Management of Dyspeptic Patients in Primary Care: Value of the Unaided Clinical Diagnosis and of Dyspepsia Subgrouping

Background: Most dyspeptic patients in primary care are managed without confirmatory investigations. In this study the reliability of the unaided clinical diagnosis and the diagnostic value of dyspepsia subgrouping are evaluated in unselected dyspeptic patients in primary care. Methods: Six hundred and twelve unselected dyspeptic patients were referred for interview and endoscopy. General practitioners stated a provisional diagnosis and a proposed management strategy. Before endoscopy, patients were classified on the basis of predominant symptoms as reflux-, ulcer-, or dysmotility-like or as unclassifiable Results: The sensitivity and the positive predictive value of the diagnosis of ulcer were 0.58 and 0.29, respectively, and those for esophagitis 0.30 and 0.43. The predictive value of a clinical diagnosis of functional dyspepsia was high, but, considering the high prevalence of the condition, the chance-corrected validity was at the same level as for the other diagnoses (0.18-0.22). Classification of patients by predominant symptoms increased the a priori probability of ulcer and esophagitis in the respective subgroups. However, more than one-third of the patients with ulcer or esophagitis were classified in inappropriate subgroups. Conclusions: It is difficult to select an appropriate management strategy for dyspeptic patients on the basis of symptoms and history alone. Dyspepsia subgroups are of limited help in the decision process because of the low predictive value of the endoscopic diagnosis.     

Accuracy of provisional diagnoses of dyspepsia in patients undergoing first endoscopy

BACKGROUND: This study assessed agreement between provisional and endoscopic diagnoses for patients with dyspepsia undergoing initial endoscopy, and examined variation between clinicians at 2 hospitals. METHODS: This was a retrospective review of 423 consecutive patients. RESULTS: Crude percentage agreement ranged from 55% to 97%. Kappa scores revealed poor agreement: peptic ulcers (0.11: 95% CI [0.05, 0.17]); gastroesophageal reflux disease (0.29: 95% CI [0.20, 0.38]); benign esophageal stricture (0.33: 95% CI [0.08, 0.58]); and cancer (0.12: 95% CI [-0.12, 0.36]). Positive and negative predictive values for cancer and benign esophageal stricture showed that agreement for a negative diagnosis was almost perfect, whereas agreement for a positive diagnosis was low. Only 17% of patients with cancer were given an accurate provisional diagnosis. Accuracy of diagnosis did not vary substantially between hospitals. CONCLUSIONS: Crude percentage agreement is misleading. Emphasis should be placed on better prediction of cancer, benign esophageal stricture, and peptic ulcer disease. Accuracy of provisional diagnosis in everyday practice is no worse than that found in prospective studies in which clinicians knew a priori that diagnoses would be scrutinized. The difficulty of predicting diagnoses supports increased reliance on endoscopy.     

One-Week Triple Therapy With Ranitidine Bismuth Citrate, Clarithromycin and Metronidazole Versus Two-Week Dual Therapy With Ranitidine Bismuth Citrate and Clarithromycin for Helicobacter pylori Infection: A Randomized, Clinical Trial

Objective: The aim of this study was to compare the efficacy and side effects of 1-wk triple therapy with ranitidine bismuth citrate (RBC) 400 mg b.i.d. , clarithromycin 500 mg b.i.d. , and metronidazole 500 mg b.i.d. , to 2-wk dual therapy with RBC 400 mg b.i.d. and clarithromycin 500 mg b.i.d. for H. pylori infection in a randomized, clinical trial.
Methods: Patients (18–80 yr) with a culture proven H. pylori infection were randomized to one of these regimens. Side effects were scored on a semiquantitative scale. Endoscopy was performed ≥4 wk after treatment. Antral biopsy samples were taken for hematoxylin-eosin stain (HE), rapid urease test, and culture and corpus samples for culture and HE. Two weeks after the endoscopy, a ¹³C-urea breath test was performed. Eradication failure was defined as detection of H. pylori by culture or by at least two other tests.
Results: A total of 104 patients, 54 men, age 54 ± 14 yr, (36 duodenal ulcer, 16 gastric ulcer, and 52 functional dyspepsia) were included. Gender, age, and diagnosis were comparable in both groups. Fourteen of 52 patients in both triple and dual therapy, respectively, had significant side effects, but all patients completed the course. Eradication results were 49 of 52 (94%; 95% CI: 84–99%) and 50 of 52 (96%; 95% CI: 87–100%) on intention to treat analysis and 44 of 46 (96%; 95% CI: 85–99%) and 48 of 49 (98%; 95% CI: 89–100%) on per protocol analysis for triple and dual therapy respectively.
Conclusion: Both regimens are very effective and well tolerated in the treatment of H. pylori infection. The triple regimen has the advantage of being shorter.     

Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage

Background and Aims:  Risk factors for mortality in acute variceal hemorrhage remain incompletely understood. Whether endoscopy timing is associated with risk of mortality has not been investigated. We aimed to investigate risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage, with emphasis on endoscopy timing.
Methods:  Three hundred and eleven (73% male and 23% female) consecutive cirrhotic patients presenting with acute variceal hemorrhage from July 2004 to July 2007 were investigated. The univariate association of endoscopy timing as the predictor for in-hospital mortality was examined. Independent risk factors for mortality were determined by multivariate logistic regression analysis consisting of clinical, laboratory and endoscopic parameters.
Results:  Twenty-five (8.04%) patients died within admission. By plotting the receiver operating curve of endoscopy timing for mortality, we selected 15 h as the optimal cut-off point to define delayed endoscopy. Multivariate regression analysis revealed that independent risk factors predictive for in-hospital mortality included delayed endoscopy performed 15 h after admission (adjusted odds ratio [aOR] = 3.67; 95% confidence interval [CI], 1.27–10.39), every point increment of model for end-stage liver disease (MELD) score (aOR = 1.16; 95% CI, 1.07–1.25), failure of the first endoscopy (aOR = 4.36; 95% CI, 1.54–12.30) and hematemesis as the chief complaint (compared with melena, aOR = 8.66; 95% CI, 1.06–70.94).
Conclusion:  Delayed endoscopy for more than 15 h, high MELD score, failure of the first endoscopy and hematemesis are independent risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage.     

Pressure Ulcers in Elderly Patients with Hip Fracture Across the Continuum of Care

OBJECTIVES: To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the postfracture period.
DESIGN: Prospective cohort study.
SETTING: Nine hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged.
PARTICIPANTS: Hip fracture patients aged 65 and older who underwent surgery for hip fracture.
MEASUREMENTS: A full-body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed one or more new stage 2 or higher pressure ulcers after hospital admission.
RESULTS: In 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). The adjusted APU incidence rate was highest during the initial acute hospital stay (relative risk (RR)=2.2, 95% confidence interval (CI)=1.3–3.7) and during re-admission to the acute hospital (RR=2.2, 95% CI=1.1–4.2). The relative risks in rehabilitation and nursing home settings were 1.4 (95% CI=0.8–2.3) and 1.3 (95% CI=0.8–2.1), respectively.
CONCLUSION: Approximately one-third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare's policy of not reimbursing hospitals for the treatment of hospital-APUs. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals.     

H pylori infection among 1000 southern Iranian dyspeptic patients

INTRODUCTION H pylori is a major cause of gastritis and peptic ulcer disease (PUD), and has been implicated in the development of gastric malignancy[1-3]. The prevalence of H pylori, a worldwide infection, varies greatly among countries and among populati…     

Epidemiology of peptic ulcer disease in cirrhotic patients: role of helicobacter pylori infection

Objective: The aim of this study was to investigate the clinical and epidemiological factors associated with the appearance of peptic ulcer in patients with cirrhosis and, in particular, the role of Helicobacter pylori infection.
Methods: A total of 201 of 220 consecutive patients included in a prospective study that aimed to evaluate the effect of dietary intervention on cirrhotic complications and survival underwent upper gastrointestinal endoscopy. At entry, an epidemiological and clinical questionnaire was completed and the presence of peptic ulcer disease or esophageal varices at endoscopy was prospectively collected. Sera were obtained and stored at −70°C until analyzed, being tested afterward for Helicobacter pylori antibodies using a commercial ELISA kit.
Results: Eleven of 201 patients had borderline anti- Helicobacter pylori IgG titers and were excluded from further analysis. In the remaining 190 patients, point prevalence of peptic ulcer was 10.5% and lifetime prevalence 24.7%. Multivariate analysis selected male sex (OR 2.3; 95%CI 1.09–4.89) and Helicobacter pylori seropositivity (OR:1.7, 95%CI 1.02–2.81) as the variables independently related to peptic ulcer disease.
Conclusions: Male sex and seropositivity for Helicobacter pylori are the major risk factors for peptic ulcer in cirrhosis.     

Impact of clinical symptoms and referral volume on endoscopy for detecting peptic ulcer and gastric neoplasms

BACKGROUND: We investigated the volume of dyspeptic patients referred by general practitioners (GPs) to upper gastrointestinal endoscopy and the impact on endoscopic findings. We also examined the correlation between clinical symptoms and endoscopic findings. METHODS: We collected data on patients sent for upper gastrointestinal endoscopy by GPs of 30 healthcare centres in 1996 in our hospital referral area of 260,000 inhabitants. In addition, national and local cancer registries were used to enumerate the gastric cancer cases detected in 1996. RESULTS: The study population consisted of 3378 patients, mean age 58 years (interquartile range 25 years, male:female 1:1.3). Among the 30 healthcare centres, referral volumes for upper gastrointestinal endoscopy varied from 0.6 to 9.2 per 1000 inhabitants per year (median 3.3/1000/year). In healthcare units with 'high' (> or = 3.3/1000/year, 15 healthcare units, 1297 patients) and 'low' (<3.3/1000/year, 15 healthcare units, 2065 patients) referral volumes, the detection rates were as follows: duodenal ulcer (DU) 3.5% (n = 46) versus 4.0% (n = 83, P = 0.5), gastric ulcer (GU) 4.9% (n = 64) versus 5.3% (n = 110, P = 0.6), gastropathy 43.8% (n = 568) versus 35.6% (n = 736, P < 0.001), gastric cancer 0.5% (n = 6) versus 0.5% (n = 11, P = 0.8), gastric polyps 2.4% (n = 31) versus 1.5% (n = 30, P < 0.05). Independent risk factors for gastric cancer were age (OR 6.5 per decade, 95% CI 2.4-17.9), male sex (OR 5.5, 95% CI 1.8-17.1) and alarming symptoms and/or signs (OR 3.6, 95% CI 1.2-10.7); for GU, Helicobacter pylori (OR 2.6, 95% CI 1.9-3.5) and alarming symptoms (OR 2.0, 95% CI 1.4-2.7); for DU, male sex (OR 1.6, 95% CI 1.1-2.2) and H. pylori (OR 3.9, 95% CI 2.7-5.5); and for gastric polyp(s), age (OR 2.0 per decade, 95% CI 1.1-3.5) and high referral volume (OR 1.7, 95% CI 1.0-2.0). A high referral volume did not associate positively either with the number of peptic ulcers or gastric cancer. CONCLUSIONS: Alarm symptoms associate strongly with significant gastric lesions such as GU and cancer. Increased referral volume results in an increased number of gastropathy and gastric polyp(s), but not of peptic ulcer or cancer.     

Dyspepsia management in primary care in The Netherlands: to what extent is Helicobacter pylori diagnosis and treatment incorporated? Results from a survey among general practitioners in The Netherlands

BACKGROUND: Many guidelines on the management of Helicobacter pylori (HP)-related dyspepsia have been launched over the past decade. The suggested policies in these guidelines are often more consensus- than evidence-based (test-and-treat policy, test and endoscope), which may cause confusion among primary-care physicians. AIM: To determine the current management of HP-related dyspepsia by Dutch general practitioners (GPs). METHODS: A random sample of 5% of all Dutch GPs (n = 355) were sent a questionnaire on the diagnosis and treatment of HP infections in dyspepsia management. RESULTS: The response rate was 66.2% (n = 235). Almost 80% of the responding GPs stated they had conducted HP testing (via endoscopy or serology) during the previous 12 months. In the same time period, more than 94% had actually prescribed a HP eradication therapy. A total of 70% of the GPs stated that they used endoscopy to test for HP infection, 54% used serology (ELISA); whole-blood tests and carbon urea breath tests were not used. Patients with a history of peptic ulcer disease, those on chronic acid-suppressive drugs and patients with recurrent ulcer-like complaints were most frequently tested for HP infection. CONCLUSIONS: Given the frequency of consultations for dyspepsia in primary care in the Netherlands (150 new dyspeptic patients per average practice per year), and the reported average number of HP tests performed (1-5 per GP per year), HP diagnosis plays a modest role in the management of dyspepsia in Dutch general practices. Neither the 'test-and-treat' policy recommended in the Maastricht guidelines, nor its advice regarding the choice of diagnostic tests (carbon urea breath test or serology), is being followed. The majority of GPs uses endoscopy for the detection of HP infection.     

Antibody Response to Specific H. pylori Antigens in Functional Dyspepsia, Duodenal Ulcer Disease, and Health

Objective: The relationship between H. pylori and functional dyspepsia remains controversial. The aim of this study was to identify a potential link between the antibody response to specific H. pylori antigens and functional dyspepsia.
Methods: A total of 50 consecutive patients with functional dyspepsia, 50 patients with duodenal ulcer (DU), and 150 healthy blood donor control subjects with no history of peptic ulceration were studied. H. pylori status was determined by IgG antibodies using a validated ELISA. In H. pylori -positive subjects, antibodies against specific H. pylori antigens were identified by Western blot.
Results: All DU patients (100%; 95%; CI, 93–100), 30 of 50 patients with functional dyspepsia (60%; 95% CI, 45–74) and 65 of 150 (43.3%; 95% CI, 34.3–51) blood donor controls tested positive for H. pylori . Forty-six of 50 (92%; 95% CI, 81–98) DU patients tested positive for the 91 kDa antigen (vacA) compared with 46 of 65 (69%; 95% CI, 58–81) control subjects and 22 of 30 (73%; 95% CI, 54–88) functional dyspepsia patients (   p < 0.01  DU versus controls). Similarly, the 120 kDa antigen (cagA) tended (   p < 0.15  ) to be more prevalent in DU patients (82%; 95% CI, 69–91) compared with controls (69%; 95% CI, 57–80) but not functional dyspepsia (77%; 95% CI, 57–90). No specific H. pylori antigens were associated with dyspepsia subgroups.
Conclusion: No specific H. pylori antigens are linked to functional dyspepsia.     

The Relationship Between Short-Term Mortality and Quality of Care for Hip Fracture: A Meta-Analysis of Clinical Pathways for Hip Fracture

OBJECTIVES: To assess the association between use of clinical pathways for hip fracture and changes in the rates of five inpatient complications and short-term mortality.
DESIGN: Meta-analysis of published studies examining clinical pathways for hip fracture, identified through systematic searches of electronic databases (MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials) and hand searches of selected article bibliographies.
SETTING: Observational and interventional studies of clinical pathways for hip fracture examining rates of deep venous thrombosis, pressure ulcer, surgical site infection, urinary tract infection, pneumonia, and inpatient or 30-day mortality.
PARTICIPANTS: Two reviewers.
MEASUREMENTS: Reviewers independently assessed eligibility and quality of studies and extracted data for outcomes of interest.
RESULTS: Meta-analysis of nine studies (4,637 patients) demonstrated lower odds of deep venous thrombosis (odds ratio (OR)=0.33, 95% CI=0.14–0.75), pressure ulcer (OR=0.48, 95% CI=0.30–0.75), surgical site infection (OR=0.48, 95% CI=0.25–0.89), and urinary tract infection (OR=0.71, 95% CI=0.52–0.98) in patients managed according to clinical pathways than in those receiving usual care. Statistically significant differences were not observed in the odds of pneumonia (OR=1.01, 95% CI=0.67–1.53) or in a combined outcome of in-hospital or 30-day mortality (OR=0.86, 95% CI=0.66–1.13).
CONCLUSION: An association was observed between clinical pathway use and lower odds of four common complications of hospitalization after hip fracture; only a small, statistically insignificant association was observed between pathway use and changes in short-term mortality, suggesting that assessments of hospital quality based on short-term mortality may not reflect important improvements in patient outcomes that hospitals may achieve using clinical pathways.     

Long-term effects of childhood abuse on the quality of life and health of older people: results from the Depression and Early Prevention of Suicide in General Practice Project

OBJECTIVES: To determine whether childhood physical and sexual abuse are associated with poor mental and physical health outcomes in older age.
DESIGN: Cross-sectional, postal questionnaire survey.
SETTING: Medical clinics of 383 general practitioners (GPs) in Australia.
PARTICIPANTS: More than 21,000 older adults (aged ≥60) currently under the care of GPs participating in the Depression and Early Prevention of Suicide in General Practice (DEPS-GP) Study. Participants were divided into two groups according to whether they acknowledged experiencing childhood physical or sexual abuse.
MEASUREMENTS: Main outcome measures targeted participants' current physical health (Medical Outcomes Study 12-item Short Form Survey, Version 2 and Common Medical Morbidities Inventory) and mental health (Patient Health Questionnaire-9 and Hospital Anxiety and Depression Scale).
RESULTS: One thousand four hundred fifty-eight (6.7%) and 1,429 participants (6.5%) reported childhood physical and sexual abuse, respectively. Multivariate models of the associations with childhood abuse indicated that participants who had experienced either childhood sexual or physical abuse had a greater risk of poor physical (odds ratio (OR)=1.35, 95% confidence interval (CI)=1.21–1.50) and mental (OR=1.89, 95% CI=1.63–2.19) health, after adjustments. Older adults who reported both childhood sexual and physical abuse also had a higher risk of poor physical (OR=1.60, 95% CI=1.33–1.92) and mental (OR=2.40, 95% CI=1.97–2.94) health.
CONCLUSION: The effects of childhood abuse appear to last a lifetime. Further research is required to improve understanding of the pathways that lead to such deleterious outcomes and ways to minimize its late-life effects.     

Occurrence, Predictors, and Outcomes of Post-Percutaneous Coronary Intervention Thrombocytopenia in an Unselected Population

Objectives: We sought to determine the occurrence, predictors, and prognostic impact of post-percutaneous coronary intervention (post-PCI) thrombocytopenia on an unselected real-world patient population.
Background: Thrombocytopenia after PCI has been shown to portend worse prognosis in clinical trials. The significance of post-PCI thrombocytopenia has not previously been examined outside the clinical trial setting.
Methods: The study cohort consisted of 1,302 consecutive patients with normal baseline platelet count (150 × 10⁹/L). Post-PCI thrombocytopenia was defined as nadir platelet count < 100 × 10⁹/L or a drop > 50% from baseline. The primary outcomes were in-hospital and 6-month rates of death and major adverse cardiovascular events (MACE), and the secondary outcomes were bleeding, need for blood transfusion, and length of hospital stay. Logistic regression was performed to identify independent predictors.
Results: Post-PCI thrombocytopenia developed in 41 patients (occurrence 3.1%). Independent predictors were baseline creatinine clearance (odds ratio [OR] 1.02 for every unit decrease, 95% confidence interval [CI] 1.01–1.03, P = 0.001), failed PCI (OR 3.8, CI 1.6–9.4, P = 0.003), and use of intraaortic balloon pump (OR 2.8, CI 1.1–6.8, P = 0.024). All study outcomes were significantly higher in patients with post-PCI thrombocytopenia. Post-PCI thrombocytopenia independently predicted MACE at 6 months (hazard ratio 2.7, CI 1.3–5.5, P = 0.0069) and all the secondary outcomes.
Conclusions: Post-PCI thrombocytopenia occurred in 3.1% of patients in an unselected real-world population and carried a significant detrimental impact on prognosis. Failed PCI was the strongest correlate identified.     

Diagnostic value of carcinoembryonic antigen in malignant pleural effusion: a meta-analysis

Background and objective:   Conventional tests are not always helpful in making a diagnosis of malignant pleural effusion (MPE). Many studies have investigated the utility of pleural carcinoembryonic antigen (CEA) in the early diagnosis of MPE. The present meta-analysis determined the accuracy of CEA measurement in the diagnosis of MPE.
Methods:   A systematic review of English language studies was conducted and data on the accuracy of pleural CEA concentrations in the diagnosis of MPE were pooled using random effects models. Receiver operating characteristic curves were used to summarize the overall test performance.
Results:   Forty-five studies met the inclusion criteria for the meta-analysis. The summary estimates for CEA in the diagnosis of MPE were: sensitivity 0.54 (95% CI: 0.52–0.55), specificity 0.94 (95% CI: 0.93–0.95), positive likelihood ratio 9.52 (95% CI: 6.97–13.01), negative likelihood ratio 0.49 (95% CI: 0.44–0.54) and diagnostic odds ratio 22.5 (95% CI: 15.6–32.5). Analysis of a subset of 11 studies which examined the value of pleural CEA in ruling out a diagnosis of malignant mesothelioma found that the sensitivity and specificity of a CEA level exceeding cut-off values were 0.97 (95% CI: 0.93–0.99) and 0.60 (95% CI: 0.55–0.65), respectively.
Conclusions:   Measurement of pleural CEA is likely to be a useful diagnostic tool for confirming MPE, and is also helpful in the differential diagnosis between malignant pleural mesothelioma and metastatic lung cancer. The results of CEA assays should be interpreted in parallel with clinical findings and the results of conventional tests.     

Dyspepsia in relation to Helicobacter pylori infection and psychosocial work stress in white collar employees

Objective: We undertook an investigation of the relationship between psychosocial work stress and Helicobacter pylori ( H. pylori ) infection with dyspepsia.
Methods: We conducted a cross-sectional study among 189 employees of a health insurance company in the city of Ulm, Germany.
Results: A clear association between work-related psychosocial factors and the occurrence of dyspeptic symptoms during the past 3 months was evident. Persons who were considered to have a critical style of coping with work demands suffered more often from dyspeptic symptoms. Current infection with H. pylori was not associated with prevalence of dyspeptic symptoms. These results were also confirmed by adjustment for age, gender, smoking status, education, and use of antiinflammatory drugs within the past 3 months, by means of multivariate analysis. The odds ratio (OR) for having a dyspepsia symptom score in the upper tertile versus the 1st or 2nd was 3.22 (95% confidence interval [CI], 1.56–6.65), given that the employee was considered to have a critical style of coping with work demands. The OR for having a dyspepsia symptom score in the upper tertile given H. pylori infection was 1.23 (95% CI, 0.44–3.46), indicating no association of current H. pylori infection with dyspeptic symptoms.
Conclusions: A critical style of coping with work demands may be an important determinant for dyspepsia-like symptoms. Therefore, in the absence of an underlying disease, specific intervention programs should be targeted at the behavior of the affected individual ( e.g. , stress-reduction programs) rather than on the treatment of specific symptoms or infection with H. pylori .     

Peptic ulcer disease in dyspeptic patients with ischemic heart disease: search and treat?

OBJECTIVE: The aim of this study was to determine the prevalence and risk factors for peptic ulcer disease (PUD) in dyspeptic patients with ischemic heart disease (IHD), and to assess whether the healing of PUD before coronary artery bypass grafting (CABG) could reduce the need for urgent postoperative endoscopy. PATIENTS AND METHODS: A series of 894 patients referred to Dubrava University Hospital in Zagreb for elective CABG during the period from May 1998 until April 2001 was prospectively analysed. Dyspepsia was assessed by a questionnaire, PUD by upper gastrointestinal endoscopy, and H. pylori status by histology/Giemsa staining and the rapid urease test. The need for urgent postoperative endoscopy (hematemesis and/or melena, sudden onset of anemia or unexplained epigastric pain) was compared between the prospective study group of 894 patients and a series of 463 patients referred for CABG to Dubrava University Hospital during the period from January 1997 until April 1998. RESULTS: Gastroduodenal dyspepsia predominated in 184 (20.6 %) patients, 142 (77.2 %) of them with Helicobacter (H.) pylori infection and 69 (37.5 %) with verified PUD. Univariate analysis indicated the increased risk of multiple PUD to be related to a previous diagnosis of PUD (OR 3.61, 95 % CI 1.32 - 9.82), H. pylori infection (OR 18.86, 95 % CI 2.31 - 153.98), use of aspirin (OR 5.70; 95 % CI 1.80 - 18.03) and left coronary artery occlusions (3.10, 95 % CI 1.00 - 9.59). Multivariate analysis pointed to H. pylori infection (OR 16.30, 95 % CI 1.57 - 168.53) and left coronary artery occlusions (OR 4.84, 95 % CI 1.05 - 22.30) as independent risk factors for multiple PUD. The OR for urgent postoperative endoscopy due to a major gastrointestinal event was 9.9 (95 % CI 2.2 - 45.1) and the OR for active peptic ulcer with stigmata of recent bleeding was 6.9 (95 % CI 1.4 - 33.1) in the group of patients with IHD who were not submitted to evaluation for dyspepsia prior to elective heart surgery. CONCLUSIONS: In areas with a high prevalence of H. pylori infection, endoscopy and a "search and treat" strategy for IHD patients with dyspepsia before elective cardiac surgery should significantly reduce the need for urgent postoperative endoscopy due to major gastrointestinal events.     

The impact of Helicobacter pylori eradication on peptic ulcer healing

Objective: Current literature was reviewed analyzing the outcome of peptic ulcer healing in relation to the results of the posttherapeutic Helicobacter pylori (HP) status.
Methods: Literature was reviewed along with an analysis of 60 studies, comprising a total of 4329 patients.
Results: Successful Helicobacter pylori eradication was found to induce a better response in peptic ulcer healing, regardless of diagnosis: gastric ulcer 88% vs 73% (odds ratio [OR] 2.7,   p < 0.01  ), duodenal ulcer 95% vs 76% (OR 5.6,   p < 0.0001  ), and peptic ulcer 95% vs 76% (OR 6.6,   p < 0.0001  ), for patients having their HP infection successfully cured versus those remaining HP-positive, respectively (Fisher's exact test). For all evaluated time points (≤ 6, 7–8, and 10–12 wk after beginning treatment), HP-negative patients had higher healing rates than HP-positive patients (95% vs 82%, 94% vs 69%, and 96% vs 78% with corresponding OR of 4.2, 6.5, and 7.4, all   p < 0.0001  , Fisher's exact test). The use of concomitant acid suppression therapy during initial HP eradication provided a benefit on peptic ulcer healing only for patients with persistent HP infection (improved healing rates of 78% vs 67%; otherwise rates were 94–96%). Likewise, prolonged acid inhibition in HP treatment failures after the initial HP treatment phase resulted in 7–20% improved healing rates, whereas patients becoming HP-negative did not profit.
Conclusion: Successful HP eradication therapy accelerates peptic ulcer healing even without concomitant acid suppression.     

Long-term clinical outcomes of the Drug-Eluting Stents in the Real World (DESIRE) Registry

Background: Recently, cardiologists have treated more complex patients and lesions with drug-eluting stents (DES). However, long-term efficacy and safety of the off-label use of these new devices is yet to be demonstrated.
Methods: The Drug-Eluting Stents in the Real World (DESIRE) registry is a prospective, nonrandomized single-center registry with consecutive patients treated solely with DES between May 2002 and May 2007. The primary end-point was long-term occurrence of major adverse cardiac events (MACE). Patients were clinically evaluated at 1, 3, and 6 months and then annually up to 5 years.
Results: A total of 2,084 patients (2,864 lesions and 3,120 DES) were included. The mean age was 63.8 ± 11.5 years. Diabetes was detected in 28.9% and 40.7% presented with acute coronary syndrome. Cypher™ was the predominant DES in this registry (83.5%). Mean follow-up time was 2.6 ± 1.2 years and was obtained in 96.5% of the eligible patients. Target lesion revascularization (TLR) was performed in 3.3% of the patients. Q wave myocardial infarction (MI) occurred in only 0.7% of these patients and total stent thrombosis rate was 1.6% (n = 33). Independent predictors of thrombosis were PCI in the setting of MI (HR 11.2; 95% CI, 9.6–12.4, P = 0.001), lesion length (HR 4.6; 95% CI, 3.2–5.3, P = 0.031), moderate to severe calcification at lesion site (HR 13.1; 95% CI, 12.1–16.7, P < 0.001), and in-stent residual stenosis (HR 14.5; 95% CI, 10.2–17.6, P < 0.001).
Conclusion: The use of DES in unselected population is associated with long-term safety and effectiveness with acceptable low rates of adverse clinical events.     

Non-invasive model predicting clinically-significant portal hypertension in patients with advanced fibrosis

Background and Aims:  Hepatic venous pressure gradient (HVPG) has been established as a predictor for the development of varices, clinical decompensation and death. In the present study, the primary objectives were to determine the diagnostic accuracy of the model developed by using readily-available data in predicting the presence of significant portal hypertension and esophageal varices.
Methods:  This study included a total of 61 consecutive treatment-naive patients with advanced fibrosis (METAVIR F3, F4), established by liver biopsy. All patients underwent subsequent HVPG measurement and upper gastrointestinal endoscopy within 1 week of liver biopsy.
Results:  Seventeen patients (F3, 2/26; F4, 15/35) had clinically-significant portal hypertension (HVPG ≥ 10 mmHg). The Risk Score for predicting significant portal hypertension was 14.2 − 7.1 × log₁₀ (platelet [10⁹/L]) + 4.2 × log₁₀ (bilirubin [mg/dL]). The area under the receiver–operator curve (AUC) curve was 0.91 (95% confidence interval [CI], 0.84–0.98). The optimized cut-off value (Risk Score = −1.0) offered a sensitivity of 88% (95% CI, 62–98%) and a specificity of 86% (95% CI, 72–94%). The AUC of the Risk Score in predicting varices was 0.82 (95% CI, 0.67–0.98). The cut-off had a sensitivity of 82% (95% CI, 48–97%) and a specificity of 76% (95% CI, 62–86%).
Conclusion:  A predictive model that uses readily-available laboratory results may reliably identify advanced fibrosis patients with clinically-significant portal hypertension as well as esophageal varices. However, before accepted, the results of the current study certainly should be validated in larger prospective cohorts.