Diagnosis and treatment of Helicobacter pylori infection among California Medicare patients

BACKGROUND

Antibiotic treatment of Helicobacter pylori infection in active peptic ulcer disease has been demonstrated to speed ulcer healing, reduce the risk of rebleeding, and prevent long-term recurrence. The objective of this study was to determine whether Medicare patients with peptic ulcer disease who are admitted to acute care hospitals are being tested or treated for H pylori infection as recommended by a National Institutes of Health consensus panel.

METHODS

The study was designed as a retrospective medical records survey. From the Medicare National Claims History File, all persons 65 years and older admitted to California fee-for-service hospitals for peptic ulcer disease in 1994 were identified. A random sample of 600 claims was selected for review. After exclusions, 524 patients were eligible for study. The main outcome measures were (1) the proportion of patients who were tested for H pylori infection by 1 of the 5 available methods (histopathologic study, urease assay, microbiologic culture, serum antibody testing, or urea breath test) and (2) the proportion who were treated with antibiotics (amoxicillin, tetracycline, clarithromycin, or metronidazole) for H pylori infection.

RESULTS

Thirty-nine percent of patients with peptic ulcer disease were tested for H pylori infection and 3% were treated empirically. Only 47% of the patients who had a positive diagnostic test result for H pylori were treated with antibiotics.

CONCLUSION

Because diagnosis and treatment of H pylori infection has been demonstrated to improve outcomes and decrease expenses, the data indicate a substantial opportunity to improve the care of elderly Medicare patients with peptic ulcer disease.

Defecation disorders and the role of defecography

This continuing education article discusses abnormalities of defecation and the physical mechanisms by which these abnormalities occur. The article also describes the role of defecography and other imaging techniques used to diagnose abnormalities of defecation.

Structure of the complex of an Fab fragment of a neutralizing antibody with foot-and-mouth disease virus: positioning of a highly mobile antigenic loop

Data from cryo-electron microscopy and X-ray crystallography have been combined to study the interactions of foot-and-mouth disease virus serotype C (FMDV-C) with a strongly neutralizing monoclonal antibody (mAb) SD6. The mAb SD6 binds to the long flexible GH-loop of viral protein 1 (VP1) which also binds to an integrin receptor. The structure of the virus-Fab complex was determined to 30 A resolution using cryo-electron microscopy and image analysis. The known structure of FMDV-C, and of the SD6 Fab co-crystallized with a synthetic peptide corresponding to the GH-loop of VP1, were fitted to the cryo-electron microscope density map. The SD6 Fab is seen to project almost radially from the viral surface in an orientation which is only compatible with monovalent binding of the mAb. Even taking into account the mAb hinge and elbow flexibility, it is not possible to model bivalent binding without severely distorting the Fabs. The bound GH-loop is essentially in what has previously been termed the 'up' position in the best fit Fab orientation. The SD6 Fab interacts almost exclusively with the GH-loop of VP1, making very few other contacts with the viral capsid. The position and orientation of the SD6 Fab bound to FMDV-C is in accord with previous immunogenic data.

Lesions produced by the extravasation of urine from the upper urinary tract

We present six cases which illustrate the spectrum of clinical features, macroscopic findings and light microscopic findings of urine extravasation from the upper urinary tract. The early lesions are characterized macroscopically by an oedematous, glistening or gelatinous appearance to the renal perihilar and peripelvic fat. Light microscopically there is lipolysis with associated foamy macrophages, multinucleate giant cells and lymphocytes. Immunohistochemical staining for Tamm-Horsfall protein is strongly positive in the extracellular space and in the foamy macrophages confirming urine extravazation. Later lesions are characterized by cicatrization of fibrous tissue around the renal pelvis and hydronephrosis. Microscopically there is relatively bland fibrosis with occasional lymphocytes and histiocytic cells. The late lesions are also characterized by extracellular deposits of weakly eosinophilic, granular or hyaline material, the so called 'urinary precipitates'. These deposits stain strongly with diastase PAS and weakly positive for Tamm-Horsfall protein. The staining of these urinary precipitates is analogous to renal tubular hyaline casts, thus supporting the theory that they are derived from uroproteins. We consider that these deposits are pathognomic of past urine extravasation.

Early detection techniques in breast cancer management

This article examines the three early detection techniques for breast cancer-clinical examination, mammography and breast self-examination-as components of a breast health management program. Each method is examined in detail, with particular emphasis on the health care provider's role in educating the patient about breast health and breast self-exam.

Prostaglandin E2 for cervical ripening: a multicenter study of patients with prior cesarean delivery

To evaluate the maternal and fetal outcomes of a large cohort of women treated with prostaglandin E2 (PGE2) gel for cervical ripening prior to trial of labor after previous cesarean delivery. Beginning in 1990 all pregnant patients with previous cesarean delivery presenting for prenatal care at 10 California hospitals were prospectively studied. We analyzed multiple parameters to compare outcomes of cases in which PGE2 gel was used to outcomes in a control group in which PGE2 was not used. Data were examined by X2 testing. During the study period 5022 patients underwent trial of labor after prior cesarean delivery. Of these 5022 patients, 453 (9%) were treated with PGE2 gel. There was no significant difference in the incidence of uterine rupture between the PGE2 group and the control group. Indicators of maternal and perinatal morbidity were not significantly higher in the prostaglandin treated group. The use of PGE2 gel for cervical ripening appears to be relatively safe in patients with prior cesarean delivery.

Medical imaging of trauma to the upper cervical spine

This article provides a comprehensive look at trauma to the upper cervical spine. It begins with an in-depth discussion of vertebral anatomy, then focuses on types of cervical trauma and examines the diagnostic techniques used to image cervical trauma.

Mesoscopic gels at low agarose concentration: perturbation effects of ethanol

Aqueous agarose solutions at low concentrations (0.5 g/liter) were temperature quenched below the spinodal line to form mutually disconnected mesoscopic gels. In the presence of 6% ethanol, these solutions, obtained by quenching at the same temperature depth as in pure water, appear much more fluid, as determined by probe diffusion experiments. We show by static and dynamic light scattering that this can be explained by the solvent-mediated effects of ethanol, leading to a globular shape of mesoscopic agarose gels, rather than to an extended rodlike structure observed in pure water. Our findings show the significant effects of solvent perturbations on particle condensation and, therefore, may be useful in understanding the role of the solvent in the folding of biomolecules.

Studies on the structure, regulation, and pathogenic potential of anti-dsDNA antibodies

Studies of anti-double-stranded (anti-ds)DNA antibodies have provided insights into how and why these antibodies arise in systemic lupus erythematosus. In this review we discuss the experimental approaches that have been used by our laboratory to study these autoantibodies. Structure/function analyses including site-directed mutagenesis have helped characterize the molecular genetics of anti-dsDNA antibodies, and more recently peptide libraries have been used to define molecular motifs that these antibodies bind. Most of the pathogenic anti-dsDNA antibodies observed in lupus are somatically mutated. We demonstrated in vitro and in vivo that anti-bacterial antibodies can mutate to acquire specificity for dsDNA. Furthermore, using a fusion partner constitutively expressing bcl-2, NSO(bcl-2), we have shown the existence of anergic or preapoptotic B cells making antibodies that cross-react with both bacterial antigen and dsDNA. Whether defects in the regulation of these antibodies might contribute to serum expression of anti-dsDNA antibodies in some individuals remains unknown. A major emphasis of this review is the regulation of anti-dsDNA antibodies in a transgenic mouse model harboring the gene for the heavy chain of a pathogenic anti-dsDNA antibody. Nonautoimmune transgenic mice effectively regulate autoreactive B cells by anergy and deletion, while their autoimmune counterparts do not. The vast majority of anergic B cells expressing high-affinity transgenic anti-dsDNA antibody fail to display allelic exclusion of the heavy chain. We postulate that this may be one mechanism that allows them to escape deletion. Comparative studies on light chain usage in both the autoimmune and the nonautoimmune transgenic mouse strains have demonstrated that within the autoreactive B-cell population, there are subsets that are differentially regulated. Ultimately transgenic animals making pathogenic autoantibodies may provide us with a system for testing novel therapies for autoimmune disease.

Epidemiology of systemic sclerosis

There have been few recent studies of the descriptive epidemiology of systemic sclerosis, but in recent work the limited form of the disease seems more prominent than reported in previous studies. Molecular genetic investigation of systemic sclerosis remains disappointing in identifying susceptibility alleles. There are some associations in relation to HLA class II alleles, specifically DP, DQ, and DR. These associations, however, seem to be more important in predicting the nature of the autoimmune response rather than describing disease susceptibility itself. The study of occupational and environmental influences has been dominated by studies on the role of silicone gel breast implants. These studies, driven by medicolegal constraints, have overwhelmingly failed to prove any association. Other studies confirm the continuing likelihood that organic solvents are implicated, at least in a proportion of cases.

A comparison of disease status in rheumatoid arthritis patients attending and not attending a specialist clinic

The objective was to test the hypothesis that rheumatoid arthritis (RA) patients currently not receiving specialist care have milder and less active disease than clinic attenders. The subjects were recruited from a media campaign aimed at identifying RA patients for a nationwide twin study. All subjects were interviewed at home and examined. Data from serological and radiological investigations were obtained. Data were also obtained about any specialist care, including the date, where relevant, of the most recent hospital appointment. For subjects reporting ever attending a specialist clinic, the current status (discharged/under current care) and the date of their most recent appointment were verified from hospital records. Data from 149 patients were analysed, of whom 114 (76%) were current hospital clinic attenders at the time of interview, 10 (7%) had never attended and 25 (17%) were ex-attenders. There was a similar proportion with current morning stiffness (> 1 h) in all three groups (60%). The median number of (i) swollen (S) joints, (ii) tender (T) joints and (iii) swollen and tender (ST) joints was almost identical-current attenders: (S) 7, (T) 9, (ST) 11; ex-attenders: (S) 5, (T) 8, (ST) 10; never attenders: (S) 7, (T) 14, (ST) 17. There were similar proportions with radiological erosions in the current and ex-attenders (79 and 72%, respectively). Current attenders were, however, substantially more likely to be taking disease-modifying drugs. In these volunteer patients, those currently managed entirely in primary care did not have less severe or active disease.

Role of stereotactic biopsy in diagnosing breast cancer

Only 10% to 20% of nonpalpable breast lesions are malignant, yet all suspicious lesions must undergo biopsy. For many women with breast abnormalities, needle biopsy is a less expensive, quicker and better tolerated alternative to surgical excisional biopsy. Localization techniques that may be used during needle biopsy include clinical guidance, the grid coordinate system, ultrasound guidance and stereotactic guidance. Of these four options, only stereotactic guidance permits localization of a lesion in three dimensions. This article explains the principles behind stereotactic localization and discusses the equipment and personnel involved in the stereotactic breast biopsy procedure. It also discusses patient positioning techniques and sampling technique during stereotactic breast biopsy, with particular emphasis on the mammographer's role throughout the procedure.

Obstetric and gynaecological factors in susceptibility to peripheral joint osteoarthritis

There is clear evidence that the age period coinciding with the peak age of the menopause is associated with an increased prevalence of osteoarthritis and this fits in with clinical observation of high likelihood of presentation at this age. A number of pieces of biological evidence also support the notion that changes in sex hormone status might influence risk of degenerative disease at peripheral joint sites. There do not appear, however, to be any important epidemiological predictors based on menstrual or obstetric history that might be useful in predicting who these women might be.

Epidemiology, diagnosis and treatment of prostate cancer

Prostate cancer is the most commonly diagnosed cancer in the United States. This article outlines the anatomy of the prostate gland, the epidemiology and natural history of prostate cancer, current diagnostic and screening techniques, treatment options and prognostic implications.

The bundling of actin with polyethylene glycol 8000 in the presence and absence of gelsolin

Actin filament and bundle formation occur in the cytosol under conditions of very high total macromolecular concentration. In this study we have utilized the inert molecule polyethylene glycol 8000 (PEG) as a means of simulating crowded conditions in vitro. Column-purified Ca-actin was polymerized in the absence and presence of gelsolin (to regulate mean filament lengths between 50 and 5000 mers) and PEG (2-8%) using various concentrations of KCl and/or 2 mM divalent cations. Bundling was characterized by the scattered light intensity and mean diffusion coefficients obtained from dynamic light scattering, as well as by fluorescence and phase-contrast microscopy. The minimum concentration of KCl required for bundling decreases both with increasing concentration of PEG at a fixed mean filament length, and with decreasing filament length at a fixed concentration of PEG. In the absence of divalent cation, bundling is reversible on dilution, as determined by intensity levels, diffusion coefficients, and microscopy. However, with either 2 mM Mg2+ or Ca2+ added, bundling is irreversible under conditions of higher PEG concentrations or longer filaments, indicating that osmotic pressure effects cannot fully explain actin bundling with PEG. Weaker divalent cation-binding sites on actin as well as disulfide bonds appear to be involved in the irreversible bundling.

Survey of the fragile X syndrome and the fragile X E syndrome in a special education needs population

To begin to understand the population dynamics of the fragile X (FRAXA) mutation and to learn more about the fragile X E (FRAXE) syndrome, we have initiated a surve of children in special needs education programs in the public school system. With respect to the FRAXA syndrome, we found approximately 1/1,000 full mutations among males. No large alleles at the FRAXE locus were observed among 462 individuals. The allele distributions at the two loci among Caucasians and among African Americans were examined as well as the level of heterozygosity. We found a significant difference in the FRAXA allele distribution among the two ethnic groups; the major difference was due to the lack of smaller alleles among the African Americans. No difference was found for the FRAXE allele distribution among the two groups. The level of heterozygosity was less than predicted by the allele distribution at both loci. This is probably due to unidentified large alleles among females with a test result of a single band. Alternatively, this excess may indicate that the population is not at equilibrium.

Paget's disease of bone and unvaccinated dogs

The etiology of Paget's disease is unknown, but several observations suggest a viral cause. Since canine distemper virus is among those proposed to be a causal agent, we investigated the hypothesis that dog ownership may increase the risk of Paget's disease of bone by means of a case control study. One hundred and fifty patients with Paget's disease and 185 controls were interviewed using a structured questionnaire administered by the same interviewer. Participants were asked about their socioeconomic background and their exposure to pets. The risk of Paget's disease was not significantly increased in individuals. However, ownership of a mongrel dog was associated with a significant increase in risk (OR = 1.6; 95% CI = 1.0-2.4) and the risk increased still further with the ownership of an unvaccinated dog (OR = 2.8; 95% CI = 1.8-4.5). Additionally, ownership of cats and birds excluding dog owners, increased the risk of Paget's disease (OR = 2.5; 95% CI = 1.0-5.0; OR = 2.3; 95% CI = 1.0-5.3, respectively). These data suggest that previous exposure to cats, birds, and dogs unvaccinated for canine distemper may increase the risk of an individual developing Paget's disease of bone.

Advances in lithotripsy and stone disease treatment

Stone disease can be traced back as far as the human record. This article traces the diagnosis and treatment of stone disease from primitive attempts at stone removal in ancient civilizations to the advent of extracorporeal shock wave lithotripsy (ESWL) in the 1970s. ESWL revolutionized the treatment of stone disease, offering patients a less painful alternative to the traditional surgical removal of stones. This article discusses recent advances in ESWL, describes the radiologic technologist's role in diagnosing and managing stone disease, and outlines future prospects in the treatment of stone disease.

Chimeric hepatitis B virus core particles as probes for studying peptide-integrin interactions

An RGD-containing epitope from the foot-and-mouth disease virus (FMDV) VP1 protein was inserted into the e1 loop of the hepatitis B virus core (HBc) protein. This chimeric protein was expressed at high levels in Escherichia coli and spontaneously assembled into virus-like particles which could be readily purified. These fusion particles elicited high levels of both enzyme-linked immunosorbent assay- and FMDV-neutralizing antibodies in guinea pigs. The chimeric particles bound specifically to cultured eukaryotic cells. Mutant particles carrying the tripeptide sequence RGE in place of RGD and the use of a competitive peptide, GRGDS, confirmed the critical involvement of the RGD sequence in this binding. The chimeric particles also bound to purified integrins, and inhibition by chain-specific anti-integrin monoclonal antibodies implicated alpha 5 beta 1 as a candidate cell receptor for both the chimeric particle and FMDV. Some serotypes of FMDV bound to beta 1 integrins in solid- phase assays, and the chimeric particles competed with FMDV for binding to susceptible eukaryotic cells. Thus, HBc particles may provide a simple, general system for exploring the interactions of specific peptide sequences with cellular receptors.

Decision tree and postpartum management for preventing dehydration in the "breastfed" baby

Dehydration and poor weight gain in breastfed infants are common but potentially preventable problems. Serious consequences are severe hypernatremic dehydration, severe weight loss, and severe hyperbilirubinemia with possible irreversible damage to the baby's brain or other vital organs. The dangers of dehydration have been emphasized by recent media reports of severe cases. These reports have resulted in increased, but often inappropriate, intervention in breastfeeding. On the basis of our experience at the Hospital for Sick Children, and the Doctors Hospital (Toronto), we have developed a decision tree and management protocol to assess breastfeeding, intervene effectively, and prevent such problems. If all breastfeeding mothers and babies are evaluated by qualified staff before discharge using this tool, it is expected that the serious consequences associated with babies leaving hospital appearing to be breastfeeding, but in fact not breastfeeding at all, will be prevented. Application of this approach, however, will require considerable upgrading of nurses' and physicians' skills and knowledge with regard to breastfeeding. A case report is presented.

Identification of iron superoxide dismutase and a copper/zinc superoxide dismutase enzyme activity within the marine cyanobacterium Synechococcus sp. WH 7803

Three constitutive forms of superoxide dismutase activity have been demonstrated in the cyanobacterial marine picoplankter Synechococcus sp. WH 7803 using polyacrylamide gel activity staining techniques. A protein which gave a positive non-haem iron stain on native polyacrylamide gels exhibited N-terminal similarity to both the iron superoxide dismutase and the manganese superoxide dismutase of Escherichia coli. The metal prosthetic group of each of the three activity bands was characterised by analysing their differential sensitivities to 5 mM H2O2, 2 mM cyanide and 2 mM of the copper chelator diethyldithiocarbamate. Three distinct superoxide dismutase activities were observed, an iron superoxide dismutase, a copper/zinc superoxide dismutase and a third form which has not been identified. Growth of Synechococcus cells in ASW medium containing no added iron resulted in no alteration in the activity of the iron superoxide dismutase. Growth of cultures in the absence of copper or zinc resulted in differential changes in the activities of the copper/zinc superoxide dismutase and the unidentified superoxide dismutase.