Unsedated transnasal EGD: an alternative approach to conventional esophagogastroduodenoscopy for documenting Helicobacter pylori eradication.

BACKGROUND: The aim of this study was to assess the yield of antral biopsies performed via unsedated transnasal esophagogastroduodenoscopy, a technique that does not require conscious sedation with its concomitant costs and complications, for documentation of Helicobacter pylori eradication. METHODS: Nineteen patients who were previously CLO test positive on conventional esophagogastroduodenoscopy and subsequently treated for H pylori infection were enrolled. The subjects had not received antibiotic therapy in the prior month and had no prior gastric surgery. By using a GIF-N30 fiberoptic endoscope and a tiny cup biopsy forceps (1.8 mm diameter), unsedated transnasal endoscopy was performed and antral biopsy specimens were taken for a CLO test, histologic analysis (Dieterle stain), and tissue culture. On the same day, the subjects underwent a carbon 13-labeled area urea breath test. All subjects completed a visual analog scale, rating the acceptability of the unsedated transnasal examination and the previous sedated conventional esophagogastroduodenoscopy. RESULTS: There was no statistically significant difference between the results of the CLO tests (5/19 positive) versus the 13C-urea breath test (4/19 positive) (p = 0.96), the CLO tests versus histologic findings (5/19 positive) (p = 0.71), or the 13C-urea breath test versus histologic findings (p = 0.96). All tissue culture results were negative. The overall acceptability of unsedated transnasal esophagogastroduodenoscopy was similar to that of sedated conventional esophagogastroduodenoscopy. CONCLUSION: Unsedated transnasal esophagogastroduodenoscopy, a technique that eliminates the costs and complications associated with conscious sedation, is a feasible and accurate alternative to conventional esophagogastroduodenoscopy when documentation of H pylori eradication and confirmation of gastric ulcer healing are both indicated.

Evaluation of dyspepsia and functional gastrointestinal disorders: a cost-benefit analysis of different approaches.

OBJECTIVE: To establish a decision rule for diagnostic testing in patients with dyspepsia. DESIGN: Medical decision analysis using a decision-tree model. METHODS: Costs and benefits associated with two alternative strategies are compared. In the first strategy, empirical therapy alone is provided. The second strategy also includes tests to diagnose the cause of dyspepsia. RESULTS: It is more beneficial to test than to employ empirical treatment alone if the a-priori probability P of an organic disease is larger than the ratio of the costs T of testing to the costs C of a missed diagnosis: P > T/C. In most clinical situations, the costs of a missed diagnosis outweigh the costs of testing by a factor of 5-10, for which the cost ratio is 10-20%. CONCLUSION: Diagnostic tests should be performed in patients with dyspepsia, whenever the probability of finding organic disease exceeds the ratio of the cost of testing to the cost of missing this diagnosis.

Costs of duodenal ulcer therapy with antibiotics.

BACKGROUND: Intermittent or maintenance therapy with histamine2 antagonists, highly selective vagotomy, or antibiotic therapy to eradicate Helicobacter pylori all represent distinct, viable options to manage duodenal ulcer disease. Comparing the costs associated with these four approaches could help in deciding among them. METHODS: The decision model of a Markov chain was used to compare the costs of the four approaches and their influence on the natural course of duodenal ulcers. Direct costs were calculated from the average wholesale prices of drugs and from charges for medical services submitted to and allowed by the Health Care Financing Administration. Average annual income was used to estimate indirect costs. RESULTS: The model predicted that after antibiotic therapy, 99.7% of patient time is spent free of duodenal ulcer. The corresponding percentages were 96.6% for maintenance therapy, 94.4% for vagotomy, 89.4% for intermittent therapy, and 82.8% without therapy. For an individual patient after 15 years, the expected total costs of a treatment approach involving antibiotics are $995, compared with $10,350 for intermittent therapy with histamine2 antagonists, $11,186 for maintenance therapy with histamine2 antagonists, and $17,661 after vagotomy. Incorporating upper gastrointestinal tract endoscopy to verify eradication of H pylori raises the costs of the antibiotic therapy option to $2426. Increasing the annual infection rate of H pylori from baseline 1% to 10% raises the expected costs after 15 years to $3431. Decreasing the H pylori eradication rate from baseline 80% to 50% raises the costs to $2679. CONCLUSIONS: Compared with other options, antibiotics to eradicate H pylori are the cheapest therapy for duodenal ulcer and provide the least time spent with an active ulcer. From an economic perspective, antibiotics represent the treatment of choice.

Coordination of deglutition and phases of respiration: effect of aging, tachypnea, bolus volume, and chronic obstructive pulmonary disease.

The effects of aging, tachypnea, bolus volume, and chronic obstructive pulmonary disease on the coordination of swallowing with the phases of respiration were studied by concurrent respirography and submental surface electromyography. Study findings showed that in young healthy volunteers, during rest, there is preferential coupling of subconscious swallowing with the expiratory phase of continuous respiration. This preferential coupling of swallowing with expiration was found to increase relative to other phases of respiration during water swallows and tachypnea (P < 0.05). Respiratory phase occurrence of swallowing and postdeglutitive resumption of respiration during exacerbation of chronic obstructive pulmonary disease was found to be significantly different compared with the basal state (P < 0.05). Respiratory phase occurrence of subconscious swallowing in the elderly was found to be different from the young (P < 0.05). Position had no significant effect on the coordination of swallowing and phases of respiration. We concluded that in resting young volunteers the majority of deglutitions are coupled with the expiratory phase of swallowing. This coupling is increased in frequency by the presence of a liquid bolus and tachypnea. And finally, age and chronic obstructive pulmonary disease alter this coordination significantly.

Preoperative testing for fecal occult blood: a questionable practice.

The benefit of fecal occult blood testing (FOBT) in patients without gastrointestinal symptoms who are hospitalized for an elective surgical procedure is uncertain. To resolve this issue, we analyzed the costs and benefits of preoperative FOBT by the model of a decision tree. In 2- and 3-way sensitivity analyses, the costs of diagnostic and therapeutic procedures and the probabilities of their various outcomes are varied simultaneously so that we might study their joint influence on the outcome of the decision analysis. The decision analysis shows that preoperative FOBT is associated with a smaller benefit than would be its omission. The higher cost and lower net benefit of preoperative FOBT reflect the impact of false-positive tests for occult blood. False-positive FOBT leads to expenditures for negative gastrointestinal work-ups, increased procedural costs, and a diminished rate of success for the elective surgical procedure, by delaying it. This outcome of the analysis is insensitive to large variations in the costs and probabilities built into the model. We conclude that screening for fecal occult blood provides no benefit if done routinely in patients who are hospitalized for any major surgical procedure.

Testing for Helicobacter pylori in the diagnosis of Zollinger-Ellison syndrome.

Infection with Helicobacter pylori is associated with almost all cases of peptic ulcer. Using Bayes' formula, we evaluated whether testing for H. pylori in a patient with proven ulcer might help in the work-up of a Zollinger-Ellison syndrome (ZE). A negative test for H. pylori in a patient with duodenal ulcer would raise a pretest probability for ZE of 10-20% to a posttest range of 61-78%. The information provided by a negative test result with respect to ZE is greater in younger than in older ulcer patients. It is also greater in duodenal than gastric ulcer. We conclude that testing for H. pylori in ulcer patients, in whom ZE constitutes a possible differential diagnosis, adds substantially to the decision making at relatively low cost and little additional risk to the patient.

Erythrocyte aldehyde dehydrogenase: assay of a potential biochemical marker of alcohol abuse.

Erythrocyte aldehyde dehydrogenase (ALDH; EC 1.2.1.3) may be a new biochemical indicator of alcohol abuse. An improved assay for it is described and characterized. We found that expression of erythrocyte ALDH activity in terms of hemoglobin was valid, and preferable to expression in terms of erythrocyte volume. A normal reference interval was determined from results for 375 healthy subjects (236 men, 139 women). We compared these data with results for 109 men admitted to our alcohol detoxification program. The mean erythrocyte ALDH of the alcohol abusers was 30% lower than our mean value for men (p less than 0.001). Values did not change between the time the patient presented for admission and greater than 48 h later (when blood-ethanol concentration was zero). Other variables that affect erythrocyte ALDH activities--changes in pH, temperature, other assay conditions, and drug treatments such as disulfiram and nitrate anti-anginals--are discussed.

Erythrocyte aldehyde dehydrogenase and clinical chemical markers of alcohol abuse and alcoholism.

An improved method for the measurement of erythrocyte aldehyde dehydrogenase (ALDH) activity was developed and used to determine the enzyme activity in 38 male Caucasian patients admitted to this VA Medical Center for alcohol detoxification. Patients who had been treated within a year prior to the study with any drug known to inhibit ALDH, such as disulfiram, were excluded from the study. In agreement with previous reports, the erythrocyte ALDH levels were decreased relative to non-alcoholic controls. However, no useful correlation was found between the erythrocyte ALDH levels and any of 35 standard clinical chemical and hematological parameters including those that indicated alcoholic liver disease.

Effect of cholera toxin on ileal water and solute transport after resection of the proximal small intestine in the rat.

Intestinal adaptation after extensive small bowel resection results in mucosal hypertrophy and an increased capacity of the remaining small intestine to absorb solutes and water. We tested the ability of the adapted rat ileum to respond to a secretory stimulus, cholera toxin. Six weeks after 50% jejunal resection (short gut) or sham operation water and solute transport were measured in a 16 cm segment of ileum before and after exposure to cholera toxin in a single pass in vivo perfusion system. During the control periods absorption of glucose, acetate and water per unit length of intestine was significantly greater in short gut animals (P less than 0.05 to 0.001). After exposure to cholera toxin absorption of glucose and acetate was significantly reduced in both groups (P less than 0.05 to 0.01). Sodium and chloride secretion and net change in water movement in response to cholera toxin were significantly greater (P less than 0.05 to 0.01) in short gut animals. Generally the differences between short gut and sham operation animals disappeared when the data were normalised for mucosal weight. Chloride secretion per gram mucosa was less in short gut animals (P less than 0.001). The data indicate that the adapted small bowel is not only capable of enhanced absorption but also of enhanced net secretion in response to cholera toxin. The changes reflect the increased number of enterocytes per unit length of intestine after intestinal adaptation.

Seasat altimeter calibration: initial results.

Preliminary analysis of radar altimeter data indicates that the instrument has met its specifications for measuring spacecraft height above the ocean surface (+/- 10 centimeters) and significant wave height (+/- 0.5 meter). There is ample evidence that the radar altimeter, having undergone development through three earth orbit missions [Skylab, Geodynamics Experimental Ocean Satellite 3 (GEOS-3), and Seasat], has reached a level of precision that now makes possible its use for important quantitative oceanographic investigations and practical applications.

Cephalosporin-associated pseudomembranous colitis.

Diarrhea and pseudomembranous colitis appeared in a patient receiving antibiotic therapy with cephalosporin derivatives only. There was a prompt remission following treatment with cholestyramine resin.