Charles Lucas

Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center.

BACKGROUND This study was performed to elucidate the etiology, effectiveness of diagnostic and therapeutic modalities, and outcomes in patients with acute lower gastrointestinal bleeding. METHODS A retrospective review of the medical records of 1,112 consecutive patients admitted to the surgical service of a single urban emergency hospital with lower gastrointestinal bleeding from 1988 to 2006. Two groups were compared: 1988-1997 and 1998-2006. RESULTS All patients underwent colonoscopy, 33.2% within 24 h of admission. Hematochezia was the most frequent presentation (55.5%), followed by maroon stool (16.7%) and melena (11.0%). Most patients, 690 (62.1%) also had upper endoscopy. Sixty-six patients subsequently had barium enemas. Eleven of 27 nuclide scans were positive. Arteriography was performed on 22 patients, with 11 positive results and 2 therapeutic. No statistical difference was found in procedures performed in our 2 time periods. Diverticulosis (33.5%), hemorrhoids (22.5%), and carcinoma (12.7%) were the most common etiologies with the diagnosis of diverticulosis more common in the 1998-2006 time period. The small bowel was the source in 14 total patients. Spontaneous cessation of the bleeding occurred in 863 (77.6%) patients. Endoscopic control increased from 1% in 1997-1998 to 4.4% in 1998-2006 (P < .05) with a corresponding decrease in the need for operative control from 22.6% to 16.6% in this same time period (P < .05). Furthermore, among elective operations, there was a decrease in right hemicolectomies from 31.6% of total elective cases to 13.9% (P < .05). Emergent operations were needed in 3.4% and 4.8% of patients. The readmission rate did not change over time and was 5.2% overall with >50% because of diverticular bleeding. CONCLUSION In this urban setting, diverticulosis, hemorrhoids, and carcinoma were the most common causes of severe acute lower gastrointestinal bleeding (LGIB) with diverticular bleed causing the highest recurrence. Colonoscopy allows for diagnosis in most patients with severe acute LGIB requiring hospitalization. Furthermore, it is now being used more effectively for hemostasis resulting in less operative intervention to control bleeding.

Impact of ethnicity on left ventricular mass and relative wall thickness in essential hypertension

This study was designed to evaluate the impact of ethnicity on left ventricular (LV) mass, and relative wall thickness in 527 patients (57% men, mean age 60 +/- 7 years) with mild to moderate high blood pressure. There were 63% Caucasians, 21% African-Americans, and 16% Hispanics. LV mass was indexed according to body surface area, height, and height to the allometric power of 2.7. Relative wall thickness included the 4 widely recognized patterns: normal, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. LV mass indexed to body surface area was similar among all 3 ethnic groups (Caucasians 117.1 g/m2, African-Americans 119.2 g/m2, Hispanics 122.7 g/m2); however, when indexed to height and height to the power of 2.7, Hispanics had slightly larger masses than the other 2 groups (Hispanics 168.1 and 73.3 g/m2.7 vs Caucasians 159.8 and 64.4 g/m2.7 [p = NS and p < 0.005]; and vs African-Americans 164.8 and 69.2 g/m2.7 [p = NS for both]). Using body surface area, the concentric remodeling was the predominant form of cardiac adaptation in Caucasians (36%) and African-Americans (42%), whereas the concentric hypertrophy pattern was 38% in Hispanics. Using indexing for both height and height to the power of 2.7, the concentric hypertrophy pattern predominated in all 3 ethnic groups (Caucasians 48% and 51%; African-Americans 68% and 66%; Hispanics 59% and 65%). In conclusion, because of the independent impact of weight on high blood pressure, LV mass adjusted to height or to height at the power of 2.7 should be reported in population studies. The concentric hypertrophy pattern--classic LV response to pressure overload conditions--is better represented when LV mass is indexed to height or to height to the allometric power of 2.7 than to body surface area.

Multicenter clinical evaluation of long-term efficacy and safety of labetalol in treatment of hypertension

The long-term efficacy and safety of labetalol, an antihypertensive agent with combined beta- and alpha-blocking activity, were evaluated alone (number = 193) and in combination with a diuretic (number = 144) in an open-label multicenter trial of 337 hypertensive patients aged 21 to 75 years, including initially 205 (61 percent) men and 219 (65 percent) Caucasians. There were 219 (65 percent) mild, 85 (25 percent) moderate, and 33 (10 percent) severe hypertensive patients. Labetalol (100 to 1,200 mg twice a day) alone or in combination with a diuretic reduced the mean standing blood pressure by 13/11 and 25/16 mm Hg to 135/88 and 130/91 mm Hg, respectively (p less than 0.01), and supine blood pressure by 6/7 and 18/13 mm Hg to 141/86 and 138/90 mm Hg (p less than 0.01), respectively. Blood pressure reductions observed at one month were maintained after one year; 206 (62 percent) patients had 10 mm Hg or greater reductions and 184 (56 percent) patients were maintained at diastolic blood pressures less than 90 mm Hg. Most frequently reported drug-related side effects included fatigue (14 percent), dizziness (12 percent), nausea (11 percent), nasal stuffiness (8 percent), headache (4 percent), and male sexual dysfunction (14 percent). Side effects were generally of mild to moderate intensity and often transient. In addition, in 27 (8 percent) patients reversible asymptomatic transaminase elevations to greater than twice normal developed at some time during the study. In 13 (4 percent) patients these alterations resolved during continued labetalol therapy, but in five (2 percent) patients these marked elevations led to discontinuation of the drug. A total of 32 (9.5 percent) patients were terminated prematurely due to side effects (most commonly genitourinary or gastrointestinal) possibly attributable to the drug. These findings indicate that labetalol with or without a diuretic is a potentially effective, safe, and relatively well-tolerated long-term antihypertensive therapy.

Cecal perforation due to adynamic ileus.

SummaryThree cases of cecal perforation due to adynamic ileus are described—one following fracture of the right femur and two following elective surgical procedures consisting of routine herniorrhaphy and transthoracic vagotomy. The mechanism of perforation is though to be ischemia and gangrene on the antemesenteric border of the cecum, due to stretching and narrowing of the nutrient vessels during distention. Cecostomy and decompression are the treatment recommended.

Role of left ventricular hypertrophy in diastolic dysfunction in aged hypertensive patients.

Objective To evaluate the influence of left ventricular hypertrophy (LVH) on the diastolic dysfunction in older hypertensive patients. Methods In total 665 patients (58% men, 61% White, aged 55–80 years) with mild-to-moderate essential hypertension underwent Doppler echocardiography. Data included left ventricular dimensions, left ventricular mass index, body mass index, E- and A-wave mitral flow velocities, E:A ratio, deceleration time and three mitral flow patterns [normal (E:A ratio >1.0, deceleration time >150 ms), impaired relaxation (E:A ratio <1.0, prolonged deceleration time according to age), and restrictive physiology (E:A ratio >2.1, deceleration time <150 ms)]. Data were distributed according to age (50–59, 60–69, and 70–80 years). Results The overall prevalence of sex-adjusted LVH in this study was 65%. When we compared hypertensive patients with and without LVH, the E- and A-wave velocities, E:A ratio, and deceleration time were similar. Moreover, the prevalences of normal, impaired relaxation, and restrictive physiology patterns among patients with and without LVH did not differ significantly (20, 79.5, and 0.5 versus 24, 75.5, and 0.5%). When the mitral flow patterns were adjusted according to age, the impaired relaxation pattern increased further with age (to 73% during the fifth decade, 83% during the sixth decade, and 88% during the seventh decade). Conclusions LVH is not an independent factor associated with abnormal flow patterns in hypertensive patients aged over 50 years with normal systolic contractility. The impaired relaxation is the predominant pattern of diastolic dysfunction in older hypertensive patients and increases further with aging.

Influence of beta2 agonism and beta1 and beta2 antagonism on adverse effects and plasma lipoproteins: Results of a multicenter comparison of dilevalol and metoprolol

Dilevalol combines vasodilation due to selective beta 2 agonism and nonselective beta antagonism. We studied 311 patients randomized to dilevalol and 138 to metoprolol in a multicenter trial. After a 4-week placebo washout, dilevalol was titrated from 200 to 1,600 mg once daily and metoprolol from 100 to 400 mg to a goal supine diastolic blood pressure less than 90 and greater than or equal to 10 mm Hg decrease from baseline. Responders were followed for 1 year. The average age of patients was 51 years; 72% were men and 54% were white. Both drugs reduced blood pressure effectively to a similar level. Fewer patients discontinued dilevalol than did those taking metoprolol (9 vs 16%; p less than 0.03). More metoprolol-treated patients withdrew because of depression (6 vs less than 1%; p = 0.03) and impotence (5 vs less than 1%; p = 0.03). Lipoprotein levels before and after treatment were measured in 99 patients treated for 53.5 weeks with dilevalol (mean dose 438 mg). Dilevalol increased high-density lipoprotein (HDL) cholesterol by 2.5 mg/dl to 47.2 (p = 0.05), reduced low-density lipoprotein (LDL) cholesterol by 2.5 mg/dl, increased HDL/LDL by 0.03, and decreased total cholesterol/HDL cholesterol by 0.18. Triglycerides increased by 21 mg/dl (p = 0.06). In patients with an initial HDL cholesterol less than 35 mg/dl, dilevalol increased it by 9 mg/dl. In patients treated with metoprolol, the only significant change (p = 0.02) was a 41.9-mg/dl increase in triglyceride levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Achieving therapeutic goals in insulin-using diabetic patients with non-insulin-dependent diabetes mellitus: A weight reduction-exercise-oral agent approach

Non-insulin-dependent diabetes mellitus (NIDDM) is the most common form of diabetes in the civilized world. Its consequences include microvascular and macrovascular disease, both of which appear to evolve from a common background of obesity and physical inactivity. The current study was undertaken in obese patients with NIDDM to see whether improvements could be made in glycemic control as well as in many cardiovascular risk factors (obesity, hypertension, lipid abnormalities, and physical inactivity) that are typical of this condition. Fifteen obese insulin-using patients with NIDDM (average body mass index, 34.0) were treated with a 500-calorie formula diet for eight to 12 weeks. Administration of insulin and diuretics was discontinued at the onset of the study. A eucaloric diet was begun at eight to 12 weeks and maintained until Week 24. A behaviorally oriented nutrition-exercise program was instituted at the beginning of the study. Glipizide or placebo was added (randomized) at Week 15 if the fasting plasma glucose level in patients exceeded 115 mg/dl. Patients lost an average of 22 pounds over the course of 24 weeks. Frequency and duration of physical activity increased significantly from baseline, as did the maximal oxygen consumption rate. Glycemic control by 15 weeks (without insulin) was similar to baseline (with insulin). With the addition of glipizide at Week 15, both fasting plasma glucose and glucose tolerance improved significantly. This improvement was not observed with placebo. In addition, both systolic and diastolic blood pressure decreased by about 10 mm Hg. There were no significant changes in the levels of serum lipids or glycosylated hemoglobin. In conclusion, a multifaceted intervention program, employing weight reduction, exercise, diet, and glipizide therapy, can be instituted in insulin-using patients with NIDDM, with improvement in glycemic control and in certain risk factors (hypertension, obesity, physical inactivity) for cardiovascular disease.

A Study of the Efficacy and Safety of Moexipril in Mild to Moderate Hypertension.

This placebo-controlled, double-blind, multicenter study examined the efficacy, safety, and tolerability of the angiotensin-converting enzyme inhibitor, moexipril, in lowering blood pressure in mildly to moderately hypertensive patients. Patients were initially randomized into four groups, two of which received moexipril 7.5 mg per day and two received moexipril 15 mg per day, for first 12 weeks of treatment. Patients then entered a withdrawal phase with one of the groups in each dose category continuing that dose of moexipril and one receiving placebo for 12 more weeks. From 223 patients randomized initially, 190 completed the 12-week withdrawal phase. In the two dosage groups from baseline to 12 weeks, sitting diastolic blood pressure decreased from 101.1 to 92.8 mm Hg for the 7.5-mg group and from 100.7 to 91.3 mm Hg for the 15-mg group (p > 0.05 baseline to week 12 in both groups) with a significant difference between those groups attained at week 12 only (p = 0.03). By the end of the withdrawal phase (24-week evaluation), the group that continued to receive 7.5 mg moexipril decreased diastolic blood pressure by 8.2 mm Hg, whereas the corresponding placebo group decreased diastolic blood pressure by 3.7 mm Hg. Although the difference between these two groups was not significant at the 24-week end point, all other time points differed significantly between groups at p ≤ 0.017. Similarly, whereas the corresponding placebo group had a mean reduction in diastolic blood pressure of 4.6 mm Hg, the group that continued 15 mg of moexipril showed a mean diastolic blood pressure reduction of 10.6 mm Hg (p > 0.001 between groups). No comparison between the two moexipril dosage groups was significant, however, during the withdrawal phase. These results during medication withdrawal indicate that moexipril is effective in significantly lowering diastolic blood pressure.

Step II Treatment with Labetalol for Essential Hypertension

Labetalol, a new alpha- and beta-adrenergic blocking agent, was administered to 57 patients with essential hypertension whose standing diastolic blood pressure was 105 to 120 mm Hg after three and four weeks of placebo therapy and greater than 90 mm Hg after three to four weeks of therapy with hydrochlorothiazide, 25 mg twice a day. Patients were then randomly assigned on a double-blind basis to receive either labetalol, 100 mg twice a day, or placebo combined with hydrochlorothiazide. Thereafter, the dose of labetalol was titrated weekly in both groups to a maximum of 400 mg twice a day to achieve a standing diastolic blood pressure of less than 90 mm Hg that was also decreased from the hydrochlorothiazide baseline by 10 mm Hg or more (therapeutic goal). Labetalol was abruptly discontinued after four weeks of treatment and patients were given hydrochlorothiazide alone for two additional weeks. After one week of labetalol therapy, 100 mg twice a day (added to hydrochlorothiazide), there was a significantly greater reduction in supine systolic/diastolic blood pressure (6/5 mm Hg, p less than 0.04/less than 0.03) and standing blood pressure (9/7 mm Hg, p less than 0.01/less than 0.01) than with placebo therapy (3/0.5 and 3/1 mm Hg, respectively). The blood pressure reduction in the labetalol-treated group was associated with a 4 and 5 beats per minute reduction in the supine and standing heart rates, respectively. The median labetalol dose required to achieve the standing diastolic blood pressure goal was 400 mg twice a day. After four weeks of labetalol treatment, the mean reduction in blood pressure from the hydrochlorothiazide baseline was 12/13 mm Hg (p less than 0.01/0.01) in the standing position and 8/8 mm Hg (p less than 0.01/0.01) in the supine position. These blood pressure reductions were accompanied by a mean reduction in heart rate of 7 beats per minute. The most frequently reported complaints other than thiazide-induced nocturia included dizziness, fatigue, nausea, rash, and/or pruritus. Most of these complaints were reported at a similar incidence while patients were receiving placebo or hydrochlorothiazide alone as when receiving labetalol with hydrochlorothiazide. After abrupt withdrawal of labetalol, no evidence of rebound hypertension was observed. Labetalol is a safe and effective step II drug when added to hydrochlorothiazide for the treatment of patients with moderate to moderately severe hypertension.

Treatment of Obese Patients with Dexfenfluramine: A Multicenter, Placebo-Controlled Study.

This randomized, placebo-controlled, double-blind study was designed to evaluate the safety and efficacy of dexfenfluramine (Dfen). Dfen 15 mg BID, and placebo were administered for 12 weeks to 337 moderately obese patients on calorically restricted diets. Patients were monitored for an additional 4 weeks. Efficacy was evaluated in 321 patients who were an average of 52% in excess of ideal body weight. Dfen-treated patients lost significantly more weight than did those treated with placebo (p ≤ 0.001). Small nonsignificant fluctuations in body weight were observed during the 4-week posttreatment period in both groups. The most common drug-related side effects were diarrhea, asthenia, dry mouth, and thirst (p ≤ 0.05 compared with placebo). Dexfenfluramine may become a valuable addition to weight loss and weight management programs.