Muthoka L. Mutinga

Normotensive blacks have heightened sympathetic response to cold pressor test.

The purpose of this study was to compare sympathetic nerve activity responses to the cold pressor test in black and white normotensive subjects. We recorded muscle sympathetic nerve activity (microneurography of the peroneal nerve), arterial blood pressure, and heart rate in 9 normotensive American blacks (24 +/- 2 years, mean +/- SEM) and 10 normotensive American whites (28 +/- 2 years) at rest and during hand immersion in ice water (cold pressor test). Body weight was not different in the two groups (72.4 +/- 3.7 versus 74.1 +/- 3.8 kg, black versus white subjects). During supine rest, mean arterial pressure (92 +/- 2 versus 93 +/- 3 mm Hg, black versus white), heart rate (66 +/- 4 versus 62 +/- 3 beats per minute, black versus white), and muscle sympathetic nerve burst frequency (12 +/- 2 versus 17 +/- 3 bursts per minute, black versus white) were not different in the two groups. During the cold pressor test, mean arterial pressure, heart rate, and muscle sympathetic nerve activity increased from supine rest in both groups. The magnitudes of increases in mean arterial pressure and total minute muscle sympathetic nerve activity were significantly greater in blacks than whites (33.5 +/- 3 versus 22.4 +/- 3 mm Hg and 416 +/- 24% versus 243 +/- 31% of control, respectively, black versus white, P < .05). The increases in heart rate were most significantly different for the two groups. These data suggest that the enhanced pressor response to cold stress observed in normotensive blacks is attributable to greater increases in peripheral sympathetic nerve activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Does mortality occur early or late in acute pancreatitis

SummaryAbstract: Several prior studies have suggested that 80% of deaths in acute pancreatitis occur late as a result of pan-creatic infection. Others have suggested that approx half of deaths occur early as a result of multisystem organ failure. The aim of the present study was to determine the timing of mortality of acute pancreatitis at a large tertiary-care hospital in the United States.Methods: Patients with a diagnosis of acute pancreatitis (ICD-9 code 577.0) admitted to Brigham and Women’s Hospital from October 1, 1982 to June 30, 1995 were retrospectively studied to determine total mortality, frequency of early vs late deaths, and clinical features of patients with early (≤14 d after admission) or late deaths (>14 d after admission).Results: The overall mortality of acute pancreatitis was 2.1% (17 deaths among 805 patients). Eight deaths (47%) occurred within the first 14 d of hospitalization (median d 8, range 1–11 d), whereas 9 occurred after 14 d (median d 56, range 19–81). Early deaths resulted primarily from organ failure. Late deaths occurred postoperatively in 8 patients with infected or sterile necrosis and 1 patient with infected necrosis treated medically. Conclusion: Approximately half of deaths in acute pancreatitis occur within the first 14 d owing to organ failure and the remainder of deaths occur later because of complications associated with necrotizing pancreatitis. Improvement in mortality in the future will require innovative approaches to counteract early organ failure and late complications of necrotizing pancreatitis.

Validation of a clinical prediction rule for severe acute lower intestinal bleeding.

OBJECTIVES:Acute lower intestinal bleeding is a heterogeneous disorder and identification of high-risk patients is challenging. We previously retrospectively identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to prospectively validate a clinical prediction rule for severe acute lower intestinal bleeding.METHODS:This was a prospective, observational cohort study of consecutive patients admitted to an academic, tertiary care or a community-based teaching hospital for management of acute lower intestinal bleeding. Data were collected on seven previously identified predictors of severe bleeding: heart rate ≥ 100/min, systolic blood pressure ≤ 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 h of evaluation, aspirin use, and >2 comorbid conditions. Severe bleeding was defined as transfusion of ≥2 units of red blood cells, and/or a decrease in hematocrit of ≥20% in the first 24 h, and/or recurrent rectal bleeding after 24 h of stability (accompanied by a further decrease in hematocrit of ≥20%, and/or additional blood transfusions, and/or readmission for acute lower intestinal bleeding within 1 wk of discharge). Patients were stratified into 3 risk groups according to the previously developed prediction rule: low (no risk factors), moderate (1–3 risk factors), and high (>3 risk factors).RESULTS:A total of 275 patients with acute lower intestinal bleeding were identified. The risk of severe bleeding in each risk category was similar in the validation and derivation cohorts (p values >0.05): low risk 6% versus 9%, moderate risk 43% versus 43%, and high risk 79% versus 84%. The area under the receiver operating characteristic curve was 0.754 for the validation cohort and 0.761 for the derivation cohort. The magnitude of the risk score was significantly correlated with major clinical outcomes including surgery, death, blood transfusions, and length of stay.CONCLUSION:We have developed and prospectively validated a clinical prediction rule for acute severe lower intestinal bleeding. This prediction rule could improve the triage of patients to appropriate levels of care and interventions, and guide a more standardized approach to acute lower intestinal bleeding.

Development and Validation of a Colon Cancer Risk Assessment Tool for Patients Undergoing Colonoscopy

OBJECTIVES:Diagnostic criteria for hereditary colorectal cancer (CRC) are complex. “Open-access” colonoscopy makes it challenging to identify who needs genetic evaluation, intensive surveillance, and screening for extracolonic tumors. Our aim was to develop a simple, preprocedural risk assessment tool to identify who may be at highest risk for CRC.METHODS:A total of 631 outpatients undergoing colonoscopy at two academic practices completed a questionnaire assessing personal and family histories of CRC, polyps, and Lynch syndrome (LS)-associated malignancies. Subjects were considered to be high-risk if one of the nine prespecified characteristics of hereditary CRC syndromes was met. Through recursive partitioning analysis, an algorithm of fewest questions needed to capture the most high-risk individuals was developed. The results were validated in 5,335 individuals undergoing colonoscopy at five private endoscopy centers and tested in 285 carriers of mismatch repair mutations associated with LS.RESULTS:About 17.7% and 20.0% of individuals were classified as high-risk in the development and validation cohorts, respectively. Recursive partitioning revealed three questions that were most informative for identifying high-risk patients: (i) “Do you have a first-degree relative with CRC or LS-related cancer diagnosed before age 50?” (ii) “Have you had CRC or polyps diagnosed before age 50?” (iii) “Do you have ≥3 relatives with CRC?” When asked successively, these questions identified 77% of high-risk individuals in both cohorts and 271 of 285 (95%) of mutation carriers.CONCLUSIONS:Approximately one in five individuals undergoing colonoscopy would benefit from further risk assessment. We developed a simple, three-question CRC Risk Assessment Tool to identify the majority of patients who require additional assessment and possible genetic evaluation.

The Clinical Significance of Right-sided Colonic Inflammation in Patients with Left-sided Chronic Ulcerative Colitis

Background:Rarely, patchy right colonic inflammation has been observed in patients with left sided chronic ulcerative colitis (CUC), but the clinical significance of this finding is unknown. Therefore, the aim of this study was to evaluate the clinical and pathologic features and natural history of CUC patients with left-sided colitis combined with patchy right colonic inflammation and to compare the clinical course to a control group of patients with isolated left-sided CUC. Methods:Twelve patients with clinically and pathologically confirmed left-sided CUC, but also with patchy right colonic inflammation, were identified from a cohort of 352 consecutive patients with CUC who underwent colonoscopy at the Brigham and Womens Hospital between 1996 and 2000. In this cohort, 127 patients had left-sided colitis. As the first study to use controls in this setting, 35 consecutive patients with left-sided CUC, but without patchy right colonic inflammation, were selected and evaluated during the same time period. In all patients, the medical records were reviewed for a wide variety of clinical, endoscopic, and pathologic features. The mean follow-up time for the study and control groups was 105 ± 128 and 112 ± 80 months, respectively. Results:Patients in the study group were significantly older than the control group at the time of diagnosis (47 ± 17 years vs 35 ± 14 years, p = 0.048), but the two groups had a similar gender distribution (25% male vs 40% male), prevalence of extraintestinal manifestations (25% vs 11%), frequency of nonsteroidal anti-inflammatory drug use (75% vs 50%), family history of colitis (27% vs 15%), current tobacco use (8% vs 3%), history of appendectomy (8% vs 0%), and overall severity of disease (33% vs 46%). None of the patients in the study group, and only one control patient, had disease progression to pancolitis. One study patient developed high-grade dysplasia in the rectum that required a colectomy. None of the study or control patients developed clinical or pathologic features of Crohns disease. Conclusions:Rarely patients with left-sided CUC may have patchy right colonic inflammation. The clinical features and natural history of patients with left-sided CUC and patchy right colonic inflammation is similar to patients with isolated left-sided CUC.

Race, Family History of Hypertension, and Sympathetic Response to Cold Pressor Testing

This laboratory recently reported that the blood pressure and muscle sympathetic nerve activity (MSNA) responses to cold pressor testing are greater in normotensive blacks than in age- and weight-matched normotensive whites. The present study was designed to determine the relationship between race, family history of hypertension, and sympathetic response to cold pressor testing. The study used microneurography to measure MSNA responses to cold pressor testing in normotensive blacks with (n = 8) and without (n = 8) and normotensive white subjects with (n = 8) and without (n = 10) a positive family history of hypertension. Resting blood pressure was lower in black subjects without a positive family history of hypertension but otherwise resting blood pressure, heart rate, and MSNA were similar in the four groups. Black subjects with a family history of hypertension manifested a greater increase in blood pressure and MSNA than both white groups. Blood pressure and sympathetic responses of black subjects with a negative family history of hypertension tended to be intermediate and were not statistically different from the other three groups. These results indicate that the greater sympathetic response to cold stress observed in normotensive African-Americans is true only of black subjects with a positive family history of hypertension.

The nature of after-hours telephone medical practice by GI fellows

Abstract OBJECTIVE: Gastroenterology fellows on-call often serve as the initial or only contact for patients calling “after hours” with questions and symptoms. These fellows are rarely trained specifically in how to handle these calls. The aim of this study was to determine whether there are particular topics in telephone medicine that ought to be covered in new fellow training. Therefore, we sought to evaluate the nature of after-hours pages initiated by patients and to document the advice given by fellows. METHODS: The content of 100 patient-initiated telephone calls with GI fellows was recorded prospectively over 7 months. We included pages received between 5 PM and 8 AM daily as well as daytime calls on weekends. Fellows documented the time and length of the call, the issue raised by the patient, the advice given, and the patient’s gender and attending gastroenterologist. When a particular patient paged more than once in a 24-h period, the repeat calls were not counted toward the 100-call tally. RESULTS: Twenty-two percent of calls occurred between 11 PM and 7 AM. Eighty-three percent of calls lasted less than 10 min. Sixty-seven percent of patients called because of symptoms. Only 30% of patients calling with symptoms were referred to the emergency room. Although only 1 of 13 patients with procedure-related (i.e., postendoscopy) symptoms required admission to the hospital, 18 of 54 (33%) patients with nonprocedure-related symptoms required admission either immediately or within a month of calling after hours. CONCLUSIONS: Most after-hours calls from patients are related to symptoms. Patients calling with postprocedure symptoms rarely require admission to the hospital. Conversely, a significant number of patients calling with nonprocedure-related symptoms require admission within 30 days. Fellowship directors should consider providing training to fellows in the evaluation of symptoms over the telephone.

Successful desensitization to 6-mercaptopurine in a patient with Crohn's disease.

1. Aho AJ, Heinonen R, Lauren P. Benign and malignant mucocele of the appendix. Acta Chir Scand 1973;139:392–400. 2. Landen S, Bertrand C, Maddern GJ, et al. Appenciceal mucoceles and pseudomyxoma peritonei. Surg Gynecol Obstet 1992; 175:401–4. 3. Wolff M, Ahmed N. Epithelial neoplasms of the vertiform appendix. Cancer 1976;37:2511–22. 4. Jones CD, Eller DJ, Coates TL. Mucinous cystadenoma of the appendix causing intussusception in an adult. Am J Gastroenterol 1992;5:898–9. 5. Deans GT, Spence RAJ. Neoplastic lesions of the appendix. Br J Surg 1992;82:299–306. 6. McGinnis HD, Chew FS. Mucin-producing adenoma of the appendix. Am J Roentgenol 1993;160:1046.

Postpartum Laboratory Follow-up in Women With Hepatitis B in Massachusetts From 2007 to 2012.

Goals: To determine postpartum hepatitis B virus (HBV) laboratory testing rates and identify factors associated with a lack of follow-up testing in Massachusetts. Background: Screening for HBV infection in pregnant women is standard of care. Guidelines recommend that patients with chronic HBV have ongoing care and laboratory testing, but little is known about postpartum maternal HBV care outcomes. Study: We conducted a retrospective cohort study using Massachusetts Virtual Epidemiologic Network, an electronic public health surveillance system maintained by the Massachusetts Department of Public Health. We identified women who tested hepatitis B surface antigen positive during their first reported (index) pregnancy in Massachusetts from 2007 to 2012 and measured HBV-related laboratory tests reported to Massachusetts Department of Public Health during and after pregnancy. Results: We identified 983 hepatitis B surface antigen positive pregnant women. Half (492/983) did not have evidence of additional postpartum HBV laboratory testing following their index pregnancy. Women who had postpartum laboratory tests reported were younger [mean age (SD): 29 (5.3) vs. 31 (5.5) y, P=0.0001] and more likely to have >1 pregnancy during the study period (41% vs. 1%, P<0.0001). There were no differences in race, ethnicity, and US born status. On multivariable logistic regression, older age predicted a lower likelihood of having postpartum laboratory testing (odds ratio, 0.77; 95% confidence interval, 0.70-0.90). Conclusions: Postpartum maternal HBV follow-up laboratory testing occurred in only half of Massachusetts women and did not vary by race, ethnicity, or US born status. Our results were limited to a single state surveillance database, which likely underestimates the number of tests ordered.

Peripartum Care for Mothers Diagnosed with Hepatitis B During Pregnancy: A Survey of Provider Practices

Objectives Hepatitis B (HBV) remains a significant public health burden, despite effective therapy. Routine HBV screening is recommended during pregnancy to reduce the risk of vertical transmission, but the rates of follow-up care peri-partum are low. The aim of this study was to evaluate physician practices and knowledge regarding HBV in women diagnosed perinatally. Methods A survey was distributed to obstetricians and midwives within the Partners HealthCare system at Brigham and Women’s Hospital and Massachusetts General Hospital. Results Of 118 survey respondents (response rate 56%), 97% reported that they always tested for hepatitis B, and 77% referred new diagnoses of HBV during pregnancy to a HBV specialist for further care. Only 10% of respondents reported that there was formal referral mechanism in place to facilitate follow-up care for mothers diagnosed with hepatitis B infection. 91% of survey respondents selected hepatitis B surface antigen as the correct screening test, and 76% selected hepatitis B immune globulin with vaccination for the newborn as the correct prophylaxis regimen. Only 40 and 51% of respondents accurately identified serologies that were consistent with acute and chronic infection, respectively. Conclusions for Practice Routine screening for HBV in this population presents an important opportunity to identify cases and to reduce the public health burden of this disease. Providers were somewhat knowledgeable about HBV, but the lack of formal referral mechanism may explain why HBV follow-up is suboptimal in this healthcare system. Supplemental provider education and formal linkage to care programs may increase rates of follow-up HBV care.