Management of left-sided colonic obstruction by subtotal colectomy and ileocolic anastomosis

OBJECTIVE: To assess complications and functional results of emergency subtotal colectomy with ileocolic anastomosis for acute left-sided colonic obstruction. DESIGN: Retrospective study. SETTING: University hospital, Netherlands. SUBJECTS: 37 patients with acute left-sided colonic obstruction. INTERVENTIONS: Emergency subtotal colectomy with immediate anastomosis (n = 20), Hartmann's procedure (n = 13) or double-loop transverse colostomy (n = 4). MAIN OUTCOME MEASURES: Mortality, morbidity, duration of hospital stay, frequency of defecation, and continence. RESULTS: Morbidity after subtotal colectomy was 10% (n = 2) and mortality 0. There was one anastomotic dehiscence that required a temporary ileostomy. Mean hospital stay was 15 days (range 10-31). All had adequate continence. After 6 weeks mean frequency of defecation was 3/24 hrs (range 2-6). 9 patients died within 2 years of metastatic disease. CONCLUSIONS: Subtotal colectomy with ileocolic anastomosis is a suitable procedure for treating left-sided colonic obstruction provided that pelvic floor function is adequate and a skilled surgeon is available.     

Anticoagulant rodenticide poisoning in dogs in The Netherlands

The occurrence, the diagnosis, and the treatment of anticoagulant rodenticide poisoning in dogs in the Netherlands was evaluated by a survey among Dutch veterinarians carried out by the National Poisons Control Center (NPCC). The survey included information on 54 dogs, 32 being treated by veterinarians who consulted the NPCC and 22 that were admitted to the Utrecht University Clinic for Companion Animals (UUCCA). The poisons that were suspected were brodifacoum (n = 19), bromadiolone (n = 14), difenacoum (n = 8), difethialone (n = 6) and chlorophacinone (n = 1). In 6 dogs the identity of the poison was unknown. Of 31 dogs with hemorrhages, 2 died shortly after presentation to practitioners and 2 died shortly after admission to the UUCCA. Signs of bleeding occurred especially in poisoning by brodifacoum (n = 16). In all but one of the dogs without hemorrhages, the intake of poison had taken place within 24 hours before presentation. The method of treatment varied, with the induction of vomiting and the use of vitamin K mentioned most. The choice of therapy was determined by the length of time after intake of the poison, the clinical signs and whether or not an anticoagulant toxicosis was suspected at the time of the initial examination. These findings provide the basis for discussion of several aspects of diagnosis and treatment.     

Patterns of clinical metastasis in breast cancer: an analysis of 100 patients

Many patients diagnosed with breast cancer will develop metastases and these have diverse presentations. We have reviewed 100 consecutive patients who have died with metastatic breast cancer, to determine the frequency, sites and mode of presentation of recurrent disease. The commonest site of failure was loco-regional (n = 61), this usually presented with a mass, but a minority of patients also complained of pain. Bone metastases developed in 60 patients and produced bone pain, pathological fracture (n = 6) or cord compression (n = 5). Pulmonary metastases producing shortness of breath were diagnosed in 34 patients and were asymptomatic in a further 10. Intra-abdominal metastases were found at some time in 23 patients, most commonly in the liver (n = 20) and the majority complained of epigastric pain (n = 17). Brain metastases occurred in 23 patients and produced a wide range of symptoms including those of a space-occupying lesion (n = 10), cranial nerve palsy (n = 7), diabetes insipidus (n = 3), focal limb weakness (n = 2) and meningitis (n = 1). Three patients had choroid metastases producing reduced visual acuity. Recurrent breast carcinoma can present in a variety of ways, therefore any new symptom or sign should be considered to represent recurrence until proved otherwise.     

Injury of the posterior ligament complex in patients with acute spinal trauma: evaluation by MR imaging

OBJECTIVE: We undertook this study to use MR imaging to determine the frequency of injury to the posterior ligament complex of the thoracolumbar spine in patients who have undergone acute thoracolumbar trauma. SUBJECTS AND METHODS: Sixty-eight patients with varying severity of thoracolumbar trauma were examined prospectively. The majority of injuries were related to motor vehicle accidents. The second most common cause was falls. Patients were examined with plain radiography and MR imaging. In addition to conventional MR imaging sequences consisting of T1-weighted and fast spin-echo T2-weighted sagittal and axial images, a fat-suppressed T2-weighted sagittal sequence was performed. The findings were correlated with surgery in six cases and with follow-up clinical examination that included physical examination and conventional anteroposterior and lateral radiographs. RESULTS: Posterior ligament complex injury was detected in 53% (n = 36) of all patients. Such injury was most common in patients with flexion-distraction (n = 15) and patients with dislocation fracture (n = 4). Of the patients with dislocation fracture, all had posterior ligament complex injury. Of the 24 patients with burst fractures, posterior ligament complex tear occurred in 42% (n = 10). Of the 23 patients with compression fractures, 26% (n = 6) had posterior ligament complex tear. Injury to the interspinous ligaments occurred with decreasing frequency in patients with injury to the supraspinous ligament, flaval ligaments, posterior longitudinal ligament, and anterior longitudinal ligament. Surgical findings correlated with MR imaging in all six patients who underwent surgery. CONCLUSION: Injury to the posterior ligament complex, which is often encountered in patients with burst and compression fractures, can be reliably revealed by MR imaging.     

Hip fracture incidence among elderly Asian-American populations

This study estimated national age- and sex-specific nontraumatic hip fracture incidence rates for elderly Chinese Americans, Japanese Americans, and Korean Americans. Based on a 50 percent sample of 1992 Medicare enrollees with the race/ethnicity code "Asian" and "other," cohorts of persons with distinctive Chinese (n = 24,366), Japanese (n = 28,762), and Korean (n = 5,470) names were followed passively for 2 years for a hospitalization with a diagnostic code indicating hip fracture. Cohorts of whites and blacks were followed for comparison. Year of immigration was deduced from the year of issuance of the Social Security number. Age-adjusted hip fracture incidence was lower for all three Asian-American groups than for whites. For females, the standardized fracture ratio relative to whites was 30.1 for Chinese, 73.2 for Japanese, and 52.8 for Koreans; for males, the standardized fracture ratio was 41.9 for Chinese, 58.1 for Japanese, and 90.7 for Koreans. Persons whose Social Security numbers were issued after the immigration Act of 1965 had an adjusted relative risk of 1.37 (95% confidence interval 1.05-1.78) compared with those in the US before that year, after adjustment for age, sex, and ethnic group.     

Prevention of parasitic infections (excluding toxoplasmosis) in immunocompromised patients

Fracture frequency was studied in 107 hypopituitary patients with GH deficiency (GHD) (69 men, mean age 53 years, range 18-74 and 38 women, mean age 54 years, range 31-73). Routine hormonal replacement therapy was given, except GH. Five male patients and 15 female patients with untreated hypogonadism were allocated to a separate group. The mean duration of hypopituitarism was 13.4 years. The prevalence of a history of fractures was assessed using questionnaires. A subsample of the G?teborg WHO MONICA Project was used as a reference population (n = 323). The total fracture frequency was threefold higher (P < 0.001) in patients (24.1%) compared with controls (8.7%) (odds ratio 3.49) (1.85-6.56; 95% confidence intervals). In men (n = 64) the fracture frequency was 25.0%, compared with 7.8% among the controls (P < 0.001). In women (n = 23) the fracture frequency was 21.7%, compared with 9.5% among the controls (P = 0.08). The odds ratios for fracture frequency were 3.97 (1.81-8.40; 95% confidence intervals) and 2.64 (0.89-7.81; 95% confidence intervals) in men and women respectively. In conclusion, adult hypopituitary patients with GHD had a threefold increased fracture frequency compared with controls. Further studies are needed to ascertain whether long-term recombinant human GH treatment can reduce the fracture rate in hypopituitary patients with GHD.     

Complications in Paget disease at MR imaging

PURPOSE: To determine the MR imaging findings in patients with complications of Paget disease of bone. MATERIALS AND METHODS: Of 45 patients with Paget disease who underwent MR imaging, 33 (26 men, seven women; age range, 64-91 years) with known complications of the disease were examined. Imaging in this subgroup included radiography (n = 26), computed tomography (n = 12), bone scintigraphy (n = 15), and magnetic resonance (MR) imaging (n = 33). Patients were examined specifically for musculoskeletal and neurologic complications of Paget disease, including fracture, basilar impression, spinal stenosis, bone tumor, and osteoarthrosis. RESULTS: The 56 complications documented in the 33 patients were fracture (n = 17), neurologic entrapment (n = 19), neoplasm (n = 9), and arthropathy (n = 11). MR imaging was beneficial in the diagnostic evaluation of basilar impression (n = 7), spinal stenosis (n = 12), and the tumor stage (n = 9). It also helped to successfully evaluate pagetic bone narrowing of the coracoacromial arch, which was associated with impingement syndrome and rotator cuff rupture (n = 2). The signal intensities in pagetic bone were most commonly similar to those in fat; this finding had a 100% negative predictive value in excluding neoplasm. CONCLUSION: Although Paget disease is diagnosed economically with conventional radiography, MR imaging is well suited for demonstrating the presence and extent of several characteristic disease complications, including basilar impression, spinal stenosis, and secondary neoplasm.     

Preoperative biliary drainage, colonisation of bile and postoperative complications in patients with tumours of the pancreatic head: a retrospective analysis of 241 consecutive patients

OBJECTIVE: To analyse the outcome of preoperative biliary drainage in patients being operated on for a tumour in the pancreatic head. DESIGN: Retrospective study. SETTING: University hospital, The Netherlands. SUBJECTS: Consecutive series of 241 patients. MAIN OUTCOME MEASURES: Decline in bilirubin concentrations and bacterial contamination of bile as a result of preoperative drainage. Incidence of postoperative complications in patients who underwent preoperative drainage and those who did not. RESULTS: 184/241 patients underwent preoperative biliary drainage. Endoscopic drainage was the most effective, shown by a median reduction in bilirubin concentrations of 82%, 74%, and 50% after endoscopic drainage (n = 149), papillotomy (n = 25) and external drainage (n = 10), respectively. Bacterial contamination of bile was significantly more common when an endoprosthesis was used, but did not result in a higher rate of infective complications. 163 Whipple's resections, 33 total pancreatectomies, and 45 biliary-enteric bypasses were performed. 137/241 (57%) patients had postoperative complications. There was no significant difference in the incidence of postoperative complications between patients who had preoperative biliary drainage and those who did not (p = 0.4).     

Prone position favors motor development of infants

OBJECTIVE: To determine the motor development in infants sleeping in the supine position compared to infants sleeping in the prone position, and to compare the levels of motor development of infants playing only in the supine position and of infants playing in the prone position as well. DESIGN: Prospective blinded comparing study. SETTING: Department of Physical Therapy, Maasziekenhuis, Boxmeer, the Netherlands. METHODS: Various measuring instruments were used in the home environment to determine the levels of motor development at the age of 5 months of 21 healthy infants born at term selected from a group of 160 infants attending the infant welfare clinic. RESULTS: Infants sleeping in the prone position (n = 8) showed a higher motor development than infants sleeping in the supine position (n = 13). Infants playing in the prone and supine position (n = 5) had a higher motor development than infants who played exclusively in the supine position (n = 15). CONCLUSION: Sleeping and playing in the prone position was accompanied by a higher motor development in healthy mature-born infants at the age of 5 months.     

Follow-up evaluation of open intra-articular fractures of the calcaneus

The results of a follow-up evaluation of open intra-articular calcaneal fractures are presented. A modified Merle d'Aubigné functional score and Zwipp radiographic score were used. A retrospective analysis of 35 patients with 36 open intra-articular fractures represents the basis of the study. At the time of follow-up examination (on average 44 months after the injury), 5 amputations of the affected extremity and 4 ankle arthrodeses had been carried out. The 23 patients still able to bear weight on the affected hindfoot and possessing a functional ankle joint were radiographically and functionally evaluated. No excellent results were documented. Only 6 good functional and 2 good radiographic outcomes were noted. In 17 instances, a poor functional or radiographic score was given. Devastating results were seen in the course of treatment of third-degree open joint depression or comminuted intra-articular fractures (n = 15): 9 cases of osteomyelitis, 5 amputations, 1 partial calcanectomy, 1 arthrodesis. An open reduction as part of the primary treatment (n = 6) led to local complications in all instances. The most favorable results were seen after nonoperative fracture management: complication-free course of treatment in 4 of 11 patients. All workmen's injuries led to a permanent disability, and these patients received compensation. The treatment and salvage of the soft-tissue envelope should be paramount in all therapeutic decisions. The fracture treatment must not further jeopardize these tissues. An aggressive operative treatment of local complications, including arthrodesis or amputation, is recommended.     

An Sp1 binding site polymorphism in the COLIA1 gene predicts osteoporotic fractures in both men and women

Genetic factors play an important role in the pathogenesis of osteoporosis, and recent studies have shown that a polymorphic Sp1 binding site in collagen type I alpha1 (COLIA1) gene is associated with bone mass and vertebral fractures in women from the U.K. Information on the predictive value of the COLIA1 Sp1 polymorphism in other populations is limited, however, and no studies have yet been performed in osteoporotic males. In view of this, we analyzed COLIA1 genotypes in relation to bone density and biochemical markers of bone turnover and the presence of osteoporotic fractures in a case-control study of Danish men and women. COLIA1 genotype was determined by polymerase chain reaction analysis of genomic DNA extracted from peripheral blood samples and related to bone mass, biochemical markers of bone turnover, and the presence of fracture in a study of 375 osteoporotic vertebral fracture patients and normal controls. There was no significant effect of COLIA1 genotype on bone mass or biochemical markers when data from the control group (n = 195) and fracture group (n = 180) were analyzed separately. However, the genotype distribution was significantly different in the fracture cases compared with age-matched controls (chi2 = 16.48, n = 249,p = 0.0003) due mainly to over-representation of the ss genotype in the fracture patients (14.3% vs. 1.4%), equivalent to an odds ratio for vertebral fracture of 11.83 (95% confidence interval 2.64-52.97) in those with the ss genotype. Similar differences in genotype distribution between osteoporotic patients and controls were observed in both men (chi2 = 11.52, n = 95, p = 0.0032, OR = 2.04) and women (chi2 = 6.90, n = 154, p = 0.032, OR = 1.37). In keeping with the above, logistic regression analysis showed that the ss genotype was an independent predictor of osteoporotic fracture (p = 0.028). This study confirms that the COLIA1 Sp1 polymorphism is significantly associated with osteoporotic vertebral fractures. The association is seen in both men and women, and the effect on fracture risk appears to be partly independent of bone mineral density. Our results raise the possibility that genotyping at the Sp1 site could be of clinical value in identifying individuals at risk of osteoporotic fractures in both genders.     

Reversibility of Schistosoma mansoni-associated morbidity after yearly mass praziquantel therapy: ultrasonographic assessment

OBJECTIVE: To study the outcome of osteoporosis assessment and rehabilitation in post-fracture patients. METHODS: This was a retrospective survey of the records of patients who had been referred to us from orthopaedic departments for rehabilitation after a fracture. RESULTS: A significant number of patients had had previous fractures (n = 17) or risk factors for osteoporosis (n = 16). The mortality rate was 4%. A significant proportion of patients (9/44) who had been living in their homes required placement in residential or nursing homes and additional care after rehabilitation. CONCLUSION: Our audit showed that post-fracture patients received optimum care, as set out in the Royal College of Physicians guidelines, but could benefit additionally from assessment and treatment of osteoporosis as set out in the Department of Health (DOH) Guidelines.     

Accelerated hyperfractionated radiotherapy combined with induction and concomitant chemotherapy for inoperable non-small-cell lung cancer--impact of total treatment time

PURPOSE: To determine the importance of fall characteristics, body habitus, function, and hip bone mineral density as independent risk factors for hip fracture in frail nursing home residents. SUBJECTS AND METHODS: In this prospective, case-control study of a single, long-term care facility, we enrolled 132 ambulatory residents (95 women and 37 men) aged 65 and older, including 32 cases (fallers with hip fracture) and 100 controls (fallers with no hip fracture). Principal risk factors included fall characteristics, body habitus, measures of functional assessment, and hip bone mineral density by dual-energy X-ray absorptiometry. RESULTS: In multivariate analysis, including only those with knowledge of the fall direction (n=100), those who fell and suffered a hip fracture were more likely to have fallen sideways (odds ratio 5.7, 95% confidence interval [CI] 1.7 to 18, P= 0.004) and have a low hip bone mineral density (odds ratio 1.9, 95% CI 0.97 to 3.7, P=0.06) than those who fell and did not fracture. When all participants were included (n=132) and subjects who did not know fall direction were coded as not having fallen to the side, a fall to the side (odds ratio 3.9, 95% CI 1.3 to 11, P=0.01), low hip bone density (odds ratio 1.8, 95% CI 1.03 to 3, P=0.04), and impaired mobility (odds ratios 6.4, 95% CI 1.9 to 21, P=0.002) were independently associated with hip fracture. Sixty-seven percent of subjects (87% with and 62% without hip fracture) had a total hip bone mineral density greater than 2.5 SD below adult peak bone mass and were therefore classified as having osteoporosis using World Health Organization criteria. CONCLUSIONS: Among frail elderly nursing home fallers, the preponderance of whom are osteoporotic, a fall to the side, a low hip bone density, and impairment in mobility are all important and independent risk factors for hip fracture. These data suggest that, among the frailest elderly, measures to reduce the severity of a sideways fall and improve mobility touch on new domains of risk, independent of bone mineral density, that need to be targeted for hip fracture prevention in this high-risk group.     

Interference by carbohydrate substrates, flavonoids, and monosaccharide derivatives on bacterial beta-D-glucuronidase assays

PURPOSE: To determine if suprarenal placement of inferior vena cava (IVC) filters is associated with renal dysfunction or other complications. MATERIALS AND METHODS: Case files of all patients with suprarenal vena caval filter placement since 1985 were reviewed for clinical and biochemical evidence of renal dysfunction and renal vein thrombosis. The occurrence of associated complications, including IVC occlusion, filter fracture, device migration, and recurrence of pulmonary embolism was also recorded. RESULTS: Twenty-two (2.9%) of 764 IVC filters were implanted above the renal veins: titanium Greenfield filter modified hook (TGF-MH) (n = 16), LGM type I (n = 2), LGM type II (n = 2), and Bird's Nest (BN) type I (n = 2). Reasons for suprarenal filter placement included thrombus to the level of the renal veins (n = 9), failure or poor position of the infrarenal filter (n = 6), pregnancy or intent of pregnancy (n = 4), and the malpositioning of BN filters above the renal veins (n = 2). A single patient demonstrated evidence of transient renal dysfunction. Pulmonary embolus was found at autopsy in one patient. Abdominal radiographs were obtained at follow-up of 18 patients and demonstrated a 2 cm or more migration of the filter in five patients (27.7%). This rate of migration was significantly different from the 3% migration rate reported by the authors' institution in the follow-up of 320 infrarenal IVC filters. There was one filter fracture (5.5%.) and penetration of the IVC occurred in one patient (5.5%). CONCLUSION: Follow-up indicates suprarenal IVC filter placement is safe, and no evidence of permanent renal dysfunction after placement was found. Filter migration was the most frequent complication, but no clinical sequelae were noted with these patients.     

Comparison of position repeatability of a human operator and an industrial manipulating robot

STATEMENT OF PROBLEM: Implant-supported restorations in the partially edentulous jaw have been performed at the Mayo Clinic for more than 10 years. Clinical performance of the implants and the prostheses should be reported to ensure effectiveness of this procedure. PURPOSE: This retrospective study described results for implant survival, implant fracture rate, prosthetic complications, and design changes that may impact these results. MATERIAL AND METHODS: A retrospective chart review was conducted of all registered implant patients in a large multispecialty medical center. Patients with a partially edentulous jaw who had received endosseous implants to support and retain dental prostheses were included in this review. Implant survival and fracture, prosthetic complications, and demographic data were recorded and analyzed through Kaplan-Meier methods. RESULTS: A total of 1170 implants were placed in four anatomic locations: anterior maxilla, posterior maxilla, anterior mandible, or posterior mandible. Location of implants was shown to have no effect on implant survival (p = 0.7398), implant fracture rates (p = 0.2385), screw loosening (p = 0.8253), or screw fracture (p = 0.2737). Development of new restorative components has resulted in significantly better rates of implant survival without fracture (p = 0.0054), screw function without loosening (p < 0.0001) and screw function without fracture (p = 0.0013). Implant survival seems to have been improved with the new components (p = 0.0513). CONCLUSIONS: Implant survival in this study was independent of anatomic location of implants. Virtually all clinical performance factors were improved by design changes in implant restorative components that were brought to market in early 1991.     

The use of bilateral mammary artery in myocardial revascularization. The risk factors emergent from a multivariate analysis conducted on 474 patients

Between January 1989 and March 1997, 175 patients with traumatic shoulder dislocation were treated by conservative means (median age 41 years, 39 F, 136 M). In 78 patients (17 F, 61 M) a clinical and radiological follow up (median 50 months, range 6-106) could be obtained. Additionally, a diagnostic ultrasound was carried out in all patients. The recurrence rate in the group younger than 30 years (G < 30; n = 35) was 86%; in the group older than 30 years (G > 30; n = 43) it was 21% (P < 0.05). Persisting neurological deficits were found in 6 patients (8%). According to the Rowe score, 16 patients (46%) of the G < 30 achieved excellent or good results, in the G > 30, 29 patients (67%). In 17% of cases, a glenohumeral arthrosis was diagnosed be radiological means. 18% had radiological signs of a previous fracture of the greater tuberosity. Hill-Sachs lesions were identified in 19% of cases. Rotator cuff tears were diagnosed in 9% by ultrasound. No relationship between the duration of immobilization and the recurrence rate was found (P = 0.95). The recurrence rate following primary shoulder dislocation depends primarily on the patients' age.     

Making vitamin C lipophilic enhances its protective effect against free radical induced peroxidation of low density lipoprotein

Human sera contain anti-5-hydroxymethyl-2'-deoxyuridine (HMdU; an oxidized thymidine) autoantibodies (aAbs), which are significantly higher in chronic inflammatory diseases. The intent of this study was to establish whether anti-HMdU aAbs can serve as predictors of breast and colorectal cancer risk. Sera of 169 women were analyzed by ELISA. Women healthy at blood donation but who were diagnosed 0.5-6 years later with breast or colorectal cancer exhibited significantly increased anti-HMdU aAbs over the age-matched controls (P = 0.028 and P < 0.001, respectively). Subjects diagnosed with rectal cancer had the highest levels of anti-HMdU aAbs (44.80 +/- 11.50; n = 6) in comparison to colon (29.03 +/- 2.49; n = 33) and breast (35.86 +/- 8.55; n = 9) cancers. Individuals with benign breast disease also had elevated anti-HMdU aAb (35.12 +/- 8.77; n = 10), with a borderline statistical significance (P = 0.095), whereas those with benign gastrointestinal tract diseases had those titers (30.95 +/- 3.64; n = 8) significantly increased (P < 0.02). Anti-HMdU aAb levels in subjects with a family history of any cancer (23.57 +/- 2.86; n = 55) did not significantly differ from those of the controls (19.41 +/- 2.90; n = 48), but women with a family history of breast cancer (two primary relatives or one with a bilateral disease) showed increased levels (34.48 +/- 8.16; n = 8; P = 0.024). Ps for linear trend of age-adjusted odds ratios were 0.049 for breast and < 0.001 for colorectal cancers. Anti-HMdU aAb titers showed a remarkable stability over a period of 6 years, with a low (14%) intraindividual variance. Thus, elevated anti-HMdU aAb titers may be an early signal of cancer risk, because they were significantly increased in otherwise healthy women who had a family history of breast cancer; in those who had benign breast disease or benign gastrointestinal tract diseases; and, most importantly, in those who at 0.5-6 years after the initial blood donation developed breast or colorectal cancer.     

cagA-positive Helicobacter pylori populations in China and The Netherlands are distinct

The aim of this research was to study whether and to what extent Chinese cagA-positive Helicobacter pylori isolates differ from those in The Netherlands. Analysis of random amplified polymorphic DNA (RAPD)-PCR-assessed DNA fingerprints of chromosomal DNA of 24 cagA-positive H. pylori isolates from Dutch (n = 12) and Chinese (n = 10) patients yielded the absence of clustering. Based on comparison of the sequence of a 243-nucleotide part of cagA, the Dutch (group I) and Chinese (group II) H. pylori isolates formed two separate branches with high confidence limits in the phylogenetic tree. These two clusters were not observed when the sequence of a 240-bp part of glmM was used in the comparison. The number of nonsynonymous substitutions was much higher in cagA than in glmM, indicating positive selection. The average levels of divergence of cagA at the nucleotide and protein levels between group I and II isolates were found to be high, 13.3 and 17.9%, respectively. Possibly, the pathogenicity island (PAI) that has been integrated into the chromosome of the ancestor of H. pylori now circulating in China contained a different cagA than the PAI that has been integrated into the chromosome of the ancestor of H. pylori now circulating in The Netherlands. We conclude that in China and The Netherlands, two distinct cagA-positive H. pylori populations are circulating.