Trends in acute non-variceal bleeding in Israel in 1996-2007: a significant decrease in the rates of bleeding peptic ulcers

BACKGROUND

A decrease in the incidence of hospital admissions for acute non-variceal upper GI bleeding (AUGIB) has been reported in regions with a low prevalence of Helicobacter pylori (HP) infection.

AIM

To investigate trends in hospital admissions for AUGIB in Israel, where the prevalence of HP infection is intermediate.

METHODS

We have searched the National Hospital Discharge Database of the Israeli Ministry of Health, where all admissions to acute care hospitals for the period January 1, 1996 through December 31, 2007 are compiled. Using a validated strategy, we identified all admissions for AUGIB according to ICD-9-CM codes. Incidence rates were calculated and adjusted to reflect the age and gender distribution of the Israeli population.

RESULTS

The overall rates of hospital admissions for AUGIB decreased significantly from 29.3 to 16.8 cases/10(5)population/year (p<0.0001). The decreases were similar in both genders. This decrease was due to decreased rates of bleeding from duodenal ulcers (from 13.6 to 5 cases/10(5)population/year) and gastric ulcers (from 4.3 to 2.4 cases/10(5)population/year). The rates of bleeding from other causes remained unchanged. The rates of surgical interventions bleeding control decreased significantly (overall from 11 to 4%). The in-hospital mortality rate varied between 7.6 and 7%, did not change significantly in both genders but increased significantly with age during the study period.

CONCLUSIONS

A decline in the overall incidence of AUGIB during the study period was due to a significant decrease in the rate of bleeding peptic ulcers.

Effects of different delay of reinforcement procedures on variable-interval responding

Two experiments studied responding in the rat when the first bar press after a variable period of time produced a cue light that remained on for either 10, 30, or 100 sec and terminated with the delivery of food. In Experiment I, response rate decreased and time to the first response after reinforcement increased as the delay of reinforcement increased. Similar results were obtained whether the delay consisted of retracting the lever during the delay, a fixed delay with no scheduled consequence for responding, or every response during the delay restarted the delay interval. In Experiment II, fixed-delay and fixed-interval schedules of the same duration during the delay period had no differential effect on either response rate or time to the first response after reinforcement, but differentially controlled responding during the delay periods.

Differential effects of token reinforcement on instruction-following behavior in retarded students instructed as a group

This study was addressed to the problem of applying behavior modification techniques on a group basis to a class of retarded students with "attentional deficits". Seven boys, age 8 to 15 yr, characterized as showing severe "attentional" problems or disruptive behavior in their respective classrooms, participated daily for 30-min sessions in a special class over a 1.5-month period. In each session, verbal instructions were given to the class as a whole. In control sessions, each appropriate instruction-following response by a child produced praise for that child. In experimental sessions, appropriate responses also produced tokens exchangeable for tangible reinforcers after the session. Token reinforcement differentially maintained instruction-following behavior in four children while one responded appropriately to most instructions and a second improved continuously during the study. While the data suggest that the present approach can be successfully applied to the alteration of instruction-following behavior in retarded children, its major contribution may be that of providing objective quantitative information about such behavior.

A double-blind, multicentered study comparing the accuracy of diagnostic markers to predict short- and long-term clinical events and their utility in patients presenting with chest pain

BACKGROUND

Millions of patients present annually with chest pain, but only 10% have myocardial infarction (MI). We recently reported comparative sensitivity and specificity of available markers in the diagnosis of MI; however, optimum interpretation of marker results requires prognostic follow-up data.

HYPOTHESIS

The study was undertaken to study the accuracy of CK-MB subforms, troponin I and T, myoglobin, and CK-MB in predicting clinical events at 30 days and 6 months.

METHODS

In all, 955 consecutive patients with chest pain were enrolled in a prospective, multicenter, double-blind study to test the prognostic accuracy of these markers.

RESULTS

Myocardial infarction was diagnosed in 119 by CK-MB mass criteria and unstable angina (UA) in 203 patients by clinical criteria. Follow-up at 30 days and 6 months was available in 824 and 724 patients, respectively, with mortalities of 2.8 and 4.14%, respectively. Cumulative 6-month mortality was 5.6% in MI, 4.4% in UA, and 3.0% in others. Revascularization was reported in 9.3% of patients by 6 months. A positive test on each of the markers except myoglobin was predictive of revascularization. The composite endpoint of death or revascularization occurred in 107 patients by 6 months and a positive result on each of the markers was predictive of this composite endpoint (p < 0.05). The relative risk of death or revascularization for patients who did not have MI but tested positive on each of the markers was > 1.0 but did not reach statistical significance.

CONCLUSIONS

With the possible exception of myoglobin, each of the diagnostic markers displayed similar prognostic performance in patients with chest pain presenting to emergency departments. The most appropriate markers to triage patients with chest pain, which has both adequate early diagnostic sensitivity and prognostic accuracy, are the CK-MB subforms.

Nondigestive symptoms in non-erosive reflux disease: nature, prevalence and relation to acid reflux

BACKGROUND

Nondigestive symptoms are frequent in the irritable bowel syndrome (IBS).

AIM

To characterize nondigestive symptoms in non-erosive gastro-oesophageal reflux disease (NERD) patients, as features of IBS are common in patients with NERD.

METHODS

A prospective, case-control study. NERD was defined in patients with reflux symptoms, a normal oesophageal mucosa and oesophageal pH < 4 for > or = 5% of the time during 24-h pH monitoring. Nondigestive symptoms were scored on validated scales of somatic pain, urinary, sleep and neurasthenia. IBS was defined by the Rome I criteria.

RESULTS

pH-positive NERD patients (n = 326) scored significantly higher than controls (nonpatient hospital visitors; n = 174) on all scales. The scores of pain, sleep and neurasthenia were highly specific in the discrimination of NERD patients from controls. In patients, nondigestive symptoms were independently associated with age, reflux symptoms severity and IBS status, but not with oesophageal acid exposure. NERD patients who met diagnostic criteria for IBS (49%) scored significantly higher on all the nondigestive symptoms scales than those had not met [IBS(-)]. Yet, IBS(-) patients scored significantly higher than controls on all scales.

CONCLUSIONS

Nondigestive symptoms were highly prevalent in NERD patients and were specific in their discrimination from controls. Nondigestive symptoms correlated with reflux symptoms and were predicted by IBS status.

Functional heartburn vs. non-erosive reflux disease: similarities and differences

BACKGROUND

Bowel symptoms have been associated with non-erosive reflux disease (NERD). However, their role in functional heartburn (FH) has not been established.

AIMS

To characterize bowel symptoms in FH and NERD patients, and investigate their role as predictors of severity of reflux symptoms.

METHODS

A prospective study of patients with normal upper endoscopy undergoing a 24-h oesophageal pH monitoring for the evaluation of reflux symptoms. Patients with oesophageal acid exposure <3.1% and a symptom index <50% were classified as FH (n = 60), while those with oesophageal acid exposure >4% were defined as NERD (n = 160). Symptom severity was scored on validated scales.

RESULTS

In FH, a female predominance was noted (P < 0.001). Reflux symptoms were scored higher in NERD patients (P < 0.001) while bowel symptoms were similarly scored in the two groups. In both groups, severity of reflux symptoms was independently associated with a composite score on the bowel scales (P < 0.001) and was not predicted by oesophageal acid exposure. In FH, reflux symptom severity was inversely related to age (P = 0.03), while in NERD, the opposite was true (P = 0.01).

CONCLUSIONS

In both FH and NERD, bowel symptoms were the strongest predictors of reflux symptoms severity. A female preponderance, and an opposite relationship between reflux symptom severity and age, indicate that FH and NERD may be distinct entities.

Potential of information technology in dental education

The use of information technology (IT) in dentistry is far ranging. In order to produce a working document for the dental educator, this paper focuses on those methods where IT can assist in the education and competence development of dental students and dentists (e.g. e-learning, distance learning, simulations and computer-based assessment). Web pages and other information-gathering devices have become an essential part of our daily life, as they provide extensive information on all aspects of our society. This is mirrored in dental education where there are many different tools available, as listed in this report. IT offers added value to traditional teaching methods and examples are provided. In spite of the continuing debate on the learning effectiveness of e-learning applications, students request such approaches as an adjunct to the traditional delivery of learning materials. Faculty require support to enable them to effectively use the technology to the benefit of their students. This support should be provided by the institution and it is suggested that, where possible, institutions should appoint an e-learning champion with good interpersonal skills to support and encourage faculty change. From a global prospective, all students and faculty should have access to e-learning tools. This report encourages open access to e-learning material, platforms and programs. The quality of such learning materials must have well defined learning objectives and involve peer review to ensure content validity, accuracy, currency, the use of evidence-based data and the use of best practices. To ensure that the developers' intellectual rights are protected, the original content needs to be secure from unauthorized changes. Strategies and recommendations on how to improve the quality of e-learning are outlined. In the area of assessment, traditional examination schemes can be enriched by IT, whilst the Internet can provide many innovative approaches. Future trends in IT will evolve around improved uptake and access facilitated by the technology (hardware and software). The use of Web 2.0 shows considerable promise and this may have implications on a global level. For example, the one-laptop-per-child project is the best example of what Web 2.0 can do: minimal use of hardware to maximize use of the Internet structure. In essence, simple technology can overcome many of the barriers to learning. IT will always remain exciting, as it is always changing and the users, whether dental students, educators or patients are like chameleons adapting to the ever-changing landscape.

The μPIVOT: an integrated particle image velocimeter and optical tweezers instrument for microenvironment investigations

A novel instrument to manipulate and characterize the mechanical environment in and around microscale objects in a fluidic environment has been developed by integrating two laser-based techniques: micron-resolution particle image velocimetry (μPIV) and optical tweezers (OT). This instrument, the μPIVOT, enables a new realm of microscale studies, yet still maintains the individual capabilities of each optical technique. This was demonstrated with individual measurements of optical trap stiffness (∼70 pN μm(-1) for a 20 μm polystyrene sphere and a linear relationship between trap stiffness and laser power) and fluid velocities within 436 nm of a microchannel wall. The integrated device was validated by comparing computational flow predictions to the measured velocity profile around a trapped particle in either a uniform flow or an imposed, gravity-driven microchannel flow (R(2) = 0.988, RMS error = 13.04 μm s(-1)). Interaction between both techniques is shown to be negligible for 15 μm to 35 μm diameter trapped particles subjected to fluid velocities from 50 μm s(-1) to 500 μm s(-1) even at the highest laser power (1.45 W). The integrated techniques will provide a unique perspective toward understanding microscale phenomena including single-cell biomechanics, non-Newtonian fluid mechanics and single particle or particle-particle hydrodynamics.

Polycomb-mediated methylation on Lys27 of histone H3 pre-marks genes for de novo methylation in cancer

Many genes associated with CpG islands undergo de novo methylation in cancer. Studies have suggested that the pattern of this modification may be partially determined by an instructive mechanism that recognizes specifically marked regions of the genome. Using chromatin immunoprecipitation analysis, here we show that genes methylated in cancer cells are specifically packaged with nucleosomes containing histone H3 trimethylated on Lys27. This chromatin mark is established on these unmethylated CpG island genes early in development and then maintained in differentiated cell types by the presence of an EZH2-containing Polycomb complex. In cancer cells, as opposed to normal cells, the presence of this complex brings about the recruitment of DNA methyl transferases, leading to de novo methylation. These results suggest that tumor-specific targeting of de novo methylation is pre-programmed by an established epigenetic system that normally has a role in marking embryonic genes for repression.

Pilot study of the combination of EGFR and mTOR inhibitors in recurrent malignant gliomas

Malignant gliomas are frequently characterized by amplification of the epidermal growth factor receptor (EGFR) and loss of PTEN tumor suppressor gene. Twenty-eight heavily pretreated patients with recurrent malignant gliomas were administered EGFR inhibitors (gefitinib or erlotinib) in combination with the mTOR (mammalian target of rapamycin) inhibitor sirolimus. The regimens were reasonably well tolerated. Nineteen percent of patients experienced a partial response and 50% had stable disease. Six-month progression-free survival for glioblastoma patients was 25%.

The alteration of behavior in a special classroom situation

Unproductive classroom behavior was eliminated in two emotionally disturbed boys by removing social consequences of the behavior. Behavior which was more adequate and efficient with respect to social and scholastic adjustment was shaped and maintained with social reinforcers.

Selected growth of cubic and hexagonal GaN epitaxial films on polar MgO(111)

Selected molecular beam epitaxy of zinc blende (111) or wurtzite (0001) GaN films on polar MgO(111) is achieved depending on whether N or Ga is deposited first. The cubic stacking is enabled by nitrogen-induced polar surface stabilization, which yields a metallic MgO(111)-(1 x 1)-ON surface. High-resolution transmission electron microscopy and density functional theory studies indicate that the atomically abrupt semiconducting GaN(111)/MgO(111) interface has a Mg-O-N-Ga stacking, where the N atom is bonded to O at a top site. This specific atomic arrangement at the interface allows the cubic stacking to more effectively screen the substrate and film electric dipole moment than the hexagonal stacking, thus stabilizing the zinc blende phase even though the wurtzite phase is the ground state in the bulk.

Electromagnetic interference with implantable cardiac pacemakers by video capsule

BACKGROUND

Electromagnetic fields, such as those generated by cellular phones and metal detectors, may interfere with normal pacemaker function. However, it remains unclear whether the wireless capsule endoscope interacts with implanted pacemakers. This prospective study evaluated potential interactions between the M2A video capsule (Given Imaging, Yoknam, Israel) and implanted pacemakers.

METHODS

A total of 100 consecutive patients (70 men, 30 women) with an implanted pacemaker (95 on bipolar mode) were studied. The testing was performed with a functional testing device (Test Cap) for the Given Diagnostic System that reproduces the effect of the video capsule by transmitting at exactly the same frequency. During continuous electrocardiographic monitoring and recording, 100 tests were carried out without changing the pacemaker settings. Those with a positive result were retested 1 week later.

RESULTS

The 100 pacemakers evaluated in the study population included the following: 70 dual chamber (11 DDD, 56 DDDR, 3 VDD) and 30 ventricular inhibited (12 VVI, 18 VVIR). In 4 of the 100 patients, pacemaker interference (noise-mode function forcing a synchronous mode) was registered during the Test Cap operation. Three patients had a dual-chamber pacemaker, and one had a single-chamber pacemaker. The interference was reproducible in all cases 1 week later. None of the implanted pacemakers tested was affected by oversensing.

CONCLUSIONS

Electromagnetic interferences with pacemakers from the M2A video capsule can occur, but this is without clinical significance. No potentially dangerous pacemaker inhibition was observed.

Irritable bowel, smoking and oesophageal acid exposure: an insight into the nature of symptoms of gastro-oesophageal reflux

BACKGROUND

In gastro-oesophageal reflux disease, oesophageal acid exposure correlates with symptoms but explains only a small fraction of their variance.

AIMS

To elucidate the effects of irritable bowel syndrome and smoking on gastro-oesophageal reflux disease symptoms and to clarify whether they modulate the relationship between oesophageal acid exposure and symptoms.

METHODS

The relationship between oesophageal acid exposure, irritable bowel syndrome (Rome I criteria), smoking status and symptoms was investigated in patients with a normal gastroscopy who underwent a 24-h oesophageal pH monitoring.

RESULTS

Of 256 patients with gastro-oesophageal reflux disease, 16% were smokers and 50% met the criteria for irritable bowel syndrome (irritable bowel syndrome+). The extent of oesophageal acid exposure was unrelated to smoking or irritable bowel syndrome status. Oesophageal acid exposure, irritable bowel syndrome status and current smoking independently predicted symptoms. Irritable bowel syndrome and smoking modulated the effect of oesophageal acid exposure on symptoms: oesophageal acid exposure was predictive of symptoms only in non-smokers. However, irritable bowel syndrome was a significant predictor of symptoms both in smokers and in non-smokers. Smoking was associated with symptoms only in irritable bowel syndrome+, while oesophageal acid exposure was associated with symptoms irrespective of irritable bowel syndrome status.

CONCLUSIONS

In patients with non-erosive gastro-oesophageal reflux disease, smoking and irritable bowel syndrome independently predicted symptoms, without affecting the extent of oesophageal acid exposure. The relationship between oesophageal acid exposure and symptoms was affected significantly, and in opposite directions, by smoking and irritable bowel syndrome.

Validation of a brief inventory for diagnosis and monitoring of symptomatic gastro-oesophageal reflux

BACKGROUND

This article presents a brief inventory for the diagnosis and monitoring of GORD symptoms.

METHODS

The inventory consists of five items pertaining to different aspects of GORD to be graded for frequency on a 5-point Likert scale. It was validated on a consecutive group of GORD patients diagnosed either by endoscopy (n = 25) or by 24-h ambulatory pH monitoring (acid exposure time > or = 5%; n = 233) and control subjects (n = 300).

RESULTS

Each of the inventory items was significantly associated with GORD (P < 0.001). Factor analysis indicated that all items loaded on a single scale with a high reliability (Cronbach alpha 0.88). Each item was weighted by its respective odds ratio in favour of GORD and a total score for the scale was then calculated as the sum of weighted scores on the five individual items. Receiver-operator (ROC) curve analysis implemented on a random sample comprising 67% of the group indicated that a total weighted score of 31.6 (percentage of the maximal possible weighted score) was 91% sensitive and 92% specific in the diagnosis of GORD. This score was then validated on the rest of the sample, where it correctly classified patients and controls with a sensitivity of 89% and specificity of 94%. The score proved stable on repeated administration in controls and in patients with stable symptoms, and decreased by 66% (P < 0.001) after 1 month of treatment with omeprazole in patients who reported symptom relief.

CONCLUSIONS

The scale described in this article is a brief, simple and accurate measure, for the diagnosis of GORD as well as for monitoring its symptoms.

Cleaning up the river: a metaphor for functional digestive disorders

The irritable bowel syndrome is characterized by abdominal pain, altered bowel habits and various other digestive symptoms. Emotional factors are important in some patients. I describe here a metaphor which links the altered motility of the digestive system to the emotional contents it may embody. A metaphor of a river is used to evoke both a smooth, coordinated flow through the normal digestive tract and a normal flow in the management of the patient's emotions. The possibility that some blockage has occurred in the river, resulting in perturbation of the normal flow is then suggested to the patient. This is followed by a suggestion for the patient to clear the blockage. This approach may lead patients to work on the emotional components of their symptoms, resulting in their subsequent resolution. I have used this approach with several patients and it proved very effective. This paper demonstrates the use of this metaphor in one of the patients.

Extraintestinal symptoms in irritable bowel syndrome and inflammatory bowel diseases: nature, severity, and relationship to gastrointestinal symptoms

Patients suffering from the irritable bowel syndrome (IBS) tend to have extraintestinal symptoms. The purposes of this study were to compare the nature and severity of these symptoms in IBS patients in relation to patients with inflammatory bowel disease (IBD) and to nonpatients and to clarify the relationship between intestinal and extraintestinal symptoms. A consecutive group of male patients and a control group of age-matched male subjects were studied. Symptoms were graded for severity using a validated, self-administered inventory. There were 53 IBS patients, 55 IBD patients (32 Crohn's disease), and 56 controls. IBS patients scored significantly higher than IBD patients on constipation, dyspepsia, and reflux scales. Musculoskeletal symptoms, neurasthenia, and sleep scores were similar in IBS and IBD patients, and both groups scored significantly higher than the controls. The scores of urinary, thoracic, and oral symptoms were similar in IBD patients and in controls. However, IBS patients scored significantly higher than both groups on all these scales. Reflux symptoms were the most powerful predictors of extraintestinal symptoms, both in IBS and in IBD. Diarrhea was predictive of extraintestinal symptoms only in IBD. In conclusion, IBS patients experienced extraintestinal symptoms to the same extent, or even more than patients with IBD. However, the relationship between intestinal and extraintestinal symptoms differed in the two conditions.

[Severity assessment by APACHE III system in Spain]

BACKGROUND

To assess the performance of the prediction equation of the APACHE(Acute Physiology Age and Chronic Health Evaluation) III prognostic scoring system when applied in Spain.

PATIENTS AND METHOD

Prospective multicenter cohort study that included 10786 adult patients from 86 Spanish intensive care units (ICU). Data collection during first 24 hours of admission: acute physiology score, age and comorbilties,for calculating APACHE III score; treatment location prior to ICU admission and main diagnosis admission category for applying the mortality prediction equation of APACHE III system. Main outcome was observed hospital mortality.

RESULTS

Age was 57.74 (0.16); 68% males. Non-operative patients represented 76% of sample. APACHE III score was 53.75(0.26); observed and predicted hospital mortality were 21.2% and 19.8% respectively, with a standardized mortality ration of 1.07. The Chi2 Hosmer-Lemershow statistic was (H) 135.6, (C) 133.91: p < 0.001. The area under the Receiver Operating Curve (ROC) was 0.808, and correct classification at mortality risk of 50% was 82%. Uniformity of fit was better for non-operative diagnoses and for patients admitted from the emergency area. Calibration was excellent for risk lower than 60% but slightly underestimated observed risks above this level.

CONCLUSIONS

The American APACHE III equation fit well when applied to Spanish critical patients but with limitations. Discrepancies could be attributed to differences in case-mix and variations in practice style.

Dyspepsia as a somatic expression of guilt: a case report

A 58-year-old woman developed chronic, severe symptoms of heartburn, epigastric pain, and regurgitation that persisted for 2 years. She underwent a thorough evaluation and no organic cause was identified. Therefore, a diagnosis of dyspepsia was made. Her symptoms were refractory to pharmacological treatment. Upon further probing, the patient reported that the onset of her symptoms coincided with the death of her son of cancer 2 years earlier. She blamed herself for the death of her son and admitted to a need for self-punishment. A brief course of treatment using metaphors and hypnosis resulted in a complete resolution of her symptoms, which did not recur during a follow-up of 12 years. This is the first published report of the treatment of dyspepsia using hypnotic methods.