A socio-economic study of patients with ulcerative colitis

A material is presented of 222 patients with ulcerative colitis, who on admission to hospital during the 5-year period 1960-65 were permanent residents in the county district of Copenhagen or the municipality of Gentofte, the population of which was used as a control material. This material was divided into 21 socio-economic groups. It is shown with statistical significance that within the two socio-economic groups 'civil servants + salaried grades', and 'wage-earners', the patients were found at a relatively higher educational and economic level. The distribution on the other socio-economic groups was the same as in the control material.

Controlled clinical trial of treatment with cimetidine for non-ulcer dyspepsia

The effect of cimetidine (1 g daily) and placebo was studied in a controlled clinical trial comprising 50 patients with non-ulcer dyspepsia in whom an organic abnormality responsible for the dyspeptic symptoms was not disclosed by a standardized and extensive examination programme. Reduction of symptoms occurred in 13 (54%) out of 24 patients treated with cimetidine and in 16 (62%) out of 26 treated with placebo. The difference was insignificant, as were the alterations in the individual dyspeptic symptoms between the groups. Only 6 patients (25%) on cimetidine and 8 (31%) on placebo treatment had a total relief of symptoms. Of these, all cimetidine-treated patients remained free from symptoms during the successive 3-month observation period, while the dyspeptic symptoms relapsed in 3 (38%) placebo-treated patients. Subsequent resumption of placebo treatment reduced the symptoms in all 3 patients, but only one became free from symptoms. Cimetidine does not seem to be superior to placebo in the treatment of non-ulcer dyspepsia in patients without any previous history of ulcer or without any sign on endoscopy of an active or previous ulcer disease.

Does Helicobacter pylori infection explain all socio-economic differences in peptic ulcer incidence? Genetic and psychosocial markers for incident peptic ulcer disease in a large cohort of Danish adults

BACKGROUND

Peptic ulcer epidemiology has changed considerably within the past century. The aim of this study was to assess the 11-year cumulative incidence of peptic ulcer disease and examine the relationship between ulcer incidence and psychosocial and genetic factors.

METHODS

A random sample of 2416 Danish adults with no history of peptic ulcer disease residing in Copenhagen County, Denmark, attended a population-based prospective cohort study in 1983 and 1994. All participants reported whether they had had an ulcer diagnosed within the observation period. Information on socio-economic factors, family history of peptic ulcer disease (PUD) and lifestyle practices was obtained from a questionnaire. Lewis blood group antigens were assessed from blood samples and Helicobacter pylori infection status was determined with an in-house IgG ELISA.

RESULTS

The overall 11-year cumulative incidence proportion of PUD was 2.9% (95% CI (2.2; 3.6)), i.e. 1.6% (95% CI (1.1; 2.1)) for duodenal ulcer, and 1.3% (95% CI (0.8; 1.7)) for gastric ulcer. Poor socio-economic status increased the risk of PUD independently of H. pylori infection (odds ratio 2.7, 95% CI (1.1; 6.1)) and accounted for 17% of all ulcer cases. High physical activity at work increased the risk of PUD in people infected with H. pylori (odds ratio 2.6, 95% CI (0.8; 8.0)). Family history of PUD or Lewis blood group antigens did not relate to ulcer incidence.

CONCLUSIONS

Poor socio-economic status is an important risk factor for PUD that exerts its effect independently of H. pylori infection. Strenuous work may increase the risk of PUD in people with H. pylori infection. Genetic factors do not influence the risk of PUD in Danish adults.

Risk factors for peptic ulcer disease: a population based prospective cohort study comprising 2416 Danish adults

BACKGROUND

No population based prospective cohort study has previously assessed the impact of multiple risk factors, including Helicobacter pylori infection, on the incidence of peptic ulcer disease (PUD).

AIMS

To identify risk factors for PUD and estimate their relative impact on ulcer incidence.

SUBJECTS

Random sample of 2416 Danish adults with no history of PU.

METHODS

Sample members were interviewed in 1982 and 1994. PUs diagnosed within the observation period were verified through medical records. Information on psychosocial factors, lifestyle practices, and medication was obtained from a questionnaire completed at study entry. H pylori infection status was determined by ELISA.

RESULTS

The main risk factors for PUD were H pylori infection (odds ratio 4.3 (95% confidence interval 2.2; 8.3)), tobacco smoking (3.8 (1.7; 9.8)), and use of minor tranquillisers (3.0 (1.4; 6.6)). Intake of non-steroid anti-inflammatory drugs did not affect the incidence of PUD (0.4 (0.1; 2.3)). In those with increased antibodies to H pylori, tobacco smoking (12.7 (2.8; 56.8)) and intake of spirits (2.4 (1.1; 5.4)) increased the risk of PUD whereas moderate leisure time physical activity (0.3 (0.2; 0.7)) protected against PUD.

CONCLUSIONS

Tobacco smoking and H pylori infection are the main risk factors for PUD in Danish adults. Physical activity may protect against PUD in those infected with H pylori.

[Exchange of paraclinical information between the primary and secondary health sectors]

INTRODUCTION

The purpose of the study was to investigate the extent to which, biochemical test results obtained in the primary health sector could be regarded as valid information in the clinical assessment of patients admitted to hospital.

METHODS

The study was based on a questionnaire, which was designed to assess the value of historical biochemical data in the initial diagnostic process. The data was transferred from the laboratory of Copenhagen general practitioners (KPLL) database to a computer terminal in the emergency medical ward at H:S Bispebjerg Hospital.

RESULTS

It was possible to assess historical KPLL data on close to 80% of all hospitalised patients. In 50% of these patients, doctors indicated that the data always (96%) contributed to the diagnosis. In 70%, the data further contributed to the subsequent planning of diagnostic strategy. With regard to the initial diagnosis, comparison of KPLL data with data obtained on admission always resulted in a further classification of at least one condition. The comparison of KPLL data with admission data always led to a more precise plan for further diagnostic strategy.

CONCLUSION

The comparison of KPLL data with admission data, significantly contributes to differentiate the initial diagnostic strategy. In turn, this seems to have a significant bearing on the planning of further diagnostic strategy. It is postulated that a computer-based information system, through which the primary and secondary health sectors can exchange patient-related clinical data, would lead to a more focused use of resources, and hold significant advantages for the patient.

[Tobacco and alcohol are risk factors of complicated peptic ulcers. A prospective cohort study]

Both the incidence of and mortality from bleeding and perforated peptic ulcers are growing. We assessed the association between smoking, ingestion of alcohol (including the type of alcoholic beverage), and risk of a complicated peptic ulcer in a population-based study of 26,518 Danish subjects followed up for an average of 13.4 years. There were 214 cases of incident bleeding and 107 cases with perforated ulcers. We estimated the relative risks (RRs) of incident bleeding and perforated peptic ulcers with the Poisson regression analysis. Smoking more than 15 cigarettes a day compared with never smoking increased the risk of a perforated ulcer more than threefold (RR = 3.5; 95% confidence interval [CI] = 1.7-7.1). Ingestion of more than 42 drinks a week increased the risk of a bleeding ulcer fourfold (RR = 4.4; 95% CI = 2.3-8.3) compared with ingestion of less than one drink a week. Comparison of the same group, showed that subjects who ingested more than 21 drinks a week, but no wine, were at a higher risk of a bleeding ulcer (RR = 8.8; 95% CI = 2.2-35) than drinkers of the same amount of alcohol, but with more than 25% of their intake as wine (RR = 2.4; 95% CI = 1.0-6.0).

Identifying responders to acid suppression in dyspepsia using a random starting day trial

BACKGROUND

Functional dyspepsia is a heterogeneous condition and a uniform response to drug treatment is not likely. This may be the reason for the general failure of acid suppression in clinical trials in these patients. It may be more rewarding to identify true responders to drug treatment by a single subject trial.

AIM

To develop and to test a novel single subject trial design (random starting day trial) in dyspeptic patients.

PATIENTS AND METHODS

A total of 301 dyspeptic patients entered a 16-day trial. All patients received placebo for the first 4 days and switched to omeprazole at a randomized and blinded day between day 5 and day 14. Response was defined as a sustained >/= 50% decrease in symptom score occurring in relation to drug shifting.

RESULTS

Spontaneous response varied between 0.3% and 10.6% per day, uniformly distributed over time. Overall, 53-61% of patients with organic dyspepsia had a symptom response in relation to shifting to active treatment, compared to only 23% of patients with functional dyspepsia. The only predictor of response was symptoms suggesting gastro-oesophageal reflux.

CONCLUSIONS

A random starting day trial may be a valuable tool to identify response to acid suppression in dyspeptic patients.

Eradication of Helicobacter pylori compared with long-term acid suppression in duodenal ulcer disease. A randomized trial with 2-year follow-up. The Danish Ulcer Study Group

BACKGROUND

Trials evaluating long-term management of duodenal ulcer disease have mainly been focused on recurrence of ulcers, disregarding effects on dyspeptic and reflux symptoms. Profound acid inhibition with a proton pump inhibitor is the gold standard therapy in acid-related diseases. We aimed to compare the symptomatic effects of eradication therapy with those of long-term omeprazole treatment in a design with periods both with and without acid inhibition.

METHODS

Patients with active duodenal ulcer were randomized either to omeprazole, 20 mg twice daily until healing, followed by omeprazole, 20 mg/ day for 1 year, or to eradication therapy (metronidazole, amoxicillin, and omeprazole for 2 weeks) followed by placebo for 1 year. All patients were followed up passively for an additional year. Clinical controls were performed every 2 months the 1st year (maintenance phase) and every 6 months during the passive follow-up phase. The study was multicentric and double-blind. The primary end-point was discontinuation of treatment, irrespective of reason.

RESULTS

Two hundred and seventy-six patients were randomized (139 in the eradication treatment group). In the maintenance phase there were no differences in the reporting of dyspeptic symptoms or in premature withdrawal. In the passive follow-up phase only five patients in the eradication therapy group discontinued owing to relapse of dyspeptic symptoms or ulcer, compared with 51 patients initially randomized to long-term omeprazole. There were no differences in reflux symptoms or in the development of reflux oesophagitis.

CONCLUSIONS

Eradication therapy and long-term omeprazole are equally effective in controlling dyspeptic symptoms and reflux in duodenal ulcer patients with healed ulcers. One-quarter of the duodenal ulcer patients who start eradication therapy continue to be symptomatic or fail therapy for other reasons over a 2-year period. Eradication therapy does not increase the risk of reflux in ulcer patients.

Smoking and alcohol intake as risk factors for bleeding and perforated peptic ulcers: a population-based cohort study

Both the incidence of and mortality from bleeding and perforated peptic ulcers are increasing. We assessed the association between smoking, intake of alcohol (including type of alcoholic beverage), and risk of a complicated peptic ulcer in a population-based study of 26,518 Danish subjects followed up for an average of 13.4 years. There were 214 cases of incident bleeding and 107 cases with perforated ulcers. We estimated relative risks (RRs) for incident bleeding and perforated peptic ulcers using Poisson regression analysis. Smoking more than 15 cigarettes per day compared with never smoking increased the risk of a perforated ulcer more than threefold [RR = 3.5; 95% confidence interval (CI) = 1.7-7.1)]. Drinking more than 42 drinks per week increased the risk of a bleeding ulcer fourfold (RR = 4.4; 95% CI = 2.3-8.3) compared with drinking less than one drink per week. Using the same comparison group, subjects who drank more than 21 drinks per week but no wine were at a higher risk of a bleeding ulcer (RR = 8.8; 95% CI = 2.2-35) than drinkers of the same amount of alcohol, but with more than 25% of their intake as wine (RR = 2.4; 95% CI = 1.0-6.0).

Seroconversion and seroreversion in IgG antibodies to Helicobacter pylori: a serology based prospective cohort study

STUDY OBJECTIVES

To assess the incidence of seroconversion and seroreversion in IgG antibodies to Helicobacter pylori within a 11 year observation period using these events as markers for acquisition and loss of the infection, respectively.

DESIGN

Population based prospective cohort study.

SETTING

Northern part of Copenhagen County, Denmark.

PARTICIPANTS AND METHODS

A random sample of 2527 Danish adults were examined and blood obtained in 1983 and in 1994. Matching pairs of sera were analysed for the presence of IgG and IgM antibodies to H pylori with an in house enzyme linked immunosorbent assay. Participants who were seronegative at study entry and seropositive at follow up and had a fourfold increase in baseline IgG antibody levels were categorised as seroconverters and regarded as having acquired H pylori infection. Participants who were seropositive at study entry and had at least a fourfold decrease in baseline IgG antibody levels at follow up were assumed to have lost the infection (seroreverters).

RESULTS

The seroprevalence of H pylori infection was 24.7 (95% confidence intervals (95% CI) 23.0, 26.4) % in 1983 and 24.5 (95% CI 22.8, 26. 2) % in 1994. A total of 14 participants seroconverted within the observation period (cumulative 11 year incidence proportion: 1.0 (95% CI 0.5, 1.5) %). Having increased IgM antibody levels at study entry significantly increased the likelihood of IgG seroconversion (relative risk 6.4 (95% CI 2.1, 19.6). Seroreversion was seen in 48 participants (cumulative 11 year incidence proportion: 7.7 (95% CI 5. 6, 9.8) %).

CONCLUSIONS

Changes in H pylori infection status with time are rare in Danish adults. Few adults become infected with H pylori in Denmark.

[The relationship of Helicobacter pylori to iron status--serum ferritin and hemoglobin. A seroepidemiologic survey of 2794 Danes]

We evaluated the influence of Helicobacter pylori (H. pylori) infection assessed by the levels of H. pylori serum IgG-antibodies, on iron status (serum ferritin and haemoglobin) in 2794 Danes (1425 men), aged 30-60 years. The seroprevalence of H. pylori antibodies increased with age (p < 0.01). Median serum ferritin levels were significantly lower in seropositive than in seronegative men and postmenopausal women (men 114 micrograms/L vs. 120 micrograms/L, p = 0.01; premenopausal women 37 micrograms/L vs. 40 micrograms/L, p = 0.13; postmenopausal women 63 micrograms/L vs. 77 micrograms/L, p = 0.02). Seropositive subjects had a higher prevalence of iron deficiency (serum ferritin < 15 micrograms/L) than seronegative subjects. H. pylori infection has a negative influence on iron status. We hypothesize that this may be caused by increased blood losses from the gastric mucosa.

Association of Helicobacter pylori infection with lifestyle, chronic disease, body-indices, and age at menarche in Danish adults

This study examines the association between lifestyle factors, chronic disease, body-indices, and the seroprevalence of Helicobacter pylori infection in Danish adults. The relationship between age at menarche and H. pylori infection is also assessed. A random sample of 3,608 Danish adults completed a questionnaire about lifestyle factors (smoking habits, alcohol consumption, and coffee and tea intake), doctor diagnosed chronic diseases (heart conditions, diabetes, chronic bronchitis, and hypertension), menarche, and socio-demographic factors. A total of 2,913 participants were eligible for the present study. Electrocardiographs were recorded and blood pressure and serum lipid levels (HDL cholesterol, triglyceride, and cholesterol) were measured. Height and weight were determined and body mass index (BMI) calculated. Sera were analysed with an enzyme-linked immunosorbent assay for the presence of H. pylori specific IgG antibodies. The seroprevalence of H. pylori infection was associated with weekly alcohol intake > or = 6 drinks (odds ratio 0.7, 95% confidence interval 0.6-0.9) due to a low rate of H. pylori infection among wine drinkers (odds ratio 0.6, 95% confidence interval 0.5-0.7). No associations were found with smoking habits or serum lipids. People with upper quartile BMI (> or = 26.8 kg/m2) were more likely to be seropositive for antibodies to H. pylori (odds ratio 1.6, 95% confidence interval 1.1-2.4). Chronic bronchitis (odds ratio 1.6, 95% confidence interval 1.1-2.5) and unspecified heart condition (odds ratio 2.0, 95% confidence interval 1.1-3.3) was more often seen in IgG seropositive women than in uninfected women. The likelihood of being seropositive for IgG antibodies to H. pylori increased with age at menarche (odds ratio per year 1.10, 95% confidence interval 1.02-1.19). Previously reported associations with age and socioeconomic status were confirmed. We conclude that wine drinking is associated with lower rates of H. pylori infection in Danish adults. The seroprevalence of H. pylori infection is increased in people with high BMI. H. pylori infection may relate to a history of late menarche and chronic bronchitis in Danish women.

[Peptic ulcer in Denmark, 1981-1993. Analysis of data from national patient registries]

The aim of this study was to determine whether the improvements in the treatment of peptic ulcers are associated with decreasing age- and sex-specific hospitalization and death rates for peptic ulcers in Denmark. The study was based on all discharges as registered in the National Hospital Discharge Registry and all death certificates as registered in the Danish National Board of Health from 1981 through 1993. The age- and sex-specific and age-adjusted hospitalization and death rates were estimated. In women, the age-adjusted hospitalization increased for all types of peptic ulcers. In both sexes the age-adjusted peptic ulcer mortality increased mainly due to complicated duodenal ulcers. The analysis of the age-specific hospitalization and mortality for peptic ulcer complications showed that the increasing trends mainly occurred among the elderly. The improved medical treatment of peptic ulcers has not been associated with decreasing hospitalization or death from complicated peptic ulcers in Denmark.

Lansoprazole and omeprazole in the prevention of relapse of reflux oesophagitis: a long-term comparative study

BACKGROUND

Proton pump inhibitors are superior to H2-receptor antagonists in the prevention of relapse of oesophagitis, but few data directly compare the relative efficacies of lansoprazole and omeprazole in preventing oesophagitis relapse over a prolonged period.

METHODS

Patients with healed Grade II, III or IV oesophagitis were treated with lansoprazole 30 mg o.d. or omeprazole 20 mg o.d. for 48 weeks. Endoscopy and symptom assessment were performed after 12. 24 and 48 weeks of treatment and an additional symptom assessment 36 weeks after starting treatment.

RESULTS

Intention-to-treat analysis included 248 patients (lansoprazole n = 126, omeprazole n = 122). Comparison of time to endoscopic and/or symptomatic relapse revealed no difference between the treatments. There was no significant difference between treatments with respect to the proportion of patients in whom endoscopic and/or symptomatic relapse was reported (lansoprazole 12/126 (9.5%), omeprazole 11/122 (9.0%)). No difference between the treatments in either the number or severity of adverse events was reported.

CONCLUSIONS

Continuous treatment with either lansoprazole 30 mg or omeprazole 20 mg is effective in preventing the relapse of oesophagitis over a 48-week period in a majority of patients. Both treatments exhibit a similar side-effect profile.

Serum ferritin, hemoglobin, and Helicobacter pylori infection: a seroepidemiologic survey comprising 2794 Danish adults

BACKGROUND & AIMS

Helicobacter pylori infection was recently associated with iron-deficiency anemia. The aim of this study was to examine the relationship between H. pylori infection, hemoglobin, and iron status using serum ferritin as a marker for total body iron.

METHODS

Serum ferritin, hemoglobin, and immunoglobulin G (IgG) antibodies against H. pylori were assessed in 2794 Danish adults who attended a population survey. IgG antibodies were measured with an in-house enzyme-linked immunosorbent assay, serum ferritin with an immunoradiometric assay, and hemoglobin with Coulter-S.

RESULTS

The seroprevalence of H. pylori infection did not relate to hemoglobin. Serum ferritin levels were significantly lower in men (114 vs. 120 microg/L; P = 0.01) and in postmenopausal women (63 vs. 77 microg/L; P = 0.02) who were IgG positive than in seronegative individuals. IgG-positive people more often had reduced serum ferritin levels (</=30 microg/L) than seronegative people. This association persisted in multivariate analysis after adjusting for possible confounding factors (odds ratio, 1.4; 95% confidence interval 1.1-1. 8).

CONCLUSIONS

Serum ferritin levels are reduced in people with increased IgG antibodies to H. pylori. H. pylori infection affects iron metabolism in humans.

[Helicobacter pylori infection and socioeconomic factors among adult Danes]

The aim of this study was to examine the relationship between housing conditions, educational level, occupational factors, and serologically diagnosed acute and chronic Helicobacter pylori infection. IgG, IgM, and IgA antibodies against Helicobacter pylori were measured by ELISA techniques in sera obtained from a random sample of 3589 Danes participating in a population study. Poor social status (odds ratio 2.2 [1.7-3.0]), short duration of schooling (odds ratio 2.0 [1.3-2.5]), lack of vocational training/education (odds ratio 1.4 [1.2-1.7]), unskilled work (odds ratio 1.7 [1.2-2.5]), and high work-related energy expenditure (odds ratio 1.4 [1.1-1.9]) increased the likelihood of chronic Helicobacter pylori infection. Chronic Helicobacter pylori infection was frequently found in people with a history of living abroad. Increased levels solely of IgM antibodies to H. pylori, interpreted as a sign of acute infection, were found more often in people who were divorced (odds ratio 2.3 [1.2-4.4]) or unmarried (odds ratio 2.0 [1.1-3.8]) and in people who worked long hours (odds ratio 2.0 [1.1-4.0]). In conclusion, educational and occupational factors relate to the likelihood of chronic Helicobacter pylori infection in adults. The rate of acute Helicobacter pylori infection is probably increased in single adults.

Time trends for peptic ulcer disease in Denmark, 1981-1993. Analysis of hospitalization register and mortality data

BACKGROUND

Since the mid-1980s there has been great improvement in the available diagnostic tools and treatments for peptic ulcers. The aim of this study was to determine whether these improvements have been paralleled by decreasing age- and sex-specific hospitalization and death rates for peptic ulcers in Denmark.

METHODS

The study was based on all discharges from Danish somatic hospitals as registered in the National Hospital Discharge Registry and all the death certificates as registered in the Danish National Board of Health from 1981 through 1993, when a diagnosis of peptic ulcer was recorded. The age- and sex-specific and age-adjusted hospitalization and death rates were estimated.

RESULTS

In men the age-adjusted hospitalization rate for all types of peptic ulcers decreased by 0.88, but the mortality increased by 1.19. In women the age-adjusted hospitalization and mortality increased for all types of peptic ulcers. The increasing mortality was mainly due to bleeding and perforated duodenal ulcers. The analysis of the age-specific hospitalization and mortality for peptic ulcer complications showed that the increasing trends mainly occurred among the elderly.

CONCLUSION

The improved medical treatment of peptic ulcers has not been paralleled by decreasing hospitalization or death from complicated peptic ulcers in Denmark. On the contrary, we found an increasing hospitalization and mortality from peptic ulcer complications, particularly in elderly Danish people.

Antimicrobial susceptibility testing of 230 Helicobacter pylori strains: importance of medium, inoculum, and incubation time

No standardized method of susceptibility testing for Helicobacter pylori is currently available, so before a large agar dilution study comprising 230 H. pylori strains belonging to more than 80 genetically different groups was initiated, we performed a relatively small preliminary study to determine the influences of medium, inoculum density, and incubation time. Seven media were investigated and were primarily evaluated on the basis of their abilities to support growth both semiquantitatively and qualitatively; Iso-Sensitest agar supplemented with 10% horse blood was found to be well suited for the purpose; this was closely followed by Mueller-Hinton agar with 10% horse blood, Mueller-Hinton with 10% sheep blood, and finally, 7% lysed horse blood agar. Investigations of two inoculum densities and two incubation times resulted in recommendations for the use of 10(9) CFU/ml (10[6] CFU/spot) as the inoculum and 72 h as the incubation time. A modest inoculum effect was noted for amoxicillin and metronidazole. By the methodology derived from our preliminary study, the susceptibilities of 230 H. pylori strains to six antibiotics were subsequently determined. The results were generally in accord with those of others, and apart from metronidazole, the MIC of which for approximately 25% of the strains tested was >8 microg/ml, resistance was low in Denmark. The situation might, however, quickly change when and if the number of indications for antibiotic therapy for H. pylori infections increase. Consequently, susceptibility testing of all H. pylori strains is recommended in order to survey the development of resistance, and in our hands the described methodology was relatively easy to perform and the results were easy to read.

Relation between Helicobacter pylori infection and gastrointestinal symptoms and syndromes

BACKGROUND

Helicobacter pylori is a human pathogen that colonises the gastric mucosa and causes permanent gastric inflammation.

AIMS

To assess the symptoms of H pylori infection in an adult unselected population.

SUBJECTS

A random sample of 3589 adult Danes who were examined in 1982 and 1987 (n = 2987).

METHODS

Abdominal symptoms within the preceding year were recorded at both attendances. Circulating IgG antibodies against H pylori in serum samples drawn in 1982 were measured by using in-house indirect enzyme linked immunosorbent assays (ELISA).

RESULTS

People with increased levels of IgG antibodies to H pylori were more likely than uninfected individuals to report heartburn (odds ratio (OR) = 1.26, 95% confidence interval (CI) 1.03-1.54) and abdominal pain characterised by daily length (OR = 1.33, 95% CI 0.92-1.91), nocturnal occurrence (OR = 1.62, 95% CI 1.19-2.19), spring aggravation (OR = 1.68, 95% CI 0.70-4.05), and no relation to meals (OR = 0.62, 95% CI 0.43-0.91) or stress (OR = 0.69, 95% CI 0.50-0.95). The inclusion of people with increased levels of IgG antibodies to H pylori, but without upper dyspepsia, at study entry significantly increased the likelihood of reporting upper dyspepsia at follow up (OR = 1.71, 95% CI 1.24-2.36). People with epigastric pain and increased levels of IgM antibodies to H pylori only indicative of acute H pylori infection were more likely to report nocturnal pain, heartburn, nausea, and vomiting.

CONCLUSION

H pylori infection may precede the development of dyspepsia and is associated with a variety of gastrointestinal symptoms in people with no history of peptic ulcer disease.

Socioeconomic factors in Helicobacter pylori infection among Danish adults

OBJECTIVES

This study examined the relationship between housing conditions, educational level, occupational factors, and serologically diagnosed acute and chronic Helicobacter pylori infection.

METHODS

Immunoglobulin G and immunoglobulin M serum antibodies against H. pylori were measured in 3589 Danish adults who participated in a population study.

RESULTS

Low socioeconomic status (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.7, 3.0), short duration of schooling (OR = 2.0, 95% CI = 1.3, 2.5), lack of training/education (OR = 1.4, 95% CI = 1.2, 1.7]), unskilled work (OR = 1.7, 95% CI = 1.2, 2.5), and high work-related energy expenditure (OR = 1.4, 95% CI = 1.1, 1.9) increased the likelihood of chronic H. pylori infection. Infection was frequent in people who had lived abroad. Increased levels solely of immunoglobulin M antibodies were found more often in people who were divorced (OR = 2.3, 95% CI = 1.2, 4.4) or unmarried (OR = 2.0, 95% CI = 1.1, 3.8) or who worked long hours (OR = 2.0, 95% CI = 1.1, 4.0).

CONCLUSIONS

Educational and occupational factors relate to the likelihood of chronic H. pylori infection in adults. The rate of acute infection is high in single individuals.

Seroprevalence of immunoglobulin G, M, and A antibodies to Helicobacter pylori in an unselected Danish population

The seroprevalences of increased levels of immunoglobulin G (lgG), M (lgM), and A (lgA) antibodies to Helicobacter pylori were assessed by enzyme-linked immunosorbent assay techniques in 3,589 Danes who participated in a population study in Copenhagen County in 1982. A total of 33.9% of the study population had one or more classes of increased antibodies to H. pylori. Increased levels of lgG, lgM, and lgA antibodies to H. pylori were seen in 25.9% (95% confidence interval (Cl) 24.5-27.3), 4.5% (95% Cl 2.2-7.0), and 12.0% (95% Cl 10.9-13.1) of the participants, respectively. Women were significantly more likely than men to be seropositive for lgM antibodies (Mantel-Haenszel summary odds ratio = 1.85, 95% Cl 1.34-2.57). Seropositivity for lgM antibodies to H. pylori was found less often with increasing age. An lgG antibody response was not seen in 23.7% of cases with overall increased antibodies to H. pylori. Increased levels of lgG or lgA antibodies were more frequent in people with a history of peptic ulcer disease. Seroprevalences of increased H. pylori antibodies are high in unselected populations. Primary H. pylori infections are contracted at all ages, but infection rates decline with age. Inclusion of measurements of lgA and lgM antibody levels in future screening for H. pylori may improve the diagnostic sensitivity of serologic analyses.

Epidemiology in gastroenterology

A review of the literature on gastrointestinal epidemiology during the last 25 years shows a comprehensive contribution from Danish studies. This is partly explained by very favourable conditions in Denmark for epidemiological research, due to various valid registers and a long tradition for longitudinal population and patient cohorts. Data are presented on prevalence, incidence, demography, clinical risk factors, clinical course, and prognosis of various gastrointestinal disorders. Main emphasis is put on Danish studies, which are compared with international results. Present possibilities for prophylaxis against gastrointestinal diseases and delimitation of treatment of benign diseases are discussed. It is expected that research within gastrointestinal epidemiology in Denmark will increase in the coming years.

[Prevention of duodenal ulcer recurrence with penicillin]

The aim of this study was to test the hypothesis that infection with Helicobacter pylori is essential for recurrence of duodenal ulcer. We performed a randomized controlled trial of the relapse rate of duodenal ulcer during 12 weeks treatment with penicillin V or placebo in 170 out-patients from five centres. The relapse rate was 9% during treatment with penicillin and 50% with placebo, P < 0.0001. It is concluded that infection with penicillin-sensitive bacteria, i.e. H. pylori, plays an important role for recurrence of duodenal ulcer disease. Penicillin V suppresses this infection but does not eradicate it.

The prognosis of patients with alcoholic liver disease. An international randomized, placebo-controlled trial on the effect of malotilate on survival

The aim of this study was to examine the effect of malotilate on survival in patients with alcoholic liver disease and to determine prognostic variables for survival. Four hundred and seven patients with alcoholic liver diseases, from seven European liver units, entered a randomized placebo-controlled, double-blind trial: 140 patients received malotilate 1500 mg/day, 133 patients received 750 mg/day, and 134 patients received placebo. The patients were included in the study over a period of 3 1/2 years, and the study was closed 1 year after the entry of the last patient. Eighty-four patients died (35, 19, 30 patients in groups 1500 mg/day, 750 mg/day, and placebo, respectively). Survival was slightly better in the 750 mg/day group than in the two other treatment groups, when tested by conventional log-rank tests (p = 0.06). However, a treatment effect was supported by a highly significant (p = 0.006) non-proportionality of the death intensity in patients receiving 750 mg/day against those receiving either 1500 mg/day or placebo. Prognostic variables for survival were evaluated using the multiple Cox regression analysis of clinical and laboratory variables and with or without liver histology variables, as determined at entry into the study. The analysis was stratified for the three treatment regimens. In the analysis including liver histology variables, independent significant prognostic variables were: years of high alcohol intake, prothrombin index, alkaline phosphatases, creatinine, immunoglobulin M, white blood cell count, and liver cell steatosis. In the analysis without liver histology variables, prognostic variables were: years of high alcohol intake, prothrombin index, alkaline phosphatases, creatinine, and immunoglobulin M.

Efficacy of sucralfate in treatment of non-ulcer dyspepsia. A double-blind placebo-controlled study

The object of this study was to assess the efficacy of sucralfate in the treatment of non-ulcer dyspepsia (NUD). The diagnosis of NUD was made by exclusion. All patients underwent an upper gastrointestinal endoscopy and abdominal ultrasound, and blood tests were done as clinically indicated. Patients with a history of peptic ulcer disease were not included. Symptomatic assessment was made at the beginning and at the end of the study. The patients registered their most prominent dyspeptic symptoms and whether they improved, were unchanged, or worsened. The study was double-blind. Placebo or 1 g sucralfate four times daily was given for 3 weeks. Over a 2-year period 104 patients were included in the study; 56 received sucralfate and 48 placebo. Nine patients were excluded because of poor compliance or side effects, six from the sucralfate group and three from the placebo group. The sucralfate and placebo groups were comparable with regard to symptom and clinical variables. Global assessment of symptoms showed that in the sucralfate group 34 improved (68%), 11 were unchanged, and 5 were worse. In the placebo group 31 improved (69%), 11 were unchanged, and 3 were worse. There was no statistically significant difference between the groups. The 3-week course of sucralfate in patients with NUD did not show symptomatic improvement over placebo.

Prevention of duodenal ulcer recurrence with penicillin. A double-blind, placebo-controlled trial

Eradication of Helicobacter pylori is associated with a reduced recurrence of duodenal ulcer (DU). The relationship between H. pylori and DU has been interpreted as causal, but the evidence has been criticized for methodologic reasons. To ascertain whether an antibiotic with no effect on epithelial-cell integrity prevents DU recurrence, we conducted a randomized double-blind trial of phenoxymethylpenicillin (PEN), 2.4 twice daily, and placebo (PLA). Patients with an active DU and positive H. pylori culture from antral biopsy specimens were treated with 40 mg omeprazole daily for 4 weeks, but at week 2 they were allocated at random to PEN (85 patients) or PLA (85 patients) for up to 14 weeks. Those without recurrence during this treatment were followed up for another 6 months. Endoscopy and H. pylori culture were performed at the end of the treatment period and at the end of follow-up, and in between if ulcer symptoms recurred. During the treatment period the ulcer relapse rate was 5 of 58 (9%) in the PEN group and 34 of 68 (50%) in the PLA group (P < 0.0001, log-rank test), with 53% and 14%, respectively, of the patients in the two groups being H. pylori-negative. The relapse rate in the PEN group did not differ between H. pylori-negative and H. pylori-positive patients. The recurrence rate in the PEN group remained low for another 5 months but then approached the rate in the PLA group. The prevalence of H. pylori-negative patients at the end of follow-up was 20% in the PEN group and 10% in the PLA group. These data provide strong evidence that DU has a bacterial cause, with H. pylori as the likely agent.

Acyclovir in the prevention of duodenal ulcer recurrence

This study tests the hypothesis that reactivation of a latent herpes simplex virus infection may be a cause of recurrent duodenal ulceration. Patients with recently healed duodenal ulcer were entered into a double blind, randomised study of maintenance treatment with the antiviral drug acyclovir (400 mg bid) versus placebo, to determine if suppression of herpes virus infection would influence the natural history of the ulcer disease. One hundred and fifteen patients entered the trial and 76 patients completed it according to the protocol. Endoscopy was performed when ulcer symptoms recurred and at the end of the 25 week trial period. In the acyclovir group the cumulated relapse rate was 63% compared with 56% in the placebo group (NS). This result suggests that reactivation of herpes simplex virus is not a cause of recurrent duodenal ulcer.

The personality pattern of duodenal ulcer patients in relation to spontaneous ulcer healing and relapse

One hundred consecutive out-patients with duodenal ulceration from a hospital and a gastroenterological clinic were tested with the Minnesota Multiphasic Personality Inventory (MMPI). This was carried out in order to investigate whether neuroticism or other personality disorders were characteristics of duodenal ulcer patients, and whether the presence of such possible personality disorders might influence the prognosis of the disease. Neuroticism occurred in 53% of the patients, but only in 5% of controls (P less than 0.0001). Overall, personality disorders were present in 69% of the patients compared with 30% of the controls (P less than 0.0001). Neuroticism was connected with a high frequency of relapse (P less than 0.05) whereas failure of spontaneous ulcer healing had no certain relation to personality disorders. Patients with non-neurotic personality disorders had more frequently suffered stressful life events before entrance to the study (P less than 0.05) and, like the neurotic patients, they had lower ego-strength to cope with such events (P less than 0.05). The results indicate that personality assessments make it possible to distinguish between subgroups of duodenal ulcer patients with different course of the disease.

Zidovudine treatment of AIDS and ARC in Denmark 1987

In 1987, a total of 138 Danish patients (94 AIDS and 44 ARC) received treatment with zidovudine, a total observation period of 572 treatment months. 15 AIDS and 1 ARC patient died after a median of 70 days (range 2-295). In the ARC group 4 patients developed AIDS (3 Pneumocystis carinii pneumonia, 1 Kaposi's sarcoma). Among the AIDS patients 38 new opportunistic infections were reported. 24 of these opportunistic infections occurred within 6 weeks after treatment initiation. 79 patients were observed for more than 3 months, 25 of these had their daily dose zidovudine reduced, usually from 1,200 mg to 600 mg, 9 others were temporarily off drug. HIV antigen was analyzed in serum samples from 93 patients. Of these, 28 (52%) of 54 initially HIV antigen-positive became antigen-negative, 7 (18%) of 39 initially HIV antigen-negative became antigen-positive within the first 8 weeks of zidovudine treatment. In 57 patients the total count of CD4+ cells were evaluated. A significant increase in the number of CD4+ cells was observed during treatment. In nearly all patients an increase in MCV and a decrease in neutrophil count was observed. 44 of the patients received a total of 307 blood transfusions on 94 occasions and 19 (14%) patients required multiple transfusions. The mortality among the AIDS patients was significantly lower compared to historical controls. In our experience zidovudine treatment is reasonably well tolerated and the side effects are manageable.

[Babesia choloepi n. sp. (Apicomplexa, Piroplasmida), a parasite of the two-toed sloth, Choloepus didactylus (Linnaeus, 1758) (Xenarthra, Bradypodidae), in French Guiana]

A two-toed sloth (Choloepus didactylus) from French Guiana showed an erythrocytic parasite morphologically related to the Babesiidae family, and described as Babesia choloepi. It is the first Babesia species described in the Edentata order.

Left ventricular performance in alcoholic patients without chronic liver disease

Left ventricular performance was studied non-invasively in 24 chronic alcoholics without liver disease. Twelve patients who had abstained from drinking for at least one month (group A) and 12 sex and age matched patients who had ceased drinking during the preceding 24 hours (group B) were studied at rest and during 50% submaximal exercise. Cardiac output and stroke volume were measured by first passage and left ventricular ejection fraction by multigated radionuclide cardiography. Twelve healthy sex and age matched controls were also studied. Haemodynamic variables were similar in group A and the controls, except that in group A left ventricular end systolic volume index did not decrease during exercise. In group B the heart rate was increased both at rest and during exercise and plasma noradrenaline concentrations were increased. The stroke volume index did not increase significantly during exercise in group B. In addition, the increase in left ventricular ejection fraction was smaller in group B than in controls. End systolic contraction was reduced in group B patients and diastolic blood pressure was increased. These results suggest that cardiac abnormalities in chronic alcoholics may be reversed after cessation of drinking if no chronic liver disease is present. Recent alcohol consumption increases sympathetic nervous activity, impairs cardiac contractility, and increases afterload during physical stress.

Haemodynamic response to exercise in patients with alcoholic liver cirrhosis

Physical work capacity was evaluated by a multistage bicycle exercise test in 29 patients, 22 men and seven women aged 35-61 years (mean 49) with alcoholic liver cirrhosis and in a sex- and age-matched control group. The maximal work load was reduced in the patient group, mean 122 vs. 186 watts in men (P less than 0.001), and 60 vs. 119 watts in women (P less than 0.005). Resting heart rate was higher in patients (91 vs. 78 beats X min-1, P less than 0.005), and the maximal heart rate was lower (159 vs. 170 beats X min-1, P less than 0.001) compared with controls. Thirteen of 29 (45%) patients compared with 5 of 29 (17%) control subjects had an increase in left ventricular ejection fraction of less than or equal to 5% during exercise (P less than 0.05). The present results suggest that an impaired capacity of the cardiac function to respond adequately to physical stress may at times contribute to the reduced physical work capacity seen in patients with alcoholic liver cirrhosis.

Developments in the treatment of peptic ulcer

A review is given of developments in the treatment of peptic ulcers from the early nineteenth century to modern times. 150 years ago long-term treatment consisted of antacids and dietary advice, while bed rest and starvation were included in most regimes around 1900. At the beginning of the 20th century the "Sippy regime" was adopted world wide, entailings, physical rest and complete neutralization of acid. The urge for complete elimination of acid led to the use of the continuous gastric drip. The side effects of these therapeutic modalities were considerable, and thus they were gradually abandoned, so that around 1950 only antacids and bed rest in the initial phase were recommended. During the last 20 years there have been dramatic developments in the medical treatment of peptic ulcers. The impact of the new drugs is discussed.

Seasonal periodicity of peptic ulcer disease. A prospective radiologic study

The possible seasonal periodicity of the occurrence of X-ray-negative dyspepsia (RND), first-time-diagnosed gastric ulcer (GU), and first-time-diagnosed duodenal ulcer (DU) was studied in a 3-year period from 1980 to 1983. Of the 1936 patients studied, 1749 had RND, 100 had GU, and 87 had DU. One or more of the three types of dyspeptic disease were more frequently seen in the period from September through January and less frequently in the period from April through August. In conclusion, the present study suggests true seasonal periodicity in the occurrence of peptic ulcer disease, at least in a population living in the northern part of Norway.

Reduction of gastric acid secretion by 10 mg and 30 mg omeprazole once daily

The reduction in gastric acid secretion by 10 mg and 30 mg omeprazole was studied in 12 patients with ulcer disease in a randomized, double-blind, two-way balanced crossover study. A standardized pentagastrin test was performed before the study and 24 h after each treatment period of 6 days. Treatment was followed by a washout period of 7 days. Omeprazole, 30 mg/day, significantly reduced basal acid output (BAO) by 90% and pentagastrin-stimulated acid output (PAO) by 45% (p less than 0.01), whereas BAO and PAO were not significantly reduced by omeprazole, 10 mg/day.

Smoking, alcohol, coffee, and familial factors: any associations with peptic ulcer disease? A clinically and radiologically prospective study

In the period between 1980 and 1983 smoking habits, alcohol consumption, coffee drinking, and familial occurrences of peptic ulcers were studied in patients with gastric or duodenal ulcer in North Norway. The results were compared with those in two control groups matched for sex and age but without anamnestically known previous peptic ulcer disease. Statistically significant increased familial occurrences of peptic ulcer were found in relatives of patients both with gastric and with duodenal ulcer, compared with the control group. Furthermore, significantly more smokers were found in the two groups of patients than in the control groups. Patients with duodenal ulcers smoked more than those with gastric ulcer. Both the consumption of coffee and that of alcohol, however, were significantly reduced in the ulcer patients compared with their controls. Therefore, both familial factors and smoking habits appear to have some relationship or even play etiologic roles in the development of peptic ulcer disease, at least in the northern part of Norway. Coffee drinking and intake of alcohol seem to be of no importance. Both tobacco smoking and familial accumulation of peptic ulcers increased the relative risks of getting both gastric and duodenal ulcer as compared with 'non-exposed' persons. Furthermore, a positive correlation was found in men between the quantity of smoking and the risk of developing duodenal ulcer.

Epidemiological aspects of peptic ulcer disease on the Faroe Islands. An interim report

A prospective epidemiological study was carried out from 1981 to 1983 to determine the incidence of peptic ulcer on the Faroe Islands. The annual incidence of first-time-diagnosed peptic ulcer was on the average 3.3 per 1000 inhabitants aged 15 years and older. No significant changes in incidence were observed during the 3-year period. The male to female ratio of peptic ulcer was 2.1:1. The annual incidences of duodenal and gastric ulcer were 2.3 per 1000 and 1.0 per 1000, respectively. The duodenal to gastric ulcer ratio was approximately 2:1 in both male and female patients. The incidence of peptic ulcer observed in the Faroe Islands is very high compared with other countries. The incidence of duodenal ulcer is of the same high magnitude as observed in Scotland, whereas the incidence of gastric ulcer is twice as high as generally found in Western countries and in accordance with the rates found in Arctic areas.

Changing demographics of peptic ulcer disease

The demography of peptic ulcer changed greatly and uniformly in western countries until the middle of this century. The demographic pattern reversed at about the turn of the century, duodenal ulcer becoming the predominant lesion, males the most often affected, and age-distribution shifting towards senior citizens. These changes have not continued beyond the 1950s, in fact a decline in the incidence of duodenal ulcer has been postulated. Although hospital admission rates have declined dramatically, there is no evidence of a general decline in the 'true' incidence of duodenal ulcer in the population. However, major changes are ongoing, but the pattern differs from country to country. These findings indicate that environmental factors other than those characterizing industrialized societies are actively involved in the etiology of peptic ulcer.

Vagal tone on the pancreatic polypeptide cell in duodenal ulcer patients. Correction for maximal and minimal secretory capacity

It has previously been suggested that pancreatic polypeptide (PP) might serve as an indicator of abdominal vagal tone in duodenal ulcer (DU) patients. In this investigation we have attempted to study the vagal tone on the PP cells by correcting the basal PP concentrations to the insulin-stimulated (maximal) and atropine-suppressed (minimal) PP responses, to correct for the PP cell mass. There was no statistically significant difference between either the directly measured basal PP concentrations or the basal PP concentrations correlated to maximal and minimal secretory capacity in 10 DU patients and 10 sex- and age-matched controls. The observations indicate that the vagal branches to the PP cells of DU patients do not have higher tone than those of normal subjects.

The incidence of gastric ulcer and duodenal ulcer in north Norway. A prospective epidemiological study

From a prospective epidemiological study of peptic ulcer disease in the northern part of Norway, incidence rates for gastric and duodenal ulcer are presented. Over a 3-year period 4234 patients were examined radiologically or endoscopically. The population at risk was 72,537 persons, 16 to 93 years old. The yearly incidence rate for gastric ulcer in women was 0.9 per 1000 and for men 1.4 per 1000. For duodenal ulcer the incidence rates were 0.8 and 1.5 per 1000, respectively. The ratio of gastric ulcer to duodenal ulcer is still 1 to 1.1 for both sexes, 1 to 0.9 in women, and 1 to 1.14 in men in the northern part of Norway. Furthermore, the present study indicates a statistically significant positive correlation between increasing age and the occurrence of peptic ulcers for both sexes.

The incidence of peptic ulcer disease related to occupation in the northern part of Norway. A prospective epidemiological and radiological study

From a prospective epidemiological and radiological study of peptic ulcer disease in the northern part of Norway, relations between occupation and the occurrence of new peptic ulcers are presented. Over a 3-year period 1861 patients with dyspeptic complaints, 557 women and 1304 men belonging to 12 different occupational groups, were studied. Special attention was paid to the fishing population, constituting 2488 men and only 55 women. In the period studied 87 gastric ulcers and 118 duodenal ulcers were found. A statistically significantly higher incidence of both gastric and duodenal ulcers was found in fishermen than in the other groups. Furthermore, significantly higher incidences of duodenal ulcers were found in men occupied in 'land or water transport'. Compared with the total male population at risk in the area studied, significantly higher incidences were found for duodenal ulcer in fishermen. The present study confirms prior reports both from Scotland and from North Norway, showing an increased incidence of peptic ulcers in the fishing population.

Cardiac performance in patients with asymptomatic alcoholic cirrhosis of the liver

Twenty patients with biopsy-proved alcoholic cirrhosis of the liver and no cardiac symptoms entered a noninvasive investigation program in which cardiac performance was evaluated. One patient was excluded from the study because of a significant ethanol content in the serum at the time of investigation and 4 patients were excluded because of significant electrocardiographic ST-segment changes during exercise testing. Fifteen patients (12 men, 3 women, median age 47 years) who had abstained from alcohol drinking for at least 2 months were studied by exercise testing, echocardiography, measurement of systolic time intervals and left ventricular (LV) radionuclide ejection fraction (EF) at rest and during submaximal exercise. Twelve healthy persons of the same age served as control subjects. Heart rate at rest was significantly elevated in the patient group, median 90 beats/min (range 62 to 128) vs 73 beats/min (range 61 to 89) (p less than 0.02). No significant differences were found in physical work capacity and systolic time intervals, and echocardiographic parameters did not differ with the exception of left atrial dimension (median 36 mm [range 22 to 47] in the patient group and 31 mm [range 17 to 38] in the control subjects, p less than 0.05). No significant difference was found in LVEF at rest. During exercise, however, the median LVEF increased only 6% in the patients versus 14% in the control subjects (p less than 0.05). The results of this study suggest that patients with alcoholic liver cirrhosis, although free of cardiac symptoms, may have a latent or preclinical cardiomyopathy that is manifest during physical stress.

Spontaneous healing of duodenal ulcers

Ninety-one patients with duodenal, pyloric, or prepyloric ulcers were studied endoscopically. Spontaneous ulcer healing was seen in 29 patients within 2 weeks (rapid healing) and in 23 patients within 6 weeks (slow healing). More ulcers healed spontaneously in women than in men (P less than 0.05). Spontaneous healing in men was related to a low gastric peak acid output (P less than 0.05). During follow-up study for 2 years of patients with spontaneously healed ulcers 13 patients had no recurrence, whereas 19 patients had 1 or 2 recurrences, which also healed spontaneously; 11 patients had to be given active treatment, and 9 patients did not complete the study. Cigarette smoking was more frequently recorded in the group receiving active treatment than in the group with spontaneous healing. In men ulcers needing active treatment during the follow-up period were related to a high peak acid output (P less than 0.05).

Changes in the pattern of peptic ulcer disease in the northern part of Norway between 1946 and 1981

The unique pattern of peptic ulcer disease in arctic areas has long been of interest. Results from a retrospective study on the occurrences of gastric and duodenal ulcer for the period between 1962 and 1964 in the northern part of Norway are presented. These results are compared with preliminary data from an ongoing investigation of peptic ulcer in the radiological department at the University Hospital of Tromsø and with those presented by others from the same area in the 1940s. It is shown that the relation between gastric ulcer and duodenal ulcer has changed markedly both for women and men. However, there is still a higher incidence rate of gastric ulcer than of duodenal ulcer in women, whereas the ratio of gastric to duodenal ulcer in men is 1:1. These results contrast sharply with those reported elsewhere in Europe and in the United States.