Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations

BACKGROUND AND AIMS

Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR.

METHODS

Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements.

RESULTS

In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11).

CONCLUSIONS

The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.

Topical moistening of mastectomy wounds with diluted tranexamic acid to reduce bleeding: randomized clinical trial

BACKGROUND

Topical administration of tranexamic acid (TXA) may be an alternative to intravenous administration to reduce bleeding with a lower risk of systemic adverse events. The aim of this study was to investigate whether moistening a surgical wound with TXA before closure, leaving a thin film of drug only, would reduce postoperative bleeding.

METHODS

This was a two-centre, stratified, parallel-group, placebo-controlled, double-blind RCT. Patients undergoing mastectomy with or without axillary lymph node clearance were randomized 1 : 1 to moistening of wound surface before closure with either 25 mg/ml TXA or 0·9 per cent sodium chloride (placebo). The primary endpoint was postoperative bleeding as measured by drain production in the first 24 h. Secondary endpoints were early haematoma, total drain production, postoperative complications and late aspirations of seroma within 3 months.

RESULTS

Between 1 January 2016 and 31 August 2018, 208 patients were randomized. Two patients were converted to a different surgical procedure at surgery, and four did not receive the intervention owing to technical error. Thus, 202 patients were included in the study (101 in the TXA and 101 in the placebo group). TXA reduced mean drain production at 24 h (110 versus 144 ml; mean difference 34 (95 per cent c.i. 8 to 60) ml, P = 0·011). One patient in the TXA group had early haematoma compared with seven in the placebo group (odds ratio (OR) 0·13 (95 per cent c.i. 0·02 to 1·07); P = 0·057). There was no significant difference in postoperative complications between TXA and placebo (13 versus 10; OR 1·11 (0·45 to 2·73), P = 0·824) or need for late seroma aspirations (79 versus 67 per cent; OR 1·83 (0·91 to 3·68), P = 0·089).

CONCLUSION

Moistening the wound with TXA 25 mg/ml before closure reduces postoperative bleeding within the first 24 h in patients undergoing mastectomy. Registration number: NCT02627560 (https://clinicaltrials.gov).

Endoscopic stent treatment of a duodenal ulcer perforation using a semi-covered stent

Placement of a covered self-expandable metal stent when primary surgery had failed to close the duodenal ulcer perforation or as a primary modality is a promising procedure when compared to other currently available types of surgical rescue or intervention.

Treatment as Prevention for Hepatitis C (TraP Hep C) - a nationwide elimination programme in Iceland using direct-acting antiviral agents

A nationwide programme for the treatment of all patients infected with hepatitis C virus (HCV) was launched in Iceland in January 2016. By providing universal access to direct-acting antiviral agents to the entire patient population, the two key aims of the project were to (i) offer a cure to patients and thus reduce the long-term sequelae of chronic hepatitis C, and (ii) to reduce domestic incidence of HCV in the population by 80% prior to the WHO goal of HCV elimination by the year 2030. An important part of the programme is that vast majority of cases will be treated within 36 months from the launch of the project, during 2016-2018. Emphasis is placed on early case finding and treatment of patients at high risk for transmitting HCV, that is people who inject drugs (PWID), as well as patients with advanced liver disease. In addition to treatment scale-up, the project also entails intensification of harm reduction efforts, improved access to diagnostic tests, as well as educational campaigns to curtail spread, facilitate early detection and improve linkage to care. With these efforts, Iceland is anticipated to achieve the WHO hepatitis C elimination goals well before 2030. This article describes the background and organization of this project. Clinical trial number: NCT02647879.

Rare and Common Variants Conferring Risk of Tooth Agenesis

We present association results from a large genome-wide association study of tooth agenesis (TA) as well as selective TA, including 1,944 subjects with congenitally missing teeth, excluding third molars, and 338,554 controls, all of European ancestry. We also tested the association of previously identified risk variants, for timing of tooth eruption and orofacial clefts, with TA. We report associations between TA and 9 novel risk variants. Five of these variants associate with selective TA, including a variant conferring risk of orofacial clefts. These results contribute to a deeper understanding of the genetic architecture of tooth development and disease. The few variants previously associated with TA were uncovered through candidate gene studies guided by mouse knockouts. Knowing the etiology and clinical features of TA is important for planning oral rehabilitation that often involves an interdisciplinary approach.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Low adherence to Helicobacter pylori testing in hospitalized patients with bleeding peptic ulcer disease

BACKGROUND

Helicobacter pylori (H. pylori) testing in patients with bleeding ulcers is recommended by society guidelines and considered a quality indicator. The aim of the study is to examine the proportion of patients with bleeding ulcers who had H. pylori testing and identify predictors associated with H. pylori testing.

MATERIALS AND METHODS

Consecutive hospitalized patients with bleeding ulcers documented endoscopically at a single center from 10/2004-5/2011 were identified retrospectively from an endoscopy database. The proportion of patients undergoing direct H. pylori testing (histology, rapid urease test, breath test or stool antigen) and any H. pylori testing (direct or serologic) were determined.

RESULTS

Among 330 patients with bleeding ulcers, 105 (32%, 95% CI 27-37%) underwent direct testing and another 52 (16%, 95% CI 12-20%) had serologic testing during a median follow-up of 9 months (range, 0-86). H. pylori testing occurred at the index hospitalization in 146 (93%) of the 157 patients tested. Among the 105 patients who had direct H. pylori testing, 90 (86%) had biopsy-based testing during the initial endoscopy. On multivariate analysis, undergoing biopsy of a gastric ulcer was strongly associated with having direct H. pylori testing performed (OR = 5.1, 95% CI 2.3-11.5; p < .0001).

CONCLUSIONS

Among patients hospitalized with bleeding ulcers, less than half received H. pylori testing and less than a third received the more accurate direct testing. Most of the direct H. pylori testing was biopsy-based with very few being tested after the index hospitalization. Efforts to increase H. pylori testing in patients with bleeding ulcers are needed to improve outcomes.

Magnetic self-organized atomic laminate from first principles and thin film synthesis

The first experimental realization of a magnetic M(n+1)AX(n) (MAX) phase, (Cr(0.75)Mn(0.25))(2)GeC, is presented, synthesized as a heteroepitaxial single crystal thin film, exhibiting excellent structural quality. This self-organized atomic laminate is based on the well-known Cr(2)GeC, with Mn, a new element in MAX phase research, substituting Cr. The compound was predicted using first-principles calculations, from which a variety of magnetic behavior is envisaged, depending on the Mn concentration and Cr/Mn atomic configuration within the sublattice. The analyzed thin films display a magnetic signal at room temperature.

Bleeding Meckel's diverticulum diagnosed and treated by double-balloon enteroscopy

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract. The diagnosis of symptomatic MD has been cumbersome. Several case reports been published regarding direct visualization of MD with double balloon enteroscopy (DBE); diagnosing a bleeding MD leading to surgical resection. We report the use of DBE for the treatment of a bleeding MD.

Fe charge state adjustment in ZnO upon ion implantation

The influence of the ion implantation process on the charge state of dilute (57)Fe impurities implanted as radioactive (57)Mn in ZnO is investigated by (57)Fe emission Mössbauer spectroscopy. One sample is additionally implanted with stable (23)Na impurities. Both Fe(2+) and Fe(3+) charge states are observed, and the Fe(3+)/Fe(2+) ratio is found to increase with the fluence of both (57)Mn/(57)Fe and (23)Na ions, demonstrating that the build-up of Fe(3+) is not related to the chemical nature of the implanted ions. The results are interpreted in terms of radiation damage induced changes of the Fermi level, and illustrate that the Fe(3+)/Fe(2+) ratio can be adjusted by ion implantation. The spin-lattice relaxation time for Fe(3+) in ZnO is found to be independent of the implantation fluence, and is evidently an intrinsic property of the system.

Comparing resonant photon tunneling via cavity modes and Tamm plasmon polariton modes in metal-coated Bragg mirrors

Resonant photon tunneling was investigated experimentally in multilayer structures containing a high-contrast (TiO(2)/SiO(2)) Bragg mirror capped with a semitransparent gold film. Transmission via a fundamental cavity resonance was compared with transmission via the Tamm plasmon polariton resonance that appears at the interface between a metal film and a one-dimensional photonic bandgap structure. The Tamm-plasmon-mediated transmission exhibits a smaller dependence on the angle and polarization of the incident light for similar values of peak transmission, resonance wavelength, and finesse. Implications for transparent electrical contacts based on resonant tunneling structures are discussed.

Helicobacter pylori breath testing in an open access system has a high rate of potentially false negative results due to protocol violations

BACKGROUND

Among available tests to detect Helicobacter pylori (H. pylori), urea breath test (UBT) is the most accurate when performed correctly in research protocols with unknown validity in clinic settings.

MATERIAL AND METHODS

A total of 595 subjects at a gastroenterology clinic were tested 620 times with UBT. Detailed information about three known factors (recent proton-pump inhibitors (PPI), antibiotics, or bismuth, H. pylori eradication treatment finished <4 weeks ago, and gastric resection) to make UBT unreliable were prospectively recorded before each test.

RESULTS

Twenty-three percent (120 of 526) of all negative tests fell in one or more of the three categories, which had the potential to make UBT unreliable. Of those carried out on persons without being treated before, the potential false negative rate was 15%. Among those with previous eradication treatment, the rate was around 45%.

CONCLUSIONS

If a negative UBT could be false negative in up to 23% of cases, then it has a serious lack of negative predictive value. A negative UBT should be considered false negative until potential protocol violations are excluded.

A pilot study to assess feasibility of the water method to aid colonoscope insertion in community settings in the United States

BACKGROUND: The water method decreases patient discomfort and sedation requirement. Applicability in non-veteran community settings in the United States (U.S.) has not been reported. AIMS: Our aim is to perform a pilot study to establish feasibility of use the water method at 2 community sites. We tested the hypothesis that compared with air insufflation patients examined with the water method would require less sedation without adverse impact on outcomes. METHODS: Two performance improvement projects were carried out. Consecutive patients who consented to respond to a questionnaire after colonoscopy were enrolled. Project 1: The design was single-blinded (patient only); quasi-randomized - odd days (water), even days (air). Colonoscopy was performed by a staff attending. Project 2: A supervised trainee performed the reported procedures. In both, patient demographics (age, gender and body mass index), amount of sedation required during colonoscopy and procedure-related variables were recorded. The patients completed a questionnaire that enquired about discomfort during colonoscopy and willingness to repeat the procedure within 24 hours after the procedure. RESULTS: Project 1: Significantly lower doses of fentanyl and midazolam were used and a higher adenoma detection rate (ADR) was demonstrated in the water group. Project 2: 100% cecal intubation rate was achieved by the supervised trainee. CONCLUSION: This is the first pilot report in the U.S. documenting feasibility of the water method as the principal modality to aid colonoscope insertion in both male and female community patients. In a head-to-head comparison, significant reduction of sedation requirement is confirmed as hypothesized. No adverse impact on outcomes was noted.

Push enteroscopy has a 96% cecal intubation rate in colonoscopies that failed because of redundant colons

BACKGROUND

Performing a complete colonoscopy to the cecum is important for ruling out malignancy and other lesions, but failure rates are significant with a standard colonoscope. A previous study using a push enteroscope for failed colonoscopies had a completion rate of 68.7%.

OBJECTIVE

To improve the cecal intubation rate by using a newer version of a push enteroscope.

DESIGN

Retrospective study at first, then a prospective study.

SETTING

Single-center veterans health care system.

PATIENTS

A total of 47 patients in whom the cecum was not reached with a regular adult colonoscope between January 2007 and December 2010 were included. Those with poor bowel preparation were excluded.

INTERVENTIONS

Repeat colonoscopy using a new version of a push enteroscope.

MAIN OUTCOME MEASUREMENTS

The rate of cecal intubation and additional pathological findings.

RESULTS

The cecum or terminal ileum was reached in 45 patients (96%). Additional significant pathological findings in the previously unexamined colon were seen in 18 patients (38%).

LIMITATIONS

Small sample size, lack of comparison with other endoscopes.

CONCLUSIONS

Colonoscopy with a push enteroscope could be advanced to either the terminal ileum or cecum in 96% of patients, which is one of the highest known completion rates in patients in whom colonoscopy failed. Clinical management changed in all patients with additional findings.

DDW 2011 cutting edge colonoscopy techniques - state of the art lecture master class - warm water infusion/CO(2) insufflation for colonoscopy

Pain limits the success of cecal intubation in unsedated patient. Carbon dioxide infusion instead of air insufflation and water infusion as an adjunction to air insufflation have both been investigated as modalities to minimize pain associated with colonoscopy. Multiple RCT support an effect of carbon dioxide in reducing pain after colonoscopy. A modern method of water infusion as the sole modality for aiding colonoscope insertion has been shown to reduce pain during and after colonoscopy. Favorable effects in reducing discomfort have been documented in both sedated and unsedated patients. Because of the need to perform water exchange in the patients with suboptimal bowel perparation, a serendipitous consequence of salvage cleansing is evident with application of the water method. The associated increase in adenoma detection especially in the proximal colon is most intriguing. The hypothesis that the water method during insertion combined with carbon dioxide insufflation during withdrawal will optimally decrease colonoscopy pain should be evaluated. The implications of increased adenoma detection by the water method also deserve to be studied.

Prevention of colorectal cancer with vitamin D

The fact that colorectal cancer (CRC) is the second leading cause of cancer mortality in the United States emphasizes the need for more effective preventive and therapeutic modalities. There is growing evidence that vitamin D may reduce the incidence of CRC. Results of epidemiologic, in vitro, in vivo animal and clinical studies suggest that a low serum vitamin D level may be a serious risk factor for CRC and a high serum vitamin D level may reduce the risk of CRC. On a molecular level, vitamin D suppresses CRC development and growth by affecting cell proliferation, differentiation, apoptosis, and angiogenesis. Vitamin D insufficiency and CRC are common in the elderly population. Vitamin D insufficiency is simple to screen for and treatable with vitamin D supplementation. Serum 25-hydroxyvitamin D (calcidiol) is the best measure of vitamin D status and should be checked routinely for individuals with risk factors for CRC. Maintaining serum concentrations of calcidiol above 32 ng/ml (80 nmol/l) in individuals whose serum calcidiol level is low may help prevent CRC as well as osteoporosis, fractures, infections, and cardiovascular disease. Daily calcidiol intake of 1000 International Units can increase serum vitamin D to sufficient levels in most elderly persons and, based on available data, may substantially lower the incidence of CRC with minimal risks.

Safety of same-day endoscopic ultrasound and endoscopic retrograde cholangiopancreatography under conscious sedation

AIM: To assess the tolerability and safety of same-day tandem procedures, endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation.

METHODS: A retrospective review was conducted at Loma Linda University Medical Center, a tertiary-care center. All 54 patients who underwent EUS followed by ERCP (group A) from 2004 to 2006 were included in the study. A second group of 56 patients who underwent EUS only (group B), and a third group of 53 patients who underwent ERCP only (group C) during the same time period were selected consecutively as control groups for comparison.

RESULTS: Conscious sedation was used in 96% of patients in group A. Mean dosages of meperidine and midazolam used in group A were significantly higher than in group B or C. Mean recovery time in group A was not statistically longer than in group B or C. There was no significant difference in the incidence of sedation-related and procedural-related complications.

CONCLUSION: Tandem EUS/ERCP procedure can be safely performed under conscious sedation with minimal adverse events. Combined procedures, however, are associated with higher dosages of sedatives, and slightly longer recovery time.

Macroglobulinaemia in an Icelandic family

Macroglobulinaemia in an Icelandic family is presented. A woman had Waldenström's macroglobulinaemia, and two of her brothers had monoclonal macroglobulinaemia of the benign form. One was asymptomatic, but the other had polyneuropathy and IgM deposits in peripheral nerves. A third brother of these siblings died of a lymphoreticular disease, which presented with a widespread neuropathy. A second sister had polyclonal increase in serum IgA and two other brothers of this sibship had IgM slightly elevated. A study of all descendants (45 in all and 19 spouses) revealed seven individuals with elevated IgM levels. No other immunoglobulin abnormalities were detected.

Clinical review of the management of fulminant clostridium difficile infection

BACKGROUND

Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy. In this review, we discuss the risk factors, pathophysiology, diagnosis, and management of fulminant CDI.

DATA SOURCES

A literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed from the period between January 1980 and June 2008 using the key words "Clostridium difficile,""pseudomembranous enterocolitis,""colectomy,""acute abdomen,""antibiotic-associated diarrhea," or "fulminant Clostridium difficile colitis." Articles not in English or not related to human subjects were excluded. For this review, we analyzed the articles identified in our original search and those articles cited in the original review articles. No randomized trials were found on the surgical management of fulminant CDI and only retrospective studies with a minimum of five patients were used in the review. With respect to medical treatment, we based our review on guideline articles, systematic reviews, and available randomized trials.

CONCLUSION

Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with end ileostomy, although the mortality rate remains high.

A magnetron sputtering system for the preparation of patterned thin films and in situ thin film electrical resistance measurements

We describe a versatile three gun magnetron sputtering system with a custom made sample holder for in situ electrical resistance measurements, both during film growth and ambient changes on film electrical properties. The sample holder allows for the preparation of patterned thin film structures, using up to five different shadow masks without breaking vacuum. We show how the system is used to monitor the electrical resistance of thin metallic films during growth and to study the thermodynamics of hydrogen uptake in metallic thin films. Furthermore, we demonstrate the growth of thin film capacitors, where patterned films are created using shadow masks.

Ultrasound examination shows disturbed proximal gastric function in symptomatic gallstone patients with dyspepsia and improvement after cholecystectomy--gallstones and gastric emptying

AIM

The aim of our study was to examine gastric function, gallbladder emptying, and dyspepsia in symptomatic gallbladder stone patients (SGBS) to see if a motility disorder, expressed by gastric function and gallbladder emptying, may cause dyspepsia in SBGS.

MATERIALS AND METHODS

Gastric function and gallbladder emptying in 21 SGBS referred for surgical treatment were measured by ultrasound after ingestion of 500 ml of a meat soup (bouillon). Dyspeptic symptoms were simultaneously recorded on a Visual Analog Scale (VAS). The patients were re-examined 10 months after cholecystectomy. Hospital staff (n = 14) served as control subjects (C).

RESULTS

In SGBS, the frontal diameter of the proximal stomach was wider than in C at both 10 minutes (55.7 vs. 48.3 mm; p = 0.053) and 20 minutes (49.3 vs. 39.5 mm; p = 0.002), and the sagittal area of the proximal stomach was larger at 10 minutes (25.0 vs. 20.9 cm (2); p = 0.03). The postprandial frontal diameter decreased significantly after cholecystectomy (immediately after the meal: 51.3 mm; p = 0.03, at 10 minutes: 47.6 mm; p = 0.05, and at 20 minutes: 39.1 mm; p = 0.004). Twenty minutes after meal ingestion, gallbladder emptying was significantly less in SGBS than in C with a mean (SD) emptying of 20 % (17) versus 33 % (18); p < 0.04. In the fasting state, SGBS felt more hunger than C (VAS 67 mm vs. 39 mm; p = 0.03). After cholecystectomy, the feeling of hunger decreased (VAS 27 mm; p = 0.01).

CONCLUSION

SGBS had a wider proximal stomach and more hunger in the fasting state than C. After cholecystectomy the proximal stomach function and the hunger score improved. Our results suggest a physiological link between symptomatic gallstone disease and dyspepsia expressed by impaired proximal gastric function.

Pain attacks in non-complicated and complicated gallstone disease have a characteristic pattern and are accompanied by dyspepsia in most patients: the results of a prospective study

OBJECTIVE

The cardinal indication for surgical treatment of gallstones is pain attacks. However, following cholecystectomy, 20% of patients remain symptomatic. It is unclear to what extent post-cholecystectomy symptoms can be ascribed to persistence of preoperative symptoms or to new pathology. The pain and digestive pattern in gallstone patients has not been defined in a recent setting with ultrasonography as the diagnostic method. The aim of this study was to characterize a pain pattern that is typical for gallstone disease and to describe the extent of associated dyspepsia.

MATERIAL AND METHODS

A total of 220 patients with symptomatic gallstone disease including complicated disease (acute cholecystitis and common bile duct stones) were interviewed using detailed questionnaires to disclose pain patterns and symptoms of indigestion.

RESULTS

All patients had pain in the right upper quadrant (RUQ) including the upper midline epigastrium. The pain was localized to the right subcostal area in 20% and to the upper epigastrium in 14%, and in the rest (66%) it was more evenly distributed. An area of maximal pain could be defined in 90%. Maximal pain was located under the costal arch in 51% of patients and in the epigastrium in 41%, but in 3% behind the sternum and in 5% in the back. The pain was referred to the back in 63% of the patients. The mean visual analogue scale (VAS) score was very high: 90 mm on a 0-100 scale. A pattern of incipient or low-grade warning pain with a subsequent relatively steady state until subsiding in the same fashion was present in 90% of the patients. An urge to walk around was experienced by 71%. Pain attacks usually occurred in the late evening or at night (77%), with 85% of the attacks lasting for more than one hour and almost never less than half an hour. Sixty-six percent of the patients were intolerant to at least one kind of food, but only 48% to fatty foods. Symptoms of functional indigestion (gastroesophageal reflux, dyspepsia or irritable bowel symptoms) were seen in the vast majority in association with attacks.

CONCLUSIONS

Gallstone-associated pain follows a certain pattern in the majority of patients. The pain is located in a defined area with a point of maximum intensity, is usually referred, and occurs mainly at night with duration of more than one hour. The majority of patients experience functional indigestion, mainly of the reflux type or dyspepsia.

Quality of life in patients with subjective food hypersensitivity: applicability of the 10-item short form of the Nepean Dyspepsia Index

The aim of this study was to investigate quality of life and applicability of the 10-item short form of the Nepean Dyspepsia Index (SF-NDI) in patients with subjective food hypersensitivity. Fifty-two adult patients and 120 controls were examined using three questionnaires: Quality of life Nepean Dyspepsia Index (NDI), Gastrointestinal Symptom Rating Scale (GSRS), and Ulcer Esophagitis Subjective Symptoms Scale (UESS). To document psychometric properties, 20 of the patients filled in the SF-NDI questionnaire once more 4 weeks later. Patients had poor quality of life compared with controls from health care workers or general population (P < 0.001). Scores on SF-NDI were significantly correlated with scores on the GSRS (r = 0.34, P = 0.02) and UESS (r = 0.41, P = 0.003). The SF-NDI performed very satisfactorily, with a high reliability, construct validity, and responsiveness. Patients with subjective food hypersensitivity have considerably reduced quality of life. The SF-NDI provides reliable, responsive, and clinically valid measures of quality of life in these patients.

Altered dopamine D2 receptor function in fibromyalgia patients: a neuroendocrine study with buspirone in women with fibromyalgia compared to female population based controls

BACKGROUND

To what extent fibromyalgia belongs to affective spectrum disorders or anxiety spectrum disorders remains disputed. Buspirone induces a hypothermic response, which most likely is due to 5-HT(1A) autoreceptor stimulation, and growth hormone (GH) release, which probably is related to postsynaptic 5-HT(1A) receptor stimulation. The prolactin response to buspirone has been suggested to be mediated through dopamine (DA) antagonistic effects.

OBJECTIVES

Based on the assumption that fibromyalgia is more strongly related to stress and anxiety than affective spectrum disorders, we hypothesized that compared to population controls, fibromyalgia patients should demonstrate an increased prolactin response (DA sensitivity) to buspirone challenge test, but no difference in hypothermic response or GH release (5HT sensitivity).

METHOD

A 60-mg dose of buspirone was given orally to 22 premenopausal women with fibromyalgia and 14 age and sex matched healthy control subjects. Core body temperature, growth hormone and prolactin levels were analyzed at baseline and after 60, 90, and 150 min.

RESULTS

Fibromyalgia patients showed an augmented prolactin response to buspirone compared to controls. Temperature and growth hormone responses did not differ from controls.

CONCLUSIONS

Dopaminergic rather than serotonergic neurotransmission is altered in fibromyalgia, suggesting increased sensitivity or density of dopamine D(2) receptors in fibromyalgia patients. Stress and anxiety is an important modulator of dopaminergic neurotransmission. Our results suggest that fibromyalgia is related to anxiety and associated with disturbance in the stress response systems.

Changes in food tolerance and lifestyle after eradication of Helicobacter pylori

BACKGROUND

It is known that patients with peptic ulcer disease (PUD) often have an unhealthy lifestyle that results in increased mortality because of smoking-related diseases. No thorough study has been done to see what changes, if any, the patient makes to lifestyle after eradication of Helicobacter pylori.

METHODS

One-hundred-and-eighty-three patients were enrolled in an open-endoscopy setting; 58% had PUD and 42% gastritis and/or duodenitis (G/D). They filled out a lifestyle questionnaire before the start of anti-Helicobacter therapy and again 1 year later.

RESULTS

The prevalence of food intolerance decreased from 71% to 44% among patients with PUD (P < 0.0001) and from 76% to 63% among patients with G/D (P = 0.09). Tolerance improved for coffee, orange juice, fried foods, spicy foods and fruits. There was no significant change in smoking or alcohol consumption after eradication. Coffee and tea consumption was unchanged. Milk consumption decreased from 4.2 dL/day to 3.3 (P = 0.01). The number of meals decreased from 3.5/day to 3.4 (P = 0.005) and snacking from 1.3 snacks/day to 1.1 (P = 0.02). Consumption of fruit increased from 4.0 to 4.3 times/week (P = 0.04), but the frequency of meat, fish, vegetables, spicy foods, salty foods, sweets and cakes did not change. The time spent on each meal was unchanged. There was no change in the time spent exercising. There were few significant differences between PUD and G/D patients.

CONCLUSIONS

Food was better tolerated, but there were no major changes in lifestyle after eradication of H. pylori. Patients therefore do not abuse the privilege of a more tolerant digestion by indulging in a more unhealthy lifestyle.

Patients with endoscopic gastritis and/or duodenitis improve markedly following eradication of Helicobacter pylori, although less so than patients with ulcers

BACKGROUND

It is well documented that dyspepsia in patients with peptic ulcer disease (PUD) improves markedly after eradication of Helicobacter pylori, while rarely does it improve in patients with functional dyspepsia. There is a large group of H. pylori-infected patients who do not qualify for either diagnosis, but in whom eradication may be considered. The aim of this study was to compare symptom severity, change in gastrointestinal symptoms 1 year after eradication and satisfaction with therapy between PUD patients and patients with endoscopic diagnoses of gastritis and/or duodenitis (G/D patients).

METHODS

The patients were randomized to one of four triple regimens containing ranitidine bismuth and metronidazole, and either oxytetracycline or spiramycine. Eradication was assessed with the 14C-urea breath test. GI symptoms were evaluated using the Gastrointestinal Symptom Rating Scale (GSRS) and the Ulcer Esophagitis Subjective Symptoms Scale (UESS) questionnaires.

RESULTS

One-hundred-and-eighty-three patients were recruited from GI outpatient clinics. Patients with PUD and G/D had similar severity of symptoms before eradication therapy. One year after H. pylori eradication, 99% of the PUD patients and 75% of the G/D patients felt better regarding their main upper GI complaint. Abdominal pain score decreased by 48% as measured by GSRS and by 78% as measured by UESS in the PUD group and by 25% and 47%, respectively, in the G/D group. Reflux symptoms decreased by 41% and 63% in PUD patients and by 28% and 45% in G/D patients; indigestion by 30% and 47% in PUD and by 20% and 34% in G/D; eating discomfort by 60% in PUD and by 35% in G/D. Sleep quality score improved by 68% in PUD and by 41% in NU patients. Constipation decreased by 22% in the PUD group. All these differences in symptoms were highly significant compared to baseline. Diarrhoea was unchanged.

CONCLUSIONS

Abdominal pain, reflux symptoms, indigestion and the ability to eat and sleep improved in both PUD and G/D patients 1 year after H. pylori eradication. Chronic diarrhoea was not induced. Abdominal pain improved significantly more in PUD than in G/D patients. Further study of the effect of H.pylori eradication in G/D patients is warranted.

Vagal tone and meal-induced abdominal symptoms in healthy subjects

BACKGROUND/AIMS

Patients with functional dyspepsia often have meal-induced dyspeptic symptoms and low vagal tone. We examined whether these variables are related in healthy subjects.

METHODOLOGY

In 40 healthy subjects vagal tone and abdominal symptoms were recorded before and after a 500-ml soup meal ingested in 1 and 4 min on separate visits. Vagal tone was indexed by respiratory sinus arrhythmia (RSA).

RESULTS

Scores for nausea and discomfort were higher when the soup was ingested in 1 min as compared with 4 min (nausea: p = 0.02; discomfort: p = 0.04). There was no difference in fullness or abdominal pain. RSA was unrelated to meal-induced symptom scores. RSA varied with respiration and body position: It was highest while breathing deeply in the sitting position (24.0 beats/min). With normal breathing RSA was highest in the supine position (9.0 beats/min), lower while sitting (7.0 beats/min) and lowest while standing (6.2 beats/min).

CONCLUSIONS

Epigastric discomfort in response to rapid ingestion of a test meal in healthy subjects was not related to vagal tone as indexed by RSA. Vagal tone varied with breathing pattern and body position. It is possible that increasing vagal tone by such measures can be beneficial in the treatment of patients with functional dyspepsia.

Factors explaining variance in perceived pain in women with fibromyalgia

BACKGROUND

We hypothesized that a substantial proportion of the subjectively experienced variance in pain in fibromyalgia patients would be explained by psychological factors alone, but that a combined model, including neuroendocrine and autonomic factors, would give the most parsimonious explanation of variance in pain.

METHODS

Psychometric assessment included McGill Pain Questionnaire, General Health Questionnaire, Hospital Anxiety and Depression Rating Scale, Eysenck personality Inventory, Neuroticism and Lie subscales, Toronto Alexithymia Scale, and Multidimensional Health Locus of Control Scale and was performed in 42 female patients with fibromyalgia and 48 female age matched random sample population controls. A subgroup of the original sample (22 fibromyalgia patients and 13 controls) underwent a pharmacological challenge test with buspirone to assess autonomic and adrenocortical reactivity to serotonergic challenge.

RESULTS

Although fibromyalgia patients scored high on neuroticism, anxiety, depression and general distress, only a minor part of variance in pain was explained by psychological factors alone. High pain score was associated with high neuroticism, low baseline cortisol level and small drop in systolic blood pressure after buspirone challenge test. This model explained 41.5% of total pain in fibromyalgia patients. In population controls, psychological factors alone were significant predictors for variance in pain.

CONCLUSION

Fibromyalgia patients may have reduced reactivity in the central sympathetic system or perturbations in the sympathetic-parasympathetic balance. This study shows that a biopsychosocial model, including psychological factors as well as factors related to perturbations of the autonomic nervous system and hypothalamic-pituitary-adrenal axis, is needed to explain perceived pain in fibromyalgia patients.

Chemical control of Penthaleus major (Acari: Prostigmata) in hayfields in Iceland

The plant parasitic mite Penthaleus major (Dugès) occurs as a pest on perennial grasses in hayfields in Iceland, northern Norway, and southern Greenland. In these areas it appears as a summer phenomenon, contrary to more southern locations, where it appears as a pest on winter crops. Up to 500 individuals of P. major were collected per day in pitfall traps. Spring application of 44 ml/ha of permethrin and 5 ml of deltamethrin significantly reduced but did not eliminate the populations of P. major the following weeks. In addition to this immediate effect, spring application also decreased the mite populations in the fall and even the following spring. Additional effects might be obtained by earlier spring application. Despite a significant reduction in mite populations and reduction in visible plant damage, significant differences on dry matter yield were rarely registered. A side effect of application was a small but significant reduction in potassium-content of the yield, and the reduction in mite population was accompanied by a corresponding reduction in the number of spiders.

Controversies in dyspepsia

Even in the absence of visible lesions like an ulcer, cancer or oesophagitis, patients with functional dyspepsia may complain of severe dyspeptic symptoms and have a poor quality of life. Characteristically, these patients also often have a low estimate of their own health and have complaints from several organ systems. The cause of the disease is not known. Both central nervous system and gastric disturbances appear to be involved, and their relative importance is controversial. There is no clear beneficial effect of acid suppression or H. pylori eradication although effects of such therapy may be seen in minor subgroups. New findings emphasise the importance of distinguishing between functional dyspepsia and gastro-oesophageal reflux disease, which exhibit completely different gastric accommodation patterns to a meal and have very different therapeutic potential. The effect of drugs like glyceryl trinitrate, glucagon, sumatriptan and buspirone which all concomitantly improve symptoms and gastric accommodation support the important role of abnormal gastric accommodation to meals in patients with functional dyspepsia. A hypothetical model for the pathogenesis of functional dyspepsia is presented. It incorporates four established abnormalities: various psychological abnormalities, low vagal tone, impaired gastric relaxation, and visceral hypersensitivity, in a logical interplay along the brain-gut axis.

[Educational level, occupation and income of those who became disability pensioners in Iceland in the year 1997.]

INTRODUCTION

All claims for disability benefits in Iceland are managed by the State Social Security Institute of Iceland. The decision to grant a claimant disability benefits was until September 1999 mainly based on medical certificates but social and economic factors were also taken into consideration. As information on social and economic conditions in medical certificates is limited it was decided to investigate these factors particularly. In this paper a comparison of educational level, employment, and income is made between new recipients of disability benefits and a random sample of the Icelandic nation.

MATERIAL AND METHODS

All new recipients of disability benefits (full disability pension, partial disability pension and rehabilitation pension) in 1997 were contacted by phone and asked to answer a questionnaire. Their answers were compared with those obtained in a national survey carried out by the Institute of Social Sciences at the University of Iceland in 1996 and 1997 with a sample representing accurately the Icelandic population in terms of gender, age and place of residence. Information about average income of disability pensioners was obtained and compared to that of people in employment.

RESULTS

Educational level of those receiving disability benefits was considerably lower than expected in comparison with the population and unskilled workers were overrepresented. Contrary to what might be expected a larger proportion of the recently disabled have been employed at some time than is the case for the national sample, even though 63.6% of the new disability pensioners were women. Considerable number of those receiving disability benefits were still in employment, particularly those with partial disability pension. Mean monthly income of Icelanders participating in the labour market was almost twice that received by those on disability benefits.

CONCLUSIONS

Since lower educational level and more restricted employment opportunities characterize disability pensioners as compared to the nation, it seems likely that more varied occupational rehabilitation and educational opportunities could improve the situation of those who have had to leave the labour market because of ill health, lack of education and poor working conditions.

[Hepatocellular carcinoma in Iceland.]

INTRODUCTION

The incidence of hepatocellular carcinoma (HCC) varies throughout the world, being relatively low in Northern Europe (less than five per 100,000 population) where the majority of the patients have cirrhosis. In Iceland the prevalence of viral hepatitis and cirrhosis, the main risk factors for HCC, is lower than reported in many other countries. The aim of our study was to investigate the incidence and etiology of HCC in Iceland.

MATERIAL AND METHODS

All patients diagnosed with HCC in Iceland in 1984-1998 were included in the study. Histologic diagnosis was required for inclusion. Patients were identified from the Icelandic Cancer Registry and by reviewing autopsy and histopathology reports. Further information was obtained from medical records.

RESULTS

A total of 71 cases of HCC were identified, 51 males and 20 females. The mean age for males was 69.3 years (18-95) and 73 years (52-89) for females. The age-standardized annual incidence rate of HCC was 1.08/100,000 (males 2.10, females 0.67). The incidence did not increase significantly during the study period. Alcohol abuse (15.5%) and hemochromatosis (11%) were the most common risk factors. Twenty-three (32%) had cirrhosis but 39 (55%) had no known risk factors. Of 55 cases where non-neoplastic tissue was available for examination, 27 had liver disease.

CONCLUSIONS

1) The incidence of HCC in Iceland is lower than reported in other countries. 2) Alcohol abuse and hemochromatosis are the most common risk factors. 3) The ratio of patients with cirrhosis is low.

Outbreak of Potato Late Blight and First Report of Mating Type A2 and Metalaxyl Resistance of Phytophthora infestans in Iceland

Late blight caused by Phytophthora infestans (Mont.) de Bary was endemic on potato in Iceland from about 1890 until 1961. Probably because of a cooler climate in the 1960s, the disease disappeared and there were no epidemics until 1990 and 1991. Late blight was not found in the period 1992 to 1998 even though the weather conditions were favorable for epidemic development in some of the years. Lack of initial inoculum was probably the limiting factor for an epidemic in Iceland some years. During the summer of 1999, late blight reappeared in Iceland. In August 1999, potato leaves with single lesions of late blight were sampled from two locations and sent to the Norwegian Crop Research Institute. Isolates were trapped by placing infected leaves under tuber slices in petri dishes. Pure cultures were made by picking small pieces of mycelium from the upper side of the potato slice after 7 to 10 days incubation at 15°C and plating them onto modified rye B agar with antibiotics (1). Sixteen isolates maintained on rye B agar were paired with reference isolates of mating types A1and A2 and examined for oospores at the hyphal interfaces between the isolates (1). One isolate was typed as A2 and 15 isolates were A1. Response to metalaxyl was determined for 13 isolates in vitro (1) on rye B agar amended with 5 mg/l metalaxyl-m. One of the A1 isolates was metalaxyl-resistant and 12 isolates, including the A2 isolate, showed intermediate resistance to the fungicide. These data show that the "new" population of P. infestans is now present in Iceland as in the other Nordic countries (1). Iceland imports some seed potatoes each year, mainly from the Netherlands. Imported seed potatoes were probably the source of initial inoculum in 1999 in Iceland. In the future, oospores in the soil might be an additional inoculum source in Iceland since both mating types are now present. Reference: (1) A. Hermansen et al. Plant Pathol. 49:11, 2000.

Genotype-phenotype interactions in Wilson's disease: insight from an Icelandic mutation

Wilson's disease, an autosomal recessive disorder of copper transport, usually presents with symptoms from the liver or central nervous system. Rarely, the initial manifestation is fulminant hepatic failure. The abnormal gene (ATP7B) is located on chromosome 13q and encodes a copper-transporting ATPase. A large number of mutations have been reported. We describe a previously healthy 16-year-old girl who presented with fulminant hepatic failure. The girl died within 24 h of admission to a hospital from refractory shock. Autopsy revealed cirrhosis and widespread necrosis of the liver. The copper content of the liver was markedly increased (975 micrograms/g dry weight), strongly suggesting a diagnosis of Wilson's disease. Genetic studies revealed that the girl was homozygous for the mutation 2007 del7, which is the mutation found in all Wilson's disease patients previously identified in Iceland. This is the first known case of fulminant hepatic failure due to Wilson's disease in Iceland. Despite the same mutation, the clinical picture is vastly different from other Icelandic patients with Wilson's disease, who all presented with relatively late-onset neurological disease. This suggests that factors other than the specific mutation have significant impact on the phenotype of the disease.

[Changes in the prevalence of disability pension in Iceland 1976-1996.]

OBJECTIVE

To determine changes in the prevalence of disability pension in Iceland and to describe the distribution of those receiving disability pension according to gender, age and main diagnoses between the years 1976 and 1996.

MATERIAL AND METHODS

The study includes all those receiving disability pension on the 1st of December in the years 1976 and 1996 as ascertained by the disability register at the State Social Security Institute of Iceland. There are two levels of disability pension, full disability pension (disability assessed as being more than 75%) and reduced disability pension (disability assessed as being 50% or 65%). Information on age and gender distribution of the Icelandic population was obtained. Age-standardized risk ratio between the years 1976 and 1996 was calculated for both pension levels combined and for full disability pension alone.

RESULTS

There was no significant change in crude prevalence rate for both pension levels combined between the years 1976 and 1996, when the increase in the population was accounted for but without paying attention to changes in gender or age distribution. However, the standardized risk ratio showed a significantly decreased risk for both pension levels combined both for men and women in the year 1996 as compared with the year 1976, the age-standardized risk ratio being 0.95 and 0.93 respectively. It also showed a significant change between pension levels with an increased risk of full disability pension and a decreased risk of reduced disability pension. The increase in full disability pension was noted for both males and females and was largely independent of age. There was a significant increase in full disability pension in most disease categories. Disability due to diseases of the nervous system and sense organs and injury and poisoning increased amongst women only. A significant decrease in full disability pension due to infections and diseases of the digestive system occurred in both men and women.

CONCLUSION

The prevalence of a disability pension amongst men and women in the year 1996 as compared to the year 1976 was significantly decreased when changes in population size and age distribution had been accounted for. This is particularly interesting because unemployment was increasing just prior to the year 1996. The prevalence of full disability pension had however significantly increased in 1996 compared with 1976. A plausible explanation for the observed change in disability pension levels is a pressure from the labour market, with increasing unemployment and competition. Also, the introduction of a disability card for those with full disability pension in 1980, which granted lower price for medication and the services of physicians, is likely to have increased the pressure for the higher level of disability pension (full disability pension). It seems unlikely that the increase in full disability pension and the decrease in reduced disability pension is due to a deterioration of health of the Icelandic population. Increased disability due to injury and poisoning amongst women is probably a result of their increased participation in the labour market. The decrease in disability due to infections is a result of a reduction in the number of cases of tuberculosis and poliomyelitis. The decrease in disability due to diseases of the digestive system is probably a result of improvement in the treatment of oesophageal reflux and peptic ulcer.

[Thyrotoxicosis and coexistent diseases in atrial fibrillation.]

OBJECTIVE

To evaluate the prevalence of thyrotoxicosis and coexistent diseases in patients with atrial fibrillation admitted to a general medicine ward.

MATERIAL AND METHODS

All patients with the discharge diagnosis of atrial fibrillation were studied. The study design was retrospective for the years 1993-1994 and prospective from April 1995 through December 1997. Information on thyroid function tests was obtained from medical records in the retrospective part, but TSH, T4 and T3 were measured for patients admitted during the prospective part. Coexistent diseases were recorded.

RESULTS

Atrial fibrillation was diagnosed in 167 patients (58 in the retrospective part and 109 in the prospective part). Males were predominant (59.3%) and the average age was 73.7 years (span 26-100). Adequate information on thyroid function tests was available for 135 patients (58.6% of the retrospective part and 92.7% of the prospective part). 24 (17.8%) had abnormal thyroid function tests, predominantly women (71%). Ten had an isolated elevation of TSH, seven an isolated depression of TSH, two hypothyroidism and five other abnormalities. Hypertension was the most common coexistent disease (76 of 167 patients (45.5%). Ischemic heart disease was found in 44 (26.3%) and valvular heart disease in 27 (16.2%). No known coexistent disease was found in 32 (19.2%).

CONCLUSIONS

1) Thyrotoxicosis is rare in patients with atrial fibrillation who are admitted to a general medicine ward. Routine measurement of thyroid function tests in this patient population is therefore not warrented. 2) Unspecific abnormalities of thyroid function tests are common and are most likely due to diseases outside the thyroid gland or medications. 3) Hypertension, ischemic heart disease and heart valve disease are the most common coexistent diseases in this group of patients.

Fibromyalgia is associated with panic disorder and functional dyspepsia with mood disorders. A study of women with random sample population controls

BACKGROUND

We compared ICD-10 psychiatric disorders in female patients with fibromyalgia (n=45) or functional dyspepsia (n=18) with age-matched random sample controls (n=49).

METHOD

Version 2 of The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) was used for present state examination and lifetime diagnoses.

RESULTS

Current psychiatric disorders (somatoform pain disorder and specific phobia omitted) were diagnosed in 80% of fibromyalgia patients (OR=8.3), 83% of functional dyspepsia patients (OR=10.3) and 33% controls. Among fibromyalgia patients 27% had lifetime panic disorder. Lifetime mood disorders were found in 83% of functional dyspepsia patients. First-degree relatives with psychiatric disorder were found in 16% of the fibromyalgia patients, 50% of functional dyspepsia patients and 20% of controls.

CONCLUSIONS

Fibromyalgia is associated with panic disorder and functional dyspepsia with mood disorders in substantial subgroups. Psychiatric symptoms and somatic complaints are closely related in these disorders.

[Liver transplantaion.]

In recent years, liver transplantation has become the treatment of choice for end-stage liver disease. Chronic viral hepatitis, alcoholic cirrhosis and chronic cholestatic diseases are the most common liver diseases requiring transplantation. Complications of cirrhosis such as variceal bleeding are important indications. Prognostic survival models are also used to determine the optimal timing of transplantation. Pretransplant evaluation is designed to assess the patients general health and the condition of the vital organs. The operation is complicated but most patients recover rapidly. Postoperative complications such as hepatic artery thrombosis may require retransplantation. Following transplantation, the patient is maintained on a regimen of immunosuppressive medications. Acute cellular rejection is common but usually responds to additional immunosuppression. One and five years survival has increased to 80-90% and 65-70% respectively. Recurrent liver disease is a common problem but rarely affects short term survival. Several Icelandic patients have undergone liver transplantation. Indications are similar to other European countries.

Therapy and diagnostic tests used for Helicobacter pylori infection in the Scandinavian countries in 1998

BACKGROUND

We wanted to ascertain how Helicobacter pylori infection is managed in Scandinavia.

METHODS

A one-page questionnaire with seven questions was mailed in April 1998 to 1718 gastroenterologists in Finland, Denmark, Norway, and Sweden (excluding Swedish surgeons).

RESULTS

The questionnaire was returned by 36%. Antimicrobials were used by 99% for peptic ulcer associated with H. pylori, by 67% for mucosa-associated lymphoid tissue lymphoma, by 27% before long-term therapy with a proton-pump inhibitor (PPI), by 16% for non-ulcer dyspepsia, by 11% for reflux disease, and by 11% for other indications. In Finland several conditions other than ulcer were treated more frequently than in the other countries. The commonest primary therapy is PPI triple therapy (94%), followed by bismuth-based (11%), 'other' (2%), and PPI dual therapy (0.2%). Primary bismuth-based therapy was almost completely limited to Norway. The commonest secondary therapy for failures was also PPI triple therapy (71%), followed by bismuth-based (41%), 'other' (10%), and PPI dual therapy (1%). Clarithromycin for primary therapy was used much less frequently in Finland than in the other countries. Follow-up to ascertain whether eradication is successful was done always or often by 90% in Finland, 63% in Norway, 62% in Sweden, and 21% in Denmark and by 61% of the internists and 42% of the surgeons. The commonest method to confirm eradication was gastroscopy (69%), followed by the breath test (52%) and serology (11%).

CONCLUSIONS

In Scandinavia H. pylori associated with peptic ulcer disease is treated with antimicrobials by virtually all gastroenterologists. PPI triple therapy is the commonest regimen for primary and secondary eradication. PPI dual therapy has essentially disappeared. Fifty-four per cent confirm eradication always or often, with gastroscopy being the commonest method.

On demand therapy of reflux oesophagitis--a prospective study of symptoms, patient satisfaction and quality of life

BACKGROUND

In patients with low-grade reflux oesophagitis adequate symptom control is the aim of treatment. Effervescent tablets alleviate heartburn more rapidly than ordinary tablets.

AIM

To investigate symptom control, patient satisfaction, health-related quality of life and disease progress when ranitidine 150 mg effervescent tablets were offered as on demand treatment. We also wanted to investigate whether any biological or psycho-social factor could predict patient satisfaction.

METHOD

Consecutive patients with endoscopically verified reflux oesophagitis grade I-II were followed up for 12 months. 24 h pH-metry, disease history, symptoms and several psycho-social factors were registered at baseline and 12 months follow-up.

RESULTS

Eighty-one patients were included. Mean age was 50.7 years (range 21-82), 63% were men. Mean tablet consumption was 1.21 per day (range 7-1016 tablets/year). At the 1-year follow-up discomfort resulting from reflux symptoms was significantly reduced (P<0.001), and the patients' social and vocational life improved. Eighty-four percentage of the patients were satisfied with the treatment. 24 h pH-metry or number of reflux episodes did not change. We did not find any factors able to predict patient satisfaction.

CONCLUSIONS

On demand therapy with ranitidine effervescent tablets was well accepted by the majority of patients with reflux oesophagitis grade I. Even though the number of reflux episodes did not change, the patients experienced less discomfort due to reflux symptoms, and their social and vocational life was better. There was no significant progression of the disorder during the 1-year follow-up. No predictive factor for patient satisfaction was found.

Spiramycin is comparable to oxytetracycline in eradicating H. pylori when given with ranitidine bismuth citrate and metronidazole

BACKGROUND

We have consistently achieved about 90% eradication of H. pylori with liquid bismuth, metronidazole and oxytetracycline.

AIM

To test eradication and adverse events of ranitidine bismuth citrate (RBC) when given with metronidazole and either oxytetracycline or spiramycin.

METHODS

One hundred and eighty-three patients were randomized to one of four 10-day regimens: RBC400OM: RBC 400 mg b.d., oxytetracycline 500 mg q.d.s.; RBC400SM: RBC 400 mg b.d., spiramycin 1 g q.d.s.; RBC200OM: RBC 200 mg q.d.s., oxytetracycline 500 mg q.d.s.; RBC200SM: RBC 200 mg q.d.s., spiramycin 1 g q.d.s. Additionally, all patients received metronidazole 400 mg q.d.s. A 14C-urea breath test was performed at 8 weeks.

RESULTS

Intention-to-treat eradication rates were 94%, 91%, 94% and 89% with RBC400OM, RBC400SM, RBC200OM and RBC200SM, respectively (P = 0.81). Eradication was significantly higher in ulcer patients (97%) than in those with diagnoses other than ulcer (86%) (P = 0.009). There was a strong tendency to better eradication among those who had never smoked (100%) compared with ex-smokers (93%) and smokers (89%) (P = 0.06). Fifty-three per cent experienced at least one moderate or severe adverse event, and women had more adverse events than men (P = 0.0002).

CONCLUSIONS

All four regimens had comparable efficacy and adverse events. Eradication was significantly better in ulcer patients but there was a trend to better eradication in those who smoked less, used less alcohol and exercised more. Adverse events were frequent, perhaps because of the large dose of metronidazole used, but few patients stopped treatment.

In vitro evaluation of three-dimensional ultrasonography based on magnetic scanhead tracking

The objective of this study was to evaluate the accuracy and precision of a magnetic position sensor system for acquisition of three-dimensional (3D) ultrasound images in volume estimation of phantoms in vitro. Installation of either 0.9% solution of saline at 37 degrees C or distilled water at 20 degrees C to a condom was performed. Scanning was performed either by a continuous or stepwise acquisition. This 3D ultrasound system demonstrated good correlation (r = 0.99-1.0, n = 8) between estimated (EV) and true volumes (TV). The errors were in the range 1.3%+/-0.3% (SEM) to 1.9%+/-0.6%, independent of sound velocity. Scanning through a porcine abdominal wall positioned at the fluid surface yielded a systematic underestimation of the volume: mean (EV - TV) = -7.2+/-0.8 ml. Eight repeated scans of the same volume yielded a coefficient of variation of 1.1%. Interobserver error of the tracing procedure was 2.6%+/-0.9%. This 3D ultrasound system gave high accuracy and precision in volume estimation in vitro, and yielded low interobserver error. A change in ultrasound velocity of approximately 60 m/s did not influence the accuracy significantly. Scanning through an abdominal wall underestimated volumes slightly.