Community subgroups in dyspepsia and their association with weight loss

OBJECTIVE:  A link between dyspepsia symptoms and weight loss is controversial. We aimed to determine whether or not weight loss is a marker of dyspepsia.
METHODS:  Independent community-based cross-sectional studies. Subjects were randomly selected from the general population in Sydney, Australia. All subjects completed validated community health surveys. Two distinct data collections were used; the first as a training sample (N = 888) and the second as a validation sample to confirm the findings of the first (N = 2,907). The study was focused on weight loss, which was categorized as (a) any weight loss, (b) substantive weight loss (≥3 kg), and (c) weight loss expressed as percentage of body weight.
RESULTS:  All dyspepsia symptoms studied were positively associated with weight loss although the strength of association did vary. Nausea and vomiting were most strongly associated with weight loss as were meal-related complaints such as postprandial fullness. Similarly, clusters formed based on symptoms were strongly differentiated in terms of weight loss with clusters characterized by nausea, vomiting, and early satiety/postprandial fullness reporting 25–30% weight loss prevalence over the previous 3 months compared with around 10% prevalence in clusters characterized by low dyspepsia symptom burden. Weight loss ≥3 kg followed a similar pattern but with a prevalence approximately half that of any weight loss, while weight loss expressed as percentage of body weight followed the same pattern.
CONCLUSIONS:  Dyspepsia symptoms are clearly and, in some cases, strongly associated with weight loss, both any loss of weight and substantive weight loss. Weight loss should be considered a warning symptom of dyspepsia.     

1 Nomenclature of dyspepsia,dyspepsia subgroups and functional dyspepsia: Clarifying the concepts

There is international agreement that dyspepsia refers to pain or discomfort centred in the upper abdomen. However, the term ‘discomfort’ has been variably defined. While other symptoms may often be simultaneously present, gastro-oesophageal reflux disease can usually be clearly distinguished by the presence of predominant heartburn. Dyspepsia is a frequent reason for consultation in primary care and in gastrointestinal practice. With the widespread availability and utilization of endoscopy, it has become evident that a structural (or organic) explanation is found in only a minority of patients presenting with dyspepsia. Operationally, functional dyspepsia is defined as persistent or recurrent dyspepsia for 3 or more months in the absence of a clinically identifiable structural disease causing the symptoms. It has been proposed, based on symptoms, that functional dyspepsia be subdivided into symptom subgroups to promote patient homogeneity. The initially proposed ‘clustering’ of symptoms into ulcer-like and dysmotility-like functional dyspepsia has proved a dismal failure because of the considerable overlap observed, the lack of stability over time and the failure to identify robust pathophysiological abnormalities or responses to therapy. A subcategorization based upon the most bothersome symptom is theoretically more attractive but needs to be prospectively and rigorously tested.     

Smoking and tuberculosis: an association overlooked.

OBJECTIVES: This article discusses the role of smoking as a risk factor for tuberculosis. A review of the evidence that has been documented is presented. DATA SOURCES: Relevant articles in the medical literature derived from searching the Medline database (1966 to present) with key terms 'smoking' and 'tuberculosis'. The bibliographies of all papers thus located were searched for further relevant articles. RESULTS: On searching the database, a total of 12 studies were found. A search of the bibliographies yielded four more articles. Sixteen studies published between 1956 to the present were included in this review. The evidence suggests that smoking could be considered as an important risk factor for the development of tuberculosis. Not only does active smoking appear to heighten the chances of contracting pulmonary tuberculosis, smokers also seem to be at an increased risk for extrapulmonary tuberculosis. Exposure to environmental tobacco smoke in children seems to enhance the hazards of acquiring tuberculosis. Increased tuberculin reactivity, in a dose-dependent manner, was recorded in smokers as compared to non-smokers. CONCLUSIONS: Although an association between smoking and tuberculosis appears evident, prospective studies would help to confirm the evidence and to highlight this noxious association. Nevertheless, smoking should be considered as an important risk factor for tuberculosis.     

Functional dyspepsia: subgroups, history and outcomes

Dyspepsia is a symptom complex common both in the population and in clinical practice. Persons with dyspeptic symptoms who have not been evaluated are considered to have uninvestigated dyspepsia. If, after investigation, no structural or biochemical explanation is identified to explain the person's symptoms, the diagnosis of functional dyspepsia is made. While substantial efforts have been made to provide symptom-based criteria for the diagnosis of functional dyspepsia, the etiology and natural history of the disorder remains elusive. Population-based studies have often had difficulty distinguishing functional dyspepsia from irritable bowel syndrome. Clinically, there is clearly substantial overlap and many persons with functional dyspepsia either present with symptoms consistent with the irritable bowel syndrome or will develop such symptoms at a later date. Even if one can accept functional dyspepsia as an entity separate from irritable bowel syndrome, it is clearly a heterogeneous disorder. Unfortunately attempts using different strategies to subcategorize functional dyspepsia have not made progress with respect to elucidating pathophysiology or directing therapy. Importantly, most persons with functional dyspepsia experience symptom variability resulting in subgroup reassignment over time. Persons presenting with functional dyspepsia will likely remain symptomatic over time. Sadly, at the present time, gastroenterologists have little ability to predict what those symptoms will be, to understand the mechanism for their existence or to offer therapies that offer a reasonable likelihood of success based on a pathophysiologic rationale.     

Smoking among adult males in an urban community of Karachi, Pakistan

Smoking is the single most important avoidable cause of premature morbidity and mortality in the world. It is a major public health problem in Pakistan. The objectives of this study were to assess smoking status and its relationship to socio-demographic characteristics, and to determine the behavior of male smokers in an urban community in Karachi, Pakistan. A cross-sectional, household survey was conducted among 396 males, aged 15 years and above in January and February 2002. The overall prevalence of current smokers was 34%. By univariate analysis, the factors associated with smoking were younger age (15-29 years) (OR=4.2, 95% CI 2.1-7.3) as compared to older age (> 45 years), unmarried as compared to married (OR=3.1, 95% CI 1.9-5.4), educated for > 12 years compared to those with an education of 0-5 years (OR=2.0, 95% CI 1.2-3.3), and being student as compared to being an office/business worker (OR=3.2, 95% CI 1.8-5.4). The majority of smokers (55%) began smoking when younger than 25 years, smoked for more than 5 years (53%), smoked more than 10 cigarettes a day (55%) and smoked in public places (82%). Forty-two percent of the smokers used tobacco in other forms as well. Fifty-eight percent of smokers smoked to relieve anger and frustration and 30% smoked due to friend or peer pressure. In conclusion, smoking is a major problem in especially in younger age groups. There is an urgent need for health promotion and anti-tobacco education in combating the epidemic of smoking in Pakistan.     

Hepatitis A and Down's syndrome: lack of an association.

The occurrence of hepatitis A early in pregnancy has been reported to result in increased births of children with Down's syndrome. Eleven sets of paired sera were obtained before conception and during pregnancy from women who delivered infants with Down's syndrome. These sera were tested for antibody to hepatitis A virus with use of immune electron microscopy. None of the women had seroconversions or increases in levels of antibody to hepatitis A virus. No evidence of an association between hepatitis A and Down's syndrome was found in the women studied.     

Nutritional habits in functional dyspepsia and its subgroups: a comparative study

Objective: Research data demonstrating nutritional habits of functional dyspepsia (FD) patients are very limited. This is the first study to evaluate nutritional habits in FD subgroups according to Rome III criteria. Our aim was to evaluate nutritional habits of FD patients and determine the food items that may provoke a dyspepsia symptom. Methods: A total of 168 adults with FD and 135 healthy control subjects participated in the study. FD subjects were divided into epigastric pain syndrome (EP-FD), postprandial distress syndrome (PS-FD), mixed (MX-FD) subgroups according to Rome Criteria III. Subjects completed a questionnaire that included a short-form food frequency questionnaire. Furthermore, subjects were asked to list the food items that were causing a dyspepsia symptom. Results: Functional dyspepsia subjects had a slightly higher BMI (26.1?±?4.97?kg/m²) than control subjects (24.6?±?4.08?kg/m²). The most common symptom triggering foods among all the FD groups were fried and fatty foods (27.1%), hot spices (26.4%), and carbonated drinks (21.8%). In FD subgroups, carbonated drinks were more likely to cause a symptom in PS-FD group (37.3%) than MX-FD (25.7%) and EP-FD (22.1%) groups. There was no difference in frequency of main meals and snacks among any of the groups. Conclusion: Fatty and spicy foods and carbonated drinks were the most common symptom triggering food items in FD group. In subgroups, carbonated drinks and legumes were more likely to cause a symptom in PS-FD. Removing these food items during the course of treatment might help alleviate the symptoms.     

Empiric clustering of dyspepsia into symptom subgroups: a population-based study

BACKGROUND: Different definitions of dyspepsia are applied by researchers yet measurement of the influence of these on prevalence estimates is uncertain. Despite continued debate regarding dyspepsia subgroups, few studies have used a data-drive approach to assess the existence and relevance of symptom clusters. We aimed to address both these issues. METHODS: A random population sample (n = 2300) identified in New South Wales. Prevalence estimates of dyspepsia were calculated by applying four standardized dyspepsia definitions. Principal components analyses, using firstly the presence/absence of symptoms and then secondly severity of symptoms, were undertaken to determine if symptom factors existed. RESULTS: Prevalence estimates ranged from 11% to 36%. Similar prevalence rates for men and women were observed for all definitions except Rome II. Over one-third of respondents nominated heartburn or epigastric pain as their most bothersome symptom. However, 22% of respondents were unable to answer this question. The principal components analysis produced four symptom factors: a nausea factor, dysmotility-like dyspepsia (early satiety and fullness), ulcer-like (epigastric pain and bloating) and reflux-like (heartburn and acid regurgitation). However, the factors accounted for less than 50% of the variance. Similar factors were identified in men and women for dysmotility-like and reflux-like dyspepsia. Use of presence/absence or severity of symptoms made little difference to the symptom factors produced or the amount of variance explained. CONCLUSIONS: The prevalence of dyspepsia depends on the definition applied. While there is some empirical evidence of symptom subgroups, they appear to be of little clinical utility.     

Smoking,alcohol use and engagement in exercise and cognitive performance among older adults

Objectives: To examine cross‐sectional and longitudinal effects of history of smoking, alcohol use and engagement in exercise on cognitive performance. Method: Health habits and cognitive performance of a large community sample of older adults were assessed at measurement points two years apart. Results: Past smokers performed more poorly on tests of recall and speed of information processing at times 1 and 2 than those who had never smoked. Past smokers and moderate users of alcohol performed better on confrontation naming and working memory, than those who had never smoked or drank alcohol. Engagement in exercise was related to immediate recall and speed of processing before, but not after, controlling for covariates. Health habits were not related to longitudinal change in cognition. Conclusions: The results suggest a negative effect of history of smoking on effortful cognitive tasks and a protective effect of alcohol use on more automatic cognitive tasks among older adults.     

Smoking and ulcerative colitis: a community study

Smoking habits of patients with ulcerative colitis, diagnosed in the City of Cardiff between the 1st of January 1978 and the 31st of December 1987 were examined. There was a significant deficit of current smokers, an excess of life-long non-smokers and ex-smokers compared with the general population. Men who had previously smoked presented with colitis later than life long non-smokers (mean age difference 16.1 years). The proportion of ex-smokers in this group of patients with colitis was more than twice that expected in the general population. The interval between cessation of smoking and subsequent onset of colitis in ex-smokers was relatively short and in more than half of them occurred within 8 years. There was no significant difference in the frequency of colectomy or the extent of disease among smokers, ex-smokers or life-long non-smokers with ulcerative colitis.

---

Résumé Le tabagisme des malades porteurs de colite ulcérative diagnostiquée dans la cité de Cardiff entre le 1er janvier 1978 et le 31 décembre 1987 a été étudié. Il y avait une diminution significative des fumeurs habituels et un excès de non-fumeurs comparé à la population générale. Les gens qui avaient fumé auparavant avaient des colites plus tardivement que les non-fumeurs (moyenne d'âge de différence 16,1 ans). La proportion d'ex-fumeurs dans ce groupe de malades avec colite était plus de deux fois ce que l'on attendait dans la population générale. L'intervalle entre la céssation de tabac et le début de la colite chez les ex-fumeurs était relativement court et chez plus de la moitié d'entre-eux survenait dans les huits ans. Il n'y avait pas de différence significative dans la fréquence de la colectomie ou l'étendue de la maladie parmi les fumeurs, les non-fumeurs et les ex-fumeurs avec une colite ulcérative.

     

Self-reported lack of energy (anergia) among elders in a multiethnic community

BACKGROUND: Lack of energy, "anergia," is a possible central feature for identifying, evaluating, and treating elders with health-related problems in quality of life. METHODS: A survey was conducted on a randomly selected stratified sample (N = 2130) of three ethnic groups of community-residing elders in a defined urban geographic area: the Northern Manhattan Aging Project (NMAP). The participants were Medicare beneficiaries living north of 150(th) Street in Manhattan. The criteria for anergia were based on the presence of the major criterion "sits around a lot for lack of energy" and any two of six minor criteria. Self-reports were gathered using a computer-assisted, rater-administered interview (the Comprehensive Assessment and Referral Interview; CARE) covering: function (basic activities of daily living [ADL] and instrumental ADL [IADL]); features of geriatric syndromes such as self-rated physical health, depression, pain, respiratory distress, trouble sleeping, cognitive impairment, and cardiovascular syndromes; social isolation; and healthcare utilization. Short-term (18-month) and long-term (6-year) mortality were derived from the National Death Index. RESULTS: Three hundred eighty-six people (18% of the sample) met criteria for anergia. Anergia was more common in women than men (22% vs 12%, p <.01), in unmarried than in married persons (21% vs 13%, p <.001), and with advancing age. People with anergia used more hospitalizations, office visits, emergency room visits, and home care services and, had higher mortality rates. In multivariate analyses, the following factors had independent associations with anergia: female gender, impaired physical function and IADL, depression, pain, respiratory symptoms, urinary incontinence, hearing difficulty, feeling dizzy or weak, and social isolation and disengagement. These factors could be the initial candidates for clinical investigation of anergia of undetermined origin. Among people with anergia at baseline, 31.3% (n = 121) had persistent anergia and 33.9% (n = 131) recovered over a follow-up period of 18 months. CONCLUSIONS: Anergia in multiethnic older adults is associated with a range of clinical symptoms and diseases, with extensive health services use, and with increased mortality.     

Fluctuation in dyspepsia subgroups over time. A three-year follow-up of patients consulting general practice for dyspepsia

BACKGROUND: General practitioners base their treatment and investigation on the symptoms presented by the patients. Subgroups of dyspepsia have been defined in order to guide management. AIM: To study prospectively changes over time in the presentation of dyspepsia according to different subtypes in a general practitioner population. SUBJECTS: Patients consulting the general practitioner because of dyspeptic complaints. METHODS: A random sample of general practitioner patients consulting with different dyspepsia subtypes (ulcer-like, reflux-like, dysmotility-like, uncharacteristic and relapsing dyspepsia) were studied three years after the initial consultation by postal questionnaires to the general practitioners (obtaining information from the patient records) and to the patients (obtaining self-reported symptoms during twelve months). The subtype of dyspepsia at baseline was compared to the subtype in the patient questionnaire. RESULTS: Between 20 and 34% of the patients reported no dyspepsia after three years, with so significant difference between the subtypes. Changes from one subtype to another were common, ulcer-like and reflux-like often changed into dysmotility-like dyspepsia. Dysmotility-like dyspepsia was significantly more stable over time. Patients with more than one episode of dyspepsia changed subtype significantly less. CONCLUSIONS: Most patients who presented with dyspepsia to the general practitioner still reported symptoms three years later. Few patients with dysmotility-like dyspepsia changed subtype over time, whereas changes from one subtype to another were common in other subtypes. This implies that dyspeptic patients could end up having dysmotility-like complaints possibly due to the lack of effective treatment for this condition, compared to the other dyspepsia subtypes.     

Smoking history, alcohol consumption, and systemic lupus erythematosus: a case-control study

OBJECTIVE—To investigate the effect of smoking on the development of systemic lupus erythematosus (SLE), and the association between alcohol consumption and the disease.
METHODS—450 subjects (150 SLE patients and 300 controls) from Nottingham, UK were interviewed in a case-control study. Controls were matched to cases for age and sex. All patients met at least four of the American Rheumatology Association criteria for SLE. Controls were randomly selected from the Nottingham Family Health Services Authority register. Information was collected by interview administered questionnaire concerning demographic variables, smoking histories, and drinking habits.
RESULTS—Analysis of the data by conditional logistic regression revealed current smokers to have a significantly increased risk of development of SLE compared with never smokers (odds ratio (OR) 1.95, 95% confidence intervals (CI) 1.14, 3.31), although ex-smokers were not at increased risk. There was also suggestion of a marked, highly significant negative association between SLE and alcohol consumption, the magnitude of which increased with units consumed.
CONCLUSIONS—This study suggests that current smokers are at increased risk of developing SLE compared with non-smokers and ex-smokers. In contrast, alcohol consumption seems to be negatively associated with the disease.

Keywords: smoking; alcohol; systemic lupus erythematosus     

HLA-DR antigens in primary biliary cirrhosis: lack of association.

A study of HLA-DR antigen in 75 patients with primary biliary cirrhosis has been carried out in order to test the hypothesis that genetic factors related to genes controlling immune responses might be important in the pathogenesis of primary biliary cirrhosis. The frequencies of HLA-DR locus antigens was not significantly different from those in 200 normal controls, nor were those of tissue antigens on the A and B loci. No HLA-DR antigen was significantly associated with the appearance of granulomata on liver biopsy (possibly good prognosis) or with raised serum bilirubin (possibly bad prognosis); nor was there any association between any HLA-DR antigen and adverse reactions to D-penicillamine treatment in 17 patients with such adverse reactions. It is concluded that genetic traits related to HLA antigens studied are probably not important in the aetiology of the disease.     

Harm minimization among teenage drinkers: findings from an ethnographic study on teenage alcohol use in a rural Danish community

AIM: To examine strategies of harm minimization employed by teenage drinkers. DESIGN, SETTING AND PARTICIPANTS: Two periods of ethnographic fieldwork were conducted in a rural Danish community of approximately 2000 inhabitants. The fieldwork included 50 days of participant observation among 13-16-year-olds (n = 93) as well as 26 semistructured interviews with small self-selected friendship groups of 15-16-year-olds (n = 32). FINDINGS: The teenagers participating in the present study were more concerned about social than health risks. The informants monitored their own level of intoxication, but in order to reduce alcohol consumption they depended upon support from their peers. The informants preferred drinking in the company of well-known and trusted peers, and during drinking episodes they supervised and intervened in each others' drinking to the extent that they deemed it necessary and possible. In regulating the social context of drinking they relied on their personal experiences more than on formalized knowledge about alcohol and harm, which they had learned from prevention campaigns and educational programmes. CONCLUSIONS: In this study we found that teenagers may help each other to minimize alcohol-related harm, and teenage peer groups should thus be considered a resource for health promotion.     

Giardia lamblia in patients undergoing endoscopy: lack of evidence for a role in nonulcer dyspepsia

Previous studies have suggested that Giardia lamblia may cause nonulcer dyspepsia as the sole manifestation of infection. To explore this premise, duodenal aspirates from patients undergoing upper endoscopy were examined for Giardia and results were correlated with endoscopic findings and symptoms. Of 155 patients, 15.5% had Giardia. Patients with dyspepsia, with or without obvious lesions at endoscopy, had a similar prevalence. Patients with vomiting and diarrhea had an increased prevalence (38.5%) (p less than 0.05). The prevalence of Giardia lamblia in this patient population is surprisingly high. This study suggests that Giardia lamblia infection is not a major cause of nonulcer dyspepsia.     

Helicobacter pylori infection in the Australian community: current prevalence and lack of association with ABO blood groups

Aims: To assess the current prevalence of Helicobacter pylori infection in an Australian urban population sample and to relate this to age, gender and ABO and Rhesus blood groups. Methods: We performed a prospective epidemio­logical survey of H. pylori serological status in 500 consecutive voluntary blood donors who presented for the purpose of blood donation at the central ­Melbourne branch of the Australian Red Cross Blood Service, Victoria, Australia, and gave a Melbourne suburban home address. Results: The overall prevalence of specific anti‐H. pylori IgG antibodies in this cohort was 32% (95% confidence interval = 28?36%) and H. pylori sero­positivity increased with age. The rate of H. pylori infection was not significantly different in men and women, with anti‐H. pylori IgG anti­bodies detected in 35% (97/277) of men compared with 28% (63/233) of women (P = 0.12). Similarly, H. pylori serological status was not significantly different between subjects of different ABO (P = 0.18) or Rhesus blood groups (P = 0.55). Conclusion: This study showed that, contrary to expectation, the updated prevalence of H. pylori seropositivity (32%) in this Melbourne sample is at least as high as that found in previous Australian studies over the past 19 years. Seropositivity increased with age, and was not related to gender, confirming the infection pattern seen in other developed nations. Despite epidemiological evidence of increased peptic ulcer disease in ABO blood group O subjects, and recent evidence that H. pylori adhesion to gastric epithelial cells is mediated by blood group epitopes, no significant association between blood groups and H. pylori serological status was detected. (Intern Med J 2003; 33: 163?167)