had a molecular size close to that of free 57Co-labelled cyanocobalamin. Forty-two per cent of the radioactivity in the whole homogenate had been incorporated into 5-deoxyadenosyl-, 10% into methyl-, and 16.5% into hydroxy-cobalamin. To assess the validity of a double-isotope method for measuring the intestinal absorption of doses of the 57Co-labelled liver cobalamins, 51CrCl3 was used as a non-absorbable marker. In 14 healthy volunteers the correlation coefficient between the absorption measured by the double-isotope technique and the faecal excretion test was highly significant (r = 0.96, p less than 0.005), and there was only a small variation in the 57Co/51Cr ratio in successive stool collections. In 11 patients with chronic diarrhoea there was a significant correlation between the absorption measured by the double-isotope technique and the faecal excretion test (r = 0.92, p less than 0.005), but in some patients there was considerable variation in the 57Co/51Cr ratio in successive stool collections.

Effect of peroral antacid treatment in patients with acute upper gastrointestinal haemorrhage: a randomized controlled trial.

During recent years, it has been reported that antacids have a beneficial prophylactic effect in critically ill patients regarding upper gastrointestinal bleeding. In these trials rather complicated treatment schedules and high doses of antacids were used. The present study was designed to investigate the therapeutic efficacy of a more practical antacid treatment regimen in patients with haematemesis and/or melaena. Ninety patients, hospitalized for haematemesis and/or melaena within the past 24 hours, were included to double-blind treatment with antacids or placebo for 7 days. The dose, 20 ml liquid antacid (Balancid) with a neutralizing capacity of 105 mmol, was administered each second hour during waking hours. The groups were comparable regarding incidence of ulcer disease, age, sex, acid secretion, and usage of aspirin. Continuous bleeding or rebleeding was recorded in 15 of the 43 patients in the antacid group (34.9%), compared to 19 of the 47 patients in the placebo group (40.4%), the difference not being statistically significant. Furthermore, the requirement of blood transfusions was not significantly different in the two groups. In conclusion, the haemostatic effect of the antacid treatment regimen used in the present study was not significantly superior to placebo in patients with endoscopically verified acute upper gastrointestinal haemorrhage.

Convulsions and possible spasm of the lower oesophageal sphincter in a fatal case of propranolol intoxication.

A fatal case of propranolol intoxication is described. The patient had ingested 3-5 g of the drug and probably no other drugs. Gastric lavage could not be performed due to some kind of obstruction in the distal part of the oesophagus. At autopsy, the oesophagus was normal, and a spasm due to B-blockade is suggested. Epileptiform seizures resistant to treatment with diazepam and barbiturates were frequent and probably not solely caused by cerebral ischaemia.