Masking of 13C urea breath test by proton pump inhibitors is dependent on type of medication: comparison between omeprazole, pantoprazole, lansoprazole and esomeprazole

BACKGROUND: The need to withhold acid suppression therapy while awaiting urea breath test results is a common clinical problem in symptomatic patients. It is unclear at present if the dose or type of proton pump inhibitor or the type of test meal govern the apparent masking effect of proton pump inhibitors on the urea breath test. AIM: To prospectively evaluate Helicobacter pylori detection rates during treatment with four different proton pump inhibitors, utilizing a high-dose citric acid-based 13C urea breath test. METHODS: Patients positive for Helicobacter pylori by urea breath test were randomized to receive either omeprazole 20 mg/day, pantoprazole 40 mg/day, lansoprazole 30 mg/day or esomeprazole 40 mg/day for 14 days. A repeat breath test was performed on day 14 of treatment. RESULTS: One hundred and seventy-nine patients, mean age 45.8 +/- 16.8, completed the study. Treatment with omeprazole or pantoprazole prior to urea breath test (UBT) was associated with low false negative results, while lansoprazole and esomeprazole caused clinically unacceptable high false negative rates (pantoprazole 2.2% vs. lansoprazole 16.6%, P = 0.02, vs. esomeprazole 13.6%, P = 0.05; omeprazole 4.1% vs. lansoprazole 16.6%, P = 0.05). CONCLUSIONS: Proton pump inhibitor-induced false negative results on high-dose citric acid based urea breath test vary with the type of proton pump inhibitor used. Selection of the appropriate test meal and proton pump inhibitor may allow symptomatic individuals to continue their proton pump inhibitors prior to performing a urea breath test.     

Impact and treatment of cancer during pregnancy

Cancer is the second most common cause of death in the reproductive years and complicates up to one in 1000 pregnancies. When cancer is diagnosed during pregnancy, the management strategy must take into account both the mother and developing fetus. In this article, the four most common malignancies diagnosed in pregnant patients--cervical and breast cancer, malignant melanoma and lymphoma--will be reviewed, with an emphasis on the impact of the diagnosis and management on the pregnant patient and the developing fetus.     

What to do after a failed attempt of vacuum delivery?

OBJECTIVES: To determine whether there is a difference in maternal and neonatal outcomes if a sequential operative vaginal or cesarean delivery follows failed vacuum delivery. STUDY DESIGN: A cross sectional study. We have analyzed maternal and neonatal outcomes of 215 vacuum extractions (group 1), 106 forceps assisted deliveries (group 2), 28 deliveries in which failed vacuum extraction were followed by forceps delivery (group 3) and 22 deliveries in which failed vacuum extraction were followed by cesarean delivery (group 4). RESULTS: Compared to other groups, patients in group 4 had significantly more post partum anemia, meconium stained amniotic fluid and hospital stay (both maternal and neonatal) as well as lower pH. Apgar scores were similar in groups 3 and 4. Incidence of respiratory distress syndrome, cephalhematoma and jaundice were similar in neonates of all groups. CONCLUSIONS: If an attempted vacuum delivery has failed, the risk of adverse neonatal outcome is increased with either subsequent forceps or cesarean delivery. It should remain in the judgment of the attending obstetrician to choose the method most suitable under the given circumstances.     

The role of sonographic assessment of cervical length in the prediction of preterm birth in primigravidae with twin gestation conceived after infertility treatment

OBJECTIVE: To identify the risk factors for preterm birth in primigravidae with twin gestation and the role of transvaginal ultrasonographic assessment of the cervix. METHODS: Between January 1996 and December 1996, 54 twin pregnancies were prospectively enrolled. All women were at their first pregnancy. All women conceived following infertility treatments and all had a normal uterine cavity proven by hysterosalpingography (HSG) or hysteroscopy. Multiple logistic regression analysis was used to evaluate the association between the length of the cervix at 18-24 weeks of gestation and outcome variables, controlling for possible confounding factors. RESULTS: The mean +/- SD maternal age was 30.9 +/- 5.3 years (range 22-46), and five of them were aged 40 or more. Nine patients (20.5%) delivered prematurely, defined as spontaneous delivery at or before 34 weeks of gestation. There was no statistically significant difference between women who delivered before or after 34 weeks of gestation in regard to maternal age, body mass index (BMI), weight gain in pregnancy, smoking and work during pregnancy. The mean cervical length of patients who delivered before 34 weeks of gestation (30.1 +/- 6.1 mm) was significantly shorter than that of women who delivered after 34 weeks of gestation (42.2 +/- 6.2 mm; P < 0.001). Cervical length longer than 35 mm predicted delivery after 34 weeks of gestation with sensitivity and specificity of 88.5% and 88.9%, respectively. The positive and negative predictive values were 96.9% and 66.7%. CONCLUSION: A transvaginal ultrasonographic measurement of the cervix > 35 mm at 18-24 weeks in twin gestation can identify patients at low risk for delivery before 34 weeks. Maternal age, BMI, weights gain, smoking and work during the pregnancy did not influence the duration of the pregnancy.     

New syndrome of simplified gyral pattern,micromelia, dysmorphic features and early death

We report two sisters with a new syndrome of simplified gyral pattern, normal head circumference at birth but with subsequent development of microcephaly, intractable seizures, and early death. Dysmorphic features included coarse face, hypertrichosis, short nose, paranasal widening, long philtrum, short neck, upper limb micromelia, single transverse palmar lines, and clasp thumbs. The proband had repeated convulsions from shortly after birth and she required continuous artificial ventilation. Neurological examination showed absent sucking, rooting, Moro and grasping reflexes. MRI revealed a diffuse simplified gyral pattern with apparent agyria over the frontal lobes. Biochemical screening gave normal results. Her older sister had bilateral renal pelvic dilatation on prenatal ultrasound. She also developed severe convulsions on the first day of life, and she had to be artificially ventilated for 38 days. She had severe developmental retardation and neurological examination showed absence of spontaneous movements and Moro reflex, weak sucking reflex, and hypertonicity. CT scan of the brain showed a simplified gyral pattern. At 3 months, she developed hypocalcemia and hyperphosphatemia with normal levels of vitamin D and alkaline phosphatase, and parathyroid hormone level was low. Other biochemical tests gave normal results. She died at 5 months due to a massive aspiration event. Based on the unique clinical and radiological features found in our patients, we propose that this is a new syndrome.     

Alterations in nitric oxide production in 8-week-old lambs with increased pulmonary blood flow

Nitric oxide (NO) is an important mediator of pulmonary vascular reactivity, and decreased NO synthase expression has been demonstrated in children with advanced pulmonary hypertension secondary to congenital heart disease and increased pulmonary blood flow. Using aortopulmonary vascular graft placement in the fetal lamb, we have established a unique animal model of pulmonary hypertension with increased pulmonary blood flow. At 4 wk of age, these lambs display an early, selective impairment in agonist-induced NO responses, but an up-regulation of basal NO activity and gene expression. We hypothesized that further exposure to increased flow and/or pressure results in progressive endothelial dysfunction and a subsequent decrease in basal NO production. The objective of this study was to characterize potential later alterations in agonist-induced NO responses and basal NO activity and gene expression induced by 8 wk of increased pulmonary blood flow and pulmonary hypertension. Twenty-two fetal lambs underwent in utero placement of an aortopulmonary vascular graft (shunt), and were studied 8 wk after delivery. Both in vivo and in isolated pulmonary arteries, the pulmonary vasodilating response to endothelium-dependent agents was attenuated in shunted lambs (p < 0.05), whereas the response to endothelium-independent agents was unchanged. The pulmonary vasoconstricting responses to Nomega-nitro-L-arginine, and lung tissue endothelial NO synthase mRNA, endothelial NO synthase protein, NO synthase activity, and NO(X) levels were all unchanged. These data suggest that the increase in basal NO activity demonstrated after 4 wk of increased pulmonary blood flow is lost by 8 wk of age, whereas the attenuation of agonist-induced responses persists. We speculate that the progressive decrease in basal NO activity participates in the development of pulmonary hypertension secondary to increased pulmonary blood flow.     

The relationship between primary care physicians' adherence to guidelines for the treatment of diabetes and patient satisfaction: findings from a pilot study

BACKGROUND: Adherence to clinical guidelines improves health care outcomes, reduces expenditure and prevents the complication of unnecessary interventions. It is uncertain what effect the adherence to guidelines for treating diabetes has on patient satisfaction. Some authors have reported that the use of guidelines does not affect patient satisfaction with care, and have concluded that satisfaction is related to a physician's interpersonal skills, rather than to the quality of care. Others have reported that structured intervention programmes improve patient satisfaction with care. OBJECTIVE: The purpose of our study was to explore the association between adherence to clinical guidelines and satisfaction with care among diabetics. METHODS: The study population included 135 randomly sampled diabetes patients listed with 12 primary care physicians at two health plans in Israel, which together insure >80% of the population. Telephone interviews were conducted with the patients between August and November 2000, using structured questionnaires. Patients were asked to report on the extent to which their primary care physician treated them as indicated by the clinical guidelines of these health plans. They were also asked to rate their satisfaction with their primary care physician and the treatment of their disease. Bi-variate analysis was conducted using the chi-square statistical significance test. Multivariate analysis was conducted using logistic regression models. RESULTS: Adherence to guidelines for diabetes was associated with patient satisfaction with care, independently of the patient's ethnicity (first language), age, gender, education, medication (insulin versus other) and health plan affiliation. CONCLUSION: Patients who report being treated as recommended in practice guidelines were more likely to be satisfied with their care. This finding may encourage primary care physicians to adhere to clinical practice guidelines.     

Progesterone levels in cesarean and normal delivered term placentas

Background  

One of the most important hormones synthesized by the placenta during pregnancy is progesterone. The regulating mechanisms of progesterone synthesis and the mechanism responsible for the spontaneous onset of labor in women are still not fully understood. Progesterone is thought to have been involved in human parturition. The objective of this study was to compare the levels of progesterone in the human placentas, at the end of the gestation (37–41 weeks) in vaginal versus cesarean deliveries, and to evaluate the pattern of progesterone accumulation, instantly following its synthesis by the human placenta at the end of the pregnancy.     

Efficacy of a mucoadhesive patch compared with an oral solution for treatment of aphthous stomatitis

OBJECTIVE: The purpose of this study was to evaluate the efficacy and tolerability of a mucoadhesive patch compared with a pain-relieving oral solution for the treatment of aphthous stomatitis. METHODS: Patients with active aphthous stomatitis were randomly treated either once a day with a mucoadhesive patch containing citrus oil and magnesium salts (n = 26) or three times a day with an oral solution containing benzocaine and compound benzoin tincture (n = 22). All patients were instructed to apply the medication until pain had resolved, and completed a questionnaire detailing multiple clinical parameters followed by an evaluation of the treatment. RESULTS: The mucoadhesive patch was found to be more effective than the oral solution in terms of healing time (mean +/- SD: 36.0 +/- 22.8 hours vs 134.7 +/- 57.7, p < 0.001) and pain intensity after 12 and 24 hours (3.7 +/- 2.8 vs 6.3 +/- 2.6, p = 0.003, and 2.3 +/- 2.7 vs 5.7 +/- 2.5, p < 0.001, respectively). Local adverse effects 1 hour after treatment were significantly (p < 0.01) less frequent among the mucoadhesive patch patients compared with the oral solution patients. CONCLUSIONS: The mucoadhesive patch was found to be significantly more effective and better tolerated than the oral solution in the treatment of aphthous stomatitis.