Should we look for celiac disease among all patients with liver function test abnormalities?

Celiac disease [CD] has been found in up to 10% of the patients presenting with unexplained abnormal liver function tests [LFT]. As there is no precise data from our country in this regard, we investigated the prevalence of CD in patients presenting with abnormal LFT. From 2003 to 2008, we measured IgA anti-tissue transglutaminase [t-TG] antibody [with ELISA technique] within the first-level screening steps for all patients presenting with abnormal LFT to three outpatient gastroenterology clinics in Isfahan, IRAN. All subjects with an IgA anti-tTG antibody value of>10 ?/ml [seropositive] were undergone upper gastrointestinal endoscopy and duodenal biopsy. Histopathological changes were assessed according to the Marsh classification. CD was defined as being seropositive with Marsh I or above in histopathology and having a good response to gluten free diet [GFD]. During the study, 224 patients were evaluated, out of which, 10 patients [4.4%] were seropositive for CD. Duodenal biopsies were performed in eight patients and revealed six [2.7%] cases of Marsh I or above [four Marsh IIIA, two Marsh I], all of them had good response to GFD. The overall prevalence of CD among patients with hypertransaminasemia, autoimmune hepatitis, and cryptogenic cirrhosis was determined as 10.7% [3/28], 3.4% [2/59], and 5.3% [1/19], respectively. Serological screening with IgA anti-tTG antibody test should be routinely performed in patients presenting with abnormal LFT and especially those with chronic liver diseases including hypertransaminasemia, autoimmune hepatitis, and cryptogenic cirrhosis

Evidence-based medicine (EBM) for undergraduate medical students

<p><b>INTRODUCTION</b>Teaching evidence-based medicine (EBM) to practitioners and residents will improve their performance. There is insufficient evidence regarding the teaching of EBM in undergraduate medical education. We aimed to determine whether an EBM workshop would improve undergraduate medical student's ability to form clinical questions and search databases, as well as their attitudes towards EBM.</p><p><b>MATERIAL AND METHODS</b>This was a quasi-experimental study on fifth- and sixth-year medical students of Isfahan University of Medical Sciences. In a 4- day workshop, students learned and practised how to form clinical questions, perform literature searches and carry out critical appraisals. We assessed the student's ability to form a clinical question and their performance in searching and identifying the best clinical literature to answer the question, before and after the workshop. Students' attitudes were assessed using the Likert scale 15-item questionnaire on the last day of the workshop. Wilcoxon signed ranks test was performed to compare pre- and post-tests.</p><p><b>RESULTS</b>The workshop increased students' scores in developing clinical questions (P = 0.004, mean rank = 14) and search skills (P <0.001, mean rank = 12.50). It also improved students' attitudes towards EBM [mean = 3.76, (standared deviation = 0.7)]. The course allowed students (79.2%) to appreciate the need for EBM education for medical students. The students also commented that the course showed them the importance of EBM knowledge in effective clinical performance.</p><p><b>CONCLUSIONS</b>EBM workshop for undergraduate medical students increased their ability to form clinical questions and carry out appropriate literature searches. It also improved their attitudes towards learning and applying EBM.</p>

Are endoscopic findings predictive for the presence of H. pylori infection? What about indirect histologic findings?

It is still controversial whether certain endoscopic features can be used to diagnose Helicobacter pylori related gastritis. Our aim was to determine how macroscopic findings were related to histomorphological changes and the presence of H. pylori in patients undergoing endoscopy. The study population involved 501 consecutive gastrointestinal [GI] clinic admissions who underwent esphagogastroduodenoscopy for upper GI symptoms between October 2002 and March 2004. At least 2 antral and 2 body biopsies were obtained from each patient and were examined histologically for the presence of gastritis and were stained for H. pylori using modified Giemsa staining method. Endoscopic findings were reviewed retrospectively by two experts blinded to the H. pylori status and patients history. The endoscopic findings of gastritis, classified by a modification of the Sydney system and histological findings were determined by updated Sydney system. Statistical analysis was done using SPSS 11. A total of 501 consecutive patients [256 females, 245males] ranging from 8 to 91 years [mean, 49.5 years] were studied. H. pylori was found in 326 patients [65.1%]. Relative frequency of H pylori in females was 53% and in males was 47%. Rugal hypertrophy, raised erosion and bleeding were observed only in patients with H. pylori infection [specificity=100%]. Neutrophil activity also was observed only in patients with H. pylori infection. Among endoscopic findings, erythema showed a high sensitivity [81.3%] and positive predictive value [87.1%] for the diagnosis of H. pylori infection. Gastritis was present in 84.3% of all patients and 97% [316/326] of those with H. pylori and 56.6% [99/175] of those without H. pylori. There was significant statistical correlation between H. pylori infection and gastritis [P<0.001]. H. pylori was present in 76% [316/415] of gastritis patients and 5.1% [4/77] of patients without gastritis. An accurate endoscopic assessment of gastritis according to the Sydney system along with the histological findings is valuable indicator of H. pylori infection