Clinical trial: a randomized trial of early endoscopy, Helicobacter pylori testing and empirical therapy for the management of dyspepsia in primary care.

BACKGROUND: Early endoscopy, Helicobacter pylori eradication and empirical acid suppression are commonly used dyspepsia management strategies in primary care but have not been directly compared in a single trial. AIM: To compare endoscopy, H. pylori test and refer, H. pylori test and treat and empirical acid suppression for dyspepsia in primary care. METHODS: Patients presenting to their general practitioner with dyspepsia were randomized to endoscopy, H. pylori'test and treat', H. pylori test and endoscope positives, or empirical therapy with symptoms, patient satisfaction, healthcare costs and cost effectiveness at 12 months being the outcomes. RESULTS: At 2 months, the proportion of patients reporting no or minimal dyspeptic symptoms ranged from 74% for those having early endoscopy to 55% for those on empirical therapy (P = 0.009), but at 1 year, there was little difference among the four strategies. Early endoscopy was associated with fewer subsequent consultations for dyspepsia (P = 0.003). 'Test and treat' resulted in fewer endoscopies overall and was most cost-effective over a range of cost assumptions. Empirical therapy resulted in the lowest initial costs, but the highest rate of subsequent endoscopy. Gastro-oesophageal cancers were found in four patients randomized to the H. pylori testing strategies. CONCLUSIONS: While early endoscopy offered some advantages 'Test and treat' was the most cost-effective strategy. In older patients, early endoscopy may be an appropriate strategy in view of the greater risk of malignant disease.

Outcome of intensive oral motor and behavioural interventions for feeding difficulties in three children with Goldenhar Syndrome.

OBJECTIVE: The facial anomalies and surgeries associated with Goldenhar Syndrome often lead to feeding problems. The purpose of this study was to demonstrate the outcome of Goldenhar Syndrome children admitted to the day patient paediatric feeding programme. SUBJECTS: Three children with Goldenhar Syndrome and feeding difficulties participated, mean age 3 years. Average length of stay was 8 weeks. Upon admission all were dependent on tube feedings. METHODS: The children received four therapeutic sessions daily. The sessions included oral motor interventions, behavioural techniques and a structured meal. Data regarding children's feeding were collected at admission and discharge. RESULTS: The patients had 52% acceptance of food/drink at admission and 88.7% at discharge. Expels were 30% at admission and 14% at discharge. Mouth clean was 9.3% at admission and 97% at discharge. Total inappropriate feeding behaviours averaged 83% at admission and 27.3% at discharge. Children averaged 3.4 g per meal at admission and 105.4 g at discharge. Two children were completely weaned from tube feedings by discharge. CONCLUSIONS: Results support the hypothesis that combining oral motor and behavioural interventions offer effective treatment for children with Goldenhar Syndrome. Many children with Goldenhar Syndrome are reliant on tube feedings and this regimen allows them to eat orally, thereby improving their nutrition and quality of life.

High prevalence of sensorineural hearing loss among survivors of neonatal congenital diaphragmatic hernia. Western Canadian ECMO Follow-up Group.

OBJECTIVE: This study aimed to determine the prevalence of sensorineural hearing loss (SNHL) in 2-5-year-old survivors with neonatal respiratory failure due to congenital diaphragmatic hernia (CDH) with or without the need for extracorporeal membrane oxygenation (ECMO). STUDY DESIGN: The study design was a prospective, multicenter, longitudinal outcome study of consecutively surviving neonates admitted to a single tertiary intensive care unit. SETTING: The study was conducted at four audiologic departments affiliated with tertiary-level intensive care follow-up programs. PATIENTS: Thirty-seven surviving children receiving neonatal intensive care from February 1989 through January 1995 for neonatal respiratory failure due to CDH were studied. Excluded were 15 children with early death and I child lost to follow-up. INTERVENTION: The initial treatment depended on the severity of neonatal respiratory failure: ECMO-treated (n=31, 20 survivors) (death before ECMO initiation, 2) and non-ECMO treated (n=20, 17 survivors, another survivor lost to follow-up). MAIN OUTCOME MEASURE: Early childhood audiologic test results were measured. RESULTS: Sensorineural hearing loss was found in almost 60% of subjects: ECMO-treated, 12 (60%) of 20; non-ECMO-treated, 10 (59%) of 17. Of the 22 children with SNHL, 16 had mild- to-moderate low-frequency sloping to moderate-to-severe high-frequency loss. Of the remaining, six had severe-to-profound loss at 500 Hz and above. Seventeen children had normal responses to sound as newborns or in infancy. Five children were not tested. Documented progression was found in nine children. Twenty children currently are using amplification, and 2 have had cochlear implantation. CONCLUSIONS: Of children with CDH in this area presenting early with severe neonatal respiratory failure, SNHL developed in 60% by 2-5 years of life. Ongoing monitoring of the hearing status of children with CDH is imperative.

Acute otitis media and facial paralysis in children.

We reviewed 10 children who presented with facial paralysis after the onset of acute otitis media. The objective of the study was to examine the outcome of facial paralysis in children with acute otitis media treated without facial nerve decompression. Two groups were identified: 8 patients with incomplete paralysis and 2 with complete paralysis. Seven of the 8 patients with incomplete paralysis had rapid return of function after myringotomy and intravenous antibiotics. The eighth patient had delayed recovery requiring 9 months before complete return of function. The 2 patients with complete paralysis required mastoidectomy to control otorrhea and fever after initial myringotomy and antibiotics. Both patients had a prolonged recovery requiring 3 and 7 months for complete recovery. Patients with incomplete paralysis generally show rapid improvement following wide myringotomy and antibiotic treatment. A more protracted recovery may be expected in patients with complete paralysis; excellent return of function is expected when mastoidectomy without facial nerve decompression is employed.

Problem solving, stress, and coping in adolescent suicide attempts.

Twenty adolescents who had made suicide attempts were compared with 20 nonpsychiatric control subjects on measures of problem solving, stress, and coping. The suicidal group did not show evidence of "rigid" thinking or of deficits in the ability to generate solutions to standardized interpersonal problems. However, they did report recent histories of more severe life stress and had inaccurate appraisal of the extent to which stressful events could be controlled. Although suicidal patients were able to generate as many adaptive strategies as control subjects for coping with their own most severe recent real-life stressor, they actually used fewer. They were also more likely to identify maladaptive behaviors as ways of coping. These findings support a transactional model of adolescent suicidal behavior, whereby inaccuracies in the appraisal aspects of problem solving (but not in the solution-generation aspects) in the face of high life stress lead to a reduction in the use of adaptive efforts to cope.

Science at Harvard University, 1846-47: a case study of the character and functions of written documents.

This paper explores surviving documentation and what it reveals about the underlying social structure and relations in a historic time and place. The mid-nineteenth century is chosen as a period prior to modern bureaucracies so that documents are not found in defining filing systems. Some six hundred documents are studied individually and characterized collectively. They are examined not to tell a story, however, but for evidence of their creation and maintenance and of their physical types, functional characteristics, and relations between authors and recipients. The study reveals the fruitfulness of such an orientation to documents, which complements traditional historical uses that emphasize document content.

Tissue clay: an experimental model to evaluate its performance in soft tissue augmentation and its biologic fate.

Tissue clay (a mixture of autologous whole blood and microfibrillar collagen--Avitene) has been proposed as a medium for reconstruction in cosmetic and reconstructive deformities of the face. Its performance and biologic fate has not been evaluated experimentally. The current study employs a model using the rabbit pinna to determine, histologically, the fate of a tissue clay implant.