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Biomedical subjects

R E Clouse

Publications and source records attributed to R E Clouse.

At least 37 records · Page 2Linked to original sources
PubMed1999

Esophageal motor disorders.

A consolidation of ideas regarding the pathogenesis and management of esophageal motor disorders occurred over the past year. The development and application of diagnostic techniques has stimulated new thinking about the events responsible for peristalsis and has provided novel avenues for studying mechanisms of symptom production. Achalasia remains the most investigated and understood motor disorder, and the year's research focused heavily on management approaches for this important condition. Other topics addressed in this review include proximal esophageal symptoms and disorders, spastic disorders, and esophageal hypomotility.

Journal Article↗
PubMed1999

Cyclic vomiting syndrome in adults: clinical features and response to tricyclic antidepressants.

OBJECTIVE: Cyclic vomiting syndrome (CVS) has been described infrequently in adults, and treatment in both children and adults remains unsatisfactory. We report clinical features of a group of adults with CVS and anecdotal outcome from open-label treatment with tricyclic antidepressants, medications that have some efficacy in other unexplained gastrointestinal disorders. METHODS: Clinical data were examined from 17 adult patients with CVS seen over a 10-yr period, each having been treated with a tricyclic antidepressant. Outpatient records were reviewed, clinical outcome was extracted using a priori criteria, and findings were compared with 37 patients having usual functional nausea and vomiting who also received tricyclic antidepressant therapy. RESULTS: Symptoms in CVS began at age 35 yr (range 14-73 yr); the average episode length was 6 days (range 1-21 days) and the symptom-free interval averaged 3.1 months (range 0.5-6 months). Vomiting cycles typically began without warning, and fewer than one-third of the subjects reported a prodrome or potential trigger event, such as menstrual periods, pregnancy, or large meals. Sleep was seemingly beneficial in 23.5%. Tricyclic antidepressant therapy was associated with complete remission in 17.6% and partial response in 58.8%, but was less effective than for functional nausea and vomiting (p = 0.02). CONCLUSIONS: CVS is a rare diagnosis with distinctive features in adults. Duration of episodes and cycles varies considerably across subjects. In open-label, uncontrolled use, tricyclic antidepressants appear beneficial for some subjects but are less effective in CVS than in chronic, persistent functional nausea and vomiting.

Adolescent↗
PubMed1999

Botulinum toxin injections for achalasia symptoms can approximate the short term efficacy of a single pneumatic dilation: a survival analysis approach.

OBJECTIVE: Botulinum toxin injection can induce a temporary symptomatic remission in some patients with achalasia, but the comparative utility of the approach is not fully known. This study used survival analysis methods to better understand the ability of single or repeated botulinum toxin injections to postpone the need for other treatments. METHODS: The response to botulinum toxin in 42 patients with idiopathic achalasia who had not received prior treatment was compared with the outcome in 26 consecutive patients who underwent initial treatment with pneumatic dilation. Survival analysis methods were employed using time to retreatment as the principal outcome measure. RESULTS: Retreatment (any type) was required in 50% of subjects at 265 days (0.73 yr) after the first botulinum toxin injection. In contrast, retreatment after initial pneumatic dilation was required in <40% of patients after 2 and 5 yr of follow-up. The curves became significantly separated (p < 0.05) within 1 yr after initial treatment. Of those treated solely with botulinum toxin injections, repeated as needed, only 46% required pneumatic dilation or surgery by 2 yr. Survival analysis curves for repeated injections and initial pneumatic dilation did not differ statistically at 1 or 2 yr (p = 0.5 and p = 0.4, respectively). Correlational analyses indicated that, of the clinical parameters tested, only the degree of dysphagia for liquids was useful in selecting the better responders to botulinum toxin injections, with lesser symptoms predicting longer time to retreatment. CONCLUSIONS: Botulinum toxin injections, repeated as needed, can approximate the benefits of a single pneumatic dilation for < or = 2 yr from the standpoint of usual factors that drive further management.

Botulinum Toxins, Type A↗
PubMed1999

Functional esophageal disorders.

The functional esophageal disorders include globus, rumination syndrome, and symptoms that typify esophageal diseases (chest pain, heartburn, and dysphagia). Factors responsible for symptom production are poorly understood. The criteria for diagnosis rest not only on compatible symptoms but also on exclusion of structural and metabolic disorders that might mimic the functional disorders. Additionally, a functional diagnosis is precluded by the presence of a pathology-based motor disorder or pathological reflux, defined by evidence of reflux esophagitis or abnormal acid exposure time during ambulatory esophageal pH monitoring. Management is largely empirical, although efficacy of psychopharmacological agents and psychological or behavioral approaches has been established for several of the functional esophageal disorders. As gastroesophageal reflux disease overlaps in presentation with most of these disorders and because symptoms are at least partially provoked by acid reflux events in many patients, antireflux therapy also plays an important role both in diagnosis and management. Further understanding of the fundamental mechanisms responsible for symptoms is a priority for future research efforts, as is the consideration of treatment outcome in a broader sense than reduction in esophageal symptoms alone. Likewise, the value of inclusive rather than restrictive diagnostic criteria that encompass other gastrointestinal and non-gastrointestinal symptoms should be examined to improve the accuracy of symptom-based criteria and reduce the dependence on objective testing.

Esophageal Motility Disorders↗
PubMed1998

Cognitive behavior therapy for depression in type 2 diabetes mellitus. A randomized, controlled trial.

BACKGROUND: Psychotherapy is the principal nonpharmacologic method for the management of depression, but its usefulness for depressed patients with diabetes remains unknown. OBJECTIVE: To assess the efficacy of cognitive behavior therapy (CBT) for depression in patients with diabetes. DESIGN: Randomized, controlled trial. SETTING: Referral-based academic medical center. PATIENTS: 51 patients with type 2 diabetes and major depression. INTERVENTION: Patients were assigned either to a group that received 10 weeks of individual CBT or to a control group that received no specific antidepressant treatment. All patients participated in a diabetes education program to control for the effects of supportive attention and the possible influence of enhanced diabetes control on mood. MEASUREMENTS: Degree of depression was measured by using the Beck Depression Inventory; glycemic control was measured by using glycosylated hemoglobin levels. Outcomes were assessed immediately after treatment and 6 months after treatment. RESULTS: The percentage of patients achieving remission of depression (Beck Depression Inventory score < or = 9) was greater in the CBT group than in the control group: posttreatment, 85.0% of patients in the CBT group (17 of 20) compared with 27.3% of controls (6 of 22) achieved remission (difference, 57.7 percentage points [95% CI, 33 to 82 percentage points]) (P < 0.001); at follow-up, 70.0% of patients in the CBT group (14 of 20) compared with 33.3% of controls (7 of 21) achieved remission (difference, 36.7 percentage points [CI, 9 to 65 percentage points]) (P = 0.03). Post-treatment glycosylated hemoglobin levels were not different in the two groups, but follow-up mean glycosylated hemoglobin levels were significantly better in the CBT group than in the control group (9.5% compared with 10.9%; P = 0.03). CONCLUSIONS: The combination of CBT and supportive diabetes education is an effective nonpharmacologic treatment for major depression in patients with type 2 diabetes. It may also be associated with improved glycemic control.

Adult↗
PubMed1998

Development of a topographic analysis system for manometric studies in the gastrointestinal tract.

BACKGROUND: Intraluminal pressures from the gastrointestinal tract are conventionally analyzed from a set of two-dimensional tracings. We hypothesized that more information could be extracted by considering spatial relationships of pressure data. METHODS: A system was developed for recording pressure from up to 21 sites and analyzing the results using two- and three-dimensional plotting methods connecting data in space as well as time. Esophageal pressures were measured in 10 volunteers. Data were displayed as three-dimensional contour plots, surface plots, or animated transformations of the pressure wave as it traveled axially in the direction of bolus movement. RESULTS: Subjects tolerated catheter placement, and all analysis methods (conventional and topographic) were successfully completed in each case. At least 80% of the esophageal body and one sphincter could be sampled with the catheter in either a proximal or distal recording position. CONCLUSIONS: A topographic analysis system is available for studying time and space relationships of pressure data. These novel techniques have the potential to provide greater insight into normal and abnormal gastrointestinal motor function than conventional manometric methods.

Adult↗
PubMed1998

Predicting response to cognitive behavior therapy of depression in type 2 diabetes.

Little is known about which factors may adversely affect response to psychotherapy in diabetic patients with major depression. We studied the relationship of various demographic, diabetes, and depression characteristics to change in depression in 42 patients with type 2 diabetes who completed a randomized clinical trial of cognitive behavior therapy (CBT). Depression remitted in a significantly greater percentage of the patients treated with CBT than with the control intervention (85.0% vs 27.3%, p < 0.001). In the sample as a whole, nonremission of depression was associated with lower compliance with blood glucose monitoring, higher glycated hemoglobin (GHb) levels, higher weight, and a history of previous treatment for depression. In the group treated with CBT, the presence of diabetes complications and lower compliance with blood glucose monitoring were significant independent predictors of diminished response. These findings show that factors related to the medical illness, such as the presence of diabetes complications, may negatively influence the prognosis for recovery from depression. Specific coverage of these issues during psychotherapy may optimize the likelihood of treatment success in patients with diabetes.

Adaptation, Psychological↗
PubMed1998

Intersubject and interswallow variability in topography of esophageal motility.

Topographic plots linking averaged manometric data in time and space suggest that sequential contraction segments form esophageal peristalsis. A system capable of plotting individual swallows was developed to verify this observation and to determine intersubject and interswallow variability in their topographic appearance. Fourteen volunteers were studied with a novel computerized assimilation method capable of generating topographic contour plots as well as conventional wave forms for analysis. Contraction segments in the proximal body and lower sphincter were identified in all subjects as being separate from the remainder of the esophagus with little interswallow variation. The appearance of peristalsis through the distal body was more variable because of its intermittent separation into two dominant contraction segments (59.8% of swallows) that had poorly correlated contraction strength (median r = 0.15). Intersubject variability exceeded interswallow variability in topographic landmarks, resulting in distinctive topographic "fingerprints" of peristalsis for each subject. We conclude that topographic plotting of single swallows is feasible and confirms the presence of sequential contraction segments in the esophagus. Interswallow variability helps demonstrate two segments within the smooth-muscle body, an anatomical region of seeming homogeneity, that have sufficient contraction independence to indicate separate neuromuscular units responding to different contractile influences.

Adult↗
PubMed1998

Tricyclic antidepressants for functional nausea and vomiting: clinical outcome in 37 patients.

Tricyclic antidepressants (TCAs) have been used successfully in the treatment of irritable bowel syndrome and unexplained chest pain. Little information is available regarding their use in other functional gastrointestinal disorders. Clinical charts were analyzed from 37 outpatients (mean age 45 +/- 2 years, 25 females/12 males) with chronic nausea and vomiting that could not be explained by any conventional organic disorder (mean duration of symptoms 28 +/- 8 months). Twenty-one (57%) had chronic persistent symptoms; 16 (43%) had intermittent relapsing symptoms; 13 (35%) also had pain as a dominant complaint. Each patient had been treated with TCAs specifically for the gastrointestinal symptoms (amitriptyline, desipramine, nortriptyline, doxepin, or imipramine), and the subject group was followed for 5.4 +/- 1.1 months. Response (at least moderate symptom reduction using a priori chart rating criteria) occurred in 31 patients (84%), and complete symptom remission occurred in 19 (51%)--in 41% with the first TCA trial. Dose at response averaged 50 mg/day, and outcome was unrelated to TCA used. Logistic regression analysis revealed that pain dominance interfered with remission (P = 0.03), but other clinical characteristics were not predictive of outcome. This uncontrolled clinical experience indicates that the open-label response rate of functional nausea and vomiting to low dosages of TCAs resembles that noted in irritable bowel syndrome. TCAs should be studied in controlled fashion for this and related dyspeptic syndromes, as the success of other treatments is limited.

Adult↗
PubMed1998

Acute ileal diverticulitis.

Four cases of acute ileal diverticulitis are presented wherein early diagnosis helped avoid emergent surgery. All patients did well initially with conservative medical management. Acute ileal diverticulitis, although uncommon, should be suspected when the clinical presentation indicates an inflammatory condition of the lower right abdomen. Surgery, when required for recurrent disease, can be reserved for the interval between acute episodes.

Acute Disease↗
PubMed1998

The changing use of esophageal manometry in clinical practice.

OBJECTIVE: Clinical practice guidelines now advise against the use of esophageal manometry in the early evaluation of unexplained chest pain. We examined data from patients referred for manometric evaluation over a 10-yr period (1987-1996) to see if clinicians were changing practice patterns and whether manometric diagnoses were affected by the changes. METHODS: Principal indications for the procedure and manometric findings were extracted from a review of 1162 subjects referred to a single clinical laboratory. The tracings were analyzed using a standardized classification method and categorized according to a pathophysiology-based scheme. Referral indications and manometric diagnoses were compared for the first and second 5-yr periods of study. RESULTS: Chest pain as a referral indication declined from the first to the second half of the study period (odds ratio, 0.44; p < 0.0001), whereas dysphagia and preoperative evaluations became more common (odds ratio, 1.3; p < 0.05; odds ratio, 13.7; p < 0.0001, respectively). Similarly, hypermotility disorders decreased in frequency (odds ratio, 0.63; p = 0.0001), whereas hypomotility disorders increased (odds ratio, 1.6; p < 0.01). The decrease in hypermotility disorders was solely related to a decrease in nonspecific spastic disorders, including nutcracker esophagus (odds ratio, 0.58; p < 0.0001); the proportion of diagnoses of achalasia and diffuse esophageal spasm remained stable. CONCLUSIONS: These data show that practice patterns are already following current guidelines. They also reflect the disillusionment of clinicians with the poor specificity of manometry in chest pain management, the increasing popularity of antireflux surgery, yet the ongoing observation that nonspecific spastic disorders are closely associated with unexplained chest pain and may have a still-undefined pathogenetic role.

Adult↗
PubMed1997

Normal intestinal dietary fat and cholesterol absorption, intestinal apolipoprotein B (ApoB) mRNA levels, and ApoB-48 synthesis in a hypobetalipoproteinemic kindred without any ApoB truncation.

The purpose of this study was to characterize intestinal apolipoprotein B (apoB) metabolism in subjects with familial hypobetalipoproteinemia (FHBL), where segregation analysis supports linkage to the apoB gene but no apoB truncations are present. We investigated cholesterol and fat absorption, intestinal apoB mRNA synthesis and editing, as well as apoB-48 synthesis. Plasma triglycerides (TG) and retinyl palmitate in the chylomicron fractions were analyzed after 12 hours of fasting and then repeatedly for 14 hours after ingestion of a vitamin A-containing high-fat meal. Cholesterol absorption was assessed using a dual stable-isotope method. Mean peak times and concentrations and areas under the curve (AUCs) for fat absorption and mean percentages of cholesterol absorption were comparable in affected and nonaffected family members. Intestinal biopsies were extracted for total RNA and also incubated with 35S-methionine for measurements of apoB synthesis. Similar quantities of apoB mRNA were found to be expressed in the intestine in affected and control subjects by RNase protection assay. ApoB mRNA editing assay showed that the majority of apoB-100 mRNA was edited to the apoB-48 form to a similar extent in both groups. Virtually no apoB-100 protein was synthesized by the intestine in any subject, and apoB-48 protein synthesis was not significantly different in the affected individuals. These data are consistent with in vivo metabolism data that show normal production rates for liver-derived apoB-100 but increased apoB-100 fractional catabolic rates in affected members of this family. Thus, the molecular defect probably does not affect transcription, translation, or secretion of apoB-containing lipoproteins, but may instead affect their clearance.

Absorption↗
PubMed1997

The course of major depression in diabetes.

The course of depression in patients with comorbid medical illness is poorly understood. We report a 5-year follow-up study of 25 diabetic patients who had participated in an 8-week depression treatment trial. When a patient completed the trial, primary physicians were informed of patient outcomes and advised to monitor for relapse and treat those with ongoing depression. At the 5-year reevaluation depression was assessed using DSM-III-R criteria, and a depression severity scale was formed that reflected the presence, severity, frequency, and duration of depression episodes as well as a global assessment of functioning. Recurrence or persistence of depression occurred in 23 (92%) of the patients with an average of 4.8 depression episodes over the 5-year follow-up period. The duration of the longest episode averaged 16 +/- 4 months. Reversion to major depression occurred frequently and rapidly also in the subset that remitted during the treatment trial: 58.3% were depressed again within the first year. At the time of the follow-up interview, major depression was evident in 16 (64%) of the subjects, and glycemic control was significantly worse in this group compared with those without depression (gHb: 13.3% +/- 2.6% vs 11.1% +/- 1.9%, P = 0.03). Severity of depression over follow-up was related to the presence of neuropathy at entry and to incomplete remission during the initial treatment trial. Nineteen patients (82.6% of those who relapsed) received additional courses of antidepressant therapy, but none was treated continuously for depression prophylaxis. In this diabetic sample, depression was a recurrent condition in the vast majority of cases, and initial treatment response did not confer lasting euthymia. Whether maintenance antidepressant medication would be useful in preventing depression recurrence and promoting better glycemic control in diabetes remains to be studied.

Adolescent↗
PubMed1997

Bedside methods for detecting aspiration in tube-fed patients.

This literature review compares the efficacy of the two most commonly recommended bedside tests for detecting aspiration in tube-fed patients: (1) adding dye to the formula and observing for its appearance in tracheobronchial secretions, and (2) using glucose oxidase reagent strips to test tracheobronchial secretions for glucose-containing enteral formula. The review also describes potential problems and cost associated with each test. Several studies indicate that the dye method is far less sensitive than the glucose reagent method; further, there are anecdotal reports of potential harm to patients when dye is added to tube feedings. Specificity of the glucose method has been challenged by several authors; also, cost is probably greater with this method.

Bronchi↗
PubMed1997

Spastic disorders of the esophagus.

Spastic disorders of the esophagus are found in up to 50% of patients referred for manometry, therapy representing the most prevalent motility disorders in clinical practice. They share in common their manifestations of hypermotility, one of two principal types of esophageal motor dysfunction. Diffuse esophageal spasm is segregated from the nonspecific spastic disorders because of its demonstrated interference with bolus transit. However, the overlap among the spastic disorders in manifestation, course, and management is great; segregation of any disorder within this group is not of paramount importance. Spastic disorders, pain reproduction with provocative testing, and psychological abnormalities are coprevalent in patients with unexplained symptoms, but a cause-effect relationship of the motor abnormalities with the other findings is not established. The physician's charge in determining the relevance of a spastic disorder to the clinical presentation and for creating a treatment plan is to establish a direct relationship of motor dysfunction with symptoms-a task that may require correlation of transit abnormalities with symptoms using tests other than manometry. A variety of treatment options, invasive and noninvasive, are available today for patients who have spastic disorders, and each is effective in appropriately selected candidates.

Esophageal Motility Disorders↗