Helicobacter pylori "test-and-scope" strategy for dyspeptic patients. Is it useful and safe?

AIM: To evaluate outcome of test-and-scope strategy using 13C-urea breath test, Helicobacter pylori IgG serology, and CagA serology. PATIENTS AND METHODS: A series of 100 dyspeptic patients were studied. Biopsies were obtained for histology and rapid urease test (gold standard). Serum samples were obtained for Helicobacter pylori IgG and CagA serology, and 13C-urea breath test was carried out. RESULTS: If endoscopy had not been performed in Helicobacter pylori patients based on 13C-urea breath test, <45 years, without alarm symptoms, and without non-steroidal anti-inflammatory drug use, 15% of endoscopies would have been saved, and one gastric ulcer and two oesophagitis would have been missed. Based on Helicobacter pylori IgG serology, 21% of endoscopies would have been saved. Finally, if endoscopy had been performed only in CagA+ patients, 31% of endoscopies would have been saved, missing one gastric ulcer and two cases of oesophagitis. CONCLUSIONS: In our geographical area, the test-and-scope strategy based on 13C-urea breath test or Helicobacter pylori IgG serology would have saved only 15-20% of endoscopies. Although some relevant pathology would have been missed, it is not of a malignant type. 13C-urea breath test is the preferred non-invasive method to be used in this strategy, while Helicobacter pylori IgG serology is of limited value due to its low accuracy. With the use of CagA serology a larger number of unnecessary endoscopic examinations can be avoided.

[Pre and perioperative factors determining early in-hospital mortality in patients over 75 years of age undergoing cardiac surgery]. / Factores pre y perioperatorios determinantes de la mortalidad precoz en pacientes mayores de 75 años sometidos a circulación extracorpórea.

INTRODUCTION AND OBJECTIVES: To know the in-hospital morbidity and mortality and the related factors in patients over 75 years old undergoing cardiac surgery. PATIENTS AND METHODS: A retrospective analysis was carried out in 252 out of 2043 consecutive patients (129 female, 123 male) over 75 years of age (mean age 77.8 years; range 75 to 89 years) undergoing open heart surgery from january 1, 1994 to november 30, 1997. Isolated aortic valve replacement was performed in 128 patients, 78 underwent isolated coronary artery bypass grafting and 46 combined surgery. Preoperative determinants of morbidity and mortality were analyzed. RESULTS: The overall hospital mortality was 15.1%, 13.2% in the aortic group, 12.8% in the coronary group and 23.9% in the combined surgery group. The overall morbidity rate was 38.6% and 25.8%, 34.2% in the aortic and coronary groups, respectively. Preoperative risk factors were prior surgery (p < 0.0004) and emergency operation (p < 0.04). In aortic valve replacement, NYHA class IV (p < 0.05), prior operation (p < 0. 01) and emergency surgery (p < 0.01) were determinant. Perioperative factors of early mortality were: prolonged cross-clamping > 60 min (p < 0.02), cardiopulmonary bypass time > 90 min (p < 0.002), need for inotropic drugs (p < 0.005) and postoperative complications (p < 0.00001). Mean postoperative length of hospital stay was 12.8 +/- 8. 5 days. CONCLUSIONS: Despite the greater rate of early morbimortality in patients over 75 years of age, cardiac surgery may be performed avoiding emergency surgery, functional grade IV and prolonged length of surgery.

["Rapid" serology for the diagnosis of Helicobacter pylori infection. Evaluation of its accuracy compared with a gold-standard and its concordance with "classic" serology]. / Serología "rápida" para el diagnóstico de infección por H. pylori. Estudio de su validez frente a un patrón de referencia y de su concordancia con la serología "clásica".

AIM: To prospectively evaluate the validity of a rapid office-based diagnostic serological test (using capillary blood) in our population, taking as reference a combination of standard diagnostic methods, as well as to compare the results of this technique with those of "classic" serological tests (using venous blood). PATIENTS AND METHODS: We prospectively studied 39 consecutive patients with symptoms of the upper digestive tract who had undergone oral gastroscopy. Gastric biopsies were taken for histology and rapid urease testing, and a 13C-urea breath test was performed. An enzyme-linked immunoassay that detects IgG antibodies against Helicobacter pylori was used as a "classic" serological test and the commercial kit FlexPack HP was used as a "rapid" serological test. The endoscopist, the pathologist and those responsible for reading the rapid urease test, the 13C-urea breath test and both serological tests did not know the results of the other diagnostic methods. Patients were considered H. pylori positive when at least two of the three validated tests (rapid urease test, histology, and 13C-urea breath test) revealed infection and were considered free of infection when all tests were negative. RESULTS: Thirty-nine patients were studied. Thirty-eight per cent were male (mean age 48 +/- 15 years). The prevalence of H. pylori infection detected by the gold standard was 69.2%. The sensitivity and specificity of the "classic" serological test was 96% 95% (CI: 79-99) and 91% (59-100). "Rapid" serological testing was positive in nine patients, negative in 28 and indeterminate in two. A single digital puncture was sufficient in 80% of the patients, 15% needed two and 5% needed three. Most patients (77%) had no preference for either type of serological test while 20.5% preferred digital puncture and 2.5% venous puncture. The sensitivity, specificity, positive predictive value and negative predictive value were 31% (16-50), 91% (59-100), 89% (52-100) and 36% (19-56) respectively. Sensitivity was unaffected by age but specificity was lower in patients older than 40 years (89% vs. 100%; McNemar's test: 8; p < 0.01). Kappa's coefficient between the "classic" and the "rapid" serological tests was 0.16 (SE 0.1) and McNemar's test was 12.2 (p < 0.001), which indicates that the prevalence of infection diagnosed by both methods was not homogeneous. CONCLUSION: The "rapid" office-based serological test used in our study is of insufficient diagnostic accuracy to be used in clinical practice to identify H. pylori infection.

Age-related responses of vasoactive factors during acute exercise.

To evaluate the age-related response of vasoactive factors during acute exercise, young (n = 8, aged 23.6+/-2 years) and old (n = 13, aged 77+/-6 years) healthy volunteers performed a stress test using a treadmill, and blood samples were taken before and after exercise. There were neither basal (old people 77+/-53 vs. young people 67.6+/-40 pg/ml) nor peak exercise-related (old people 77+/-43 vs. young people 66.8+/-34 pg/ml) differences in plasma adrenomedullin (AM) between both groups. AM did not increase with exercise in either group. Regarding plasma cAMP, there were neither basal nor exercise related differences, but this nucleotide increased with exercise in both groups (old people p < 0.0001, young people p < 0.05). Plasma Atrial Natriuretic Peptide (ANP) was higher in basal (116.3+/-64 vs. 46.8+/-21 pg/ml, p < 0.003) and after exercise samples (150.2+/-76.5 vs. 68.7+/-29.5 pg/ml, p < 0.004) in old people as compared with young people. Old people showed an increase in ANP with exercise (p < 0.05), but in young people, though there was a trend to increase, it did not reach statistical significance. There were neither basal nor exercise related differences in plasma cGMP, but this nucleotide increased with exercise in both groups. Angiotensin II (AT-II) levels were lower in basal and after exercise samples in old people as compared with young people. AT-II levels did not increase with exercise in either group. These data suggest that, with increasing age, the vascular tree develops resistance to ANP and higher sensitivity to AT-II, while AM levels do not change. Exercise makes ANP changes more evident, while AM and AT-II are not modified.

Contribution of nitric oxide to exercise-induced changes in healthy volunteers: effects of acute exercise and long-term physical training.

Endothelium plays a central role in the regulation of regional blood flow through the release of certain vasoactive substances. We conducted this study to test whether an increase in the production of nitric oxide (NO) metabolites, atrial natriuretic peptide (ANP) and plasma and intraplatelet cyclic guanosine 3':5' monophosphate (cGMP) is involved in the adaptation to chronic exercise in physically trained people and in the vasodilatation induced by acute physical exercise. We studied one group of 10 trained athletes and another group of 10 untrained people. We measured plasma levels of nitrites, nitrates and cGMP and intraplatelet levels of cGMP, as an indicator of intracellular guanylate cyclase activity, and ANP before and after a maximal treadmill test. Resting cardiac rate (CR) and systolic blood pressure (SBP) were lower in the athlete group than in the control group (73.8 +/- 3.6 vs. 92 +/- 5.9; P < 0.02 and 110 +/- 2.58 vs. 118 +/- 3.27; P < 0.02 respectively). SBP did not show differences between groups after the exercise test. Diastolic blood pressure (DBP) at rest was lower in the athlete group (71 +/- 1.79 vs. 80.5 +/- 3.53; P < 0.03) and the decrease after maximal exercise was more pronounced in this group (64 +/- 2.67 vs. 74.5 +/- 3.2; P < 0.02). Basal plasma nitrites were 4.9 +/- 0.8 in the athlete group and 1.9 +/- 0.3 in the control group (P < 0.05). After exercise, test differences between groups remained (P < 0.05). Nitrates were significantly higher in the group of athletes and did not show exercise-related changes. Plasma levels of cGMP and ANP increased in both groups after the treadmill test, with no differences between groups. Among the athletes, cGMP increased from 1.11 +/- 0.1 to 2.6 +/- 0.4 (P < 0.001), whereas in the untrained group plasma cGMP rose from 1.14 +/- 0.09 to 1.86 +/- 0.2 (P < 0.01). There was a significant correlation between the increases in plasma cGMP and the atrial natriuretic peptide in both groups (r = 0.91, P < 0.0002, for athletes; and r= 0.68, P < 0.04, for control group). The intraplatelet concentration of cGMP did not show differences between groups and did not change after exercise. In conclusion, we have found increased basal levels of plasma nitrite and nitrate in trained subjects. Exercise does not produce differences in the increments of these metabolites. Therefore, we speculate the release of nitric oxide is not augmented by exercise in trained athletes.

Impaired vascular smooth muscle nitric oxide-dependent relaxation in human coronary arteries from "transplanted heart vasculopathy".

The long-term prognosis after heart transplant is mainly determined by the development of transplant vasculopathy. The pathogenic mechanism of transplant vasculopathy remain uncertain, although endothelial dysfunction has been postulated. The objective of this work is to evaluate the smooth muscle and endothelium nitric oxide relaxing mechanisms in coronary arteries from patients with transplant vasculopathy. We studied human coronary arteries obtained from heart transplant surgery specimens of patients with heart transplant vasculopathy, ischaemic cardiopathy or dilated cardiomyopathy. Rings from the coronary arteries were mounted on stainless steel hooks in 40 ml organ bath. The tissues were contracted with phenylephrine (approx. ED 80-90) and concentration-response curves were performed with glyceryltrinitrate and acetylcholine. Glyceryltrinitrate relaxed arterial rings from patients with dilated cardiomyopathy and ischaemic cardiopathy. Arterial rings from patients with heart transplant vasculopathy showed a lower response to glyceryltrinitrate. Acetylcholine induced dilatation of coronary arteries from dilated cardiomyopathy but increased the tension in coronary rings from heart transplant vasculopathy and inschaemic cardiopathy. In conclusion, there is a lower response to glyceryltrinitrate and a paradoxical response to acetylcholine in arteries from patients with transplant vasculopathy. The response to glyceryltrinitrate may be a meaningful tool in the early diagnosis of transplant vasculopathy.

Tricuspid valve replacement in rheumatic disease: preoperative predictors of hospital mortality.

BACKGROUND AND AIM OF THE STUDY: The study analyzes the possible predictive power of different clinical and hemodynamic parameters with regard to hospital mortality after the first tricuspid valve replacement. METHODS: A retrospective study of 62 consecutive patients undergoing tricuspid valve replacement from 1974 to 1994 (7.2% of all tricuspid surgery performed at our institution in this period) was completed. Hospital mortality was 37%. Twenty-three patients died in hospital after the first tricuspid valve replacement (group I) and 39 patients (group II) survived this procedure. Tricuspid insufficiency was organic in 87% of group I and 84.6% of group II. RESULTS: The parameters showing significant differences between the two groups were NYHA class IV (p = 0.05), severe congestive heart failure (p = 0.02), mean right atrial pressure (p = 0.05), pulmonary arterial resistance (p = 0.006) and mean pulmonary arterial pressure (p = 0.0001). Cardiopulmonary bypass time (p = 0.005) and aortic cross-clamp time (p = 0.05) were longer in group I. Multiple regression analysis showed that the variables with greatest predictive power for hospital death were preoperative functional class, congestive heart failure and mean pulmonary artery pressure. The model gave a p < 0.001, with r = 0.58. CONCLUSIONS: The high hospital mortality rate after tricuspid valve replacement seems to be related to clinical functional class, severe congestive heart failure, and to chronic hemodynamic changes in the right atrium and pulmonary circulation.

Effect of isosorbide-5-mononitrate on plasma and urine levels of cyclic GMP in relation to exercise in coronary patients compared with control subjects.

Nitric oxide (NO) and atrial natriuretic peptide (ANP) relax vascular smooth muscle increasing levels of cyclic guanosine 3':5' monophosphate (cGMP). Nitrovasodilators act as exogenous nitric oxide donors. The aim of this study was to ascertain the response of cGMP to exercise without medication and after the administration of 20 mg of isosorbide-5-mononitrate (IS-5-MN) in coronary patients (n = 8) and healthy control subjects (n = 9). A third group of 10 normal volunteers was studied to test plasma cGMP response to second exercise test without IS-5-MN administration. Plasma cGMP increased significantly in both patients (P < 0.02) and controls (P < 0.01) after the first ergometry. After IS-5-MN administration, plasma cGMP did not increase either before or after exercise. In normal volunteers without IS-5-MN plasma cGMP increased significantly after first (P < 0.004) and second (P < 0.0008) exercise test. In conclusion, plasma cGMP increases during exercise. Administration of IS-5-MN does not raise plasma cGMP and neither does performance of further exercise after its administration.

Local transdermal glyceryl trinitrate has an antiinflammatory action on thrombophlebitis induced by sclerosis of leg varicose veins.

To test the antiinflammatory and analgesic effects of transdermal glyceryl trinitrate (GTN) the authors carried out a double-blind, randomized, controlled clinical study in 21 patients with mild to moderate leg varicose veins who underwent vein sclerotherapy in both legs. GTN or placebo ointment was applied in a blinded protocol along the surface of the sclerosed vein every eight hours until disappearance of inflammation signs. The varicose vein in one leg was treated with GTN and compared with placebo for the vein of the other leg used as control of thrombophlebitis (TP) signs. Fifteen minutes after first application inflammation signs were observed in all cases. The intensity of inflammation signs was assessed as 26% (10.4 +/- 4.1) in GTN-treated veins and as 61.5% (24.6 +/- 6.3) (P < 0.001) in the placebo-treated veins. One hour later only 63% of cases in the GTN group and all cases in the placebo group showed signs of TP (P < 0.001). The reduction in the intensity of signs at this time was 7.7 +/- 3.9 in the GTN group and 19.7 +/- 6.3 in the placebo group (P < 0.001). All veins in the GTN group were free of signs of TP in less than forty-eight hours. In the placebo group, 45% of veins required more than forty-eight hours for complete disappearance of signs of TP (P < 0.001). The authors conclude that GTN has an antiinflammatory effect in TP induced by sclerotherapy. This action may be related to the nitric oxide released from GTN, through a direct action on the vein and the surrounding inflamed tissue.

Induction of nitric oxide synthase in human mammary arteries in vitro.

This study investigated whether human mammary arteries express an inducible nitric oxide (NO) synthase and, if so, what its effects are on vascular tone. In human mammary artery pre-contracted with phenylephrine there was a gradual time-dependent loss of tone over an 8 h period. L-Arginine and lipopolysaccharide enhanced the rate but not the magnitude of this loss in tone, whereas NG-nitro-L-arginine, NG-monomethyl-L-arginine, dexamethasone, and polymyxin B inhibited these effects. These findings indicate that incubation of human mammary artery with lipopolysaccharide resulted in the expression of an inducible NO synthase. The induction of this enzyme in human vessels may be important in the pathogenesis of septic shock.

Low levels of intraplatelet cGMP in IDDM.

OBJECTIVE: To determine the levels of intraplatelet cGMP, an index of activity of the antiaggregatory nitric oxide pathway, in IDDM patients. RESEARCH DESIGN AND METHODS: We measured intraplatelet and plasmatic cGMP levels in 22 IDDM patients and 22 age- and sex-matched control subjects. RESULTS: Intraplatelet cGMP levels decreased in the IDDM patients (0.32 +/- 0.16 pmol/10(9) platelets) when compared with the control group (0.52 +/- 0.32 pmol/10(9) platelets), P = 0.032. Plasmatic cGMP levels were not significantly different between groups. Intraplatelet cGMP levels correlated negatively with the duration of the disease (r = -0.43, P < 0.05). CONCLUSIONS: IDDM patients have lower levels of intraplatelet cGMP, which may be responsible in part for their platelet hyperactivity.

[The incidence of arrhythmias in young persons without demonstrable heart disease: a 24-hour Holter study in 100 medical students]. / Incidencia de arritmias en jóvenes sin enfermedad cardíaca demostrada: estudio con Holter de 24 horas en 100 estudiantes de medicina.

A Holter monitorization study was performed in 100 voluntary university students (64 men and 36 women). The mean age was 23.6 years and organic heart disease was ruled out in all cases. Data were analysed in different subgroups including the practice of physical activity and subjects smokers or alcohol consumers. The maximum heart rate (HR) achieved during the wake period was 138.3 +/- 20.43 beat/m. Minimum daytime heart rate was 61.42 +/- 10.32 beat/m and it was below 60 beat/m in 41 subjects. During the nighttime period, the maximum heart rate achieved by the group was 89.34 +/- 11.31 beat/m. Minimum nighttime heart rate was 45.82 +/- 6.35 beat/m. Maximum heart rate in men was 134.3 +/- 21.35 beat/m, while in women was 145.42 +/- 16.36 beat/m. Eighty students presented one or more arrhythmias, among them 28 women and 52 men (p = NS): 92% in sportsmen and women groups as compared with 79% in the non sports practicers, 90% of alcohol consumers and 82% between subjects who smoked and drank, compared with 63% in the non drinkers (p < 0.006). 48% of the subjects presented one or more supraventricular arrhythmias during the daytime or during the nighttime (p = NS). Ventricular rhythm disturbances were found in 20 subjects. There was only one case who had a non sustained ventricular tachycardia of 4 complexes. These disturbances were not increased by practising sport nor by toxic habits. In 15 cases we found sinoatrial block, with a male predominance. Five subjects presented some type of atrioventricular block, 4 of which were alcohol and tobacco consumers.(ABSTRACT TRUNCATED AT 250 WORDS)

The anti-inflammatory and analgesic action of transdermal glyceryltrinitrate in the treatment of infusion-related thrombophlebitis.

We have carried out a prospective double-blind randomized study in 40 patients with infusion-related thrombophlebitis. Twenty-two patients were included in the glyceryltrinitrate (GTN) ointment group and 18 patients in the control heparinoid group. Pain was assessed by an analogue scale. At 48 hours the analgesic index was 84.6 +/- 18 units with GTN and 49 +/- 45 units with heparinoid ointment (P < 0.01). Faster relief of oedema was also observed in the GTN-treated group. All signs of thrombophlebitis were relieved in less than 4 days in the GTN group compared with 9 days in the controls (P < 0.005). We conclude that transdermal GTN is useful therapy for infusion-related thrombophlebitis showing evidence of anti-inflammatory and analgesic effect.

[The peripheral analgesic action of the exogenous nitric oxide donor: nitroglycerin. A placebo-controlled study of the transdermal action of nitroglycerin on pain sensitivity in the forearm]. / Acción analgésica periférica del donador exógeno de óxido nítrico: nitroglicerina. Estudio control frente a placebo de la acción de la nitroglicerina transdérmica sobre la sensibilidad dolorosa en el antebrazo.

Nitric oxide is a biological mediator. In nervous system it acts like neurotransmitter and also modulate acute inflammation. In the peripheral nervous system it blocks the nociceptive stimulus through an increase in postsynaptic neurone GMPc level. Nitro-vasodilator drugs like nitroglycerin are metabolised in the cell given rise to short lived intermediates, which liberating nitric oxide that activate the guanylate cyclase enzyme, increasing the GMPc in smooth muscle cell. This study show that nitroglycerin produces an analgesic action. The pain sensitivity to pinprick test in forearm with nitroglycerin has shown a decrease in a significative manner against placebo. We speculate that nitroglycerin could have a similar action as endogenous nitric oxide in nervous system.

[Chronotropic changes and cardiac arrhythmias during anesthetic induction and intubation in patients undergoing heart surgery. Study of 79 patients using Holter monitoring]. / Cambios cronotrópicos y arritmias cardíacas durante la inducción anestésica y la intubación en pacientes sometidos a cirugía cardíaca. Estudio de 79 pacientes con registro Holter.

OBJECTIVES: To assess changes in heart rate and cardiac arrhythmias during anaesthetic induction and tracheal intubation in patients undergoing cardiac surgery. MATERIAL AND METHODS: 79 patients scheduled for cardiac surgery were divided into three groups: group I, 36 valvular diseases with a good ventricular function, group II, 22 valvular diseases with an ejection fraction less than 0.5, and group III, included 21 patients with coronary artery disease. All patients had a Holter monitoring. Anesthesia was performed with diazepam and morphine in patients with valvular disease and with diazepam and fentanyl in those with coronary artery disease. RESULTS: During anesthesia induction there were no significant increases in heart rate in the two groups of patients with valvular diseases: in group I (n = 36, with good ventricular function) heart rate increased by about 5.4 +/- 23% and in group II (n = 22, with ejection fraction less than 0.5) by 7.5 +/- 33%. In patients with coronary artery disease (n = 21) we did not observe significant decreases in heart rate (-4.28 +/- 17%). During tracheal intubation the heart rate increased by 15.9 +/- 30% in group I (p < 0.002), by 13.6 +/- 30% in group II (p < 0.02), but decreased by 1.19 +/- 23% (p = NS) in patients with coronary artery disease. During anesthetic induction we observed frequent premature beats (single forms) in 13.8% of patients in group I, 13.6% in group II, and 9.5% in group III. The incidence of this arrhythmia during tracheal intubation was 16.6%, 9%, and 14%, respectively for the three groups. Sustained ventricular tachycardia was only observed in one patient. CONCLUSIONS: Changes in heart rate and ventricular arrhythmias occurring during anesthetic induction and tracheal intubation in patients undergoing valvular and coronary surgery were infrequent and not severe.