Can the urea breath test for H.pylori replace endoscopy for the assessment of dyspepsia in primary care?

AIMS: The urea breath test may have value in the initial assessment of dyspepsia in primary care. This pilot study tracks patient and general practitioner behaviour which cannot be predicted with modelling studies. METHODS: The urea breath test was made available over a period of 18 months. The test was requested when general practitioners would normally have used a trial of medication or referred for endoscopy. Patients with a positive urea breath test had early endoscopy before treatment. Patients with a negative urea breath test were treated according to symptom response. A follow-up questionnaire was given 6-24 months after the urea breath test. RESULTS: Urea breath tests were requested on 249 patients; clinical notes and follow-up interview data were available for 207 patients (83%). The urea breath test was positive for 89 patients (43%); 70 were referred for endoscopy and peptic ulcer disease was found in 33 (47%). The urea breath test was negative for 118 patients; 14 were follow-up tests after previous H.pylori treatment. For the 104 patients with dyspepsia, a negative test and no previous treatment, 42% had 1 or more previous investigations for dyspepsia and 66% had dyspepsia symptoms for more than one year. During follow-up, 21 patients had endoscopy. Dyspepsia symptom scores were significantly lower at follow-up (p < 0.01). Using a global assessment, 66% had fewer symptoms, 22% same and 12% had more symptoms. The symptom improvement was greater if the duration of symptoms was less than one year (p < 0.05). Medication use did not change significantly. Twelve patients were dissatisfied with management; most of these would have preferred endoscopy. CONCLUSIONS: A negative urea breath test appears to have some reassurance value. The use of the urea breath test as initial assessment for dyspespia may prevent the need for some endoscopy. Further controlled studies of breath testing compared with early endoscopy are required.     

Randomized controlled trial of omeprazole or endoscopy in patients with persistent dyspepsia: a cost-effectiveness analysis

BACKGROUND: Cost-effectiveness analysis, Helicobacter pylori research and the development of proton pump inhibitors are having an increasing impact on the management of dyspepsia. However, clinical trials have not always included both H. pylori diagnosis and proton pump inhibitors in their protocols. METHODS: Patients who were referred for upper gastrointestinal endoscopy by their general practitioner were randomized to either prompt endoscopy followed by directed medical treatment (conventional group, n=38), or to empirical treatment with omeprazole and, in the case of symptom relapse, serological screening for H. pylori infection followed by eradication therapy in seropositive patients (empirical group, n=42). The study lasted for up to 1 year. RESULTS: In the empirical group, only 13 patients (31%) underwent endoscopy. The average number of days for which the patients kept records of their dyspeptic symptoms was 266 (95% CI: 226-307) in the empirical group, of which 166 (95% CI: 128-204) were symptom-free. In the conventional group, 159 (95% CI: 119-198) out of 255 days (95% CI: 209-302) were recorded as symptom-free. The average medical cost in the empirical group was $284 (95% CI: 218-350) and in the conventional group $491 (95% CI: 383-600). In the empirical group, two malignancies were found, whereas in the conventional group one malignancy was found. CONCLUSIONS: The empirical drug treatment strategy in patients with persistent dyspeptic symptoms resulted in 69% fewer diagnostic endoscopies with lower medical costs and equal effectiveness in the first year, compared to prompt endoscopy followed by directed medical treatment.     

Expression of tie receptor tyrosine kinase in human leukemia cell lines

BACKGROUND AND STUDY AIMS: Endoscopic screening of all dyspeptic patients is not cost-effective, nor is it feasible in many health-care delivery systems. To select the most appropriate candidates, various preendoscopic screening strategies have been proposed, some of which include Helicobacter pylori serology and patient age. We assessed the value of these two criteria in preendoscopic screening of a large series of dyspeptic patients, and compared the results obtained in a referral hospital (university center with an extensive H. pylori research program) with those in nonreferral hospital (participating centers that did not have such a program). PATIENTS AND METHODS: Blood samples for determination of anti-H. pylori IgG antibody were collected from patients with uninvestigated dyspepsia undergoing endoscopy at one referral hospital and in 93 nonreferral hospitals throughout Italy. For IgG antibody assay, an in-house enzyme-linked immunosorbent assay (ELISA) technique was used in the referral hospital, while a commercial kit was used in the nonreferral hospitals. RESULTS: A total of 1638 patients were evaluated at the referral hospital (845 men and 793 women, mean age 46.1 years, range 18-89), and 3281 at the nonreferral hospitals (1718 men and 1563 women, mean age 48.8, range 18-96), respectively. If endoscopy had not been performed in patients who were seronegative for H. pylori and younger than 45 years, 19% versus 17.5% of the tests would have been avoided in the referral and nonreferral hospitals, respectively, while six of 304 ulcers (2%) and no cancers would have been missed versus 35 of 557 ulcers (6.3%) and two of 557 cancers (0.3%). CONCLUSIONS: A screening strategy based on age and H. pylori serology is a valid means of selecting dyspeptic patients for endoscopy; however, the policy needs further refinement for use in nonreferral hospitals.     

Proximal and distal gastric distension in normal subjects and H. pylori-positive and -negative dyspeptic patients and correlation with symptoms

Aim of the study was to analyze gastric distension with water in H. pylori-positive and -negative dyspeptic patients and normal subjects and the correlation with symptoms. Twenty dyspeptic patients and 19 normal subjects were studied. H. pylori was determined in each dyspeptic patient with the rapid urea test at endoscopy. Gastric distension was evaluated by real-time ultrasonography with the ingestion of stepwise-increasing amounts of water up to a total of 600 ml. During distension, the symptom score was evaluated as well. The proximal stomach was significantly smaller in dyspeptic patients than in healthy controls, at 100-600 ml water (P<0.01). A larger distal stomach was observed at 500 and 600 ml of water (P<0.01). The score of bloating and fullness was greater in dyspeptics than in controls at 300 and 600 ml of water distension. The symptoms score was linearly correlated with proximal and distal gastric measurements in dyspeptic patients and in controls. No significant difference was found in dyspeptic patients regarding the H. pylori status. In conclusion, dyspeptic patients show a defective adaptation of the whole stomach to water distension and an increased symptom perception score as compared to controls. H. pylori infection does not seem to be a determining factor in these observed findings.     

The impact of direct access endoscopy, Helicobacter pylori near patient testing and acid suppressants on the management of dyspepsia in general practice

Direct access endoscopy services, Helicobacter pylori infection and more effective acid suppression therapy have influenced the management of dyspepsia in the past decade. Three hundred and ten GPs in south London were surveyed via postal questionnaire to determine the impact of these factors on the management of dyspepsia in general practice. Ninety-one per cent of GPs prescribed simple antacids as initial treatment for simple dyspepsia and referred only if symptoms did not improve. When acid suppressants were used, 41% used H2 antagonists compared with 11% for proton pump inhibitors (p = 0.0001). Risk factors for underlying malignancy were the most frequent reason for hospital referral at first consultation. Long outpatient waiting times result in about 90% of GPs choosing direct access endoscopy as the route of referral for all patients with dyspepsia, while only 36% would refer patients with sinister symptoms to direct access endoscopy if waiting times were similar to that of outpatients. H. pylori near patient testing did not seem to influence the management of dyspepsia in general practice.     

Characterization of the active site of a hydrogen sensor from Alcaligenes eutrophus

BACKGROUND: The Maastricht Consensus Report advises that, in Helicobacter pylori-positive patients after surgery for peptic ulcer disease, H. pylori should be eradicated. The aim of the present study was to investigate the symptomatic response of H. pylori eradication in previously vagotomized peptic ulcer patients with persistent dyspeptic complaints. METHODS: The study was performed as a randomized, double-blind, placebo-controlled study. Pretreatment diagnostic upper endoscopy was omitted. All the results were submitted to intention-to-treat and efficacy analyses. RESULTS: We could not find any differences between the two groups with regard to intensity or frequency of upper abdominal pain, nausea, heartburn, or other abdominal symptoms during the 12-month follow-up. The triple therapy eradication rate was 88% at both 3- and 12-month controls. CONCLUSION: Vagotomized peptic ulcer patients with persistent dyspeptic complaints should undergo a diagnostic upper endoscopy to detect ulcer recurrence before H. pylori eradication treatment is considered.     

Dyspepsia in relation to Helicobacter pylori infection and psychosocial work stress in white collar employees

OBJECTIVE: We undertook an investigation of the relationship between psychosocial work stress and Helicobacter pylori (H. pylori) infection with dyspepsia. METHODS: We conducted a cross-sectional study among 189 employees of a health insurance company in the city of Ulm, Germany. RESULTS: A clear association between work-related psychosocial factors and the occurrence of dyspeptic symptoms during the past 3 months was evident. Persons who were considered to have a critical style of coping with work demands suffered more often from dyspeptic symptoms. Current infection with H. pylori was not associated with prevalence of dyspeptic symptoms. These results were also confirmed by adjustment for age, gender, smoking status, education, and use of antiinflammatory drugs within the past 3 months, by means of multivariate analysis. The odds ratio (OR) for having a dyspepsia symptom score in the upper tertile versus the 1st or 2nd was 3.22 (95% confidence interval [CI], 1.56-6.65), given that the employee was considered to have a critical style of coping with work demands. The OR for having a dyspepsia symptom score in the upper tertile given H. pylori infection was 1.23 (95% CI, 0.44-3.46), indicating no association of current H. pylori infection with dyspeptic symptoms. CONCLUSIONS: A critical style of coping with work demands may be an important determinant for dyspepsia-like symptoms. Therefore, in the absence of an underlying disease, specific intervention programs should be targeted at the behavior of the affected individual (e.g., stress-reduction programs) rather than on the treatment of specific symptoms or infection with H. pylori.     

Review article: symptom improvement through eradication of Helicobacter pylori in patients with non-ulcer dyspepsia

The aim of this article is to determine, by reviewing the literature, whether treatment of Helicobacter pylori infection in patients with non-ulcer dyspepsia affects symptoms. Ten publications were identified through a computerized and manual literature search, and the percentage of patients with symptom improvement after successful or unsuccessful eradication therapy for H. pylori infection was calculated. In the 10 studies, symptom improvement after treatment was found in 73% of the patients that became H. pylori-negative and 45% of the patients that remained H. pylori-positive. Symptom improvement was modified by various clinical features and methodological aspects. If eradication of H. pylori failed, symptoms only improved over a short period. Symptom improvement was more pronounced in dyspeptic patients in whom H. pylori was eradicated than in those in whom H. pylori infection persisted.     

Can screening for IgG antibodies against Helicobacter pylori be used in clinical practice? Omit endoscopy in seropositive or seronegative patients?

The objective of this study was to test the feasibility of a screening strategy for IgG antibodies against Helicobacter pylori in patients presenting with upper abdominal complaints. Biopsy specimens were taken for histological and microbiological investigations from consecutive patients undergoing upper gastrointestinal endoscopy. In addition, a serum sample was taken for detection of IgG antibodies against Helicobacter pylori, using an ELISA technique. Serum samples from 1294 consecutive patients were available. IgG antibodies against Helicobacter pylori were present in 622 patients (48%), the remaining 671 (52%) were negative. If endoscopy had been omitted in seronegative patients below the age of 45 years, this would have resulted in 234 patients not endoscoped. However, it can be assumed that 62 of these patients would undergo endoscopy because of recurrent complaints due to underlying disease or abnormality. Therefore 182 of 1294 (14%) of endoscopies would have been avoided. Application of this strategy on the total group of seronegatives would save 353 of 1294 (27.3%) endoscopies. If endoscopy had been omitted in seropositive cases below the age of 45 years, and these patients were treated with anti-Helicobacter therapy, an initial 145 endoscopies would have been avoided. However, 26 of these patients would undergo endoscopy because of persistent complaints due to underlying disease. Therefore 119 (9%) endoscopies would have been avoided. Applying this strategy in the total group of seropositives would have saved 434 of 1294 endoscopies (34%). Applying the IgG screening strategy in all patients would result in a significant number of endoscopies being avoided in the seropositive group, 434 versus 353 (P < 0.001). In conclusion, omitting endoscopy in seropositive cases, regardless of age, can reduce the workload more than omitting endoscopy in seronegative cases: 34% fewer endoscopies versus 27%.     

A review of esthetic alternatives for the restoration of anterior teeth

Helicobacter pylori infection is an important cause of peptic ulcer disease and chronic gastritis. Infection with this bacterium stimulates the production of immunoglobulin (Ig) G antibody. Salivary IgG antibody tests to detect H pylori infection offer a convenient and noninvasive method of diagnosis. To evaluate an IgG salivary antibody kit, saliva was collected from 157 out-patients with dyspepsia referred for endoscopy to a tertiary centre. A salivary IgG ELISA antibody assay was performed using the Helisal Helicobacter pylori (IgG) assay kit, and at least four gastric biopsies were obtained. H pylori infection was confirmed by demonstration of the organism on Warthin-Starry silver stain (sensitivity 85%, specificity 55%). The prevalence of infection with H pylori was 30%. When the analysis was redone, excluding those treated with eradication therapy, the results were similar (sensitivity 86%, specificity 58%). The positive predictive value of the assay was 45% and the negative predictive value was 90%. Despite the ease of sampling, the assay used has limited diagnostic utility, lacking the predictive value to indicate which patients referred with dyspeptic symptoms to a tertiary care setting are infected with H pylori.     

Peptic ulcer in Greenland Inuit: evidence for a low prevalence of duodenal ulcer

In an eight years period new peptic ulcer was diagnosed in 127 Inuit patients at the Central Hospital, Dronning Ingrids Hospital, Nuuk/Godth?b. The ratios: duodenal ulcers (DU): prepyloric ulcers (PPU): gastric ulcers (GU) were 17:22:88. The male:female ratio was 2:1. 46 of the patients were living permanently in Nuuk, 81 in The Districts. There were no significant differences in the type of ulcers among the two groups. The incidence of GU among the Nuuk population was comparable to the incidence in the Danish population (0.63/1000 inhabitants per year), whereas the mean age at the time of diagnosis was only 45 years, thus the patients were approximately 15 years younger than the Danish counterparts. The incidence of DU among the Inuits was 0.15/1000 inhabitants per year, significantly less than in the Danish population. The frequency of Helicobacter (H.) pylori infection among 56 Inuits with dyspeptic symptoms was: 0.61. Only 6/12 patients suffering from DU had a positive test for H. pylori infection. Conclusions: The incidence of duodenal ulcers in the Inuit population was only 10% of the incidence in a Danish population, whereas the incidence of gastric ulcers among the Inuits was comparable to the incidence among Danes. Only 50% of Inuit patients with proven DU had a positive test for H. pylori infection, whereas the frequency of H.pylori infection in a population with dyspeptic symptoms corresponded very well to the frequency reported from other populations.     

Survey of patients with upper gastrointestinal tract dyspepsia. A trial of H2 blocker therapy or endoscopy--a randomized trial of 2 management methods

This study compared two strategies for the management of dyspepsia: therapy based on prompt endoscopy (group 1) vs an empirical treatment strategy with diagnostic endoscopy only in case of therapeutic failure or symptomatic relapse within one year (group 2). Patients without jaundice, bleeding, anaemia, or a previously diagnosed ulcer and with symptoms severe enough to justify empirical H2-blocker therapy were included. Symptoms, drug consumption, and sick-leave days were evaluated through monthly diaries. Patients with non-organic dyspepsia did not receive ulcer drugs. Of 414 patients randomized, 373 completed one year follow-up. In 68 (33%) of the 208 group 1 patients organic disease was found at endoscopy (ulcer in 45 patients). Endoscopy was eventually performed in 136 (66%) of 206 group 2 patients. Case selection for endoscopy was not improved by the empirical treatment strategy since the diagnostic profile was not altered and 40% of the presumed ulcer cases remained undiagnosed. After one year no differences in symptoms or quality of life measures were found. The empirical treatment strategy in dyspepsia was associated with higher costs, mainly due to increases in number of sick-leave days and in ulcer drug use. Prompt endoscopy is a cost-effective strategy in dyspeptic patients with symptoms severe enough to justify H2-blocker treatment.     

mRNAs coding for the calcium-sensing receptor along the rat nephron: effect of a low-phosphate diet

STUDY OBJECTIVE: To assess the role of testing for Helicobacter pylori in the management of dyspeptic patients in primary care. DESIGN: Selective review of literature frequently quoted to support use of H pylori testing. MAIN RESULTS: Testing for H pylori and referral of only positive cases for endoscopy aims to reduce the number of "unnecessary" endoscopies. Patients with negative results may receive short-term reassurance and subsequently place fewer demands on health services. However, studies to date have only assessed this practice in secondary care settings. Given the relatively high prevalence of both dyspepsia and H pylori infection, the transfer of this practice to primary care may lead to a paradoxical increase in endoscopy referrals. Identification of H pylori and prescribing of eradication treatment also aims to reduce endoscopy referrals. No primary care trials have yet assessed this approach. Given that fewer than one in four of dyspeptic patients have peptic ulceration, a high proportion may fail to respond to eradication treatment and subsequently require referral for endoscopy. The longer term clinical and psychosocial sequelae of treating or labelling patients with an infection associated with gastric cancer remain unknown. CONCLUSIONS: Given uncertainty concerning the possible adverse effects of H pylori testing in primary care, we suggest a moratorium on its use in this setting until results from relevant clinical trials become available.     

Prevalence of and risk factors for Helicobacter pylori infection in a multi-racial dyspeptic Malaysian population undergoing endoscopy

The aim of the present study was to determine the risk factors for Helicobacter pylori in a dyspeptic Malaysian population. A cross-sectional survey of 1060 consecutive patients presenting with dyspepsia at the Endoscopic Unit, University Hospital, Kuala Lumpur, Malaysia from January 1994 to July 1995 was undertaken. All patients answered a detailed questionnaire and underwent endoscopy, with two antral biopsies taken for diagnosis of H. pylori using a rapid urease test. An overall H. pylori prevalence of 49.0% was recorded. Helicobacter pylori prevalence in relation to the major endoscopic diagnoses were as follows: non-ulcer dyspepsia (NUD) 31.2%; duodenal ulcer (DU) 91.4%; and gastric ulcer (GU) 74.1%. The prevalence among the races were as follows: Malay 16.4%; Chinese 48.5%; and Indians 61.8%. Multiple logistic regression analysis identified the following as independent risk factors: > 45 years old 1.5 (1.1,2.0); male gender 1.6 (1.2,2.1); ethnic group: Chinese 2.5 (1.7,3.7); Indians 4.9 (3.2,7.5); level of education: low 2.3 (1.5,3.5); middle 1.7 (1.1,2.6); and smoking 1.6 (1.2,2.3). Analysis was also performed on DU, GU and non-UD patients separately; in both DU and GU patients, H. pylori prevalence was high regardless of age, sex, race or level of education. However, in DU patients, Indian race had an independent risk factor (Odds ratio = 7.8 (1.2,48.4)). The findings in the NUD group reflected the findings in the ?all patients' group; > 45 years old, male gender, Indian and Chinese race, and low level of education were also significant, independent risk factors. The overall differences in H. pylori prevalence between the different subgroups were mainly due to differences in the NUD group. The increased risk of H. pylori infection in Chinese and Indians points to either an inherent ethnic genetic predisposition or to socio-cultural practices peculiar to the particular race which may be responsible for transmission of the infection.     

Brief report: evaluation of the upper gastrointestinal tract in uraemic patients undergoing haemodialysis

PURPOSE OF THE STUDY: This study was performed to determine the gastrointestinal symptoms, and endoscopic and histopathological findings in patients on maintenance haemodialysis. STUDY DESIGN: Nintey-two patients on haemodialysis were enrolled in this study and 100 consecutive dyspeptic patients referred for endoscopy served as controls. They were interviewed to obtain information regarding GI symptoms and endoscopy was performed and biopsies were taken from antral mucosa for histopathological evaluation and helicobacter identification. RESULTS: Prevalence of GI symptoms in the dialysis group was extremely common (77%); with more cases in those with periods of dialysis longer than 6 months. Endoscopically observed of hiatus hernia was present in 27 patients in the dialysis group versus 14 in the control group (P<0.02). Duodenal ulcers were present in three patients of the dialysis group compared with 16 in the control group (P<0.01). Histologically, chronic superficial gastritis and mucosal atrophy tended to be more common in the dialysed patients, but this difference was not statistically significant. Helicobacter pylori were present in 45 patients in the dialysis group versus 73 in the control group (P<0.01).     

Functional dyspepsia, gastric emptying of solids, and Helicobacter pylori infection

The origin of functional dyspepsia (FD) is unknown, however, abnormal gastric emptying and infection by H. pylori have been suggested as possible causes. OBJECTIVE: The aim of this study was to test the hypothesis that infection by H. pylori could be related to alterations in gastric emptying of solids and play a role in the pathophysiology of dyspepsia. METHODS: Studies were performed on 12 controls: 6 males, 6 females, age 40 +/- 13, and on 45 FD patients: 15 males and 30 females, age 43.5 +/- 12. Clinical criteria for FD diagnosis were post-prandial epigastric pain, nausea, vomiting or epigastric bloating, with normal blood test, upper endoscopy and abdominal ultrasound. Diagnosis of H. pylori infection was either by growth positive on culture of antral biopsy or by all of the following: on Gram stain, urease test positive and visualization of microorganisms in the antral biopsy. Gastric emptying of solids was studied with a radio-nuclide technique. Patients were prospectively classified in 4 groups according to the main symptom: reflux-like, ulcer-like, dysmotility, and non-specific. RESULTS: H. pylori infection was observed in 21/32 (66%) FD patients. No significant differences in the gastric emptying of solids between the control group and patients with FD (tl/2 80 +/- 17 minutes vs 75 +/- 16 min). The presence of H. pylori infection did not influence gastric emptying rates (78 +/- 16 minutes in infected patients vs 73 +/- 15 min in non infected patients). Gastric emptying times were similar among the four subgroups of FD patients. CONCLUSIONS: No significant differences in gastric emptying of solids were found in H. pylori infected persons as compared with the controls. These findings suggest that H. pylori infection and/or changes in gastric emptying of solids do not play a role in the pathophysiology of FD.     

Patterns of symptoms in functional dyspepsia: role of Helicobacter pylori infection and delayed gastric emptying

OBJECTIVE: Functional dyspepsia (FD) is a syndrome in which several causes are probably involved. Our aim was to investigate the association between specific dyspeptic symptoms and Helicobacter pylori infection or delayed gastric emptying. METHODS: Nine hundred thirty-five consecutive outpatients with unexplained dyspepsia were studied. After appropriate investigation, 304 patients were diagnosed as affected by chronic FD and were tested for H. pylori infection and gastric emptying of solids by means of 13C-urea and 13C-octanoic acid breath tests. Four dyspeptic symptoms (epigastric pain or burning, postprandial fullness, nausea, and vomiting) were scored as absent, mild, moderate, or severe (0-3) according to their influence on the patients' activities. Symptoms of irritable bowel syndrome and gastroesophageal reflux disease were also assessed. On the basis of symptom scores, three groups were identified: "prevalent pain" (10.5%), "prevalent discomfort" (32.6 %), and "unclassifiable" dyspepsia (56.9%). RESULTS: Of the 304 patients with FD, 208 (68.4 %) were H. pylori-positive on urea breath test. Gastric emptying was delayed in 99 subjects (32.6%). Patients with "prevalent pain" were infected significantly more often (81.2% vs 59.6%; p = 0.026) and less frequently had delayed gastric emptying (6.2% vs 40.4%; p = 0.0001) than those with "prevalent discomfort." H. pylori infection was independently associated with age > or =40 yr and epigastric pain or burning > or =2 (odds ratio [OR] and 95% confidence interval [CI] 4.09 [2.39-7.00] and 1.70 [1.04-2.77], respectively). Delayed gastric emptying was independently associated with a cumulative score > or =6 for postprandial fullness, nausea, and vomiting (OR [95% CI]: 3.13 [1.06-9.18]). H. pylori status had no influence on gastric emptying. Logistic regression analysis showed that delayed gastric emptying, female sex, and concomitant symptoms of inflammatory bowel syndrome were independently associated with a cumulative score > or =6 for postprandial fullness, nausea, and vomiting (p = 0.0281, p = 0.0387, and p = 0.0316, respectively). Moreover, concomitant symptoms of gastroesophageal reflux disease, female sex, and H. pylori infection were independently associated with epigastric pain or burning > or =2 (p = 0.002, p = 0.0001, and p = 0.0875, respectively). CONCLUSIONS: Two subsets of FD patients have been identified on the basis of symptoms. One subgroup is mainly characterized by "prevalent pain," H. pylori infection, and normal gastric emptying; the other one demonstrates "prevalent discomfort" and delayed gastric emptying. These findings shed some light on possible etiopathogenetic mechanisms of FD.     

Productivity of a breeding place of Aedes albopictus in an urban environment

BACKGROUND: Traditionally, patients presenting with uncomplicated dyspepsia have been managed using empiric antisecretory therapy, followed by endoscopy in the event of persistent symptoms or complication. Since Helicobacter pylori is now accepted as an important and potentially reversible cause of ulcer disease, it is important to reevaluate the management of dyspepsia. The goal of this study is to evaluate seven outpatient strategies for the management of dyspeptic patients using a cost-utility analysis. METHODS: The study design was that of a cost-utility analysis. The model assumes that an adult patient with signs of dyspepsia but no signs of complication presents to the outpatient office of a primary care physician. Seven strategies are modeled: empiric antisecretory therapy; empiric H pylori eradication using oral omeprazole (20 mg [corrected] twice daily), clarithromycin (500 mg twice daily), and amoxicillin (1000 mg twice daily); use of either upper endoscopy, an upper gastrointestinal barium study (an upper GI), or the serum titer for H pylori as a diagnostic test to identify patients for H pylori eradication; or use of an initial diagnostic test followed by the serum titer for H pylori. The primary outcome was the cost per quality-adjusted life year (QALY) for each strategy for a 1-year period from presentation; secondary outcomes included the probability of symptomatic ulcer recurrence, cost per ulcer cure, and mortality. RESULTS: Three strategies were similarly cost-effective: empiric H pylori eradication ($1198 per QALY), use of a serum H pylori titer as an initial diagnostic test ($1214 per QALY), and empiric antisecretory therapy ($1288 per QALY). Empiric antisecretory therapy, however, was associated with significantly more symptomatic ulcer recurrences and deaths than any other strategy. CONCLUSIONS: This cost-utility analysis suggests that two strategies are reasonable for patients presenting with dyspepsia: (1) empiric H pylori eradication and (2) use of a serum H pylori titer to identify patients who might benefit from H pylori eradication. The latter strategy may be preferable because it is less likely to lead to antibiotic resistance. Strategies utilizing an upper GI or upper endoscopy (either with or without serum H pylori titer) or empiric antisecretory therapy do not improve outcomes and are associated with greater cost, morbidity, and/or mortality.     

Current aspects of using ketamine in childhood]

In this audit we tried to assess the effect of the detection of Helicobacter pylori on the change of outcome and symptoms of peptic ulcer disease outside well defined prospective studies, and its influence on treatment praxis by general practitioners. The study was carried out in the canton of Uri, a geographically closed area of Switzerland. The records of all patients with peptic ulcer disease diagnosed from 1991 to 1994 were evaluated retrospectively. In addition, the patients were followed by contact through their family doctors who were asked to fill out questionnaires on the immediate and long-term treatment of acute peptic ulcer, H. pylori therapy, recurrence of ulcers in light of symptoms or endoscopy, and on any surgery performed for ulcer disease. We found 453 patients with peptic ulcer disease proven by endoscopy, 134 patients presented with signs of ulcer bleeding, 45% of these had used nonsteroidal anti-inflammatory drugs previously. Only 9 of 453 patients required surgery. In 430 patients follow-up was possible (median of 18 months). H. pylori eradication was the primary treatment in 24% of the patients in 1991 and in 79% in 1994. Long-term prophylaxis with histamine H2 antagonists had been selected in 22%. Recurrence of the ulcer disease was seen in 157 patients during the follow-up period. The recurrence rate was 8% (3/39) in patients with documented H. pylori eradication, 43% (62/145) in patients with H. pylori eradication therapy without documentation of the result, 57% (31/54) in H. pylori positive and 50% (14/28) in H. pylori negative patients on long-term treatment with histamine H2 antagonists. 33% of the patients still had substantial abdominal pain despite using long-term histamine H2 antagonists as prophylaxis against recurrence, but this was the case in only 5% (2/39) after successful H. pylori eradication. The rate of successful antibiotic treatment improved substantially during this audit. This follow-up study demonstrates that patients with successfully eradicated H. pylori remain largely free of symptoms and of ulcer recurrence. Control of the eradication result seems to be necessary outside controlled studies. In contrast, symptoms and ulcer recurrence are frequent despite long-term treatment with histamine H2 antagonists. Few patients need surgery for ulcer disease today. Audits like this are a valuable method to improve acceptance and success of a new treatment modality.     

Neuronal ceroid-lipofuscinosis--late-infantile or Jansky-Bielschowsky type--revisited

OBJECTIVE: The aim was to explore the effect of eradication therapy on dyspeptic symptoms in patients with known peptic ulcer disease (PUD). METHOD: A total of 164 known dyspeptics and 147 non-dyspeptic attenders at six UK general practices were recruited. The Helisal Rapid Blood test was performed in the practices and eradication therapy left to the preference of the general practitioner. Patients were followed prospectively by a Likert scaled symptom questionnaire and record review. The symptom questionnaire distinguished between patients known to have dyspepsia and those not. RESULTS: There was a statistically significant decrease in dyspeptic symptoms in patients with known PUD who received eradication therapy (n = 43, Z = -2.63, P = 0.009). CONCLUSIONS: Eradication of Helicobacter pylori in primary care can lead to a reduction in consumption of H2 receptor antagonists and hence cost savings. This study demonstrates that dyspeptic symptoms also decrease. The questionnaire could be used in further studies to evaluate the effect of management on dyspeptic symptoms in the primary care setting.