Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group.

BACKGROUND: Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. METHODS: A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. RESULTS: Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. CONCLUSIONS: Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.

An audit of occipitomental radiographs.

OBJECTIVES: To audit the justification for and image quality of occipitomental (OM) radiographs obtained at a dental teaching hospital. METHODS: One hundred OM radiographs taken at Glasgow Dental Hospital and their associated request forms were analysed by two examiners retrospectively. Information recorded from the request form included the age and gender of the patient, requesting department, grade of requesting clinician, reason for the request and exposure factors. The radiographs were assessed for radiographic density, patient positioning, presence of abnormality and whether the maxillary sinuses were normal or not. It was then decided by reference to the clinical records if there had been an indication for taking the radiograph. RESULTS: The majority of the requests were from junior staff, most frequently for pain or sinusitis. Almost all were from the Departments of Oral Surgery, Oral Medicine or Dental Accident and Emergency (A&E). The technical quality of the radiographs was variable, especially with respect to superimposition of the petrous temporal bone. Over half of the cases had normal sinuses, no abnormality and no indication for the radiograph. CONCLUSIONS: Many requests were inappropriate and the resultant radiographs had a low diagnostic yield. The technical quality of the radiographs was variable. Guidelines for clinicians for the prescription of OM radiographs were produced and the protocol for radiographic technique changed.

Temperament, activity, and expectations for later personality development.

Temperament is assumed to be the biologically based, emotional core of personality. Adult personality is presumed to emerge developmentally from temperament. One mechanism that may link temperament to subsequent personality development involves caregiver expectancies. Stability in personality may be associated with caregiver expectancies about the meaning of temperament-based behavior. The expectancies, in combination with implicit theories of personality development, support stability and patterned change. This multimethod study examined the relations among motor activity differences, temperament, and expectations about future personality characteristics in preschool children. It was hypothesized that motor activity and temperament differences would be linked to teachers' expectations about later personality development. The hypothesis that expectations about such links would be moderated by the sex of the child was also examined. Outcomes generally corroborated hypotheses. Results are discussed in terms of personality development and age-related adaptations to social contexts.

Role of cholesterol synthesis in regulation of bile acid synthesis and biliary cholesterol secretion in humans.

We used lovastatin, a specific inhibitor of HMG-CoA reductase, to study the role of cholesterol synthesis in regulation of both bile acid synthesis, measured by release of 14CO2 from [26-14C]cholesterol, and biliary cholesterol secretion, measured by standard marked perfusion techniques, in humans. Six volunteers were studied in each of four periods: a) control; b) 6-10 hours after a single 40 mg oral dose of lovastatin to study acute effects; c) after 5-6 weeks of lovastatin 40 mg orally twice a day to study steady-state effects; and d) 24 h after cessation of chronic lovastatin. Mean bile acid synthesis fell to 69% of control (P less than 0.01) after single-dose lovastatin and remained at 83% of control after 5-6 weeks on lovastatin (P less than 0.05). After withdrawal of lovastatin, mean bile acid synthesis was 88% of control (NS). Mean biliary cholesterol secretion did not change after single-dose lovastatin (103% of control), but fell to 81% of control during chronic lovastatin treatment (P less than 0.05). After withdrawal of lovastatin, mean cholesterol secretion remained at 80% of control (P less than 0.05). These data suggest that in humans cholesterol synthesis is an immediate regulator of bile acid synthesis. Cholesterol synthesis also regulates biliary cholesterol secretion, but the effect is not immediate and therefore may be indirect.

Bile porphyrin analysis in the evaluation of variegate porphyria.

BACKGROUND: Variegate porphyria is a genetic disorder of porphyrin metabolism in which patients may have both neurologic dysfunction and photocutaneous lesions. Biochemical confirmation of the diagnosis can be difficult, particularly in patients without neurologic dysfunction at the time of testing. The demonstration of increased fecal excretion of porphyrin is frequently used for this purpose, but levels may be normal. Since elevated fecal porphyrin levels in variegate porphyria are presumably a consequence of increased biliary excretion, we evaluated whether analysis of porphyrins in bile distinguishes better between patients with variegate porphyria and controls. METHODS: Bile samples were collected by duodenal aspiration from 10 patients with proved variegate porphyria who had no neurologic symptoms when they were studied and 17 control subjects. Bile and fecal porphyrin levels were measured fluorometrically. RESULTS: The mean total porphyrin concentration in bile in the patients with variegate porphyria was significantly higher than that in the controls (67.8 vs. 0.71 mumol per liter; P less than 0.00002). There was more than a ninefold difference between the highest level in any control subject and the lowest level in any patient with variegate porphyria. The mean fecal porphyrin level in the patients with variegate porphyria also differed significantly from that in the controls (0.79 vs. 0.14 mumol per gram of dry weight; P less than 0.007), but four patients had levels within the control range. CONCLUSIONS: The concentration of porphyrin in bile is higher in patients with variegate porphyria than in controls, and the difference is greater than that for fecal porphyrin. Bile porphyrin measurements may be helpful in the evaluation of asymptomatic patients suspected of having variegate porphyria.

Effects of lovastatin on biliary lipid secretion and bile acid metabolism in humans.

Lovastatin, an inhibitor of HMG-CoA reductase, lowers cholesterol saturation of bile. To determine the mechanism of this effect and further define the role of cholesterol synthesis in regulation of biliary lipid metabolism, we studied ten human volunteers in a control period and again after 5-6 weeks on lovastatin, 40 mg b.i.d. Mean sterol production from acetate in mononuclear leukocytes fell from 1.18 to 0.84 pmol/min per 10(6) cells on lovastatin (P less than 0.02). Concomitantly there was reduction in mean biliary secretion of cholesterol from 143 to 96 mumol/h (P less than 0.02). On lovastatin, mean pool size of bile acids by the Lindstedt method fell from 3193 to 2917 mumol (one-sided P = 0.05) and mean pool size by the one-sample method fell from 5158 to 4091 mumol (P less than 0.002). Lovastatin had no effect on mean fractional turnover rate of either cholic acid (0.77 vs. 0.74 day-1) or chenodeoxycholic acid (0.51 vs. 0.54 day-1). Mean total bile acid synthesis was lower on lovastatin (1443 vs. 1240 mumol/day), but the difference did not quite achieve statistical significance. In humans, inhibition of cholesterol synthesis by lovastatin lowers biliary cholesterol saturation by reducing cholesterol secretion into bile. Bile acid pool size, and perhaps bile acid synthesis, are also reduced by this inhibition.

Lovastatin added to ursodeoxycholic acid further reduces biliary cholesterol saturation.

The effects of lovastatin and ursodeoxycholic acid on cholesterol saturation of gallbladder bile were examined, alone and in combination. Nine volunteers were studied before any treatment and after each of three treatment periods: lovastatin, 40 mg, twice a day; ursodeoxycholic acid, 10 mg/kg per day; and the combination of both drugs. Treatment periods were randomly ordered, lasted 4-5 wk, and each was preceded by a 3-wk washout period. Mean cholesterol saturation index decreased from a baseline value of 1.40-0.92 on lovastatin (p less than 0.008). Mean cholesterol saturation index on ursodeoxycholic acid was 0.87 and decreased to 0.70 with the addition of lovastatin (p less than 0.030). There was a strong correlation (r = 0.87, p less than 0.003) between saturation index on ursodeoxycholic acid and the further incremental reduction in saturation index with addition of lovastatin. These findings raise the possibility that addition of lovastatin to ursodeoxycholic acid treatment might improve the efficacy of this bile salt for dissolution of cholesterol gallstones, especially in patients with a suboptimal response to ursodeoxycholic acid.

Dietary fiber and personality factors as determinants of stool output.

We examined effects of fiber on stool output, since this is one of the primary mediating variables for the hypothesized relationship between fiber and disease. Total neutral detergent fiber in the dietary fiber source was predictive of stool weight but not frequency. Substantial individual differences in stool output remained when dietary factors were controlled. Personality measures were used to predict stool weight and frequency independently of diet, and accounted for about as much variance in stool output as did dietary fiber. These results suggest that personality factors predispose some persons to low stool output. These individuals may benefit particularly from dietary fiber.

The human requirement for copper. I. Healthy men fed conventional, American diets.

Each of 13 men was fed diets made from conventional foods for two to seven periods lasting 30 days in a metabolic ward. There was a total of 47 experimental periods. Supplementation of the basal diet with each of several bran or other fiber sources was done in no particular order; each subject was fed the unsupplemented diet for at least one period. The diet was designed to contain amounts of essential nutrients close to the Recommended Dietary Allowances; it resembled the "average" American diet as it contained 16% protein, 40% fat, and 44% carbohydrate. Only minimal variation in energy intake and physical activity of the men was permitted; body weight remained constant within +/- 2%. Copper in food, feces, and urine was measured during the last 12 days of each period. Linear regression of balance (intake minus the sum of fecal and urinary losses) revealed a daily requirement of 1.30 mg (95% confidence limits of 1.24 to 1.35 mg). On consideration of a calculated surface loss of 0.25 mg/day, the requirement is 1.55 mg/day. The requirement was unaffected by the type of fiber source. A review of published data revealed that this requirement substantially exceeds the amount of copper found in many conventional diets.

Effects of some cereal brans and textured vegetable protein on plasma lipids.

The hypothesis that dietary fiber lowers serum cholesterol was tested in 10 healthy men, 19 to 54 years old, who ate a mixed diet similar to the diets of many American adult males, that contained 16% of calories as protein (70% from animal), 40% as fat (P/S = 0.3), 44% as carbohydrate (9% of calories as sucrose) and 3 g of crude fiber. The energy intake ranged from 2700 to 3500 kcal adjusted to their height and weight. Weight and fitness were held constant. After 30 days of equilibration on the basal diet, they ate 26 g of either soft white wheat bran, corn bran (CB), soybean hulls (SH), textured vegetable protein, or hard red spring wheat bran (HRS) for periods of 28 to 30 days each in no particular sequence. Each fiber was fed to four to six subjects. The dietary fiber contents of soft white wheat bran, CB, SH, and HRS were: 44, 92, 87, and 51%, respectively. Mean daily fecal weight increased (P less than or equal to 0.01) from 72.4 to 144, 68 to 128, and 81 to 151 g when CB, SH, and HRS were fed respectively. No effects were noted with soft white wheat bran or textured vegetable protein. Total plasma cholesterol decreased 12% with HRS (P less than or equal to 0.05) and 14.0% with SH (P less than or equal to 0.05). Low density lipoprotein cholesterol decreased 21% with HRS (P less than or equal to 0.05). High density lipoprotein cholesterol did not change with any of the dietary fiber sources nor did the ratio of high density lipoprotein cholesterol to total cholesterol. Some triglyceride lowering effect was seen with all sources of dietary fiber (P less than or equal to 0.01). There was a significant direct correlation between the area under the oral glucose tolerance curves and the levels of total cholesterol (r = 0.57, P less than or equal to 0.0001) and low density lipoprotein cholesterol (r = 0.49, P less than or equal to 0.0007), and between fasting plasma glucose and triglycerides (r = 0.32, P less than or equal to 0.03). Results were replicated when subjects were fed the same fiber source on two occasions at 2 to 4 month intervals.

Influence of dietary fiber on trace element balance.

Five adult male volunteers were fed a diet containing (as percent of calories) 16% protein, 40% fat, and 44% carbohydrate, a diet similar to that consumed by many American males. Twenty-six grams of soft white wheat bran or corn bran were added to the daily bread, and the effects on zinc, iron, and copper balance were assessed during the last 12 days of each 30-day study period. The soft white wheat bran appeared to decrease retention of zinc in four subjects but not significantly so. Iron retention was similar in all three treatments. Copper balance was improved by addition of soft white wheat bran and to a lesser degree by corn bran. An apparent copper requirement of 1.28 mg/day for the volunteers was calculated by regression analysis.

Zinc deficiency in pregnant rhesus monkeys: effects on behavior of infants.

Zinc deprivation from day 110 to 150 of gestation in rhesus monkeys resulted in rash, alopecia, anorexia, decreased feed efficiency, and low plasma zinc in the mothers. Infants of the dams that had been deprived of zinc during gestation displayed a more rapid postnatal growth rate than infants of the control mothers. Infants of the zinc-deprived dams played and explored less than the control infants. They also associated with their mothers a greater percentage of the time and were less active. This study has shown that third trimester maternal zinc deprivation in nonhuman primates can impair behavioral development of offspring.

Hair as a biopsy material. V. Hair metal as an index of hepatic metal in rats: copper and zinc.

Hair copper in 500 day-old adult rats was found to correlate directly with copper in whole liver (P less than 0.001) and the subcellular liver nuclear (P less than 0.022), and cytosol fractions (P less than 0.001). An inverse correlation was found between copper in liver microsomes and plasma cholesterol (P less than 0.044). Similar data analysis for zinc showed no significant correlations (P greater than 0.05). The determination of copper in hair may be useful for assessing total liver copper content in human beings. Copper in liver microsomes may participate in the control of plasma cholesterol.

Adenocarcinoma of the pancreas associated with neurofibromatosis.

A case of adenocarcinoma of the pancreas in a 27-year-old woman with neurofibromatosis (von Recklinghausen's disease) is presented.

Comparison of emergent endoscopy and upper gastrointestinal series radiography in acute upper gastrointestinal haemorrhage.

A prospective study of early diagnostic procedures in acute upper gastrointestinal haemorrhage was conducted in a series of 76 patients. The diagnostic procedures included upper gastrointestinal series radiography (UGIS) and endoscopy (ENDO). The clinicians' diagnosis and management improved in a statistically significant way as a result of the findings of endoscopy. The findings of UGIS did not significantly improve diagnostic accuracy and resulted in a statistically significant adverse effect on patient management. The results suggest that endoscopy is more effective in promoting early accurate diagnosis and management in patients with acute upper gastrointestinal haemorrhage.