Encapsulated PC 12 Cell Transplants into Hemiparkinsonian Monkeys: A Behavioral, Neuroanatomical, and Neurochemical Analysis

Four cynomolgus monkeys were trained on a hand reaching task and then rendered hemiparkinsonian with an intracarotid injection of n-methyl 4 phenyl 1,2,3,6, tetrahydropyridine (MPTP). Performance on this task with the limb contralateral to the MPTP injection was significantly impaired following the lesion. Three monkeys received implants of polymer-encapsulated containing PC12 cells into the caudate nucleus and putamen. One monkey received identical implants of empty capsules and served as a control. After a transient improvement, limb use in the control monkey dissipated and returned to post-MPTP disability. Two of the three PC12 cell grafted monkeys recovered performance on the hand reach task to near normal levels for up to 6.5 mo posttransplantation. Capsules retrieved from the monkeys who recovered limb function postimplantation contained numerous viable PC12 cells that continued to release levodopa, basal dopamine, and potassium evoked dopamine. In contrast, capsules retrieved from the PC12 cell-grafted monkey which did not recover limb use on the hand reach task contained few cells which secreted negligible or undetectable levels of levodopa and dopamine. Interestingly, functional disability was not reinstated following removal of the capsules. Neuroanatomical and neurochemical evaluation of the grafted striatum did not reveal a host-derived sprouting response of catecholaminergic or indolaminergic fibers. These data indicate that xenografts of PC12 cells can survive for up to 6.5 mo in nonimmunosuppressed monkeys when immunoisolated via polymer encapsulation. Moreover, these cells continue to secrete high levels of levodopa and dopamine and induce recovery of motor function in parkinsonian nonhuman primates.

Public views on an extended role for community pharmacy

The acceptability to the general public of an extended role for community pharmacy was investigated using a social survey methodology. Within one locality, a sample of 133 respondents was drawn from four population groups who were likely to be extensive users of community pharmacy services: active elderly people, mothers of young children, carers of people with disabilities and people in full-time employment. The evidence from the interview survey was supplemented by discussions with community groups representative of the same sections of the population. The results indicate that there is considerable public support for the development of a range of new services in community pharmacies, with a majority of respondents supporting the provision of more information on prescribed medicines, opportunity to discuss minor symptoms with the pharmacist, medicine delivery services, and the holding of patient medication records. There is less support for discussing health promotion with the pharmacist, while cost was found to be a major obstacle to the acceptability of diagnostic testing. Elderly people found all aspects of the extended role less acceptable than did other respondent groups. It is concluded that there is a need to market unfamiliar services, and, if an extended role is to be developed effectively, the nature of the relationship between the roles of the community pharmacist and the GP needs to be demonstrated more clearly to service users.

Cost-effectiveness of capsule endoscopy in screening for colorectal cancer

BACKGROUND AND STUDY AIMS

Capsule endoscopy (Pillcam Colon) has recently shown acceptable accuracy in detecting colonic lesions when compared with colonoscopy. The aim of this analysis is to provide a model to assess the cost and effectiveness of population-based screening for colorectal cancer (CRC) using capsule endoscopy and to compare the cost-effectiveness with that of a colonoscopy screening program.

METHODS

The cost-effectiveness of two screening strategies using colonoscopy or capsule endoscopy were compared by a computer model based on a Markov process. In this model, a hypothetical population of 100,000 individuals aged 50 years and over, undergoes a 10 yearly screening procedure. Different thresholds for postcapsule polypectomy referral were simulated.

RESULTS

At baseline, the incremental cost-effectiveness (compared with no screening) of colonoscopy and capsule endoscopy was $ 16,165 and $ 29,244 per life-year saved, respectively. When equal compliance was simulated, the colonoscopy program was more effective and less costly than a strategy based on capsule endoscopy. When simulating an initial compliance to capsule endoscopy 30% better than colonoscopy, capsule endoscopy became the more effective and more cost-effective option. A 20% better compliance was sufficient when a higher accuracy of capsule endoscopy for polyps was assumed. A 6 mm threshold for polypectomy referral was associated with a substantial cost reduction in the capsule endoscopy program with only a small loss of efficacy.

CONCLUSIONS

The cost-effectiveness of capsule endoscopy depends mainly on its ability to improve compliance to CRC screening.

Systematic review: Endoscopic dilatation in Crohn's disease

BACKGROUND

Endoscopic dilatation for Crohn's disease has been evaluated only in some small and heterogeneous studies.

AIM

To evaluate any association between the main clinical variables and endoscopic variables and the efficacy and safety of endoscopic dilatation in Crohn's disease.

METHODS

A Medline search regarding pneumatic dilatation in Crohn's disease was performed. Several technical and clinical variables were extracted from each study to build up a descriptive, pool-data analysis. Data on individual patients were extracted from suitable studies to create a simulated population upon which a multivariate statistical analysis was performed.

RESULTS

Thirteen studies enrolling 347 Crohn's disease patients were reviewed. Endoscopic dilatation was mainly applied to postsurgical strictures, being technically successful in 86% of the cases. Long-term clinical efficacy was achieved in 58% of the patients. Mean follow-up was as long as 33 months, corresponding to 800 patient years of follow-up. Major complication rate was 2%, being higher than 10% in two series. At multivariate analysis, a stricture length < or = 4 cm was associated with a surgery-free outcome (OR: 4.01; 95% CI: 1.16-13.8; P < 0.028).

CONCLUSIONS

Endoscopic dilatation is an effective and safe treatment for short strictures caused by Crohn's disease, impacting substantially on the natural history of these patients.

Motivation to change in recent onset and long-standing bulimia nervosa: are there differences?

REASON FOR THE STUDY: Little is known about how motivation to change evolves over the course of an eating disorder. The present study compared 'stage of change' and motivation, confidence and readiness to change in two groups of patients with bulimia nervosa (BN), adolescents with a short duration of illness and adults with a long duration of illness.

METHOD

Patients completed the Severity of eating disorder symptomatology scale, Hospital Anxiety and Depression Scale and measures of stage of change and motivation, readiness and confidence to change their bulimic symptomatology at pre-treatment.

MAIN FINDINGS

Short- and long duration groups did not differ in illness severity, comorbidity, stage of change, motivation, readiness, and confidence to change. There were, however, some differences between groups in terms of the relationship between motivational measures, illness severity, duration and comorbidity.

CONCLUSIONS

There seem to be more similarities than differences between adolescents with short duration of illness and those with well-established BN in terms of their motivation to change.

Colon cancer prevention in Italy: cost-effectiveness analysis with CT colonography and endoscopy

BACKGROUND

Colorectal cancer (CRC) is a major cause of mortality in Italy. Although prevention of CRC is possible, its cost-effectiveness when applied to the Italian population is unknown. Recently, computerized tomographic colonography (CTC) has been proposed for CRC screening.

AIM

To compare the efficacy and cost-effectiveness of CTC screening in a simulated Italian population with those of colonoscopy and flexible sigmoidoscopy (FS).

METHODS

The cost-effectiveness of different screening strategies was compared using a Markov process computer model, in which in a hypothetical population of 100,000 50 year-olds were investigated by CTC, colonoscopy or FS every decade. Outcomes were projected to the Italian national level.

RESULTS

CRC incidence reduction was calculated at 40.9%, 38.2%, and 31.8% with colonoscopy, CTC and FS, respectively. As compared to no screening, all screening programs were shown to be cost-saving, allowing a saving of 11 Euro, 17 Euro, and 48 Euro per person with colonoscopy, FS and CTC, respectively. FS appeared to be less cost-effective than CTC, whilst colonoscopy appeared to be an expensive option as compared to CTC. Undiscounted national expenditure was calculated to be 1,042,489,512 Euro, 1,093,268,285 Euro, and 1,198,783,428 Euro for FS, CTC and colonoscopy, respectively, as compared to 695,818,078 Euro without screening.

CONCLUSION

CRC screening is cost-saving in Italy, irrespective of the technique applied. CTC appeared to be more cost-effective than FS, and it may also become a valid alternative to colonoscopy.

The colorectal malignant polyp: scoping a dilemma

Colorectal adenomas containing invasive carcinoma represent the majority of early colorectal cancers. The malignant polyp carries a significant risk of lympho-haematic metastasis and mortality due to the penetration of cancerous cells into the submucosal layer. The therapeutic dilemma is whether to perform endoscopic or surgical resection. A thorough assessment of the endoscopic, histological and clinical variables is needed to unravel the best treatment for each patient. In particular, a unique staging of such lesions, based on certain histopathological features, has been deeply implicated in the therapeutic choice. Aim of this article is to review the main endoscopic, histological and clinical features of the malignant polyp in order to propose a systematic management of this lesion.

The prolongation of triple therapy for Helicobacter pylori does not allow reaching therapeutic outcome of sequential scheme: a prospective, randomised study

BACKGROUND AND AIM

One-week triple therapy for Helicobacter pylori revealed, during these last few years, a decrease in the eradication rate, so that the prolongation of its duration has been proposed. A sequential scheme recently showed very satisfactory results. We performed a prospective randomised study with the aim of either evaluating whether the triple therapy prolongation may improve its effectiveness and comparing its outcome with that of sequential regimen.

PATIENTS AND METHODS

Three hundred and forty-two H. pylori positive patients completed the study. They were randomised to receive one of the following treatments: (i) a 7-day triple therapy comprising of rabeprazole (20 mg, b.i.d.) plus clarithromycin (500 mg, b.i.d.) and amoxycillin (1 g, b.i.d.); (ii) a 10-day triple therapy comprising the same scheme; (iii) a 10-day sequential regimen comprising of rabeprazole (20 mg, b.i.d.) plus amoxycillin (1 g, b.i.d.) for 5 days followed by rabeprazole (20 mg, b.i.d.) plus clarithromycin (500 mg, b.i.d.) and tinidazole (500 mg, b.i.d.) for the next 5 days. Therapeutic results were expressed using both intention-to-treat and per protocol analyses with 95% confidence intervals. A model of multivariate logistic regression analysis was performed using therapeutic outcome as a dependent variable and including endoscopic finding, smoking habit, age and sex as candidates for the model.

RESULTS

Sequential regimen showed a significant gain in the eradication rate as compared to the 7-day (P < 0.0001) and the 10-day (P < 0.01) triple therapies, respectively. Overall eradication was lower in smokers than in non-smokers, but the difference remained significant only in the 7-day triple therapy (P < 0.01). Additionally, the overall eradication was higher in peptic ulcer than dyspepsia (P < 0.01), even if this difference was significant only for both triple therapies.

CONCLUSIONS

Seven-day triple therapy achieves disappointing eradication rates in dyspeptics and smokers. Prolonging triple therapy to 10 days does not significantly improve the eradication rate. The novel 10-day sequential regimen is more effective and equally tolerated than the 10-day triple therapy.

Long-term outcome of endoscopic pneumatic dilatation in Crohn's disease

BACKGROUND

To avoid multiple surgeries in stenosing Crohn's disease, pneumatic endoscopic dilatation has been introduced. The present study evaluated the long-term clinical outcome in Crohn's disease patients after endoscopic dilatation for ileal or neoileal strictures.

PATIENTS AND METHODS

All Crohn's disease patients who underwent pneumatic dilatation of ileal or ileo-colonic strictures between January 1988 and December 2001 were invited to return for a clinical check-up in June 2002. Clinical, endoscopic and radiological reports were reviewed. Symptomatic relief from sub-occlusive symptoms without requiring surgery was considered as a positive outcome, whereas the requirement of surgery was regarded as an unfavourable outcome. Possible predictors of favourable outcome were analysed.

RESULTS

Endoscopic dilatation was technically successful in 34/43 (79%) Crohn's disease patients, with a mean number of dilatations per patient of 3 +/- 3.13. During a mean follow-up of 63.7 +/- 44.6 months, a positive long-term outcome was observed in 18 (52.9%) patients, whereas surgery was necessary in the remaining 16 cases. The risk of surgery was distinctly higher within 2 years post-dilatation than in the next 2 years (26.4% versus 8.3%, respectively; P = 0.078). No clear clinical, endoscopic or radiological predictive factors for a successful outcome were identified.

CONCLUSIONS

Endoscopic pneumatic dilatation is an effective and safe procedure to be applied to patients with stenosing Crohn's disease, offering a very long-term benefit in a sub-group of patients.

A clinical practice viewpoint: to culture or not to culture Helicobacter pylori?

Bacterial culture has played an irreplaceable role in the discovery and characterisation of Helicobacter pylori. The main topic of the present article is to critically review the role of culture in the management of H. pylori infection in clinical practice, from diagnosis to treatment. The available data suggest that H. pylori culture is an invasive, time-consuming method, offering quite low sensitivity, requiring significant cost for the patient, and which, in practice, tests very few antibiotics, with a questionable contribution to the management of non-responder patients. Therefore, whether patients should undergo (and pay for) an upper endoscopy for bacterial culture remains a debatable matter.

Critical aspects of tissue-engineered therapy for bone regeneration

Recent advances in bone tissue engineering are established on the understanding of an engineered scaffold, the molecular milieu within the osteogenic site, and the cell(s) predisposed to an osteogenic lineage. Advances in the incorporation of a generative vehicle into a skeletal defect require temporal and spatial distribution of the scaffold, growth factor, and cell compatible with enhanced bone healing. Monitoring events culminating in osteogenesis has focused on phenotypic and intracellular indicators. Phenotypic and intracellular indicators include the presence of receptors and intracellular signals that enable cell proliferation and differentiation. Progress in the areas of scaffold design, growth factor utilization, bone cell lineage, and intracellular signaling are reviewed.

Gastric epithelial cell proliferation in patients with liver cirrhosis

An increased risk for gastric cancer in patients with liver cirrhosis has recently been reported. This study was performed in order to determine gastric epithelial cell proliferation in cirrhotic patients and to evaluate the role of congestive gastropathy (CG) and Helicobacter pylori infection in this process. Thirty-six cirrhotic patients and 18 controls were enrolled in the study. All patients underwent endoscopy and three biopsies were performed in the antrum and three in the gastric body. The presence of H. pylori infection was assessed by a rapid urease test and histology. The antral biopsies were used for gastric cell proliferation assessment by an immunohistochemical analysis (Ki-67). There was no significant difference in epithelial cell proliferation between cirrhotics and controls. Gastric proliferation values were higher in patients with H. pylori infection compared with uninfected patients, both in cirrhotic (P = 0.003) and in control groups (P = 0.06). Among the cirrhotic group, we found a progressive increase in gastric cell proliferation values related to the degree of CG, the highest values being observed in cirrhotic patients with severe CG. Moreover, cirrhotics with both severe CG and H. pylori infection had the highest proliferation values when compared with all other subgroups. In conclusion, this study found that: (1) CG significantly affects epithelial cell proliferation in gastric mucosa in cirrhotic patients, (2) H. pylori infection plays a similar role in gastric cell proliferation in both cirrhotic and non-cirrhotic patients, and (3) CG and H. pylori could act synergistically in this process.

Relationship between antral lymphocyte density and basal gastrin levels in patients with Helicobacter pylori infection

BACKGROUND

The mechanism by which Helicobacter pylori causes hypergastrinaemia is not completely understood.

AIM

To evaluate whether antral lymphocyte density could play a role in this alteration.

METHODS

A total of 12 patients with active duodenal ulcer and 10 with non-ulcer dyspepsia were enrolled upon detection of Helicobacter pylori infection at endoscopy Enrolled as controls were 7 matched dyspeptic patients without Helicobacter pylori infection. Biopsy specimens were collected for Helicobacter pylori and histological assessments, and for antral lymphocyte density assessment by a histomorphometric method. A blood sample was obtained from each patient to determine basal gastrin levels. All patients were controlled by a further endoscopy 4 weeks after the end of Helicobacter pylori treatment.

RESULTS

Antral lymphocyte density (5,464 +/- 1,328 and 5,635 +/- 1,186 vs 2,267 +/- 557 lymphocytes/mm2; p<0.001 and p<0.001, respectively) and gastrin levels (66.7 +/- 14.1 and 60.4 +/- 21.7 vs 40.7 +/- 7.8 pg/dl; p=0.004 and p=0.02, respectively) were higher in duodenal ulcer and non-ulcer dyspepsia patients than in controls, while no significant differences emerged between duodenal ulcer and non-ulcer dyspepsia patients. There was a significant direct correlation between antral lymphocyte density and gastrin levels both in duodenal ulcer (r=0.77; p=0.003) and in non-ulcer dyspepsia (r=0.75; p=0.03) patients, while no correlation was found in controls [r=0.12; p=0.8). After treatment, this correlation persisted in 10 eradication failure patients (r=0.68; p=0.027), but disappeared in those successfully cured.

CONCLUSIONS

These data suggest that lymphocyte density in the antral mucosa could play a role in the impaired gastrin production occurring in patients with Helicobacter pylori infection.

The Manchester Respiratory Activities of Daily Living questionnaire: development, reliability, validity, and responsiveness to pulmonary rehabilitation

OBJECTIVES

Because there is no respiratory-specific activities of daily living (ADL) scale for use in older patients, our aim was to design and develop the Manchester Respiratory ADL questionnaire (MRADL) and to assess its validity in older patients with chronic obstructive pulmonary disease (COPD).

DESIGN

The MRADL is a composite of the most discriminative questions from the Nottingham Extended ADL Questionnaire (NEADL) and the Breathing Problems Questionnaire (BPQ).

SETTING

A University teaching hospital.

PARTICIPANTS

Participants were 188 (104 men) COPD out-patients aged 60 to 93 (mean 77) years and 55 (23 men) normal controls (NCs) aged 70 to 90 (mean 78) years. Exclusions were confusion and acute respiratory exacerbation/use of oral corticosteroid within 6 weeks.

INTERVENTION

A subgroup of COPD subjects completed a pulmonary rehabilitation program (PR) to assess responsiveness of the MRADL to intervention.

MEASUREMENTS

All subjects completed MRADL and NEADL scales, and 15 COPD subjects (11 men) completed an 8-week PR program.

RESULTS

Mean (SE) 1-second forced expiratory volume (FEV1) in COPD subjects was 0.94 (0.03) liters, and in NCs it was 1.96 (0.07) liters. MRADL discriminated better between COPDs and NCs than did the NEADL in terms of sensitivity (90% vs 76%; X2 = 4.8, P = .02) and negative predictive value (84% vs 69%; X2 = 4.5, P = .03). MRADL responded to changes during PR: pre versus post mean (SE) score 11.2 (1.1) vs 13.4 (1.1); (t = 3.09; P = .008), but NEADL was unchanged. MRADL showed high consistency (Cronbach alpha 0.91). 95% confidence limits of repeatability were -0.63 to +0.26 (P = .42) for MRADL and -0.53 to +0.26 (P = .50) for NEADL.

CONCLUSIONS

MRADL is a reliable and valid self-report scale for assessment of physical disability in older COPD patients. It is responsive to pulmonary rehabilitation.

Ascorbic acid and intestinal metaplasia in the stomach: a prospective, randomized study

BACKGROUND

Intestinal type metaplasia plays a role in intestinal type gastric carcinoma development. Ascorbic acid demonstrates a protective effect against gastric carcinogenesis, due to its ability to inactivate oxygen free-radicals as well as its nitrite-scavenging effects.

AIM

To assess whether long-term ascorbic acid administration following Helicobacter pylori eradication could affect intestinal metaplasia regression in the stomach.

METHODS

Sixty-five patients were included in the study. The inclusion criterion was the presence of intestinal metaplasia on the gastric mucosa after H. pylori eradication. An upper gastrointestinal endoscopy was performed and 3 biopsy specimens were taken in the antrum, 3 in the gastric body, and 2 in the incisura angularis. Patients were randomized to receive 500 mg of ascorbic acid o.d., after lunch (32 patients) for 6 months or no treatment (33 patients). All patients underwent to endoscopic control at the end of the 6 months.

RESULTS

H. pylori infection recurrence was detected in 6 (9.4%) patients (three from each group), and these patients were excluded from further analysis. We were unable to find evidence of intestinal metaplasia in any biopsied site of the gastric mucosa in 9/29 (31%) patients from the ascorbic acid group and in 1/29 (3.4%) of the patients from the control group (P=0.006). Moreover, a further six (20.7%) patients from the ascorbic acid group presenting chronic inactive pangastritis with widespread intestinal metaplasia at entry, showed less extensive antritis with intestinal metaplasia at control, whilst a similar finding was only seen in one patient from the control group (P=0.051).

CONCLUSION

The administration of ascorbic acid significantly helps to resolve intestinal metaplasia of the gastric mucosa following H. pylori eradication, and its use as a chemoprevention treatment should be considered.

Options for tissue engineering to address challenges of the aging skeleton

There will be more than 52 million Americans over the age of 65 by the year 2020 (U.S. Census Bureau). Regenerating form and function to bone defects in an elderly, osteoporotic population of this magnitude will be a daunting challenge. Tissue engineering options must be considered to answer this challenge. Options can include gene transfer technology, stem cell therapy, and recombinant signaling molecules. An additional component will be a carrier that localizes, protects, predictably releases cues and cells, as well as establishes an environment for restoring osseous form and function. The purposes of this article are to present an overview of the bone regenerating decrement affecting osteoporotic, elderly patients and to highlight some tissue engineering options that could offset this decrement.

Clinical and histologic predictors of Helicobacter pylori infection recurrence

Factors influencing Helicobacter pylori infection recurrence still have not been fully clarified. The aim of this study was to determine whether, after eradication of H. pylori, any clinical or histologic features could yield information on infection relapse. We enrolled in the study 72 patients successfully treated for H. pylori infection by either dual (n = 49) or triple (n = 23) therapy. H. pylori eradication was defined as a negative bacterial finding by rapid urease test and histologic assessment at least 4 weeks after cessation of therapy. Upon eradication, gastritis grading was performed and patients were asked to return for an endoscopic control 6-8 months later. The recurrence of H. pylori infection was observed in 12 of 72 (16.7%) patients. The infection recurrence rate resulted significantly higher in nonulcer dyspepsia patients (p = 0.01 ) and in women (p = 0.03), whereas infection relapse did not differ between patients treated with dual or triple therapy. There was a strong (p = 0.0001 ) relationship between the persistence of chronic active gastritis after H. pylori eradication and recurrence of infection, whereas gastritis grade and metaplasia were not related to recurrence. In conclusion, this study found that H. pylori infection recurrence after successful dual or triple therapy is fairly high and that gastroduodenal disease, gender, and gastritis activity seem to affect infection relapse.

A new highly effective short-term therapy schedule for Helicobacter pylori eradication

BACKGROUND

Although triple therapy regimens suggested in the Current European guidelines give fairly good results, several studies have reported an unsatisfactory Helicobacter pylori eradication rate (< 80%).

AIM

To evaluate the efficacy of a new short-term treatment sequence on H. pylori eradication.

METHODS

A total of 52 patients with H. pylori infection and either non-ulcer dyspepsia (34 patients) or peptic ulcer (18 patients) were enrolled to receive a 10-day therapy: omeprazole 20 mg b.d. plus amoxycillin 1 g b.d. for the first 5 days, followed by omeprazole 20 mg b.d., clarithromycin 500 mg b.d. and tinidazole 500 mg b.d. for the remaining 5 days. H. pylori infection at entry was assessed by rapid urease test and histology on biopsies from the antrum and the corpus. Bacterial eradication was assessed by endoscopy (peptic ulcer patients) or 13C urea breath test (non-ulcer dyspepsia patients) 4-6 weeks after therapy had ended.

RESULTS

All patients completed the study. H. pylori eradication was achieved in all but one patient, with an eradication rate of 98% (95% CI: 94.3-100) with intention-to-treat analysis. Patient compliance was good (consumption of prescribed drugs > 95%) for all but one patient, who took the triple therapy regimen for 4 days instead of 5 days. No major side-effects were reported but three (6%) patients complained of mild side-effects.

CONCLUSIONS

The use of this 'five plus five' therapy schedule as an initial treatment for H. pylori deserves further investigation.

Helicobacter pylori eradication with dual and low-dose triple therapy in patients with liver cirrhosis

BACKGROUND AND AIMS

Few data exist on the treatment of Helicobacter pylori infection in cirrhotic patients. In this study we assessed the efficacy of standard dual and one-week low-dose triple therapy on Helicobacter pylori eradication in cirrhotics.

PATIENTS AND METHODS

In a prospective study, 83 cirrhotic patients with epigastric pain were randomised to receive either a two-week course of dual therapy, composed of omeprazole 20 mg b.d. plus amoxycillin 1 g b.d. (n = 41) or a one-week course of triple therapy, composed of omeprazole 20 mg b.d., clarithromycin 250 mg b.d., and tetracycline 500 mg b.d (n = 42). Helicobacter pylori infection at entry and eradication 6-8 weeks after the end of therapy were assessed by rapid urease test and histology on biopsies from the antrum and corpus. When eradication did not occur with either dual or triple therapy, patients were given the alternative regimen. Helicobacter pylori eradication in these patients was assessed 6-8 weeks after the end of treatment by a further endoscopy.

RESULTS

Helicobacter pylori eradication was achieved in 87.8% (36 out of 41; 95% confidence interval 77.8-97.8%) of patients after dual therapy and in 85.7% (36 out of 42; 95% confidence interval 75.1-96.3%) of patients treated with triple therapy (p = NS). In patients in whom initial eradication was unsuccessful, re-treatment eradicated Helicobacter pylori in 4 out of 5 patients given the triple regimen and in all 5 patients who received the dual therapy. One patient was lost to follow-up. No major side-effects were reported for either treatment regimen.

CONCLUSIONS

Our data show that both dual and triple therapies are effective in Helicobacter pylori eradication in cirrhotics as well as in eradication failure patients. Therefore, the use of the dual therapy regimen is strongly suggested as an initial treatment for Helicobacter pylori eradication in cirrhotic patients.

Helicobacter pylori infection, plasma ammonia levels, and psychometric testing in cirrhotic patients

OBJECTIVE

The role of Helicobacter pylori (H. pylori) infection as a cause of hepatic encephalopathy is still debated. This study focused on the relationship between H. pylori, plasma ammonia levels, and intellectual function in cirrhotic patients.

METHODS

Forty-seven cirrhotics with latent or mild hepatic encephalopathy were enrolled in the study, upon H. pylori assessment at endoscopy. Plasma ammonia level determinations and psychometric testing were performed at entry in all patients. Patients with H. pylori infection received a 2-wk standard dual therapy and bacterial eradication was assessed at endoscopy 6-8 wk later. On this occasion, plasma ammonia levels and psychometric assessments were repeated. Patients without H. pylori infection at entry were also studied after 6-8 wk for ammonia level assessment and psychometric testing, as a control group. Patients receiving lactulose therapy and those without therapy were grouped separately for statistical analysis.

RESULTS

Among 21 patients without lactulose therapy (group A), basal plasma ammonia levels and psychometric testing scores did not significantly differ between 13 infected and eight uninfected patients. Similarly, among 26 patients undergoing lactulose therapy (group B), basal plasma ammonia concentration and psychometric testing scores did not significantly differ between 13 infected and 13 uninfected patients. Moreover, in group B, both the prevalence of previous overt hepatic encephalopathy episodes and the mean daily dose of lactulose therapy were similar between infected and uninfected patients. In addition, no significant reduction in the plasma ammonia concentrations and in psychometric testing scores emerged in both groups A and B after bacterial eradication.

CONCLUSIONS

This study failed to find a relationship between H. pylori, plasma ammonia levels, and psychometric testing scores in cirrhotic patients with latent or mild hepatic encephalopathy.

Helicobacter pylori eradication with proton pump inhibitor-based triple therapies and re-treatment with ranitidine bismuth citrate-based triple therapy

BACKGROUND

It has been suggested that short-term triple therapy comprising a proton pump inhibitor, plus clarithromycin and amoxycillin be used as first choice in treating H. pylori infection, while eradication failure patients should be further treated with a quadruple therapy. Nevertheless, conflicting results have been reported using these treatment regimens in different countries.

METHODS

A total of 278 patients with H. pylori infection were randomised to receive one-week triple therapy, comprising clarithromycin 500 mg b.d., amoxycillin 1 g b.d., and either omeprazole 20 mg b.d. (OAC; 90 patients), or pantoprazole 40 mg b.d. (PAC; 95 patients), or lansoprazole 30 mg b.d. (LAC; 93 patients). H. pylori infection at entry, and eradication 4-6 weeks after therapy had ended, were assessed by rapid urease test and histology on biopsies from the antrum and the corpus. When eradication did not occur, patients were given a 2-week treatment comprising ranitidine bismuth citrate 400 mg b.d., tetracycline 500 mg t.d.s. and tinidazole 500 mg b.d. (RBTT). Eradication in these patients was assessed 4-6 weeks after conclusion of treatment by a further endoscopy.

RESULTS

Six patients were lost to the follow-up. At the end of the first course of treatment, the overall H. pylori eradication rate was 78% (95% CI: 73-83) and 79% (95% CI: 75-84) at 'intention-to-treat' (ITT) and 'per protocol' (PP) analysis, respectively, without any statistically significant difference between treatment regimens, although a trend for better results with the omeprazole combination was observed. Moreover, H. pylori eradication was achieved in 82% (95% CI: 75-97) (ITT) and 86% (95% CI: 69-94) (PP) of 38 patients re-treated with RBTT regimen.

CONCLUSIONS

Our data found that this short-term triple therapy is not a satisfactory treatment (< 80% eradication rate) for H. pylori infection. The 2-week triple therapy used as re-treatment in eradication failure patients yielded more promising results.

Helicobacter pylori infection in dyspeptic cirrhotic patients

BACKGROUND/AIMS

To date, few studies have focused on the role of Helicobacter pylori (H. pylori) in cirrhotic patients with gastroduodenal disease and reported results are conflicting. The aim of this study was to assess the H. pylori infection rate in dyspeptic cirrhotic patients with or without gastroduodenal lesions at endoscopy.

METHODOLOGY

In a prospective study, 226 consecutive dyspeptic cirrhotic patients were enrolled in the study upon assessment of H. pylori infection. Two-hundred dyspeptic non-cirrhotic patients were also included as controls. The presence of H. pylori was detected by rapid urease test and histology (Giemsa staining) in 3 biopsy specimens from the antrum and 3 from the gastric body.

RESULTS

H. pylori infection was found in 135 (59.7%) cirrhotics and in 121 (60.5%) controls (p = NS). The prevalence of gastric ulcer was higher in cirrhotics than in controls (16% vs. 2.5%, p = 0.0001), while the prevalence of duodenal ulcer was similar (11% vs. 12%, respectively). The H. pylori infection rate was similar between cirrhotics and controls, both with gastric (83% vs. 80%) and with duodenal (88% vs. 96%) ulcers. Moreover, in our study, a H. pylori-related peptic lesion was the cause of previous gastroduodenal bleeding in 6 of 50 (12%) cirrhotic patients.

CONCLUSIONS

Our results indicated that H. pylori infection is implicated in the pathogenesis of peptic ulcer in cirrhotic patients, similar to findings in non-cirrhotic patients.

Helicobacter pylori and plasma ammonia levels in cirrhotics: role of urease inhibition by acetohydroxamic acid

BACKGROUND AND AIMS

The role of Helicobacter pylori as a cause of hyperammonaemia in cirrhotics has still not been fully clarified. This study was aimed at evaluating the effect of acute Helicobacter pylori urease inhibition by oral acetohydroxamic acid administration on blood ammonia levels in cirrhotic patients.

METHODS

Twenty-nine cirrhotics (14 males, 15 females; mean age: 63 years; Child-Pugh class: 14 A, 9 B, and 6 C) undergoing upper gastrointestinal endoscopy were enrolled in the study. The presence of Helicobacter pylori infection was assessed by rapid urease test and histology. A semi-quantitative grading of bacterial density was also performed at histology. All patients received oral acetohydroxamic acid 750 mg, and blood samples for assessment of ammonia levels were taken before and at 15, 30, 60 and 90 minutes after administration.

RESULTS

Helicobacter pylori infection was detected in 20 patients, while 9 patients were uninfected. Acetohydroxamic acid administration led to a significant reduction in blood ammonia levels at 15 and 30 minutes (mean +/- SD, 113 +/- 44 vs 101 +/- 43 and 93 +/- 38 micrograms/dl, respectively; p = 0.002) only in patients with Helicobacter pylori infection. Moreover, the reduction was statistically significant only in Child-Pugh B/C class patients and in those with moderate/marked Helicobacter pylori density in gastric mucosa. Basal ammonia levels did not differ between Helicobacter pylori positive and negative patients, nor in patients with mild and moderate/marked Helicobacter pylori density in gastric mucosa, while Child-Pugh class B/C cirrhotics had higher basal ammonia levels than class A cirrhotics, in both Helicobacter pylori positive and negative groups.

CONCLUSIONS

Our data showed that Helicobacter pylori urease inhibition by acetohydroxamic acid administration significantly reduces blood ammonia levels in patients with more advanced liver cirrhosis and in those with a high bacterial density in gastric mucosa.

Encapsulated PC12 cell transplants into hemiparkinsonian monkeys: a behavioral, neuroanatomical, and neurochemical analysis

Four cynomolgus monkeys were trained on a hand reaching task and then rendered hemiparkinsonian with an intracarotid injection of n-methyl 4 phenyl 1,2,3,6, tetrahydropyridine (MPTP). Performance on this task with the limb contralateral to the MPTP injection was significantly impaired following the lesion. Three monkeys received implants of polymer-encapsulated containing PC12 cells into the caudate nucleus and putamen. One monkey received identical implants of empty capsules and served as a control. After a transient improvement, limb use in the control monkey dissipated and returned to post-MPTP disability. Two of the three PC12 cell grafted monkeys recovered performance on the hand reach task to near normal levels for up to 6.5 mo posttransplantation. Capsules retrieved from the monkeys who recovered limb function postimplantation contained numerous viable PC12 cells that continued to release levodopa, basal dopamine, and potassium evoked dopamine. In contrast, capsules retrieved from the PC12 cell-grafted monkey which did not recover limb use on the hand reach task contained few cells which secreted negligible or undetectable levels of levodopa and dopamine. Interestingly, functional disability was not reinstated following removal of the capsules. Neuroanatomical and neurochemical evaluation of the grafted striatum did not reveal a host-derived sprouting response of catecholaminergic or indolaminergic fibers. These data indicate that xenografts of PC12 cells can survive for up to 6.5 mo in nonimmunosuppressed monkeys when immunoisolated via polymer encapsulation. Moreover, these cells continue to secrete high levels of levodopa and dopamine and induce recovery of motor function in parkinsonian nonhuman primates.

Recent progress in immunoisolated cell therapy

Biohybrid implants represent a new class of medical device in which living cells, supported in a hydrogel matrix, and surrounded by a semipermiable membrane, produce and deliver therapeutic reagents to specific sites within a host. First proposed in the mid-1970s for diabetes, this treatment modality has progressed rapidly in the past four years and is now being investigated not just for endocrine disorders but also for alleviation of chronic pain, treatment of neurodegenerative disorders, and delivery of neurotrophic factors to sites within the blood brain barrier, and as a practical alternative to conventional ex vivo.

The effects of antidepressants on the thyroid axis in depression

Thirty-nine patients with major depression were studied to determine the differential effects of desipramine (DMI) and fluoxetine (FLU) on thyroid hormones. Twenty-six percent showed some abnormality in baseline thyroid hormone levels. There were no demonstrable differences for any of the thyroid indices from baseline to the 3- or 6-week samples for the total group or for either drug by repeated measures analysis of variance. There was a significant group by time interaction for total thyroxine (TT4) between the drug treatment groups, which was caused by a small but significant increase in TT4 in the DMI sample. Correlations were performed between the change in hormones over the 6 week period and treatment response. There was a significant association between a decline in triiodothyronine (T3) levels and response to FLU but not DMI. The implications of these findings for the pathophysiology of depression and antidepressant drug mechanisms are discussed.

Somatostatin analogue phase I trials in neuroendocrine neoplasms

To further investigate the antineoplastic efficacy and safety of somatostatin analogues, 2 trials were performed. Octreotide, SMS 201-995 (Sandostatin), was escalated in doses ranging from 1,500 micrograms to 6,000 micrograms daily in 14 patients with carcinoid. Somatuline, (BIM 23014C, Angiopeptin, Lanreotide) was given in doses ranging from 2,250 micrograms to 9,000 micrograms daily to 13 neuroendocrine patients (6 carcinoid, 2 atypical carcinoid, 3 pancreatic islet cell and 2 small cell lung cancer patients). All patients successfully completed dose escalations without significant adverse effects and were evaluable for toxicity. The dose limiting side-effect of octreotide was the injection volume. No dose limiting adverse effects have been observed with somatuline. Carcinoid syndrome symptoms were better controlled with higher octreotide doses. Thirteen patients were evaluable for octreotide's antitumor efficacy with a partial response observed in 4 (31%), stable disease in 2 and progressive disease in 7 patients. Radiographic changes of increased tumor necrosis occurred in 5 patients and was independent of response. Somatuline resulted in a partial response in 4 patients (2 carcinoids, 1 gastrinoma and 1 small cell lung cancer) (31%), stable disease in 1 atypical carcinoid, and progressive disease in 8 (4 carcinoid, 1 atypical carcinoid, 2 islet cell and 1 multi-drug resistant small cell lung cancer). Six of the 8 carcinoid patients had radiographic changes of increased necrosis. Dose escalation of somatostatin analogues is well tolerated and may be associated with antitumor activity in some neuroendocrine neoplasms.

HIV in the U.K.: problems of prevalence, sociological response and health education

It is argued that the prevalence of AIDS is substantially under-represented in existing national AIDS data. Thus although official statistics demonstrate significant recent shifts in transmission routes for HIV, health educators are faced with a problem because it is difficult to develop preventive strategies against a syndrome whose prevalence can only be estimated. Problems of the true extent of the prevalence of HIV are compounded when there is a lack of knowledge about the specifics of heterosexual behaviour. It is unwise to assume that the protective strategies developed by gay men in the face of HIV are routinely available for adoption by heterosexuals, who are characterised by social divisions of age, gender and relative amounts of social power. These concerns represent a problem for health educators. To date, sociological work may not have made the most effective contribution in its support of intervention strategies against HIV/AIDS. Examination of the empirical literature on lay concepts of health and illness reveals a pessimistic stance on the part of some researchers about the ability of individuals to modify behaviour. More positive readings of their own data are possible. The traditional concerns to emphasise the socio-economic determinants of health and behaviour, now also shared by some health educators, should not obscure a concern for the fate of individuals. The most effective contribution that health promotion may be able to make to the control of HIV in the heterosexual population is to assist in the development of strategies of empowerment and 'horizontal intervention'.

Reimbursement warfare: who loses?

The challenge facing healthcare providers is to maximize available reimbursement to cover home care and outpatient management for a growing number of oncology patients who no longer meet inpatient criteria.

What people want to know about health

Brighton health authority and Brighton borough council are jointly planning a 'Healthy living centre' to provide a focal point for local health promotion activities. Sandra Winn and Martin Bradford report on a survey of community groups which not only provided information for the development of the centre but also gave useful insight into the community's concerns about health and people's needs for health information.

Retreats: getting your money's worth

Though well-done retreats can be sound investments, those investments can be substantial. Direct expenses alone can range from $200 for an in-town luncheon to $450,000 for a week-long event.

The changing pattern of calls to an AIDS advice line

An analysis of the number of and type of calls received by an AIDS advice line over a seven month period is presented. Variations in the number of calls received and differences in the types of questions asked by different sections of the population are examined. The results indicate that the number of calls received is strongly related to television publicity, and that different age and sex groups ask different questions about AIDS. There are also differences in the types of questions asked by homosexual and heterosexual callers. The results of the analysis have important implications for health education about AIDS.

Graded dose effects of angiotensin II on aldosterone production in man during various levels of potassium intake

This study was performed to evaluate the hypothesis that adrenal aldosterone output is modulated by daily potassium intake in man. Eight normotensive subjects, aged 24-38 yr, were fed 3 separate 150 mEq sodium-containing diets. Potassium content ranged from 300 mEq daily during the first week, to 80 mEq daily and 10 mEq daily for the subsequent 2 wk. On days 4 and 5 of each diet each subject took oral dexamethasone 0.5 mg B.I.D. to prevent endogenous ACTH secretion. On day 6 an infusion of angiotension II (AII) was administered in doses of 0.1, 0.3, 1.0, 3.0 and 10.0 ng/kg/min, each lasting 30 min. Blood pressure, pulse, and plasma aldosterone and potassium were measured throughout the infusions. All at infusion rates of 3 and 10 ng/kg/min, produced significant increases in plasma aldosterone values during liberal potassium intake but not when potassium intake was 10 mEq/day. We conclude that dietary potassium in man modulates All-mediated aldosterone secretion.

Assessment of cost related characteristics and conditions of long-term care patients

The present federal policy that requires a cost differential to be imposed between intermediate and skilled care residents/patients is based on a number of unproven assumptions that need to be tested. Are there groupings of cost related characteristics and conditions that allow appropriate distinctions between intermediate and skilled nursing care? If so, is the difference in the cost of care greater than the cost of collecting the data? Do the intangible costs exceed the benefits, especially if forced transfer of residents/patients is involved? If groupings do exist, will facilities reimbursed for high-cost patients be encouraged to maintain them in a state of dependence? Further, can the decisions be made reliably, even in communities where a spectrum of alternative resources is not available? Are there political reasons why objective decisions would not be acceptable to state administrators trying to balance their budgets? At the least, it appears that further research is needed in all of these areas. Before the results are in, perhaps a careful, judicious interpretation of the law is needed in order to positively affect the quality of life available to the persons consuming nursing home services.