Inpatient burden of esophageal cancer and analysis of factors affecting in-hospital mortality and length of stay.

Esophageal cancer (EC) continues to be a major source of morbidity and mortality in the United States. However, there has been a relative dearth of research into hospital utilization in patients with EC. This study examines temporal trends in hospital admissions, length of stay (LOS), mortality, and costs associated with EC. In addition, we also analyzed factors associated with inpatient mortality and LOS. We interrogated National Inpatient Sample (NIS), a large registry of inpatient data, to retrieve information about various demographic and factors associated with hospital stay in patients who were admitted for EC between the years 1998 and 2013 in the United States. After examining trends over time, multivariate analysis was performed to identify factors associated with LOS and mortality. During 1998-2013, 538,776 hospital stays with principal diagnosis of EC were reviewed. Number of hospital stays and inpatient charges increased by 397 per year (±67.8; P < 0.0001) and $3,033 per patient per year (±135; <0.0001) respectively. Mortality and LOS decreased by 0.23% per year (±0.03; P < 0.0001) and 0.07 days per year (±0.006; P < 0.0001) respectively. Multiple factors associated with LOS and mortality were outlined. Despite overall increase in hospital utilization with respect to number of admissions and inpatient charges, inpatient mortality and LOS associated with EC declined. Factors associated with inpatient mortality and LOS may help drive clinical decision-making and influence healthcare or hospital policy.

Comparison of pregnancy outcomes between women with gestational diabetes and overt diabetes first diagnosed in pregnancy: a retrospective multi-institutional study in Japan.

AIMS: To determine differences in pregnancy outcomes including diabetic complications, maternal and perinatal complications between gestational diabetes mellitus and overt diabetes in pregnancy in Japan. METHODS: A multi-institutional retrospective study compared pregnancy outcomes between gestational diabetes mellitus and overt diabetes in pregnancy. We examined pregnant women who met the former criteria for gestational diabetes mellitus and received dietary intervention with self-monitoring of blood glucose with or without insulin. Overt diabetes in pregnancy was defined as ≥2 abnormal values on 75-g oral glucose tolerance test, fasting glucose ≥126 mg/dl (7.0 mmol/l) and 2-h postprandial glucose ≥200 mg/dl (11.1 mmol/l), or glycated hemoglobin levels ≥6.5% (48 mmol/mol). RESULTS: Data were collected on 1267 women with gestational diabetes and 348 with overt diabetes in pregnancy. Pregestational body mass index was higher (26.2 ± 6.1 vs. 24.9 ± 5.7 kg, P<0.05) and gestational age at delivery was earlier (37.8 ± 2.5 weeks vs. 38.1 ± 2.1 weeks, P<0.05) in overt diabetes than in gestational diabetes. Glycated hemoglobin (6.8 ± 1.1% [51 mmol/mol] vs. 5.8 ± 0.5% [40 mmol/mol], P<0.05) and glucose on 75-g oral glucose tolerance test and prevalence of retinopathy (1.2% vs. 0%, P<0.05) and pregnancy-induced hypertension (10.1% vs. 6.1%, P<0.05) were higher in overt diabetes than in gestational diabetes. Pregnancy-induced hypertension was associated with pregestational body mass index, gestational weight gain, chronic hypertension, and nulliparity but not with 75-g oral glucose tolerance test. CONCLUSIONS: Overt diabetes in pregnancy is significantly associated with maternal complications such as retinopathy and pregnancy-induced hypertension.

Paracetamol absorption test with Wagner-Nelson analysis for safe and accurate measurements of gastric emptying in women.

The physiological and pharmacological aspects of gastric emptying in fertile or pregnant women have been studied. Scintigraphy is the reference method for measuring gastric emptying. However, it should be applied very cautiously to women of childbearing age because of the risk of substantial irratiation. In such a population, paracetamol absorption has been used safely as an index of gastric emptying, but its accuracy has been challenged. The Wagner-Nelson method is a traditional tool used to precisely evaluate drug absorption kinetics. To clarify whether the absorption kinetics of paracetamol assessed by the Wagner-Nelson method is as accurate as scintigraphy in evaluating gastric emptying in young women, gastric emptying of a 200-kcal liquid meal was measured simultaneously by scintigraphy and the paracetamol test in 10 healthy young female volunteers. Paracetamol absorption systemically overestimated the rate of gastric emptying measured by scintigraphy. By introducing a correction factor into the paracetamol test, the overestimation could be adjusted. The paracetamol test with Wagner-Nelson analysis can be a safe and accurate method for measuring gastric emptying in women of childbearing age.

Is the pattern of solid-phase gastric emptying different between genders?

BACKGROUND: In the 13C-octanoate breath test, the shape of the 13CO2 excretion curve in the ascending portion reflects a pattern of gastric emptying (GE). Recent scintigraphic studies have revealed an overall delay in solid GE in fertile women compared with men. However, it remains unknown whether women have a different GE pattern compared with men. As a symptomatic delay in solid GE is specific to the female gender, it could be hypothesized that the 13CO2 excretion curve is different in shape between genders. MATERIALS AND METHODS: Because the ascending gradient of the 13CO2 excretion curve is often biphasic, the dual function of y(t) = ( a1 . tb1 + a2 . tb2) e(-K.t) was applied to fit the breath data, where a1, b1, a2, b2, and K are constants. Assessed on the 4 h-based breath samples obtained after ingestion of a 320-kcal muffin containing 100 mg 13C-octanoate, the time versus 13CO2 excretion curve was created from 31 adult volunteers (15 men and 16 women). The curve shape was characterized by the dual function, and was compared between genders. RESULTS: In both genders, the ascending gradient exhibited the biphasic feature, characterized by an initial steep rise and the subsequent blunted increase, while the descending gradient followed the monotonous decay. The initial rise was steeper and the subsequent increase was more blunted in women than in men. CONCLUSION: Women exhibit a gender-specific pattern of the 13CO2 excretion profile. A possible explanation for this gender difference is that the post-gastric feedback regulation is more potent in women than in men.

Use of tegaserod along with polyethylene glycol electrolyte solution for colonoscopy bowel preparation: a prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND: Polyethylene glycol electrolyte solution (PEG-EL) used for colonoscopy preparation is not well tolerated by several patients. A significant number of patients have inadequate bowel preparation despite taking PEG-EL. AIMS: To determine the effect of prokinetic agent, tegaserod when given in addition to PEG-EL on patient tolerance, quality of colonic preparation and adverse side effects experienced. METHODS: In this prospective, randomized, placebo-controlled, double-blind study, a total of 130 patients scheduled for colonoscopy were enrolled. They were instructed to take three pills of either tegaserod 6 mg each or placebo (one pill twice on the day prior to and third pill in the morning on the day of colonoscopy) in addition to standard 4L of PEG-EL in the evening prior to the day of colonoscopy. Patient tolerance of preparation, quality of bowel preparation, overall satisfaction and adverse side effects were compared between the two groups. RESULTS: Fifty-five patients in placebo group and 58 patients in tegaserod group completed the study. There was no difference between the two groups in the tolerance of preparation, quality of bowel preparation, overall satisfaction and the side effects. CONCLUSION: Addition of tegaserod to polyethylene glycol electrolyte solution during colonoscopy preparation does not improve patient tolerance, quality of colonic preparation or the adverse side effects.

Clinical features and treatment of hematopoietic stem cell transplantation-associated gastric antral vascular ectasia.

Gastric antral vascular ectasia (GAVE) may occur after hematopoietic stem cell transplantation (HSCT) and cause severe and prolonged gastric bleeding. The underlying pathology of transplant-associated GAVE (HSCT-GAVE) is poorly understood and an effective therapeutic strategy has not been established yet. We retrospectively reviewed the medical records of 230 consecutive allogeneic transplant recipients in our institution between January 1997 and June 2002. We identified five patients who developed HSCT-GAVE (2.2%). Four patients had bleeding from HSCT-GAVE and one patient had HSCT-GAVE discovered incidentally. The clinical features of these patients were similar in that they all received conditioning treatment with busulfan and had history of thrombotic microangiopathy. Furthermore, treatment with a beta-blocker apparently improved the outcome of HSCT-GAVE in three patients.

Ten-year prospective follow-up study on the relationship between Helicobacter pylori infection and progression of atrophic gastritis, particularly assessed by endoscopic findings.

AIM: To ascertain the progression of atrophic gastritis due to Helicobacter pylori infection, we conducted a 10-year prospective follow-up study with annual endoscopy of the stomach. METHODS: Prospective endoscopic observation was started in 53 subjects in 1989 and 1990 after informed consent was obtained. The progression of atrophic gastritis was evaluated mainly by the endoscopic pattern of atrophy. Histological assessment was performed on biopsy specimens taken from the lesser curvature of the lower corpus. By 2000, 43 patients (20 males, 23 females, mean age 56.7 years at entry) had completed at least 10 years of endoscopic follow-up. RESULTS: Eight H. pylori-negative patients with normal fundic mucosa showed no change endoscopically or histologically. In 35 H. pylori-positive patients, the progression of histological atrophy was observed in 46% and intestinal metaplasia was observed in 49%. Fifteen of 35 H. pylori-positive cases exhibited a cephaloid shift of the endoscopic atrophic border. The cephaloid shift of the atrophic area occured suddenly. The cumulative progression rate of atrophic patterns was 6% after 2 years, 22% after 4 years, 34% after 6 years and 43% after 10 years. These atrophic changes were related to neutrophil infiltration. CONCLUSION: The progression of atrophic gastritis is a result of chronic active gastritis caused by H. pylori infection.

New mathematical model for accurate description of absorption kinetics of paracetamol given orally with a high calorie liquid meal.

OBJECTIVE: Gastric emptying (GE) of liquids is quantified as the rate of paracetamol absorption in clinical and research settings (paracetamol method). A conventional 1-compartment model assumes the first-order rate kinetics for paracetamol absorption. This assumption seems improper when paracetamol is coingested with a caloric liquid meal, because the caloric liquid leaves the stomach at a constant rate (zero-order process). Theories based on the 1-compartment model reveal that tmax and Cmax/AUCinfinity accurately reflect the rate of paracetamol absorption, but whether this is also the case when paracetamol is administered with a caloric liquid, has not been investigated. The aims of this study were to propose a new mathematical model for accurately describing absorptive behaviors of paracetamol added to a caloric liquid meal, and, using the model, to clarify the characteristics of tmax and Cmax/AUCinfinity as rate parameters. METHODS: Based on the newly developed model, tamx and Cmax/AUCinfinity were mathematically expressed in terms of GE rates. Subsequently, the characteristics of tmax and Cmax/AUCinfinity were elucidated by simulation works. RESULTS: The simulation study showed that both tamx and Cmax/AUCinfinity could reflect GE rates, tmax was a more sensitive index of GE than Cmax/AUCinfinity and tmax was less reliable than Cmax/AUCinfinity if GE is very rapid. CONCLUSIONS: In the paracetamol method using a caloric liquid test meal, tmax and Cmax/AUCinfinity are suitable for detecting delayed and rapid GE, respectively.

Primary sclerosing cholangitis complicated with idiopathic thrombocytopenic purpura.

We present a 66-year-old woman with primary sclerosing cholangitis (PSC) complicated with idiopathic thrombocytopenic purpura (ITP). Both PSC and ITP are considered to reflect an immunological disturbance. However, their coexistence is very rare and to the best of our knowledge this is only the second reported case. In Japan, PSC patients are rarely treated with liver transplantation. Fortunately, the present patient underwent successful hepatic transplantation from a brain-dead donor and simultaneous splenectomy. This case emphasizes the importance of liver transplantation as an effective treatment for primary sclerosing cholangitis.

Use of salivary acetaminophen concentration to assess gastric emptying rate of liquids.

The gastric emptying rate (GER) of liquids can be quantified by calculating the rate of acetaminophen absorption from serial plasma concentrations. As acetaminophen concentrations in saliva are well correlated with those in plasma, the salivary concentrations may be suitable for use in GER measurement. To evaluate such suitability, salivary and plasma samples were simultaneously obtained from seven healthy volunteers at 0, 0.25, 0.5, 0.75, 1.0, 1.5, and 2.0 h after they had ingested 20 mg/kg of acetaminophen mixed with a 200-ml liquid meal (200 kcal). Commonly used parameters for the rate of acetaminophen absorption were calculated from the salivary and plasma data, including the maximum concentration (Cmax), the time to Cmax (t(max)), the concentration at 0.75 h (C0.75), the area under the curve from 0 to 1.0 h (AUC1.0), and the AUC(0.5)/AUC(2.0) ratio. The mean (SD) salivary/plasma concentration ratio was 2.48 (1.47) at 0.25 h, and the means were almost unity afterwards. Significant correlations between saliva and plasma were found in all parameters studied (r = 0.77-0.90; P < 0.05). However, except for t(max), the salivary parameters overestimated those of plasma. The present results suggest that: (1) the salivary acetaminophen concentration at 0.25 h (C0.25) is a poor reflection of plasma C0.25 (2) thereby the parameters embodying salivary C0.25 such as AUC1.0 and the AUC0.5/AUC2.0 ratio, are unreliable, and (3) liquid GER can be assessed by salivary t(max) with minimal distress to the patient.

[Troglitazone for treatment of polycystic ovary syndrome].

Polycystic ovary syndrome(PCOS) is characterized by clinical symptoms such as menstrual dysfunction, unovulatory infertility, masculinization, obesity, polycystic ovary by ultrasound, and endocrine abnormalities such as hyperandrogenism, and elevated LH to FSH ratio. Recent reports suggest that insulin resistance plays an important role in the pathogenesis of PCOS, and several insulin sensitizing agents have been used for the treatment of PCOS. Troglitazone, one of the thiazolidinediones, improves not only insulin sensitivity but also hyperandrogenism and ovulatory function. Troglitazone appears to be useful in treating women with PCOS. Further investigations are needed to assess the effectiveness and safety.

Pharmacokinetic characteristics of minocycline in debilitated elderly patients.

A pharmacokinetic study of minocycline was performed in 12 debilitated elderly patients who had suffered from acute bacterial respiratory infections. Serial intravenous administrations of 100 mg minocycline were performed at least 10 times (infused for 1 hour, every 12 hours). Blood samples were obtained at 0, 1, 3, and 10 hours after initiating the first and fifth dose and 1 hour after the ninth dose (total, 9 points). The serum concentrations of unchanged minocycline were measured using high-performance liquid chromatography. The obtained data were analyzed using a two-compartment model in 11 cases and a one-compartment model in 1 case. Other clinical data were also collected simultaneously. The mean age of the subjects was 82 +/- 6 years. The elimination half-lives at beta-phase averaged 25.0 +/- 16.4 hours, the volume of distribution averaged 32.9 +/- 13.4 L, and the total clearance averaged 1.14 +/- 0.49 L/h. The correlation coefficient between the expected trough concentration of minocycline in steady-state and the dose per 1 kg body weight was.54 (P =.06), suggesting that dosage should be adjusted by body weight when administered to debilitated elderly patients. The present data are considered to be important and clinically useful because little information is available concerning the pharmacokinetics of minocycline in elderly patients.

Polymorphism of the beta3-adrenergic receptor gene and weight gain in pregnant diabetic women.

Inappropriate body weight gain during pregnancy has critical effects on the outcome for both mother and fetus. Therefore, body weight gain is an important issue in the management of pregnancy in women with diabetes. A Trp64Arg substitution in the beta3-AR gene has been reported to be associated with body weight gain and obesity in non-insulin-dependent diabetes mellitus (NIDDM) subjects. The aim of this study was to elucidate the contribution of the beta3-AR gene to body weight gain during pregnancy in subjects with diabetes. We analyzed 199 diabetic patients (NIDDM/IDDM; 131/68) and patient data was obtained from the first delivery of each individual. The mean age at diagnosis of diabetes was 22.9 +/- 7.5 years (mean +/- S.D.) and the mean age at delivery was 29.8 +/- 4.5 years. A polymorphism of the beta3-AR gene was detected by PCR-RFLP using Bst OI, which recognizes a Trp64Arg substitution. The frequency of the Trp64Arg allele was 0.15 in NIDDM and 0.17 in IDDM. Among the NIDDM subjects, excess weight gain during pregnancy, as defined by maximum BMI during pregnancy minus basal BMI before pregnancy exceeding five, was observed in 12.2% of the wild-type patients, 19.2% of heterozygotes and 28.6% of homozygotes. Homozygous subjects with NIDDM tended to show excess weight gain during pregnancy, however, this trend did not reach significance. None of the IDDM homozygotes showed excess weight gain. From our study, this beta3-AR gene polymorphism cannot be excluded as a contributing factor to excess weight gain during pregnancy in NIDDM subjects.

Pharmacokinetic interaction between acetaminophen and lansoprazole.

Because of its minimal gastric toxicity, acetaminophen is the analgesic of choice for patients with gastric acid-related disorders. Because proton pump inhibitors are widely used, concomitant prescription of acetaminophen and lansoprazole would be prevalent. This crossover study was conducted to investigate an acetaminophen-lansoprazole interaction. On one occasion, each of six healthy, fasted, male volunteers ingested 1.0 g acetaminophen dissolved in 200 mL water. On another occasion, at least 1 week apart, 30 mg lansoprazole was administered orally, simultaneously with acetaminophen, after pretreatment with the same dose of lansoprazole once daily for 2 days. Plasma acetaminophen concentrations were measured at 0, 0.25, 0.5, 0.75, 1, 2, 3, 5, and 8 hours after dosing. The peak plasma concentration of acetaminophen and the time to its occurrence were significantly higher and shorter, respectively, during the lansoprazole session than during the control session. Neither the elimination half-life nor the area under the curve was significantly different between the two sessions. Lansoprazole hastens the absorption of acetaminophen solution, but little modifies its elimination rate and bioavailability.

[Pathogenesis and management of gestational diabetes mellitus].

The definition of gestational diabetes mellitus (GDM) is carbohydrate intolerance of varying degrees of severity, with onset or first recognition during pregnancy. GDM develops due to insulin resistance during pregnancy and impaired insulin secretion. The problems of GDM are increasing the risk of adverse pregnancy outcome and development of diabetes later in life in the mother. To prevent adverse perinatal outcome, it is important to screen for glucose intolerance as early in pregnancy as possible, and to control maternal hyperglycemia intensively. To reduce the risk of future diabetes in the mother, patient should control weight and increase physical activity.

No difference in seroprevalences of Helicobacter pylori infection between patients with pulmonary tuberculosis and those without.

A previous article reported a possible relationship between a history of tuberculosis and Helicobacter pylori infection. Epidemiologic similarities exist between the two infections: Mycobacterium tuberculosis and H. pylori are transmitted from person to person and the risk of acquiring them is elevated in underprivileged environment. This study was conducted to investigate the relationship between the two infections. Serum concentrations of anti-H. pylori IgG antibody were measured in 40 tuberculosis inpatients on antituberculosis chemotherapy for no more than 3 months (group I; 52.4 +/- 21.4 years of age), 43 tuberculosis inpatients on it for more than 3 months (group II; 57.3 +/- 16.3 years), and 60 nontuberculosis outpatients (control subjects; 55.9 +/- 16.7 years). H. pylori seropositivities were similar among control subjects (73.3%), group I (65%), and group II (69.8%). The difference in the antibody concentrations was significant between control subjects and group I (353.7 +/- 321.2 vs. 176.5 +/- 197.9 U/ml) but was not significant between control subjects and group II (353.7 +/- 321.2 vs. 229.9 +/- 249.5 U/ml). The seroprevalences may not be different between patients with pulmonary tuberculosis and those without, and antituberculosis therapy may not decrease the antibody concentrations.