[Has the time come to transfer residency training from hospitals to the community? Lessons from other countries and implications for Israel]

Most medical practice has moved from the hospital to the community. Nevertheless, in the western world, including Israel, residency training in various specialties has remained mostly in the hospital. Residents have no opportunity to encounter the morbidity and the patient mix that they are likely to encounter in their future work life in the community, after their residency. Neither do they have any opportunity for practical training in medical procedures that are now practiced mainly in the ambulatory setting. Therefore, efforts are being made to promote community work in residency training in order to adapt it to medicine of the future. In this literature review the authors summarized the accumulated experience of transferring residency to ambulatory settings in other countries. The literature review deals with the organizational aspects of accreditation of residency training and with ways of coping with budgetary difficulties as well as infrastructure and faculty recruitment issues. It also reviews the accumulated experience with the content of community residency: the acquisition of knowledge and medical skills, and the maintenance of academic standards. This was done in order to benefit from the lessons learned from others' experience and to raise public discussion issues related to the implementation of this process in Israel.

Antiplatelet therapy and the risk of bleeding induced by gastrointestinal endoscopic procedures. A systematic review of the literature and recommendations

Antiplatelet drugs may increase the risk of bleeding induced by gastrointestinal endoscopic procedures. The antiplatelet effect of cyclooxygenase-1 inhibitors lasts less than 4 h. Skin and colonic bleeding times are prolonged for 3 and 5 days after aspirin and ticlopidine withdrawal respectively. Major bleeding from endoscopic biopsies is extremely rare. In the four recent largest series, the general incidence of polypectomy-induced major bleeding was 0.11-0.42%. In more than half of the cases the bleeding was delayed, usually up to 2 weeks after the endoscopy. Although three retrospective studies suggested that aspirin does not increase the risk of polypectomy-induced bleeding, the power of these studies is limited. Similarly, it is difficult to draw conclusions from the two studies that assessed the risk of aspirin use during sphincterotomy. Aspirin withdrawal may be harmful in susceptible patients, mainly if it is for more than 7 days. There is no indication to stop aspirin before esophagogastroduodenoscopy, which may reveal aspirin-induced lesions. We recommend discontinuation of aspirin 4-7 days (according to the cardiovascular risk) before other endoscopic procedures. When aspirin is indicated for primary prevention, it can be resumed 14 and 10 days after polypectomy and sphincterotomy respectively. In cases of secondary prevention, it should be resumed after 1 week.

A quantitative immunochemical fecal occult blood test for colorectal neoplasia

BACKGROUND

Guaiac-based fecal occult blood tests (FOBTs) for colorectal cancer screening are not specific for human hemoglobin and have low sensitivity. Automated-development, immunochemical FOBT is quality-controlled, is specific for human hemoglobin, and does not require diet restriction.

OBJECTIVES

To measure the sensitivity and specificity of quantitative immunochemical fecal hemoglobin measurements for detection of cancer and advanced adenoma in patients undergoing colonoscopy, to determine fecal hemoglobin thresholds that give the highest posttest probability for neoplasia, and to determine the number of immunochemical FOBTs needed.

DESIGN

Prospective, cross-sectional study.

SETTING

Ambulatory endoscopy services of the main health medical organization in Tel Aviv, Israel.

PARTICIPANTS

1000 consecutive ambulatory patients--some asymptomatic but at increased risk for colorectal neoplasia and some symptomatic--who were undergoing elective colonoscopy and volunteered to prepare immunochemical FOBTs.

INTERVENTION

The hemoglobin content of 3 bowel movements was measured, and the highest value was compared with colonoscopy findings.

MEASUREMENTS

Sensitivity, specificity, predictive values, likelihood ratios, and 95% CIs of fecal hemoglobin measurements for clinically significant neoplasia, their relationship to the amount of fecal hemoglobin measured, and the number of immunochemical FOBTs performed.

RESULTS

Colonoscopy identified clinically significant neoplasia in 91 patients (cancer in 17 patients and advanced adenomas in 74 patients). Using 3 immunochemical FOBTs and a hemoglobin threshold of 75 ng/mL of buffer, sensitivity and specificity were 94.1% (95% CI, 82.9% to 100.0%) and 87.5% (CI, 85.4% to 89.6%), respectively, for cancer and 67% (CI, 57.4% to 76.7%) and 91.4% (CI, 89.6% to 93.2%), respectively, for any clinically significant neoplasia.

LIMITATIONS

The fecal sampling method is standardized, but the sample size depends on fecal consistency. Some patients were tested while discontinuing aspirin and anticoagulant therapies. Study patients were at increased risk, and results might not apply to average-risk populations.

CONCLUSIONS

Quantitative immunochemical FOBT has good sensitivity and specificity for detection of clinically significant neoplasia. Test performance in screening average-risk populations is not known.

Can quantification of faecal occult blood predetermine the need for colonoscopy in patients at risk for non-syndromic familial colorectal cancer?

BACKGROUND

Patients at risk for non-syndromic (Lynch or polyposis) familial colorectal neoplasia undergo colonoscopic surveillance at intervals determined by clinically ascertained protocols. The quantitative immunochemical faecal occult blood test for human haemoglobin is specific and sensitive for significant colorectal neoplasia (cancer or advanced adenomatous polyp).

AIM

To determine immunochemical faecal occult blood test efficacy for identifying significant neoplasia in at-risk patients undergoing elective colonoscopy.

METHODS

We retrospectively identified consecutive at-risk patients who provided three immunochemical faecal occult blood tests before colonoscopy. Quantitative haemoglobin analysis was performed by the OC-MICRO automated instrument using the 100 ng Hb/mL threshold to determine positivity.

RESULTS

In 252 at-risk patients undergoing colonoscopy; five had cancer, 14 an advanced adenoma and 46 a non-advanced adenoma. The immunochemical faecal occult blood test was positive in 31 patients (12.3%). Sensitivity, specificity, positive and negative predictive values for cancer were: 100%, 90%, 16% and 100%, and for all significant neoplasia: 74%, 93%, 45% and 98%. With 88% fewer colonoscopies, all colorectal cancers and 74% of all significant neoplasia would have been identified by this one-time immunochemical faecal occult blood test screening.

CONCLUSIONS

A sensitive, non-invasive, interval screening test might be useful to predetermine the need for colonoscopy in this at-risk population and minimize unnecessary examinations. This favourable retrospective evaluation will be extended to a prospective study.

Celecoxib leads to G2/M arrest by induction of p21 and down-regulation of cyclin B1 expression in a p53-independent manner

A unique in vitro system has been developed in our lab that consists of normal enterocytes derived from the rat ileum (IEC-18 cells) and their transformed derivatives with c-K-ras (R1 cells), anti-sense bak (B3 cells) and cyclin D1 (D1 cells). R1 and B3 cells express high level of COX-2 protein and PGE2. IEC 18 and D1 cells express negligible amount of COX-2, and produce very low level of PGE2. A relatively low dose of celecoxib (5-10 microM) induced G2/M arrest, followed by induction of apoptosis in the transformed but not in the normal cells. Down-regulation of cyclin B1 and up-regulation of p21 expressions independent of p53 might have cause this cell cycle block. Growth inhibition was related to COX-2 function with 90-95% reduction in PGE2 production. These findings may be of clinical importance, since low concentration of celecoxib can be achieved in human serum following standard anti-inflammatory (100-200 mg bid) regime.

Survey of primary physicians' knowledge of colorectal cancer screening

OBJECTIVE

Colorectal cancer (CRC) is the most common of the gastrointestinal cancers in Israel. The low rate of patient compliance to a recent CRC screening program of Clalit Health Services, a major health management organization in Israel, prompted the present survey of primary care physicians' knowledge and practices regarding CRC screening.

METHODS

A 23-item questionnaire, formulated according to the policy of the Israel Ministry of Health and the recommendations of the American Gastroenterological Association, was distributed to 150 primary physicians of Clalit Health Services. The relative ratio of correct to incorrect answers was calculated for every question and by professional group.

RESULTS

The response rate was 89%. Total score (out of a maximum 23) was 20.68 for family physicians (experts in family medicine), 17.79 for experts in other fields, and 17.82 for general practitioners (average, 0.90, 0.77, and 0.77, respectively). The score for the family physicians was significantly higher than for the other two groups (P=0.0070). Clustering items by specific issues yielded significantly better scores for the family physicians in four areas: screening (P=0.0164), appropriate test for high-risk population in Israel (P=0.0012), definition of average-risk population (P=0.0012), and CRC symptoms (P=0.0108). A low level of knowledge on the definition of the high-risk population was noted in all three groups.

CONCLUSIONS

Experts in family medicine in Israel have significantly greater knowledge of most issues of CRC than primary care experts in other fields and general practitioners, although all three groups lack knowledge on the definition of the high-risk population. Continuing physician education should focus on these areas.

MF tricyclic and sulindac retard tumor formation in an animal model

New selective cyclooxygenase-2 inhibitors offer the benefit of cancer protection with less gastrointestinal toxicity associated with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). We hypothesize that MF tricyclic and sulindac can retard all stages of tumor formation in nude mice. In a blinded placebo controlled study, 3 types of experiments were performed: 1) 2.5 x 10(6) cells were injected into 2 flanks of nude mice subcutaneously, as a model for in situ cancer (n = 192); 2) 1 x 10(6) cells were injected into the cecum of mice as a model for in situ colorectal cancer (n = 78) and 3) 0.5 x 10(6) cells were implanted into the splenic subcapsule to establish a colorectal cancer liver metastasis model (n = 78). The animals were fed with standard chow containing either placebo, MF tricyclic (67 mg/kg of chow) or sulindac (150 mg/kg of chow). Mice that were given MF tricyclic or sulindac, at clinical anti-inflammatory plasma concentrations, were significantly more tumor free and had significantly smaller primary tumors and fewer metastases, as compared to mice that consumed placebo. The mortality and the latency period were significantly better in the treatment groups. These findings suggest that selective COX-2 inhibitors may serve as an adjunct to standard therapy in colorectal cancer.

Eradication of Helicobacter pylori can be accurately confirmed 14 days after termination of triple therapy using a high-dose citric acid-based 13C urea breath test

BACKGROUND

Confirmation of Helicobacter pylori eradication by urea breath test (UBT) is currently performed 4-6 weeks after completion of therapy because of unacceptable false-negative results in UBTs performed earlier. Use of a high-dose citric acid test meal appears to enable accurate detection of H. pylori even during short term therapy with proton pump inhibitors.

AIM

To evaluate if use of a high dose citric acid (4.0 g) test meal can decrease the interval required for confirmation of eradication after triple therapy.

METHODS

233 patients positive for H. pylori were randomized to undergo UBT at 7 days or 14 days after triple therapy, and again at 6 weeks. The latter test was considered the gold standard test.

RESULTS

The UBT performed 6 weeks after the end of treatment found that 79.9% were cured. The same test 7 days after therapy found false-negative detection of H. pylori in 7.3% patients compared to 3.2% patients examined after 14 days. The sensitivity, specificity, positive and negative predictive values and accuracy for evaluation on day 14 were 80, 100, 100, 96.3 and 96.7%, respectively.

CONCLUSIONS

High-dose citric acid-based UBT is a valid test for the assessment of H. pylori status 14 days after triple therapy. This may obviate the delay in instituting second-line eradication therapy, or further evaluation of the symptomatic patient unresponsive to therapy despite eradication.

Performance characteristics and evaluation of an automated-developed and quantitative, immunochemical, fecal occult blood screening test

OBJECTIVES

Guaiac fecal occult blood colorectal cancer (CRC) screening tests (FOBT) are faulted for low sensitivity and nonspecificity for human hemoglobin (Hb). Automated-developed, immunochemical, human Hb FOBT (I-FOBT) is specific, eliminates diet restrictions, and Hb quantification allows selection of a threshold for colonoscopy. Aims were to determine 1) test reproducibility; 2) test stability; 3) intrapatient daily I-FOBT variation; 4) test sensitivity and specificity for neoplasia in 500 symptomatic/high-risk patients undergoing colonoscopy; and 5) to correlate fecal Hb measurements with findings.

METHODS

The desktop instrument OC-Sensor (Eiken, Japan) automatically develops and quantitates 50 tests/h for Hb. Patients prepared three tests, which were quantified and then 1) repeatedly re-examined; 2) stored at 4 degrees C or 20 degrees C or 28 degrees C and repeatedly examined; and 3) fecal Hb levels were correlated with colonoscopic findings.

RESULTS

Five I-FOBTs re-examined five times in 1 day had no significant measurement changes. Thirty tests stored for 21 or more days had a decay/day of 0.3%+/- 0.4 at 4 degrees C (NS), 2.2%+/- 1.7 at 20 degrees C (NS), and 3.7%+/- 1.8 at 28 degrees C (p < 0.05). There were intrapatient variations between the three daily I-FOBTs (NS). At the recommended 100 ng Hb/mL threshold, all six cases of CRCs and 20 out of 28 cases of advanced adenomas were detected; evaluated together their sensitivity and specificity were 76.5% and 95.3%.

CONCLUSIONS

Desktop, automated-developed, quantitative I-FOBT is now available. Refrigerated OC-Sensor samples are stable for 21 days, easy to prepare and develop and, at the 100 ng Hb/mL threshold, have high sensitivity, specificity, and negative predictive values for significant neoplasia. Suitability for population CRC screening awaits further evaluation.

Thioacetamide-induced hepatic damage in a rat nutritional model of steatohepatitis

BACKGROUND:: Nonalcoholic steatohepatitis is most often attributed to the effects of obesity, hyperlipidemia, diabetes mellitus and drugs. It is still unknown whether livers with steatohepatitis are more vulnerable to toxic damage. AIM:: To determine the effect of the hepatotoxicant thioacetamide in a rat nutritional model of hepatic steatohepatitis. METHODS:: Steatohepatitis was induced in rats by placing them on a methionine-choline deficient diet for 1 month. Thioacetamide was administered by three consecutive intraperitoneal injections (300mg/kg) at 24h intervals. RESULTS:: Following treatment with thioacetamide, the elevated serum levels of liver enzymes and blood ammonia, liver necroinflammation and the survival rate after 48h were not different between rats with normal or fatty liver. However, those parameters were significantly worse when steatohepatitis regressed after return to normal diet for 1 month (P < 0.01). Western blot analysis of hepatic extracts revealed no difference in cytochrome P4502E1 levels between livers with steatohepatitis and steatohepatitis after regression, suggesting that the enhanced hepatotoxicity after regression of steatohepatitis could not be attributed to increased cytochrome P4502E1. CONCLUSIONS:: In a nutritional model of steatohepatitis, rats with fatty liver were not more vulnerable than normal rats to liver damage induced by thioacetamide. However, liver damage was significantly more severe in rats with steatohepatitis after 1 month regression.

PADMA-28, a Tibetan herbal preparation is an inhibitor of inflammatory cytokine production

BACKGROUND

Previous studies have shown that PADMA-28, a multicomponent, traditional Tibetan herbal plant preparation possesses a variety of beneficial effects on several experimental models of inflammatory and immune processes, including autoimmune diabetes and autoimmune encephalomyelitis. In humans, PADMA-28 attenuated the symptoms associated with intermittent claudications in atherosclerotic patients.

OBJECTIVE

To assess the effect of PADMA 28 on the immune system, e.g. cytokine (interleukins) production.

DESIGN

Cytokine production by human blood monocytes (derived from 12 healthy donors) stimulated in vitro, either by endotoxin (LPS) from Salmonella typhi or by lipoteichoic acid (LTA) from group A Streptococci was modulated by PADMA-28.

RESULTS

The present study showed that an aqueous extract of PADMA-28 strongly decreased the production of the inflammatory cytokines IL-1beta, IL-6, IL-8 and TNF-alpha, and more moderately, also decreased the anti-inflammatory cytokine IL-10 induced by LPS. However, the LTA - induced IL-10 production was [not significantly] increased by the low dose PADMA-28, while not effected at all by the higher dose of PADMA-28.

CONCLUSIONS

The data from these finding suggest a possible clinical efficacy of PADMA-28 either in autoimmune and in inflammatory conditions or in post-inflammatory sequelae, as previously shown in in vivo and human studies, probably by decreasing inflammatory cytokines.

Application of Maastricht 2-2000 guidelines for the management of Helicobacter pylori among specialists and primary care physicians in israel: are we missing the malignant potential of Helicobacter pylori?

BACKGROUND

The Maastricht 2-2000 guidelines on the current management of Helicobacter pylori infection were recently adopted by the Israeli Gastroenterological Association.

GOAL

To determine the impact of these clinical guidelines on the current knowledge, attitudes, and management of H. pylori among primary care physicians, hospital internists, and gastroenterologists in Israel.

STUDY

Self-administered, voluntary, anonymous questionnaires were given personally to 229 physicians, 73 primary care physicians, 71 internists, and 85 gastroenterologists. The questions evaluated 4 main issues in the management of H. pylori: (1). the optimal diagnostic test, (2). indications for eradication, (3). combination and duration of triple therapy, and (4). the need for confirmation following eradication.

RESULTS

There were significant variations in the adherence of those recommendations among gastroenterologists, internists, and primary care physicians. Specifically, 94.1% of gastroenterologists and 88.9% of internists consider the urea breath test the test of choice for H. pylori diagnosis compared with 60.0% of the primary care physicians. Significant differences in the eradication indications for mucosa-associated lymphoid tissue (MALT) lymphoma, first-degree relatives of gastric cancer patients, atrophic gastritis, functional dyspepsia, and concomitant use of nonsteroidal antiinflammatory drugs were demonstrated among gastroenterologists and the other groups.

CONCLUSIONS

Primary care physicians may not be aware of important indications for diagnosis and eradication of H. pylori related to the risk of gastric malignancy or concomitant use of nonsteroidal antiinflammatory drugs. Public health agencies may need to increase penetration of the Maastricht 2000 recommendations to primary care physicians.

Prevalence of Helicobacter pylori infection in health-care personnel of primary care and gastroenterology clinics

BACKGROUND & AIMS

Helicobacter pylori (Hp) infection clusters within families, is usually acquired early in life, and is strongly associated with lower socioeconomic status during childhood. Transmission in adulthood is relatively rare, and reports on the prevalence of Hp infection among health personnel, especially endoscopists, are controversial. The present prospective study evaluated the prevalence of Hp infection in health-care workers in primary-care clinics and in gastroenterology units.

METHODS

Health care personnel from gastrointestinal units (n = 191) and primary care-clinics (n = 98) of the Clalit Health Services (CHS) in Israel underwent the carbon 13 breath test (13C-UBT) and completed a 21-item demographic and socioeconomic questionnaire. The control group consisted of 4633 symptomatic patients with no evidence of previous Hp infection.

RESULTS

The 13C-UBT was positive in 108 gastrointestinal unit personnel (73%) and 70 primary-care workers (71%); both rates were statistically higher significantly than the 53% positivity in the controls. Comparison of the 13C-UBT Hp-positive and Hp-negative health-care personnel yielded a significantly higher index of crowded living conditions in the Hp-positive group. In the gastrointestinal unit workers, Hp positivity was also associated with several years in practice, and in the primary-care workers, with Sephardic (Asian and African origin) versus Ashkenazi (Europe and American) origin. Profession (physician, nurse, technician, secretary, or maintenance worker), history of duodenal ulcer, smoking, marital status, and blood group did not have predictive value for Hp colonization.

CONCLUSIONS

The prevalence of Hp infection in Israel is higher in health-care staff of primary-care clinics and gastrointestinal units than in the general population. This may be related to socioeconomic facts and professional hazard. Further studies are needed to clarify this issue.

Thioacetamide-induced hepatic damage in a rat nutritional model of steatohepatitis

BACKGROUND

Nonalcoholic steatohepatitis is most often attributed to the effects of obesity, hyperlipidemia, diabetes mellitus and drugs. It is still unknown whether livers with steatohepatitis are more vulnerable to toxic damage.

AIM

To determine the effect of the hepatotoxicant thioacetamide in a rat nutritional model of hepatic steatohepatitis.

METHODS

Fatty liver was induced in rats by placing them on a methionine-choline deficient diet for one month. Thioacetamide was administered by 3 consecutive intraperitoneal injections (300 mg/kg) at 24 h intervals.

RESULTS

Following treatment with thioacetamide, the elevated serum levels of liver enzymes and blood ammonia, liver necrotic inflammation and the survival rate after 48 h were not different between rats with normal or fatty liver. However, those parameters were significantly worse when fatty liver regressed after return to normal diet for one month (p < 0.01). Western blot analysis of hepatic extracts revealed no difference in cytochrome P4502E1 levels between fatty livers and fatty livers after regression, suggesting that the enhanced hepatotoxicity after regression of fatty liver could not be attributed to increased cytochrome P4502E1.

CONCLUSIONS

In a nutritional model of steatohepatitis, rats with fatty liver were not more vulnerable than normal rats to liver damage induced by thioacetamide. However, liver damage was significantly more severe in rats with fatty livers after one month regression of steatosis.

The effect of herbal remedies on the production of human inflammatory and anti-inflammatory cytokines

BACKGROUND

Some herbal remedies are sold as food additives and are believed to have immune-enhancing properties.

OBJECTIVES

To study the effect of five herbal remedies--Sambucol Black Elderberry Extract, Sambucol Active Defense Formula and Sambucol for Kids (with known antiviral properties), Protec and Chizukit N (containing propolis and Echinacea, claimed to be immune enhancers)--on the production of cytokines, one of the main components of the immune system.

METHODS

The production of four inflammatory cytokines (interleukin-1 beta, tumor necrosis factor alpha, and IL-6 and IL-8) and one anti-inflammatory cytokine (IL-10) was tested using blood-derived monocytes from 12 healthy donors.

RESULTS

The Sambucol preparations increased the production of five cytokines (1.3-6.2 fold) compared to the control. Protec induced only a moderate production of IL-8 (1.6 fold) and IL-10 (2.3 fold) while Chizukit N caused only a moderate increase in IL-10 production (1.4 fold). Both Protec and Chizukit N caused moderate decreases in IL-1 beta, TNF alpha and IL-6 production. Lipopolysaccharide, a known activator of monocytes, induced the highest levels of cytokine production (3.6-10.7 fold).

CONCLUSIONS

The three Sambucol formulations activate the healthy immune system by increasing inflammatory and anti-inflammatory cytokines production, while the effect of Protec and Chizukit N is much less. Sambucol could therefore have immunostimulatory properties when administered to patients suffering from influenza (as shown before), or immunodepressed cancer or AIDS patients who are receiving chemotherapy or other treatments.

Botulinum toxin type-A in therapy of patients with anismus

INTRODUCTION

Anismus is a common cause of constipation and outlet obstruction. Standard therapy with laxatives or biofeedback has conflicting results. Surgical treatment gives poor results and has practically been abandoned.

PURPOSE

This study was designed to evaluate the efficacy of botulinum toxin type-A (Botox) injection to the puborectalis muscle in patients with anismus.

METHODS

Twenty-five patients (15 females; mean age, 23.2) with history of constipation and symptoms of outlet obstruction underwent anorectal perfusion manometry and video-proctography. All patients were found to have a nonrelaxing puborectalis muscle on both modalities. All have been unable to expel a rectal balloon. Each patient who participated in the study was randomly assigned to undergo local injection of Botox--10 units to each side of the puborectalis or 20 units to the posterior aspect of this muscle. Eight patients underwent further injections1-5 every 3 months in accordance with previous results. Follow-up was conducted 1, 4, 12, and 24 weeks after injection. Straining, anorectal pain, and overall satisfaction were assessed on a visual analog scale. Weekly evacuation, fecal incontinence, and complications were recorded. At the weekly meeting, each patient underwent anorectal manometry with a balloon expulsion test.

RESULTS

Manometric relaxation was achieved after the first injection in 18 patients (75 percent). Once relaxation was achieved, it lasted throughout the follow-up. Nine patients (37.5 percent) expelled the rectal balloon after the first injection. Seven of 16 patients who failed the first injection had an additional one. In 2 patients it was successful (28.6 percent). Symptom improvement of 29.2 percent in straining index was recorded during follow-up. In 3 patients (12.5 percent) pain developed after injection. No other complications were observed. Overall satisfaction with Botox injection results was observed in 58.3 percent.

CONCLUSIONS

Botox injection to the puborectalis muscle has been found to have a limited therapeutic effect on patients suffering from anismus. Our results justify the need for further double-blind placebo-controlled trials to determine the exact role of botulinum toxin type-A in anismus.

Evaluation of a novel continuous real time (13)C urea breath analyser for Helicobacter pylori

AIM

To evaluate the sensitivity and specificity of a new (13)C urea breath test, Oridion BreathID, for the diagnosis of Helicobacter pylori.

METHODS

A total of 97 consecutive symptomatic patients referred for upper endoscopy were included in the 'pre-therapy' part of the study. After endoscopy the patients were analysed for H. pylori by Oridion BreathID. BreathID continuously sampled the subject's breath for 20 min, and displayed the results on the BreathID screen in real time. Results of the BreathID were compared with the 'gold standard' (rapid urease test and histology). We also prospectively tested the validity of BreathID in comparison to isotope ratio mass spectrometry, in 40 patients referred to monitor the efficacy of H. pylori eradication treatment.

RESULTS

Complete agreement was observed between the 'gold standard' and the Breath ID test in 96.9% (94 out of 97) of the patients. The sensitivity and specificity of BreathID were 97.8% and 96.1%, respectively. The correlation between BreathID and isotope ratio mass spectrometry breath test was 100%.

CONCLUSIONS

The Oridion BreathID has comparable sensitivity and specificity to the claims of the currently available urea breath tests. Furthermore, BreathID has the potential advantages of ease of use with minimal medical staff requirement, and real time rapid results (20 min maximum) which may make the BreathID preferable to other urea breath test assays.

Primary neoplasms of the small bowel

Primary neoplasms of the small bowel are unusual and constitute 1-5% of all gastrointestinal tract neoplasms. Preoperative diagnostic difficulties, frequent dissemination at the time of the diagnosis, and poor prognosis are characteristic of this pathology. During a period of 26 years we treated 61 patients with tumors of the small bowel, 44 malignant and 18 benign (1 patient had both). The most common symptoms were abdominal pain (62%), weight loss (41%), and gastro-intestinal bleeding (31%). More than half of the patients were treated as emergencies and among the remaining, the most useful diagnostic test was the small intestinal barium study. Seventeen patients were operated on for intestinal obstruction, 6 of them due to intussusception of the tumor, while 8 other patients presented with perforation and 7 with massive gastrointestinal bleeding. Leiomyoma was the most frequent benign lesion. Among malignancies lymphoma was encountered in 38.6%, followed by adenocarcinoma (29.6%) and leiomyosarcoma (22.8%). Lymphoma was predominant among Sephardic Jews. Curative procedures were attempted in all but one of the benign cases and in 21 of the malignant cases. At the time of surgery metastases were present in 23 patients. The postoperative mortality was high (20% and 14% in the benign and malignant groups, respectively) most probably due to the high incidence of emergency surgery in a high risk population. The prognosis of the malignant tumors was poor with a 5-year survival of 18%. Their disappointing course seems to be related to late diagnosis because of nonspecific symptoms and difficulty in bringing the tumor to the fore. Hopefully, a greater awareness will lead to an earlier diagnosis and improve the prognosis.

Pharmacological effects of the continuous administration of an LHRH agonist in the ageing male rat: comparison with orchidectomy

The age-related changes in tissue response to chronic treatment for 1 month with a potent LHRH agonist were investigated in the ageing male rat, and the observed pharmacological effects were compared with orchidectomy. In both young (4 months) and old (22 months) rats, treatment resulted in a significant decrease in the weights of prostates and testes, a decrease in plasma LH and testosterone levels, a loss of LH receptors in the testes and in a complete depletion of prostatic nuclear androgen receptors, reaching levels observed after castration. In young rats, treatment with an LHRH agonist or orchidectomy induced a three- or sixfold increase in prostatic creatine kinase (CK) activity which may have been induced by the local stimulatory effect of oestradiol arising from the conversion of precursor steroids secreted by the adrenal. On the other hand, in old rats, 7 days after orchidectomy or after treatment with an LHRH agonist a twofold increase or no change was induced in prostatic CK activity respectively. SDS gel electrophoresis patterns of cytosolic prostatic proteins of young rats treated with an LHRH agonist or young rats orchidectomized 7 days previously revealed the presence of several intensified proteins, two of them having apparent molecular weight of 67 kDa and 43 kDa, whereas in the old rats treated with LHRH agonist or old rats castrated 7 days previously, these two proteins were not intensified. The results of this study confirmed that continuous treatment with an LHRH agonist to young and old rats induces medical castration since the pharmacological effects observed were the same as those induced with surgical castration.(ABSTRACT TRUNCATED AT 250 WORDS)

Double-blind controlled trial of flumazenil in patients who underwent upper gastrointestinal endoscopy

The antisedative effect of flumazenil, a benzodiazepine antagonist, was studied in a double-blind placebo controlled trial in 61 patients who underwent upper gastrointestinal endoscopy and sedation with benzodiazepines. The efficacy of flumazenil in reversing the effect of both benzodiazepines, diazepam and midazolam, was significantly higher than placebo (p less than 0.0001). The effect of flumazenil was prompt and was clearly noticed at the first assessment, 5 min after its administration. In none of the patients was a relapse of the sedative effect of the benzodiazepines noticed. The administration of flumazenil was free of major side effects. Flumazenil administration permits an earlier discharge of patients following endoscopy. Its availability in the endoscopy suite may improve the outcome of serious but rare side effects related to benzodiazepines.

The incidence and significance of serum hCG and CEA in patients with gastrointestinal malignant tumors

Beta-human chorionic gonadotropin (hCG) is normally produced and secreted by trophoblastic cells in pregnancy, by tumors arising from those cells and by a wide variety of tumors of nonendocrine origin. Gonadotropin is produced and secreted by various tissues (stomach, pancreas, ovary, etc.) and the incidence of ectopic secretion varies between 0 and 43%. Our report is an attempt to evaluate the incidence of high plasma beta hCG levels in 101 patients with gastrointestinal malignant tumors. The results revealed negative beta hCG in the control samples, while in the studied patients 41 were positive for beta hCG (44.4%). Three samples from oesophagus squamous cell carcinoma were positive. Twenty-five out of 69 with colorectal carcinoma had raised serum beta hCG (36.8%). Gastric carcinoma showed positive beta hCG in 52% of the patients. Among all the patients high beta hCG levels were far more common in those with positive lymphnodes (P less than 0.05). The beta hCG levels decreased with colorectal carcinoma tumor size and with smaller tumors there was the probability of increasing positive serum measurements (P less than 0.05). The patients with adenocarcinoma of the stomach showed good statistical correlation between stages of the disease at the operation time to beta hCG levels. In our opinion this serological assay will become one of the markers to be added to our armamentarium in the evaluation of patients with gastrointestinal malignant tumors.

Paget's disease of the male breast

Histologically proved Paget's disease of the breast with negative hormonal receptor assay in a 73-year-old man induced a review of the 27 valuable cases of the literature. Our patient is disease-free, eight years after treatment by modified radical mastectomy and adjuvant irradiation. Peak incidence of the disease is between 50 and 70 years of age. The most frequent presenting signs reported are ulcerations and eczematous lesions of the nipple (71.4%) with discharge and bleeding in 39.3% of the cases. Other findings are a palpable mass (42.8%) and involved axillary lymph nodes (53.5%). The treatment of choice is shown to be radical or modified radical mastectomy with adjuvant radiotherapy. To date, no proof exists of the value of hormone receptors assays and routine adjuvant hormone therapy is not practiced.

Choledochoduodenostomy for benign and malignant biliary tract diseases

Although nonsurgical alternative treatments for primary or retained common bile duct stones--such as dissolution of gallstones with deoxycholic acids and, especially endoscopic papillotomy--have become available, choledochoduodenostomy (CDS) has been used with increasing frequency over the past decade, with extension of the indications for its use. We report our experience with side-to-side CDS in 116 patients with benign (65 patients) and malignant (46 patients) biliary diseases. Even though the mean age of our patients with benign disease--patients who underwent urgent operations because of obstructive jaundice (74%), liver damage (approximately 60%), and other biliary complications--was 66.8 years, the perioperative mortality was 3.07% and the long-term follow-up results were excellent with no biliary complications. In regard to the controversy about the use of CDS in malignant biliary obstructions, our experience shows that none of the 42 patients had any complication due to malignant invasion of the stoma, and only one patient had ascending cholangitis; the perioperative mortality in this group was 8.6%. In our opinion, CDS is a relatively safe, definitive procedure for treatment of benign and malignant biliary diseases, with good long-term results in high-risk, aged patients.

Modified properties of serum cholinesterases in primary carcinomas

Cholinesterases were characterized in the serum of 77 treated and 11 untreated patients having primary carcinomas of various tissue origins and 21 healthy volunteers which served as controls. In most of the samples, pseudocholinesterase (BuChE) accounted for almost all cholinesterase (ChE) activity and was inhibited by the organophosphorous poison tetraisopropyl pyrophosphoramide (iso-OMPA). In samples from the tumor-bearing patients, ChE degraded 733 +/- 59 nmole acetylcholine/h/mg protein, lower than the 960 +/- 175 nmole/hour/mg levels measured in controls. Tumor serum ChE exhibited elevated sensitivity to 1,5-bis-(4-allyldimethyl ammonium phenyl)-pentan-3-one dibromide (BW), the selective bisquaternary inhibitor of "true" acetylcholinesterase (AChE), with no correlation to age, sex, staging of tumor, presence of metastases or the specific treatment protocol, and with a different distribution pattern from the decrease in ChE specific activity or the sensitivity to iso-OMPA. In sucrose gradients, ChE sedimented as 12S in controls whereas in tumor serum samples from treated patients an additional component of 6 to 7 S, inhibited by both iso-OMPA and BW, also was detected. However, the ChE activity in serum of patients with diagnosed carcinomas before surgery and medical treatment appeared to be nondistinguishable from controls. These findings suggest that the modified properties of serum cholinesterases in carcinoma patients are not the result of the tumor itself, but that the common therapy protocols used in the treatment of primary carcinomas may cause the appearance of soluble ChE activity with properties of both AChE and BuChE, which accumulates in the serum.