Effect of non-steroidal anti-inflammatory drugs on formation of gallbladder stones.

Evidence suggests prostaglandins are involved in the pathogenesis of cholesterol gallstones and that nonsteroidal anti-inflammatory drugs (NSAIDs) may be effective in the management of biliary colic. We studied the prevalence of gallstones in patients chronically treated with NSAIDs. The cohort consisted of all adult patients undergoing ultrasonographic examination of right upper quadrant. One hundred forty subjects filled out a detailed questionnaire about medication history. Twenty-two percent of subjects taking NSAIDs chronically had gallstones compared to 33% in those patients not taking NSAIDs (p > 0.05). We conclude that routine chronic NSAID use does not have significant impact on the prevalence of gallstones.

Chronic abdominal wall pain. Diagnostic validity and costs.

Chronic abdominal wall pain (CAWP) is common and frequently mistaken for visceral pain. We determined the stability of this diagnosis with Main Outcome Measures of: (a) change of pain intensity after local anesthetic-corticosteroid injection, (b) pain relief after three or more months follow-up, and (c) costs of diagnostic procedures for visceral causes of abdominal pain in patients with confirmed CAWP. Seventy-nine patients fulfilled tentative criteria for CAWP; 72 (91%) experienced > or = 50% pain relief with anesthetic injection and were followed for at least three months (mean = 13.8 months). Abdominal pain in four patients was later diagnosed as caused by visceral disease. CAWP was confirmed in 56 of remaining 68 patients; 12 of 19 patients with recurrent pain were unavailable for re-injection of anesthetic. Thirty patients with confirmed CAWP had had diagnostic procedures to exclude visceral disease costing almost $700 per patient. CAWP is usually easily identified and treated; greater awareness should minimize misdiagnosis.

Pill-esophagitis caused by nonsteroidal antiinflammatory drugs.

A case of meclofenamate-induced pill-esophagitis is reported, and the relevant literature is reviewed. The role of posture, amount of fluid chaser, esophageal obstruction or dysmotility, drug formulation, physical and chemical properties of the drug, and concomitant ingestion of alcohol, as well as the diagnosis and management of such cases, are discussed.

Gender differences in Manning criteria in the irritable bowel syndrome.

The objective of this study was to determine if gender differences exist when using the Manning criteria for diagnosis of irritable bowel syndrome. In an outpatient setting, 61 women and 36 men with entry complaints of abdominal pain, altered bowel habits, or both underwent full evaluation by board-certified/eligible gastroenterologists who also systematically rated the presence or absence of the six Manning criteria. Irritable bowel syndrome was defined as the absence of an organic disease explanation for the entry complaints. This determination was made by two other board-certified gastroenterologists after patients had been in the study for 9 months. These raters were independent of the study and rated the transcripts of patients' clinic visits, all other available clinical data from this and other clinics, all laboratory data obtained during the 9-month study period, and the results of a 9-month telephone follow-up to patients and their physicians. Sixty-five percent of the study population had no organic disease explanation for the entry symptoms, thereby representing irritable bowel syndrome for this study. A similar proportion and type of organic disease and irritable bowel syndrome were experienced by men and women. For the total sample of 97 subjects, the correlation of the Manning criteria with irritable bowel syndrome was 0.22 (P less than 0.01). In the 61 women, correlation between the Manning criteria and irritable bowel syndrome was significant (r = 0.47; P less than 0.01). In the 36 men, however, the correlation was in the opposite direction, although it was not significant (r = -0.16). It was concluded that significant gender differences exist when using the Manning criteria for the diagnosis of irritable bowel syndrome and that the Manning criteria were not of diagnostic value in men.

Psychosocial factors are associated with health care seeking rather than diagnosis in irritable bowel syndrome.

The objective of this prospective study was to test the hypothesis that 6 reportedly important psychosocial factors were useful criteria for diagnosing the irritable bowel syndrome. Ninety-seven new patients with entry complaints of abdominal pain, altered bowel habits, or both underwent full evaluation by board-certified or -eligible gastroenterologists in an outpatient setting. The independent measures were 6 questionnaires concerning anxiety, depression, stress, lack of social support, somatization, and abnormal illness behavior. The dependent measure, irritable bowel syndrome, was defined as the absence of an organic disease explanation for patients' entry complaints. Two other board-certified gastroenterologists, independent of the study, made this determination. Their rating was based on full review of transcripts of patients' clinic visits, laboratory data, and the results of a 9-mo telephone follow-up to patients and their physicians. Sixty-five percent of the sample had no organic disease explanation for the entry symptoms, thereby representing irritable bowel syndrome. The psychosocial predictors did not show a significant association with irritable bowel syndrome; the power of the study was 0.86. Post hoc analysis revealed that patients with organic disease, as well as patients with irritable bowel syndrome, had significantly more (p less than 0.01) psychosocial abnormality than normal subjects, which likely contributed to the inability of the psychosocial predictors to distinguish irritable bowel syndrome from organic disease. It was concluded that psychosocial criteria were of limited value in differentiating irritable bowel syndrome from organic disease but that they were determinants of health care seeking for the entire study group.

Effects of desipramine on irritable bowel syndrome compared with atropine and placebo.

Antidepressant treatment trials of irritable bowel syndrome (IBS) have suggested beneficial effects. Twenty-eight patients with the disorder (9 constipation-predominant, 19 diarrhea-predominant) completed a double-blind crossover study using desipramine, atropine, and placebo in random sequence. A four-week observation period preceded three six-week test periods. Bowel habits, abdominal distress, and affect were reported daily and in biweekly evaluations. Psychological assessments and rectosigmoid contractile studies were done in each period. Stool frequency, diarrhea, abdominal pain, depression, and slow contractions decreased significantly more in diarrhea-predominant patients during desipramine compared with placebo and atropine treatments. Diarrhea-prone patients' depression scores fell more in all periods than constipation-prone patients. Fifteen patients (13 diarrhea-predominant) improved globally during desipramine, five during placebo and six during atropine treatments. Desipramine may be helpful in treating IBS, perhaps through antidepressant and antimuscarinic effects.

Diagnostic cues in gastroenterology.

Twenty seven gastroenterologists (15 physicians and 12 surgeons) were studied to capture their policy in the usage and weighting of cues in making a diagnosis. This was a relatively small sample and on account of possible sampling bias only tentative generalisations will be made. Five case vignettes, each consisting of four to eight cues, were used. Subjects were asked to give their percentage likelihood estimates of various diagnostic possibilities after each cue. This gave an indication of their perception of the significance of various cues in relationship to each diagnosis. There were marked variations in cue weighting by these experts, and in particular, most individuals were far off the mean regarding the weighting of certain clinical features, thus displaying idiosyncratic behaviour in these instances. As may be expected, there were differences in disease prevalence estimates between physicians and surgeons. Early information had an overwhelming effect on the final diagnosis. In most cases the expert relied on a few critical cues rather than on a pattern to make a diagnosis. In view of the strong influences of early diagnostic formulations, these findings confirm the need for doctors to learn to use and collect accurate factual information on prevalence rates and on the most significant critical cues for various disease processes. The study highlights some of the problems faced by novices in learning from experts who may teach them contradictory information about what are the most significant factors in coming to a diagnosis.

Prevalence of hepatitis B in 27 Michigan hemodialysis centers.

A large epidemiological survey of inhospital chronic hemodialysis patients was conducted in 27 (93%) of the 29 dialysis centers in Michigan. Serum was collected from 699 patients on chronic maintenance hemodialysis for periods from one month to eight years. Hepatitis B surface antigen (HBsAg) was determined in all patients by radioimmunoassay and positive samples were confirmed by specific neutralization. Antibody against HBsAg (anti-HBs) was determined by radioimmunoassay in 110 HBsAg negative patients from six dialysis units with a high prevalence of hepatitis B. HBsAg was detected in 80 (11.4%) patients distributed among 21 (78%) of 27 dialysis units and anti-HBs in 34 (31%) patients from the selected dialysis units. The prevalence of HBsAg was related to duration of dialysis, number of blood transfusions, and to a history of bilateral nephrectomy, but not to age, sex, race, nor the underlying renal disease. Twenty-one (26%) of the 80 HBsAg positive patients had not been previously identified by the clinical laboratories of their institutions. Since preventive measures were not taken in the care of these inapparent carriers of HBsAg, they represent an unrecognized risk.

Hepatitis B surface antigen in urine of hemodialysis patients.

As part of an extensive epidemiological survey of chronic hemodialysis patients in Michigan, hepatitis B surface antigen (HBsAg) was identified in the sera of 79 of 701 (11%) patients. Of these patients, 59 were carriers of HBsAg for three or more months. Urine samples were collected from 36 of 39 HBsAg carriers having urinary output. Of these samples, 19 (52%) were positive for HBsAg by radioimmunoassay; this was confirmed by specific antibody neutralization. The HBsAg was not identified in the urine of seven hemodialysis patients who were lacking serum HBsAg or in urine samples from three HBsAg sero-carriers who had normal renal function. Patients undergoing maintenance hemodialysis appear to constitute a large reservoir of HBsAg chronic carriers. This study indicates that a minimum of 50% of persistent HBsAg carriers who are producing urine have detectable HBsAg in single, randomly timed, unconcentrated urine specimen. These data suggest that urine may represent a potential vehicle for transmission in nonparenterally acquired hepatitis B.

Teaching peer review at Michigan State University.

Two groups of students at Michigan State University participated in an exercise intended to teach them the process of peer review. Neither group of students completed the exercise beyond the initial steps. The authors discuss the concerns of the students and make suggestions for implementing a program of peer review in undergraduate medical school curricula.

Prevalence and awareness of hyperlipoproteinemia in physicians and their spouses.

A survey of the prevalence of hyperlipoproteinemia was conducted on physicians and their spouses. For those who were classified as having hyperlipoproteinemia, 84 to 88 per cent of the men and 94 to 96 per cent of the women were unaware that they possessed this risk factor. The implication of this lack of awareness among physician is discussed, and the need for further physician education is stressed.