Journal of the Association for Academic Minority Physicians : the official publication of the Association for Academic Minority Physicians最新文献

Information on ethnicity as related to gallstones has been limited by insufficient or inaccurate characterization of ethnicity. Nevertheless, in recent years, ultrasonography has allowed limited examination of ethnic differences in the risk of gallbladder disease, defined by a history of cholecystectomy or ultrasonographic detection of gallstones. Among women, the risk of gallbladder disease is highest among American Indians, followed by Hispanics, non-Hispanic whites, and non-Hispanic blacks. Men differ from women by having lower risk in all ethnic groups and by having a similar prevalence between Hispanics and non-Hispanic whites. It does not appear that the type of stone differs much according to ethnic group in the United States. Well-known risks for gallbladder disease, such as obesity, weight loss, pregnancy, and low alcohol use do not explain differences in ethnic risk. As yet, genetic markers have not been identified that would explain differences in risk among ethnic groups. Higher case fatality rates among non-Hispanic blacks than non-Hispanic whites suggest that blacks may have inadequate access to medical care for gallbladder disease.

It is well recognized that nonsteroidal antiinflammatory drugs (NSAIDs) induce gastrointestinal (GI) ulcerations, perforation and bleeding, which clearly limit their therapeutic value. The recent introduction of NSAIDs with selective cyclooxygenase-2 (COX-2) inhibitory effect is a major pharmacologic milestone in therapeutics. Selective COX-2 inhibitors exhibit considerable dissociation between their antiinflammatory/analgesic action and their GI toxicity. However, from a therapeutic consideration, there are still several unresolved and confusing issues with these drugs such as: the pharmacologic classification of the COX-2 selectivity; therapeutic value as antirheumatic/analgesic drugs; potential toxicity in patients at risk for the development of ulcer-related complications or patients with inflammatory bowel disease and potential renal toxicity. Although existing clinical efficacy studies with celecoxib and rofecoxib, two selective COX-2 inhibitors, were associated with considerably lower ulcerogenic rates when compared with nonselective NSAIDs, there are no long term outcome studies with these drugs similar to the MUCOSA trial performed with misoprostol. Furthermore, the selectivity of COX-2 inhibitors appears to be specific to the stomach and duodenum but not the kidney. While awaiting additional long term studies with selective COX-2 inhibitors, we recommend instituting prophylactic therapy with misoprostol in patients at risk for the development of ulcer related complications. In conclusion, we believe that the introduction of selective COX-2 inhibitors will revolutionize the treatment of pain and inflammation. However, additional basic and clinical studies are required to address the pharmacologic and therapeutic uncertainties for this class of drugs.

Gastroesophageal reflux disease (GERD) is one of the most frequently encountered illnesses in the Western Hemisphere. GERD encompasses a spectrum of disorders in which reflux of gastric content into the esophagus causes symptoms and/or damage to the esophagus, oropharynx, or respiratory tract. This article provides a brief update on the pathophysiology and pharmacology of drugs used for the treatment of GERD. The etiology of GERD is multi-factorial and is believed to be principally a consequence of altered motility states in the esophagus and stomach. The drugs used for the treatment of GERD are continuously evolving, but as yet no drug has been shown to cure this chronic, relapsing disease. Antacids, prokinetics, and gastric antisecretory agents are the principal drugs currently used to treat GERD in conjunction with life-style modifications. Due to their ultrashort duration of buffering action, antacids are primarily used as self-medication for temporary relief of mild GERD symptoms. The prokinetic drug cisapride effectively resolves symptoms and heals mild-to-moderate esophagitis, with efficacy similar to that of the histamine H2-receptor antagonists. H2-receptor antagonists exhibit moderate inhibition of gastric acid secretion and are effective for resolving symptoms and healing mild-to-moderate esophagitis. In addition, H2-receptor antagonists slightly augment the therapeutic efficacy of cisapride for healing mild-to-moderate esophagitis. However, use of H2-receptor antagonists at higher doses and higher frequency approaches the efficacy of proton pump inhibitors in healing erosive esophagitis. Given their potent and long-lasting acid-reducing efficacy, proton pump inhibitors have become the drugs of choice for many patients with GERD. Despite progress in the medical treatment of GERD, there are still several unresolved questions relating to cost-effective strategies with specific drugs, how long pharmacologic therapy should be maintained, and when surgical intervention is warranted. Additional studies are clearly needed to address the unresolved treatment issues in GERD.

Technical advances are changing the attitude toward surgery as a last-resort treatment option for gastroesophageal reflux disease (GERD). Although a number of effective medications are currently available to manage GERD, surgery is definitive therapy, and its results are long-term, eliminating both medication compliance problems and the high cost of lifelong drug therapy. Numerous procedures are available for GERD; laparoscopic Nissen fundoplication is emerging as highly suitable and successful for most patients with simple GERD. For the best clinical result, however, the procedure must be tailored to the patient's disease and to the preoperative study results of esophageal pathology and function. The multidisciplinary collaboration of the gastroenterologist, radiologist, and surgeon will be key to the future management of GERD.

This study tested the hypothesis that diminished exocrine pancreatic function observed in Cu(2+)-deficient rats is associated with alterations in the cholecystokinin (CCK) signal transduction pathway. Male Sprague-Dawley rats were maintained on either a control diet (11 ppm Cu2+) or a Cu(2+)-deficient diet containing 6000 ppm triethylenetetramine tetrahydrochloride. For the duration of the study rats had free access to water and food. After 4 weeks, rats were sacrificed and pancreatic acini isolated for measurement of amylase content, cholecystokinin-stimulated amylase release and total inositol phosphate formation. Plasma Cu2+ levels were significantly (P < 0.05) decreased in rats on a Cu(2+)-deficient diet (19.2 +/- 3.4 micrograms Cu2+/dL), compared with the control diet (77.0 +/- 3.5 micrograms Cu2+/dL). Both amylase content of pancreatic acini and total CCK-8-stimulated amylase release were significantly decreased in Cu(2+)-deficient rats. In addition, Cu(2+)-deficient rats exhibited a decrease (153.5 +/- 30.9%) in the magnitude of CCK-8-stimulated total inositol phosphate formation compared with control rats (220.8 +/- 11.9%). Moreover, CCKA receptor affinity on pancreatic membranes was not significantly altered by Cu(2+)-deficiency, while CCKA receptor density was significantly (P < 0.05) decreased in Cu(2+)-deficient rats. The addition of Cu2+ to the binding assay of Cu(2+)-deficient rats did not restore receptor density to control values. The data demonstrates that adequate dietary intake of Cu2+ is important to maintain the functional integrity of the exocrine pancreas.

Inflammatory bowel disease primarily affects adolescents and young adults, presenting management concerns for obstetricians caring for these women during pregnancy. Interdisciplinary care by the obstetrician and gastroenterologist and selection of individual courses of management produce pregnancy outcomes that approach those of an unaffected population. Routine medical management using glucocorticoids, metronidazole, and asacol derivatives as well as more aggressive therapy using immunomodulators azathioprine and 6-mercaptopurine are shown to be of low risk to the fetus. Effective medical management greatly reduces need for surgical intervention during pregnancy. An understanding of current management perspectives assures positive pregnancy outcomes for mother and infant.

Gastroesophageal reflux disease (GERD) is defined as the presence of symptoms and/or tissue damage resulting from the reflux of gastric contents into the esophagus. It occurs as a result of transient or persistent reduction in lower esophageal sphincter (LES) pressure, influenced to some degree by the presence or absence of a hiatal hernia, and the failure of the usual clearance mechanisms that normally rid the distal esophagus of noxious materials. Heartburn and regurgitation are the most common symptoms, but extraesophageal symptoms related to aspiration may occur. The clinical presentation itself is often diagnostic, but techniques such as endoscopy, barium swallow, and pH monitoring are confirmatory. Management generally involves life-style changes with or without added pharmacologic therapy. A small percentage of patients require antireflux surgery. Pharmacologic management options include acid-neutralizing agents such as antacids and alginate, prokinetic agents such as metoclopramide and cisapride, and antisecretory drugs such as the histamine H2 blockers and the proton pump inhibitors. Once the patient is healed pharmacologically, maintenance pharmacologic therapy is necessary to prevent relapse. Antireflux surgery may be indicated in patients whose diagnosis is clear, who respond well to pharmacologic therapy, but who, for one reason or another, are not candidates for long-term pharmacologic management. Preventing the advent of Barrett's esophagus is one goal of therapy, because of the risk of developing adenocarcinoma of the esophagus. The management of Barrett's esophagus is discussed.

Aging patients often complain about chronic ocular irritation, which is commonly related to dryness of the eyes. To determine the effect of hormone replacement therapy (HRT) on ocular complaints and tear production, we compared these parameters in postmenopausal women who were taking or not taking HRT. A questionnaire was administered to determine the number of ophthalmic complaints of 79 women who were postmenopausal at least 1 year (mean, 22 +/- 13.5 years) and were not using any ophthalmic drops or medication known to contribute to dry eyes. A Schirmer test with anesthesia was performed on each subject to quantify tear production. We found that the number of ophthalmic complaints of women taking HRT was statistically fewer (P = 0.015) than women not taking HRT. Women taking HRT for 5 years or longer had statistically fewer complaints and greater tear production, as measured by the Schirmer test, than women taking HRT for 5 years or less. The study concluded that women taking HRT have significantly fewer ocular complaints than women not taking HRT. HRT may help alleviate symptoms related to ocular dryness in postmenopausal women.