Empirical treatment followed by a test-and-treat strategy is more cost-effective in comparison with prompt endoscopy or radiography in patients with dyspeptic symptoms: a randomized trial in a primary care setting.

OBJECTIVE: Management of patients with dyspepsia remains controversial. No consensus has yet been reached concerning diagnostic and medical strategies. We conducted a randomized trial to assess the effectiveness of three management strategies for patients with uninvestigated persistent dyspeptic symptoms. METHODS: A total of 199 patients presenting in primary care with dyspeptic symptoms (age 18-65 years, no alarming symptoms) were randomized to either empirical treatment with omeprazole and, in the case of symptomatic relapse, serological Helicobacter pylori infection testing plus eradication therapy (treat-and-test group), prompt upper gastrointestinal endoscopy (endoscopy group) or prompt upper gastrointestinal radiography (radiography group) followed by directed medical treatment. Symptoms, patients' satisfaction and use of resources were recorded during 6 months of follow-up. RESULTS: Sixty-nine patients were assigned to the treat-and-test group, 64 to the radiography group and 66 to the endoscopy group. The median age was 44 years; 104 patients were male and 37% were H.pylori infected. A total of 170 patients (85%) returned the 6 months questionnaire. The numbers of patients with complete symptom relief in the treat-and-test group, endoscopy group and radiography group were 21, 16 and 15, respectively, at 3 months (P = 0.59), and 23, 13 and 12, respectively, at 6 months (P = 0.05). Twenty-two patients in the treat-and-test group underwent endoscopy or radiography. Two patients in the endoscopy group and four patients in the radiography group underwent more than one diagnostic test. The average medical cost per patient for the treat-and-test group was euro 276, for the endoscopy group euro 426 and for the radiography group euro 321, respectively. CONCLUSION: Empirical treatment followed by a test-and-eradicate strategy resulted in fewer diagnostic tests, more symptom relief and lower medical costs compared with prompt upper gastrointestinal radiography or endoscopy in the management of uninvestigated patients with persistent dyspeptic symptoms.

Covenant between gastroenterology and internal medicine in The Netherlands: a major step forward.

Recently, The Netherlands Society of Gastroenterohepatology (Nederlands Genootschap Maag-Darm-Leverartsen; NGMDL) and the Netherlands Association of Internal Medicine (Nederlandse Internisten Vereniging; NIV) set up a covenant to optimise the collaboration between internists and gastroenterologists. Important points: certification of endoscopic skills; training of residents of internal medicine with regard to pathology of the stomach, intestines and liver as well as to endoscopy, and the training in internal medicine of residents in gastroenterology; defining competence of gastroenterologists for night and weekend duties in internal medicine.

A concept for a decision support system based on practical experiences from a national disease emergency. The Dutch experience.

In 1997-1998, the Netherlands experienced a large epidemic of classical swine fever (CSF). The magnitude of this epidemic stressed the role information systems could play in supporting the management during an eradication campaign. The enforcement of an eradication strategy can become very complicated, especially with large epidemics, due to time pressure and many different procedures that have to be executed at the same time. The application of comprehensive information systems may result in more control over the process and in a relief of the operational management. After a brief description of the Dutch epidemic the authors provide an overview and the general application of four different types of information systems, classified as decision support systems. The application of these information systems in animal disease control is illustrated by providing concepts for a system architecture for transaction processing, management and executive information support and decision support. The application of a data warehouse as part of this systems architecture is explained. The eradication of CSF from the Netherlands was complicated by several factors. It is important to notice that information systems cannot prevent these factors. However, information systems can support disease control authorities in controlling these factors.

Short-term follow-up by serology of patients given antibiotic treatment for Helicobacter pylori infection.

Helicobacter pylori serology and in particular enzyme-linked immunosorbent assays for the measurement of immunoglobulin G (IgG) antibody titers form an accurate means of diagnosing H. pylori infection in patients before treatment. H. pylori serology is of limited value in monitoring treatment because of the slow decline in antibody titers. In the present study we aimed to measure the most suitable moment after antibiotic treatment at which serology should be used to monitor treatment. Sixty-four patients who had nonulcer dyspepsia and H. pylori infection and who underwent upper gastrointestinal endoscopy because of persistent dyspeptic symptoms were included in the study. H. pylori cure was confirmed by histology and culture 5 weeks after the completion of the antibiotic treatment. Serological examination was performed before therapy and at 5 weeks, 10 weeks, and 1 year after the completion of antibiotic treatment. Diagnostic performance was assessed by receiver-operating characteristic analysis. The areas under the receiver-operating characteristic curves of the H. pylori antibody titers at 5 weeks, 10 weeks, and 1 year after the completion of treatment were 0.53 (95% confidence interval [CI], 0.36 to 0.69), 0.60 (95% CI, 0.43 to 0.76), and 0.78 (95% CI, 0.63 to 0.93), respectively. The areas under the receiver-operating characteristic curves of the changes in H. pylori IgG antibody titers at 5 weeks, 10 weeks, and 1 year after the completion of treatment in comparison with the pretreatment titers were 0.85 (95% CI, 0.72 to 0.97), 0.96 (95% CI, 0.89 to 1.0), and 1.0 (95% CI, not estimable), respectively. We conclude that serology forms a useful means of monitoring treatment in patients with nonulcer dyspepsia and H. pylori infection as early as 10 weeks and maybe even sooner after the completion of treatment for the infection.

Severe upper abdominal pain due to a large hepatocellular adenoma.

A large hepatocellular adenoma was diagnosed in a female patient who was referred for severe upper abdominal pain. She had been using oral contraceptives over a period of 14 years. The clinical features, diagnosis and treatment are discussed.

Estimating sample sizes for a two-stage sampling survey of seroprevalence of pseudorabies virus (PRV)-infected swine at a regional level in The Netherlands.

In the European Union, vaccination campaigns against Pseudorabies virus (PRV) in swine have been started to eradicate PRV. Specific sampling designs are needed to monitor PRV seroprevalence at a regional level. This paper demonstrates how sampling theory can be applied to design a disease seroprevalence survey, using PRV as an example. In the spring of 1994, the four regions in the Netherlands covered by the regional Animal Health Services were monitored with respect to PRV seroprevalence. Per region, blood samples from approximately 1400 herds, with two animals per herd, were collected. The sampling design accounted for stratification by fattening pig and sow population within each region. The regional PRV seroprevalence of swine in the Southern region was the highest (24.9%), closely followed by the PRV seroprevalence of swine in the Eastern region (20.5%). These regions have the highest density of swine in the Netherlands. The PRV seroprevalence in the Western and Central region (11.7%) was about half of the seroprevalence in the Southern and Eastern regions; the lowest regional PRV seroprevalence was observed in the Northern region (3.5%). The Northern part also has the lowest pig density. The PRV seroprevalence was approximately two times higher in sows than in fattening pigs.

Improvement of gastric inflammation and resolution of epithelial damage one year after eradication of Helicobacter pylori.

AIMS: To investigate the effect of eradication of Helicobacter pylori infection on gastric epithelial damage and gastritis, scored according to the Sydney system. METHODS: Gastritis scores and epithelial damage were assessed in gastric biopsy specimens before, and five weeks and one year after anti-H pylori therapy in 66 patients with H pylori related gastritis. RESULTS: The mean initial levels of activity, inflammation, atrophy, intestinal metaplasia, and H pylori scores were higher in the antrum than in the corpus or fundus. Eradication of H pylori resulted in an improvement in the mean inflammatory score in antral biopsy specimens from 2.23 before treatment to 1.32 and 1.06, respectively, five weeks and one year after treatment. Corresponding values for fundic biopsy specimens were 1.30, 0.36 and 0.35. Activity scores improved from 1.41 before treatment to 0.13 and zero, respectively, five weeks and one year after treatment in antral biopsy specimens and from 0.60 before treatment to zero in fundic biopsy specimens. Before treatment, epithelial damage was present in 51% of biopsy specimens taken from the antrum and 23% of those from the corpus. Five weeks after eradication of H pylori none of the biopsy specimens revealed evidence of epithelial damage. CONCLUSION: Eradication of H pylori is followed by a rapid, significant improvement in the gastritis score and resolution of epithelial damage in antral and fundic mucosa.

Basal serum gastrin concentrations before and after eradication of Helicobacter pylori infection measured by sequence specific radioimmunoassays.

BACKGROUND: Helicobacter pylori infection of the antral mucosa is responsible for an increase in basal and stimulated serum gastrin. In the present study we have investigated whether gastritis induced by H. pylori is responsible for abnormalities in the processing of gastrin in dyspeptic patients. METHODS: Basal serum gastrin was measured by radioimmunoassay before, 5 weeks, and 1 year after anti-H. pylori therapy in 73 H. pylori positive functional dyspeptic patients. Three region-specific antisera were used, specific for the biologically active carboxy-terminal part, the biologically inactive amino-terminal part of gastrin 1-17, and for the non-sulphated tyrosyl residue in gastrin 1-17. RESULTS: Basal serum gastrin levels were markedly (P < 0.01) decreased 5 weeks and 1 year after successful eradication of H. pylori (n = 39) but not in the patients in whom treatment failed (n = 34). A decline of gastrin was observed for each of the three radioimmunoassays. CONCLUSION: The decrease of serum gastrin levels in all three radioimmunoassays after a successful eradication of H. pylori does not point to major changes in the processing of gastrin. These results suggest that G-cells in the antral mucosa are not functionally affected by the inflammation.

Short report: smoking habits and the acquisition of metronidazole resistance in patients with Helicobacter pylori-related gastritis.

Thirty-three dyspeptic patients with colonization of Helicobacter pylori in the gastric antrum were treated with tripotassium dicitrate bismuthate 120 mg q.d.s. for 28 days and metronidazole 250 mg q.d.s. for 10 days starting on day 19. Five weeks after cessation of this treatment regimen H. pylori was eradicated in 23 patients. In 8 of the remaining 10 patients, H. pylori had become resistant to metronidazole. In this study resistance was significantly associated with smoking habits, but not with age, bacterial load, gastritis score or alcohol consumption.

Obstructive jejunal adenocarcinoma in the Muir-Torre syndrome.

A young male patient was referred for endoscopic resection of a recto-sigmoid polyp and abdominal complaints. His medical history revealed a sebaceous adenoma resection from his back and a tubular adenoma excision from his right upper eyelid. After disclosure of a jejunal tumour on a small bowel enema and given the remarkable family history characterized by the frequent occurrence of bowel cancer, the diagnosis of Muir-Torre syndrome was established. This syndrome pertains to the combination of sebaceous gland tumours/adenomas in combination with gastrointestinal or genitourinary tract tumours. Inheritance takes place in an autosomal dominant manner. It usually occurs in males at an early age. Given its low malignancy potential, early detection of the syndrome renders a favourable prognosis. Careful examination and follow-up also involving the small intestine are mandatory for patients and relatives.

Acute intermittent porphyria and primary liver-cell carcinoma.

A patient known with acute intermittent porphyria who developed primary liver-cell carcinoma is described. No other risk factors were found. A possible association of acute intermittent porphyria with the development of primary liver-cell carcinoma has been suggested in recent, mainly Scandinavian literature. So far this association has never been described in The Netherlands.

[Evaluation of the roentgenological and endoscopic diagnosis in malignities of the proximal digestive tract]. / Evaluatie van de röntgenologische en de endoscopische diagnostiek bij maligniteiten van de proximale tractus digestivus.

During 1968-1988 one endoscopist performed 3154 endoscopic examinations of the upper gastrointestinal tract and detected 400 (13%) malignancies. Endoscopy was indicated in persisting dyspepsia or abnormal findings on X-ray examination of the stomach. In 242 patients earlier subjected to partial gastrectomy 7% stomach cancers were found. No difference existed in the incidence of stomach cancer between patients with either BI and BII gastrectomy. Initially no malignancy was detected in 9 (2.3%) patients. The maximum diagnostic delay was 5 months in these patients. This finding underlines the necessity of a strict follow-up scheme when studying malignancies.

Relapsing pleural exudate complicating chronic pancreatitis.

Chronic pancreatitis, often with a pseudocyst, is a rare cause of a pleural exudate. A pancreatic pleural fistula is created, leading to a relapsing massive haemorrhagic pleural exudate with a very high amylase content. The diagnosis is confirmed by means of endoscopic retrograde pancreatography. Treatment is primarily conservative; surgical drainage is sometimes necessary. The prognosis is generally favourable. The case history of a young woman with this condition is presented.

Estimation of maximum expiratory flow-volume variables in children.

Different protocols for pulmonary function testing were evaluated in 611 children, 6-9 years old. Attention was paid to the necessary minimum number of acceptable maneuvers, the necessary maximum number of attempts, and the best of seven different methods for summarizing variables from maximum expiratory flow-volume (MEFV) curves. The results of the study indicate that it is not useful to continue pulmonary function testing after eight attempts. The differences between the results from three or five acceptable maneuvers are not substantial for any method; in children, obtaining three acceptable curves seems sufficient. When flow variables are selected from one acceptable curve, as in the American Thoracic Society (ATS) guidelines, the reproducibility is somewhat less good than in methods in which results of various curves are averaged or selection is made from different curves. The method that has been recommended by the European Community for Coal and Steel for the selection of MEFV variables in teenagers and adults in Europe, was also demonstrated to be suitable for younger children.

Immunofluorescence detection of liver cell membrane autoantibodies using PLC/PRF/5 cells.

Detection of liver cell membrane autoantibodies is routinely performed by immunofluorescence testing of patient sera on rabbit hepatocyte suspensions. We have investigated the possible use of cells from the PLC/PRF/5 human hepatoma cell-line. These cells were employed as substrate in an immunofluorescence test which was compared with the conventional rabbit hepatocyte assay. We found a close correlation between the results obtained with these different substrates on visual reading. We furthermore compared visual reading of immunofluorescence preparations with flow-cytometrical analysis of immunostained cell suspensions. The results with these different methods were largely confirmatory. The PLC/PRF/5 cells are easily available and should therefore be regarded as a highly valuable new substrate for detection of liver cell membrane autoantibodies. Flow cytometry appears to be a technically simple and reliable method for quantitative analysis.

In vitro and in vivo cytotoxic activity of native and ricin conjugated monoclonal antibodies to HBs antigen for Alexander primary liver cell carcinoma cells and tumours.

In in vitro and in vivo systems, native or ricin conjugated monoclonal anti-HBs, are capable of inhibiting or slowing the growth of Alexander primary hepatocellular carcinoma cells. Failure of the immune response to this component of the hepatitis B virus may be one permissive factor in the development of some primary liver cell carcinoma in chronic HBV carriers.

Hepatitis B virus and host cell membrane antigens on a primary hepatocellular carcinoma cell line.

We have defined some membrane antigens of the cultured hepatocellular carcinoma cell line PLC/PRF/5, which contains the integrated genome of hepatitis B virus. Using fluoresceinated antibodies, we identified HLA Class 1 glycoprotein and HB surface antigen on the membrane. Only in a minority of cells was physical association of these antigens demonstrated by co-capping. The presence of a "division" antigen was indicated by reactivity of the cells with the murine monoclonal antibody OKT9.

Injuries in confined sows. Incidence and relation with behaviour.

A survey has been carried out to determine if welfare relevant differences could be found between the various systems of individual housing (stalls and tethering by neck collar, neck harness and shoulder girth) for dry sows. The pattern of lesions on the integument has been used as an indicator for well-being. The set up of this way of assessing well-being, called the Ekesbo Method, has been described briefly. Except for neck collar tethering, the sows did not show major differences in lesion level. Neck collar tethering is therefore strongly discouraged. The other systems are, to a large extent, comparable. Yet a number of system dependent differences do occur. Initial adaptation to tethering can be a problem. Also, when the size of the system is not in good harmony with the body size, the number of lesions increased. Shoulder girth, especially in combination with fixing to the partition, slightly hampered the sows when getting up. Also floor design had an influence on the lesion pattern. Poor quality slats induced an increase in the number of lesions. Between full concrete floors and good quality slats no difference could be demonstrated. The Ekesbo Method seems to be a useful way to assess well-being in different environments.