bluuebunny/crossref_metadata_2025 huggingface dataset:
Perceived food and drug allergies in functional and organic gastrointestinal disorders
Authors: Bhat K. , Harper A. , Gorard D. A.
Published: March 2003

Background:

Gastrointestinal symptoms are often due to functional disorders. Many individuals with abdominal symptoms believe they are allergic to or intolerant of various foods.

Aim:

To assess whether self‐reported allergy is linked to a subsequent functional or organic diagnosis.

Methods:

One thousand new patients attending a district hospital gastroenterology clinic completed a questionnaire about believed drug and food allergies and foodstuffs thought to worsen symptoms. No attempt was made to confirm patients' self‐reported allergies or intolerances. Final diagnoses were classified as organic or functional.

Results:

Nineteen per cent of patients reported drug allergies, 14% reported food allergies and 30% identified foods that worsened symptoms. Atopic patients reported more allergies. Forty‐eight per cent of patients had a functional diagnosis. Women were twice as likely as men to have a functional diagnosis. Patients subsequently diagnosed with a functional disorder were more likely than those with organic disease to report drug allergies (odds ratio, 1.92; 95% confidence interval (CI), 1.39–2.65), food allergies (odds ratio, 4.14; 95% CI, 2.73–6.26) or foods that worsened their abdominal symptoms (odds ratio, 3.08; 95% CI, 2.31–4.10). The likelihood of symptoms being functional increased even further if adverse reactions to both drugs and foods were reported. Patients with weight gain were more likely to report food allergy, and those with both features were very likely to have a functional disorder (odds ratio, 4.58; 95% CI, 3.08–6.86).

Conclusions:

Patients with gastrointestinal symptoms who report drug or food allergies or worsening of symptoms with various foods are more likely to have functional than organic illness. Enquiry about perceived allergies and intolerances may help in the early identification of functional gastrointestinal disorders.
Paroxetine for the treatment of interferon‐α‐induced depression in chronic hepatitis C
Authors: Kraus M. R. , Schäfer A. , Faller H. , Csef H. , Scheurlen M.
Published: March 2003

Background : Psychiatric side‐effects may require dose reduction or premature discontinuation of interferon therapy in chronic hepatitis C. New strategies are needed in order to prevent the premature termination of interferon therapy.

Aim : To evaluate prospectively the efficacy and tolerability of antidepressant therapy (paroxetine, a selective serotonin reuptake inhibitor) in patients with chronic hepatitis C treated with interferon‐α who have developed interferon‐induced major depression.

Methods : A sub‐group of 14 individuals from 121 consecutively treated hepatitis C patients developed substance‐induced major depression without suicidal ideation during interferon‐α treatment. The individuals in this sub‐group received paroxetine after the occurrence of depression (20 mg daily until termination of interferon therapy). Diagnostic scores for depression (and anger–hostility) were obtained in a repeated measures design (Hospital Anxiety and Depression Scale and Symptom Checklist 90 Items Revised).

Results : Eleven of the 14 patients (78.6%) with interferon‐induced major depression were able to complete interferon‐α therapy as scheduled under concomitant paroxetine treatment (three dropouts: insufficient improvement of depression, occurrence of epileptic seizures, paroxetine‐induced nausea/dizziness). Within 4 weeks after the start of paroxetine medication, depression scores declined significantly in all patients.

Conclusions : Our data suggest that concomitant therapy with paroxetine is an effective way to treat interferon‐induced depression in patients with chronic hepatitis C.
Azathioprine in paediatric inflammatory bowel disease: an Italian multicentre survey
Authors: Barabino A. , Torrente F. , Ventura A. , Cucchiara S. , Castro M. , Barbera C.
Published: March 2003

Aim : To assess the efficacy and safety of azathioprine in a paediatric population with inflammatory bowel disease.

Patients and methods : One hundred and twenty‐three Italian children treated with azathioprine were studied retrospectively. The treatment duration and causes of its discontinuation, side‐effects and variation in corticosteroid dose were assessed.

Results : The mean age at inflammatory bowel disease diagnosis was 9.8 ± 3.6 years, and at the start of azathioprine therapy 11.8 ± 4.3 years. The mean duration of treatment was 19 ± 16 months. Fifty patients (41%) stopped treatment due to surgery (12%), prolonged remission (11%), non‐response (7%), severe side‐effects (7%) and poor compliance (3%). Of the 73 patients (59%) remaining on azathioprine, 11 had never been treated with corticosteroids, 27 were able to stop them and 35 were still on a very low daily dose (91% < 0.3 mg/kg). The difference in the daily corticosteroid dose between the beginning of azathioprine treatment (1 ± 0.6 mg/kg) and the conclusion of the study (0.18 ± 0.16 mg/kg) was statistically significant. Side‐effects were recorded in 48 of the 123 patients (39%), but only eight required discontinuation of azathioprine.

Conclusions : Azathioprine was efficacious in 70% of patients, but ineffective in 20% and induced severe toxicity in 7%. Corticosteroids were stopped or markedly reduced in 62% of patients, but they were never given in 9%.
The potential risk factors leading to peptic ulcer formation in autoimmune disease patients receiving corticosteroid treatment
Authors: Luo J.‐C. , Chang F.‐Y. , Lin H.‐Y. , Lu R.‐H. , Lu C.‐L. , Chen C.‐Y. , Lee S.‐D.
Published: March 2003

Aim : To study the potential risk factors leading to peptic ulcer disease among autoimmune disease patients on corticosteroid treatment.

Methods : One hundred and thirty‐eight corticosteroid‐treated autoimmune disease patients were enrolled; their demographic data were recorded and laboratory data were measured. Endoscopy was performed to assess the occurrence of peptic ulcer disease. Helicobacter pylori infection was diagnosed on the basis of rapid urease test and histological examination.

Results : Twenty‐eight (20%) of 138 autoimmune disease patients had peptic ulcer disease, including 17 with gastric ulcer, eight with duodenal ulcer and three with gastric ulcer plus duodenal ulcer. Eighty five (62%) had used non‐steroidal anti‐inflammatory drugs and 46 (33%) had H. pylori infection. The majority of peptic ulcer disease subjects showed the following characteristics: age ≥ 60 years; male; smokers; non‐steroidal anti‐inflammatory drug users, particularly the non‐specific cyclo‐oxygenase inhibitors; presence of hyperpepsinogenaemia I; low H. pylori colonization (P < 0.05). Multivariate analysis revealed that an age ≥ 60 years [odds ratio (OR), 6.80; P = 0.001], smoking (OR, 7.94; P = 0.004) and the use of non‐specific cyclo‐oxygenase inhibitors (OR, 4.71; P = 0.030) were the predominant risk factors for the development of peptic ulcer disease among these patients, whereas H. pylori infection showed a protective role (OR, 0.20; P = 0.022).

Conclusions : Old age, smoking and the use of non‐specific cyclo‐oxygenase inhibitors are risk factors for peptic ulcer disease in autoimmune disease patients on corticosteroid treatment. H. pylori infection appears to protect against peptic ulcer disease in these patients.
Furazolidone‐based triple ‘rescue therapy’ vs. quadruple ‘rescue therapy’ for the eradication of Helicobacter pylori resistant to metronidazole
Authors: Isakov V. , Domareva I. , Koudryavtseva L. , Maev I. , Ganskaya Z.
Published: March 2003

Background : The optimal treatment of patients with Helicobacter pylori resistant to metronidazole has not been established.

Aim : To compare the efficacy of quadruple and furazolidone‐based triple therapy in the eradication of H. pylori resistant to metronidazole.

Methods : Duodenal ulcer patients (n = 70) in whom initial eradication therapy failed and who harboured H. pylori strains resistant to metronidazole were randomized to receive one of the following 7‐day regimens: colloidal bismuth subcitrate, 240 mg, tetracycline, 750 mg, and furazolidone, 200 mg, each given twice daily (BTF), or omeprazole, 20 mg b.d., colloidal bismuth subcitrate, 240 mg b.d., tetracycline, 500 mg q.d.s., and metronidazole, 500 mg b.d. (OBTM). H.pylori status was assessed by culture, histology and rapid urease test before treatment and 4–6 weeks after therapy. Susceptibility to metronidazole was assessed by the agar dilution method.

Results : H. pylori eradication rates with intention‐to‐treat/per protocol analyses were: BTF, 85.7%/90.9%; OBTM, 74.2%/89.6%. Duodenal ulcers were healed in nine of 10 (90%) patients in the BTF group and in all patients (12/12) (100%) in the OBTM group (P = N.S.). A significantly lower rate of adverse events was observed in the BTF group than in the OBTM group (31.4% vs. 60%, P = 0.03), but there was no difference in terms of discontinuation of treatment (2/35 vs. 6/35, P = N.S.).

Conclusions : The 1‐week BTF regimen was as effective as the OBTM regimen, and produced less adverse events. Thus, it may be used in patients in whom resistance of H. pylori to metronidazole is suspected.
Systematic review: patient‐centred endpoints in economic evaluations of gastro‐oesophageal reflux disease
Authors: Vakil N. , Rydén‐Bergsten T. , Bergenheim K.
Published: March 2003

Aim : To perform a systematic review of the economic literature on gastro‐oesophageal reflux disease to evaluate (a) the use of patient‐centred effectiveness end‐points, or (b) the use of patient‐centred economic end‐points, and the influence of these end‐points on the outcome of the model.

Methods : Three electronic databases (EMBASE, BIOSIS and Medline) were used, together with a manual search of meeting abstracts for relevant articles. The quality of the studies was determined by the Drummond criteria.

Results : Our initial search identified 179 articles and a manual search revealed 78 abstracts and articles. A total of 47 studies (36 fully published articles and 11 abstracts) met the seven Drummond criteria for inclusion in our evaluation.

Conclusions : This systematic review demonstrates that many of the published economic evaluations available today take the perspective of the third‐party payer and focus on pharmaceutical costs relevant to the third‐party payer. Our study also demonstrates that there are a number of costs of illness determinations, such that pharmaceutical costs account for only a small proportion of the total costs of managing gastro‐oesophageal reflux disease. Future economic analyses should consider an evaluation of the patient's desire for complete symptom relief by including cost–utility assessments or willingness to pay data.
Efficacy of quadruple therapy with pantoprazole, bismuth, tetracycline and metronidazole as rescue treatment for Helicobacter pylori infection
Authors: Boixeda D. , Bermejo F. , Martín‐De‐Argila C. , López‐Sanromán A. , Defarges V. , Hernández‐Ranz F. , Milicua J. M. , García‐Plaza A.
Published: March 2003

Aim : To study the efficacy of a 7‐day quadruple regimen combining pantoprazole, bismuth, tetracycline and metronidazole as rescue treatment for Helicobacter pylori infection after failure of standard triple therapy.

Methods : A prospective study was made of 140 patients infected with H. pylori and diagnosed with peptic ulcer or non‐ulcer dyspepsia in whom triple therapy with proton pump inhibitor, clarithromycin and amoxicillin had failed. The patients were treated with quadruple therapy including pantoprazole, 40 mg twice daily, colloidal bismuth subcitrate, 120 mg four times daily, tetracycline, 500 mg four times daily, and metronidazole, 500 mg three times daily, for 7 days. Two months after completion of therapy, a 13C‐urea breath test was performed to confirm eradication.

Results : With quadruple therapy, the H. pylori eradication rates were 82% (95% confidence interval (CI), 75–88%) by ‘intention‐to‐treat’ and 85% (95% CI, 79–91%) by ‘per protocol’. No major side‐effects were observed. No differences in eradication success were observed in relation to underlying disease (peptic ulcer: 85% (95% CI, 76–91%) vs. non‐ulcer dyspepsia: 83% (95% CI, 68–93%)) or smoking habits (smokers: 86% (95% CI, 75–93%) vs. non‐smokers: 83% (95% CI, 71–91%)).

Conclusion : Quadruple therapy with pantoprazole, bismuth, tetracycline and metronidazole for 7 days is an effective H. pylori eradication treatment for patients in whom standard triple therapy has failed.
Reappraisal of non‐invasive management strategies for uninvestigated dyspepsia: a cost‐minimization analysis
Authors: Ladabaum U. , Chey W. D. , Scheiman J. M. , Fendrick A. M.
Published: March 2003

Background : The benefits of the Helicobacter pylori test‐and‐treat strategy are attributable largely to the cure of peptic ulcer disease while limiting the use of endoscopy.

Aim : To reappraise the test‐and‐treat strategy and empirical proton pump inhibitor therapy for the management of uninvestigated dyspepsia in the light of the decreasing prevalence of H. pylori infection, peptic ulcer disease and peptic ulcer disease attributable to H. pylori.

Methods : Using a decision analytical model, we estimated the cost per patient with uninvestigated dyspepsia managed with the test‐and‐treat strategy ($25/test; H.pylori treatment, $200) or proton pump inhibitor ($90/month). Endoscopy ($550) guided therapy for persistent or recurrent symptoms.

Results : In the base case (25%H. pylori prevalence, 20% likelihood of peptic ulcer disease, 75% of ulcers due to H.pylori), the cost per patient is $545 with the test‐and‐treat strategy and $529 with proton pump inhibitor, and both strategies yield similar clinical outcomes at 1 year. H. pylori prevalence, the likelihood of peptic ulcer disease and the proportion of ulcers due to H.pylori are important determinants of the least costly strategy. At an H. pylori prevalence below 20%, proton pump inhibitor is consistently less costly than the test‐and‐treat strategy.

Conclusions : As the H. pylori prevalence, the likelihood of peptic ulcer disease and the proportion of ulcers due to H. pylori decrease, empirical proton pump inhibitor becomes less costly than the test‐and‐treat strategy for the management of uninvestigated dyspepsia. Given the modest cost differential between the strategies, the test‐and‐treat strategy may be favoured if patients without peptic ulcer disease derive long‐term benefit from H.pylori eradication.
Meta‐analysis: the effect of probiotic administration on antibiotic‐associated diarrhoea
Authors: Cremonini F. , Di Caro S. , Nista E. C. , Bartolozzi F. , Capelli G. , Gasbarrini G. , Gasbarrini A.
Published: March 2003

Background : Antibiotic‐associated diarrhoea can be attributed in part to imbalances in intestinal microflora. Therefore, probiotic preparations are used to prevent this diarrhoea. However, although several trials have been conducted, no conclusive evidence has been found of the efficacy of different preparations, e.g. Lactobacillus spp. and Saccharomyces spp.

Aim : To conduct a meta‐analysis of the data in the literature on the efficacy of probiotics in the prevention of antibiotic‐associated diarrhoea.

Methods : A literature search was performed of electronic databases, Abstract Books and single paper references. Data were also obtained from the authors. Only placebo‐controlled studies were included in the search. The Mantel–Haenszel test was used to estimate the relative risk for single studies and an overall combined relative risk, each study being submitted to the Mantel–Haenszel test for homogeneity.

Results : Twenty‐two studies matched the inclusion criteria. Only seven studies (881 patients) were homogeneous. The combined relative risk was 0.3966 (95% confidence interval, 0.27–0.57).

Conclusions : The results suggest a strong benefit of probiotic administration on antibiotic‐associated diarrhoea, but further data are needed. The evidence for beneficial effects is still not definitive. Published studies are flawed by the lack of a placebo design and by peculiar population features.
Foetal intrauterine growth restrictions with Helicobacter pylori infection
Authors: Eslick G. D. , Yan P. , Xia H. H.‐X. , Murray H. , Spurrett B. , Talley N. J.
Published: March 2003

Background : Helicobacter pylori infection has been associated with growth restriction in young children.

Aim : To determine whether there is an association between H. pylori infection and intrauterine growth restriction.

Methods : Four hundred and forty‐eight consecutive pregnant women (aged 15–44 years), attending for routine examinations in the third trimester, were enrolled. Clinical, demographic and previous obstetric data, as well as smoking history, were collected. At delivery, the weight, height, gender and status of the neonate were recorded; intrauterine growth restriction was defined if the birth weight was below the 10th percentile according to the gestational age for infants born in Australia.

Results : Eighty‐nine (20%) women were seropositive for H. pylori. The prevalence of H. pylori was significantly lower in Caucasians (17%) vs. non‐Caucasians (42%, P < 0.0001). There were 34 (7.5%) cases of intrauterine growth restriction (7% Caucasians, 16% Asians, 12% Aborigines and 0% Pacific Islanders). Intrauterine growth restriction was more common in H. pylori‐seropositive women than in H. pylori‐seronegative women [13.5% vs. 6%; odds ratio (OR)=2.41; 95% confidence interval (CI), 1.14–5.08; P=0.018]. A multiple logistic regression model revealed that smoking (OR=3.55; 95% CI, 1.62–7.79; P=0.002), maternal height (OR=0.48; 95% CI, 0.28–0.80; P=0.005) and H. pylori seropositivity (OR=2.59; 95% CI, 1.12–5.95; P=0.025) were all independent risk factors for intrauterine growth restriction.

Conclusions : H. pylori infection in pregnant women may affect foetal intrauterine growth.
Herbal medicinal products for non‐ulcer dyspepsia
Authors: Thompson Coon J. , Ernst E.
Published: March 2003

Background : Non‐ulcer dyspepsia is predominantly a self‐managed condition, although it accounts for a significant number of general practitioner consultations and hospital referrals. Herbal medicinal products are often used for the relief of dyspeptic symptoms.

Aims : To critically assess the evidence for and against herbal medicinal products for the treatment of non‐ulcer dyspepsia.

Methods : Systematic searches were performed in six electronic databases and the reference lists located were checked for further relevant publications. No language restrictions were imposed. Experts in the field and manufacturers of identified herbal extracts were also contacted. All randomized clinical trials of herbal medicinal products administered as supplements to human subjects were included.

Results : Seventeen randomized clinical trials were identified, nine of which involved peppermint and caraway as constituents of combination preparations. Symptoms were reduced by all treatments (60–95% of patients reported improvements in symptoms). The mechanism of any anti‐dyspeptic action is difficult to define, as the causes of non‐ulcer dyspepsia are unclear. There appear to be few adverse effects associated with these remedies, although, in many cases, comprehensive safety data were not available.

Conclusions : There are several herbal medicinal products with anti‐dyspeptic activity and encouraging safety profiles. Further research is warranted to establish their therapeutic value in the treatment of non‐ulcer dyspepsia.
Effects of rabeprazole, lansoprazole and omeprazole on intragastric pH in CYP2C19 extensive metabolizers
Authors: Saitoh T. , Fukushima Y. , Otsuka H. , Hirakawa J. , Mori H. , Asano T. , Ishikawa T. , Katsube T. , Ogawa K. , Ohkawa S.
Published: March 2003

Aim : To investigate the inhibitory effects on gastric acid secretion of three proton pump inhibitors, omeprazole, lansoprazole and rabeprazole, using a three‐way crossover design in healthy Helicobacter pylori‐negative,S‐mephenytoin 4′‐hydroxylase (CYP2C19) homo‐ and hetero‐extensive metabolizers.

Methods : Eight healthy Japanese male volunteers were enrolled. After the administration of rabeprazole (10 mg/day), lansoprazole (30 mg/day) or omeprazole (20 mg/day), intragastric pH monitoring was commenced from 24 h before the first proton pump inhibitor dose, and continued for days 1–3 after proton pump inhibitor administration. The pH electrode was used for 48 h and changed just before pH monitoring on day 2.

Results : For the administration of 10 mg/day rabeprazole, the mean ratios of the 24‐h pH ≥ 3 holding timewere 5.7 ± 1.1%,13.6 ± 2.2%, 35.3 ± 2.7% and 62.8 ± 3.1% for the pre‐treatment day and days 1, 2 and 3, respectively. The same ratios for lansoprazole (30 mg/day) were 5.7 ± 0.7%, 7.4 ± 1.5%, 13.6 ± 3.4% and 26.6 ± 4.9%; the same ratios for 20 mg/day omeprazole were 5.9 ± 0.9%, 6.1 ± 1.2%, 11.4 ± 2.8% and 16.4 ± 4.6%. The mean ratio of the 24‐h pH ≥ 3 holding time of days 1–3 increased significantly compared to the pre‐treatment day (P < 0.01) with the administration of rabeprazole and lansoprazole. The magnitude of inhibition of gastric acid secretion after rabeprazole administration was stronger than that after lansoprazole. A significant elevation of the mean ratio of the 24‐h pH ≥ 3 holding time was demonstrated on days 2 and 3 with omeprazole (P < 0.01).

Conclusions : In H. pylori‐negative CYP2C19 extensive metabolizers, rabeprazole (10 mg/day) shows a faster onset of rising intragastric pH and a stronger inhibition of gastric acid secretion than do lansoprazole (30 mg/day) or omeprazole (20 mg/day).
Mechanisms of initiation and perpetuation of gut inflammation by stress
Authors: Hart A. , Kamm M. A.
Published: March 2003

Inflammatory bowel disease involves an interaction between genetic susceptibility, a host mucosal immune response and the enteric flora. However, the relapsing and remitting course underlines the importance of other modifiers, such as psychological stress. Doctors and patients share the view that stress plays a role in the initiation and perpetuation of disease. Levels of chronic perceived stress have been shown to correlate with symptom relapse and mucosal appearance, and stress management therapy has been shown to be beneficial. Animal models provide further evidence that stress may play a role in disease initiation and reactivation.

Elucidation of the gut–brain–immune axis has provided insight into the mechanisms by which stress may result in gut inflammation. Stress can alter intestinal physiological function. Stress can increase gut permeability, increase ion secretion by a mechanism involving neural stimulation or mast cells, increase mucin release and deplete goblet cells. Stress causes parasympathetic activation via a mechanism involving corticotropin releasing factor, ultimately affecting mucosal mast cells. Stress also results in increased bacterial adherence and decreased luminal lactobacilli. As a result of all these changes luminal antigens may gain access to the epithelium, causing inflammation.
Bloating in functional bowel disorders
Authors: Zar S. , Benson M. J. , Kumar D.
Published: March 2003

Bloating is a frequently reported symptom in functional bowel disorders. It usually occurs in combination with other symptoms, but may also occur in isolation. The severity of bloating tends to worsen during the course of the day and improves overnight. Although frequently considered to be a subjective phenomenon, recent studies have shown that bloating is associated with a measurable increase in abdominal girth.

The pathophysiology of bloating remains elusive, but the evidence supports a sensorimotor dysfunction of the bowel. The possible mechanisms include abnormal gas trapping, fluid retention, food intolerance and altered gut microbial flora. Further studies are needed to define the sensorimotor abnormalities associated with bloating, which might be segmental and transient rather than generalized and persistent.

The lack of understanding of this symptom is paralleled by a limited availability of therapeutic options. Conventional medications used in functional bowel disorders are not helpful and may indeed worsen the symptoms. In future, new drugs with activity against serotonin and kappa receptors, or novel approaches such as the use of exclusion diets, probiotics and hypnotherapy, may prove to be useful.
Anxiety but not depression determines health care‐seeking behaviour in Chinese patients with dyspepsia and irritable bowel syndrome: a population‐based study
Authors: Hu W. H. C. , Wong W.‐M. , Lam C. L. K. , Lam K. F. , Hui W. M. , Lai K. C. , Xia H. X. H. , Lam S. K. , Wong B. C. Y.
Published: March 2003

Aims : To study the prevalence of dyspepsia and irritable bowel syndrome and the effects of co‐existing anxiety and depression on health care utilization by a population survey in Chinese.

Methods : Ethnic Chinese households were invited to participate in a telephone survey using a validated bowel symptom questionnaire and the hospital anxiety and depression scale. Gastrointestinal symptoms were classified as dyspepsia and irritable bowel syndrome according to the Rome I criteria and gastro‐oesophageal reflux disease by the presence of weekly heartburn or acid regurgitation. The anxiety and depression scores were compared between patients who sought medical attention and those who did not, using multiple logistic regression analysis.

Results : One thousand, six hundred and forty‐nine subjects completed the interview (response rate, 62%). The population prevalences of dyspepsia, irritable bowel syndrome and gastro‐oesophageal reflux disease were 18.4%, 4.1% and 4.8%, respectively. Dyspepsia and irritable bowel syndrome were associated with anxiety, depression, medical consultation, sick leave and adverse effects on social life. The degree of anxiety was an independent factor associated with health care‐seeking behaviour in both dyspeptics (P=0.003) and irritable bowel syndrome patients (P=0.036).

Conclusions : Irritable bowel syndrome and dyspepsia are associated with anxiety, depression, significant social morbidity, health care utilization and days off work. Anxiety is an independent factor in determining health care utilization in patients with dyspepsia and irritable bowel syndrome.
Hepatic venous pressure gradient measurements to assess response to primary prophylaxis in patients with cirrhosis: a decision analytical study
Authors: Hicken B. L. , Sharara A. I. , Abrams G. A. , Eloubeidi M. , Fallon M. B. , Arguedas M. R.
Published: March 2003

Background: The measurement of the hepatic venous pressure gradient may identify a suboptimal response to beta‐blockers in patients with varices at risk for bleeding. However, the cost‐effectiveness of routine hepatic venous pressure gradient measurements to guide primary prophylaxis has not been examined.

Methods: We used decision analysis to evaluate two hepatic venous pressure gradient measurement strategies relative to standard beta‐blocker therapy in a hypothetical cohort of patients with high‐risk varices: (i) hepatic venous pressure gradient measurement 4 weeks after the initiation of beta‐blocker therapy; and (ii) hepatic venous pressure gradient measurement prior to and 4 weeks after the initiation of beta‐blocker therapy. The total expected costs, variceal bleeding episodes and deaths were calculated over a 1‐year time horizon.

Results: Beta‐blocker therapy was associated with total costs of $1464, seven variceal bleeding episodes, one variceal bleeding episode‐related death and 15 deaths. One hepatic venous pressure gradient measurement was associated with total costs of $5015, four variceal bleeding episodes, one variceal bleeding episode‐related death and 15 deaths. Two hepatic venous pressure gradient measurements were associated with total costs of $8657, four episodes of variceal bleeding, one variceal bleeding episode‐related death and 15 deaths. Compared with beta‐blocker therapy alone, the incremental costs per variceal bleeding episode prevented and death averted were, respectively, $108 185 and $355 100 (one hepatic venous pressure gradient measurement) and $202 796 and $719 300 (two hepatic venous pressure gradient measurements). The results were sensitive to the time horizon of the analysis, the probability of bleeding whilst on beta‐blockers and the cost of hepatic venous pressure gradient measurement.

Conclusion: Hepatic venous pressure gradient measurement to guide primary prophylaxis is an expensive strategy for reducing variceal bleeding or death, especially in patients with limited life expectancy, such as those with advanced, decompensated cirrhosis.
Cyclo‐oxygenase‐2 expression in Barrett's oesophageal carcinogenesis: an immunohistochemical study
Authors: Cheong E. , Igali L. , Harvey I. , Mole M. , Lund E. , Johnson I. T. , Rhodes M.
Published: March 2003

Background : The incidence of Barrett's oesophageal adenocarcinoma is increasing more rapidly than any other malignancy in industrialized countries. Cyclo‐oxygenase‐2 appears to play an important role in gastrointestinal carcinogenesis. Previous studies on cyclo‐oxygenase‐2 expression in Barrett's oesophageal carcinogenesis have utilized tissue samples obtained from different patients. We sought a definitive comparison of cyclo‐oxygenase‐2 expression in the sequence of Barrett's metaplasia–dysplasia–adenocarcinoma within the same patients.

Methods : Paraffin‐embedded oesophago‐gastrectomy specimens from 20 patients, containing successive stages of Barrett's metaplasia, high‐grade dysplasia and adenocarcinoma, were analysed for cyclo‐oxygenase‐2 expression by immunohistochemistry.

Results : Cyclo‐oxygenase‐2 was constitutively expressed in the basal layers of cells in the adjacent normal squamous oesophageal epithelium, but a higher cyclo‐oxygenase‐2 expression was observed in Barrett's metaplasia. A further increase in cyclo‐oxygenase‐2 expression was detected in high‐grade dysplasia, but cyclo‐oxygenase‐2 was decreased in adenocarcinoma tissue, regardless of its stage or level of differentiation.

Conclusions : Cyclo‐oxygenase‐2 expression is progressively increased when squamous oesophageal epithelium develops into Barrett's metaplastic epithelium and then into high‐grade dysplasia, but appears to decrease when adenocarcinoma develops. These findings may be significant for an effective chemo‐prevention strategy with selective cyclo‐oxygenase‐2 inhibitors.
A prospective, comparative study of the para‐aminobenzoic acid test and faecal elastase 1 in the assessment of exocrine pancreatic function
Authors: Sonwalkar S. A. , Holbrook I. B. , Phillips I. , Kelly S. M.
Published: March 2003

Background : The assessment of exocrine pancreatic insufficiency is part of the routine work‐up of patients with persistent diarrhoea or suspected steatorrhoea. Direct and indirect tests for the diagnosis of exocrine pancreatic insufficiency have their drawbacks. Measurement of faecal elastase 1 by enzyme‐linked immunoabsorbent assay is a simple, non‐invasive, robust test for exocrine pancreatic insufficiency.

Methods : We performed a prospective comparison of the para‐aminobenzoic acid test and faecal elastase 1 test in 45 patients being investigated for diarrhoea or suspected steatorrhoea. Details of clinical suspicion, imaging and response to treatment were recorded.

Results : Exocrine pancreatic function was normal in 20 patients with normal para‐aminobenzoic acid and faecal elastase 1 levels. Eight patients had exocrine pancreatic insufficiency with low para‐aminobenzoic acid and faecal elastase 1 levels, which improved with enzyme supplementation. In 14 of the 15 patients with low or borderline low para‐aminobenzoic acid and normal faecal elastase 1 levels, a non‐pancreatic cause was found; one patient had a false positive para‐aminobenzoic acid test. Two had normal para‐aminobenzoic acid but low faecal elastase 1 levels. One improved with pancreatic supplementation, and imaging revealed chronic pancreatitis. The other had a false positive faecal elastase 1 test related to profuse diarrhoea.

Conclusions : Faecal elastase 1 estimation is a simple, non‐invasive, robust test of exocrine pancreatic insufficiency, performed on an out‐patient stool sample. Its diagnostic performance is superior to that of the para‐aminobenzoic acid test in investigating patients with diarrhoea or suspected steatorrhoea.
Randomized controlled study of rabeprazole, levofloxacin and rifabutin triple therapy vs. quadruple therapy as second‐line treatment for Helicobacter pylori infection
Authors: Wong W. M. , Gu Q. , Lam S. K. , Fung F. M. Y. , Lai K. C. , Hu W. H. C. , Yee Y. K. , Chan C. K. , Xia H. H. X. , Yuen M. F. , Wong B. C. Y.
Published: March 2003

Aim : To test the efficacy of rabeprazole, levofloxacin and rifabutin triple therapy vs. quadruple therapy for the second‐line treatment of Helicobacter pylori infection.

Methods : One hundred and nine patients who had failed previous H. pylori eradication were randomized to receive: (i) rabeprazole, 20 mg b.d., rifabutin, 300 mg once daily, and levofloxacin, 500 mg once daily, for 7 days (triple therapy); or (ii) rabeprazole, 20 mg b.d., metronidazole, 400 mg t.d.s., bismuth subcitrate, 120 mg q.d.s., and tetracycline, 500 mg q.d.s., for 7 days (quadruple therapy). Endoscopy and culture were performed before treatment.

Results : The clarithromycin (79% vs. 21%, P < 0.001) and metronidazole (89% vs. 40%, P < 0.001) resistance rates were significantly higher in patients with previous exposure than in those with no previous exposure. The intention‐to‐treat and per protocol eradication rates were 91%/91% for the triple therapy group and 91%/92% for the quadruple therapy group. For patients with double resistance to metronidazole and clarithromycin, the eradication rates were 85% (17/20) in the triple therapy group and 87% (13/15) in the quadruple therapy group. Compliance was greater than 95% for both regimens.

Conclusion : Rabeprazole, levofloxacin and rifabutin‐based triple therapy and quadruple therapy were equally effective as second‐line treatments for H. pylori infection.
Influence of the selective serotonin re‐uptake inhibitor, paroxetine, on gastric sensorimotor function in humans
Authors: Tack J. , Broekaert D. , Coulie B. , Fischler B. , Janssens J.
Published: March 2003

Background : The role of 5‐hydroxytryptamine in the control of gastric fundus tone in humans is still unknown. Selective 5‐hydroxytryptamine re‐uptake inhibitors act both centrally and peripherally to enhance the availability of physiologically released 5‐hydroxytryptamine.

Aim : To study the influence of a selective 5‐hydroxytryptamine re‐uptake inhibitor, paroxetine, on gastric fundus tone, on the perception to gastric distension and on gastric accommodation to a meal.

Methods : Sixteen healthy volunteers underwent a gastric barostat study on two occasions, after pre‐treatment with placebo or paroxetine, 20 mg/day. Graded isobaric and isovolumetric distensions were performed and perception was scored by a questionnaire. Subsequently, the amplitude of the gastric accommodation to a mixed liquid meal was also measured.

Results : Pre‐treatment with paroxetine did not alter the thresholds for perception and discomfort during isobaric (4.7 ± 2.3 vs. 4.0 ± 2.0 mmHg and 13.3 ± 3.1 vs. 12.7 ± 2.3 mmHg above the minimum intragastric distending pressure, N.S.) and isovolumetric (307 ± 90 vs. 417 ± 114 mL and 772 ± 74 vs. 750 ± 76 mL, N.S.) distensions. Paroxetine significantly enhanced the amplitude of the meal‐induced fundus relaxation (136 ± 51 vs. 255 ± 43 mL, P < 0.05).

Conclusions : Pre‐treatment with paroxetine enhances gastric accommodation to a meal. These data suggest that the release of 5‐hydroxytryptamine, probably at the level of the enteric nervous system, is involved in the control of the accommodation reflex in humans, and that paroxetine may be beneficial to patients with impaired post‐prandial fundus relaxation.
Consent to clinical trials in anaesthesia
Authors: Montgomery J. E. , Sneyd J. R.
Published: March 2003

In order to evaluate satisfaction with, and recollection of, the consent process, we sent a postal questionnaire to 204 patients who had taken part in one of six clinical trials. Three trials were multicentre commercial studies and three were ‘in house’. The readability of the different patient information sheets was compared. Seventy‐seven per cent of patients responded, of whom 82% remembered having an information sheet. Most (99%) thought this was easy to read and understand. Five patients claimed that they had felt pressurised to take part in the trials. Nearly all patients (97%) realised that participation was voluntary and that other treatment would not be affected; 83% knew they could have changed their minds. There were no differences in the response patterns between the patients taking part in the different trials although the patient information sheets produced by pharmaceutical companies were longer and more complex than the ‘in hospital’ variety. We conclude that increasing the amount and complexity of information does not alter patient satisfaction. Taken overall, patients were content with the way they were approached when asked for consent for clinical trials.
Postoperative respiratory function in children after abdominal surgery
Authors: Chabas E. , Gomar C. , Villalonga A. , Sala X. , Taura P.
Published: March 2003

Thirty children undergoing urological and abdominal surgery were entered into a randomised trial comparing the effects of epidural and intramuscular morphine on postoperative respiratory function. The forced vital capacity and the forced expired volume in 1 s were measured before and 6 h after surgery and on each of the following seven days. Significant decreases (p < 0.01) in forced vital capacity and forced expired volume in 1 s were seen after surgery. After the first postoperative day, a gradual recovery in pulmonary function was observed but the measured parameters had not returned to their pre‐operative control values by the end of the study. There were no statistically significant differences between the two groups during the study with respect to forced vital capacity and forced expired volume in 1 s. The quality of analgesia was better in the epidural morphine group than in the intramuscular morphine group. The incomplete recovery of pulmonary function suggests that pain is not the only cause of postoperative respiratory changes in these patients.
Exogenous adenosine potentiates hypnosis induced by intravenous anaesthetics
Authors: Kaputlu İ. , Şadan G. , Özdem S.
Published: March 2003

We investigated the effect of adenosine on hypnosis induced by thiopentone, propofol and midazolam in mice. The onset and duration of hypnosis were determined by the loss of righting reflex. Adenosine and 2‐chloroadenosine caused a significant shortening of onset of sleep‐time and prolongation of duration of sleep‐time in all groups (p < 0.05). Dipyridamole administration before combined intravenous anaesthetic‐adenosine or intravenous anaesthetic‐2‐chloroadenosine administration produced similar effects to adenosine (p < 0.05). The adenosine antagonist theophylline, given before intravenous anaesthetic‐adenosine or intravenous anaesthetic‐2‐chloroadenosine administration caused a significant delay in onset of sleep‐time and shortening in the duration of sleep‐time (p < 0.05). We conclude that central excitatory noradrenergic neurones play an important role in adenosine, 2‐chloroadenosine and dipyridamole‐induced hypnotic responses to intravenous anaesthetics and their inhibition by adenosine antagonists.
Power spectral analysis of the electroencephalogram during increasing end‐expiratory concentrations of isoflurane, desflurane and sevoflurane
Authors: Schwender D. , Daunderer M. , Klasing S. , Finsterer U. , Peter K.
Published: March 2003

We studied the effects of increasing end‐expiratory concentrations of isoflurane (0.3, 0.6, 0.9, 1.2 vol.%) (n = 12 patients), desflurane (1.5, 3.0, 4.5, 6.0 vol.%) (n = 12 patients) and sevoflurane (0.5, 1.0, 1.5, 2.0 vol.%) (n = 12 patients) on power spectral analysis of the electroencephalogram (EEG). Spectral edge frequency (SEF), total power (TP) and relative power in the delta, theta, alpha and beta band were calculated. EEG changes were very similar within the three groups. SEF decreased, TP and relative power in the delta and theta band increased, power in the beta band decreased in a dose‐dependent fashion with comparable regression lines. This indicates that MAC equivalent administration of isoflurane, desflurane and sevoflurane in clinically applied dose ranges is associated with equipotent EEG suppression.
Anaesthetic induction time for tracheal intubation using sevoflurane or halothane in children
Authors: Inomata S. , Yamashita S. , Toyooka H. , Yaguchi Y. , Taguchi M. , Sato S.
Published: March 2003

The current study was designed to determine the anaesthetic induction time required for tracheal intubation (TimeEI) with equipotent inspired concentrations of 5% sevoflurane and 2.5% halothane in oxygen. TimeEI that prevents 50% and 95% of patients from coughing and gross purposeful muscular movements after intubation was defined as TimeEI50 and TimeEI95, respectively. Thirty‐six patients aged 1–7 years were enrolled in the study. Anaesthesia was induced via mask and when TimeEI attained a predetermined value, intubation was performed using an uncuffed tube. Each TimeEI at which tracheal intubation was attempted was predetermined according to the up‐and‐down method. When intubation was accomplished without gross purposeful muscular movements, it was considered a smooth intubation. Determination with this method revealed that TimeEI50 and TimeEI95 for the sevoflurane/halothane groups were 147/214 s and 194/255 s, respectively. In conclusion, it is possible to determine TimeEI using an inspired sevoflurane concentration of 5% and halothane 2.5% in oxygen. The technique with 5% sevoflurane seems more practical for paediatric anaesthesia induction in busy clinical situations.
The efficacy of ginger root in the prevention of postoperative nausea and vomiting after outpatient gynaecological laparoscopy
Authors: Visalyaputra S. , Petchpaisit N. , Somcharoen K. , Choavaratana R.
Published: March 2003

To determine the anti‐emetic effect of ginger as compared to droperidol, 120 patients scheduled to have gynaecological diagnostic laparoscopy as day cases were randomly allocated into placebo, droperidol, ginger and ginger plus droperidol groups to receive either 2 g of ginger or 1.25 mg of droperidol or both. There were no significant differences in the incidences of postoperative nausea which were 32%, 20%, 22% and 33%, and vomiting which were 35%, 15%, 25% and 25% in the four groups, respectively. We conclude that ginger powder, in the dose of 2 g, droperidol 1.25 mg or both are ineffective in reducing the incidence of postoperative nausea and vomiting after day case gynaecological laparoscopy.
Obstructive sleep apnoea syndrome in children
Authors: Warwick J. P. , Mason D. G.
Published: March 2003

Obstructive sleep apnoea syndrome in children is a complex disorder characterised by repeated nocturnal episodes of increased upper airway resistive load. It is most commonly associated with adenotonsillar hypertrophy and more children are now presenting for adenotonsillectomy. These children may pose different anaesthetic problems to those having surgery for recurrent infection alone and anaesthetic morbidity and mortality has been reported. In addition, due to the varied symptomatology of the condition, children with unrecognised obstructive sleep apnoea syndrome may present for incidental surgery. This is of importance as patients with undiagnosed obstructive sleep apnoea syndrome may experience additional peri‐operative morbidity when undergoing incidental surgery. This article aims to review the aetiology, pathophysiology, clinical presentation and anaesthetic management of children with obstructive sleep apnoea syndrome.
A system for psychomotor evaluation; design, implementation and practice effects in volunteers
Authors: Hope A. T. , Woolman P. S. , Gray W. M. , Asbury A. J. , Millar K.
Published: March 2003

This paper describes the design, implementation and assessment of PsychE, a psychomotor evaluation system. Six standard tests are included: numeric vigilance, a dual task, probed memory recall, simple reaction time, choice reaction time and semantic long‐term memory. The test presentations are described in detail. Practice effects were assessed in 10 healthy volunteers and were only evident in the performance measures for the simple reaction time test. For the remaining five tests, stable performance was reached within a single test session. The volunteers were healthy and most were regular users of computers. Therefore, the lack of practice effects cannot be assumed for the general population. A control group is essential for all studies using these tests. The system is implemented on an IBM‐compatible personal computer and includes a database shell for the convenient collection, storage and analysis of performance data.
The use of lamotrigine in neuropathic pain
Authors: Di Vadi P. P. , Hamann W.
Published: March 2003

Sodium channel antagonists have been used in the management of neuropathic pain for several years. Recent evidence suggests that lamotrigine, which is active at glutaminergic excitatory synapses, is very effective in producing pain relief. We have successfully used lamotrigine in two patients suffering from neuropathic pain. Our results suggest that this novel channel antagonist can be used to treat neuropathic pain. Double blind placebo control studies are therefore needed to substantiate these findings.
Evaluation of an improved scoring system for the grading of direct laryngoscopy
Authors: Yentis S. M. , Lee D. J. H.
Published: March 2003

A modified version of the Cormack and Lehane scoring system was prospectively evaluated in 663 patients requiring tracheal intubation. In the modified system, grade 2 (only part of the glottis visible) was divided into 2a (part of the cords visible) and 2b (only the arytenoids or the very posterior origin of the cords visible). One hundred and sixty‐two intubations (24.4%) were scored as grade 2a and 43 (6.5%) as grade 2b, of which seven (4.3%) and 29 (67.4%), respectively, were difficult, defined as requiring more than one laryngoscopy or the use of specialist equipment. Grade 2b denotes a laryngoscopic view that is relatively common and is often associated with difficulty passing a tracheal tube. The modified scoring system thus provides more information than the original Cormack and Lehane system and its use should be considered when recording the ease of tracheal intubation in the anaesthetic record or in studies of tracheal intubation.
Severity of illness scoring systems and performance appraisal
Authors: Ridley S.
Published: March 2003

A large number of severity of illness scoring systems have been developed and they are widely used in intensive care practice. However, they are complex systems with their basis in mathematics. To use such systems effectively, it is important to appreciate what factors influence their performance so that they can be compared fairly and used most appropriately. The purpose of this review is to describe the methods commonly used to assess the various facets of performance in severity of illness scoring systems. The performance of the most frequently used scoring systems in adult intensive care practice are presented. The shortfalls, misuse and strengths of scoring systems are also discussed.
The management of metformin overdose
Authors: Teale K. F. H. , Devine A. , Stewart H. , Harper N. J. H.
Published: March 2003

Only two cases of deliberate self‐poisoning with metformin have been described in the literature. We report the management of three cases, all of which presented with severe lactic acidosis. Two cases had a fatal outcome. The options for treatment and previous cases reported in the literature are reviewed. Recommendations for the management of metformin overdose include early recognition, intensive support of the cardiovascular system, the correction of metabolic acidosis and the maintenance of body temperature. The use of venovenous haemofiltration against a non‐lactate containing fluid may improve outcome when sodium bicarbonate alone fails to reverse severe systemic acidosis.