The influence of team experience on outcomes of endovascular stenting of abdominal aortic aneurysms.

OBJECTIVE: To determine whether the experience of the specialist team was associated with adverse events following endovascular treatment of abdominal aortic aneurysms. METHODS: The EUROSTAR database is a voluntary registry of 2863 patients admitted to 93 hospitals in Europe with an abdominal aortic aneurysm treated with endovascular stenting. Mortality, rupture and the need for secondary interventions were the main outcomes. RESULTS: In patients who underwent endovascular stenting by the most experienced specialist teams the mortality rate was 40% lower than in those treated by the least experienced teams (adjusted hazard ratio 0.60, 95% confidence interval: 0.4-1.0; p = 0.05). Also patients treated by the most experienced specialist teams were 68% less likely to have adverse events necessitating a secondary intervention than those treated by the least experienced teams (adjusted hazard ratio 0.32, 95% confidence interval: 0.2-0.5; p < 0.001). The crude rupture rate was 0.1% among patients treated by the most experienced specialist teams and 0.8% among those treated by the least experienced teams (p = 0.74). CONCLUSIONS: Specialist teams with a high level of experience of endovascular abdominal aortic aneurysm stenting encounter lower mortality rates and fewer adverse events leading to secondary interventions.     

Helicobacter pylori infection treatment of nonulcer dyspepsia: an analysis of meta-analyses

BACKGROUND: Meta-analysis is often used to resolve uncertainty in magnitude of effect between studies. However, several meta-analyses investigating the association between Helicobacter pylori infection and nonulcer dyspepsia reported contradictory results. GOALS: To perform a systematic review of the conflicting data in meta-analyses examining the association between H. pylori infection and nonulcer dyspepsia. STUDY: Five meta-analyses were identified: three studied the relation between H. pylori treatment and nonulcer dyspepsia, one studied the relation between H. pylori eradication and nonulcer dyspepsia, and one reported both. Data on search strategy, study selection, study inclusion, data abstraction, reported results of included studies, and summarized effect estimates were collected. RESULTS: Overall, 29 studies were included in the five meta-analyses. Nine studies (31%) were evaluated in more than one meta-analysis. There was no disagreement between the meta-analyses concerning the interpretation of outcome per investigated study; the results from seven (24%) studies showed improvement of dyspeptic symptoms after H. pylori treatment or eradication. The odds ratio of symptom relief in the control groups relative to the treated groups varied between 0.30 (95% CI = 0.2-0.5) to 0.88 (95% CI = 0.7-1.2). The proportion of patients' symptom free due to H. pylori treatment varied between 11% and 38%. CONCLUSIONS: The reported conflicting results between the meta-analyses were mainly a result of differences in study selection (eligibility and quality criteria) and relatively small. In a subgroup of patients with nonulcer dyspepsia, H. pylori eradication is useful for relief of symptoms.     

The influence of pretreatment on cure rates of Helicobacter pylori eradication

BACKGROUND: Many patients treated for H. pylori infection have been taking a proton pump inhibitor beforehand. There is conflicting evidence whether pretreatment influences the efficacy of H. pylori eradication. The aim of this study was to investigate the influence of pretreatment on cure rates of H. pylori eradication. METHODS: Patients with H. pylori positive peptic ulcer disease or functional dyspepsia were treated with two-day quadruple therapy (lansoprazole 30 mg twice daily, and colloidal bismuth subcitrate 120 mg, tetracycline 250 mg and metronidazole 250 mg, all eight times a day). Patients were randomised to receive either three-day pretreatment with lansoprazole 30 mg twice daily or no pretreatment. H. pylori was diagnosed using CLO, histology and culture. RESULTS: Twenty-five (66%) of 38 patients with pretreatment and 32 (84%) of 38 patients without pretreatment were cured (p=0.06). After adjustment for diagnosis, smoking status and metronidazole resistance the influence of pretreatment became slightly less pronounced (OR 0.44, 95% CI 0.1-1.7). Nonsmokers and patients with peptic ulcer disease were more likely to achieve H. pylori eradication than smokers and patients with functional dyspepsia, respectively (adjusted odds ratios: 4.79 (1.2-19) and 4.32 (1.0-18)). CONCLUSIONS: This two-day quadruple therapy reached an overall cure rate of 75%. Nonsmokers and patients with peptic ulcer disease were more likely to achieve H. pylori eradication. Three-day pretreatment with a proton pump inhibitor may decrease cure rates of this two-day quadruple therapy.     

Local staging of prostate cancer using magnetic resonance imaging: a meta-analysis

Our objective was to determine the influence of patient-, study design-, and imaging protocol characteristics on staging performance of MR imaging in prostate cancer. In an electronic literature search and review of bibliographies (January 1984 to May 2000) the articles selected included data on sensitivity and specificity for local staging. Subgroup analyses examined the influence of age, prostate specific antigen, tumor grade, hormonal pre-treatment, stage distribution, publication year, department of origin, verification bias, time between biopsy and MR imaging; consensus reading, study design, consecutive patients, sample size, histology preparation, imaging planes, fast spin echo, fat suppression, endorectal coil, field strength, resolution, glucagon, contrast agents, MR spectroscopy, and dynamic contrast-enhanced MRI. Seventy-one articles and five abstracts were included, yielding 146 studies. Missing values were highly prevalent for patient characteristics and study design. Publication year, sample size, histologic gold standard, number of imaging planes, turbo spin echo, endorectal coil, and contrast agents influenced staging performance ( p=0.05). Due to poor reporting it was not possible to fully explain the heterogeneity of performance presented in the literature. Our results suggest that turbo spin echo, endorectal coil, and multiple imaging planes improve staging performance. Studies with small sample sizes may result in higher staging performance.     

Long-term follow-up of empirical treatment or prompt endoscopy for patients with persistent dyspeptic symptoms?

BACKGROUND: There are concerns about the safety and possible high costs of ongoing proton pump inhibitor therapy of empirical management strategies for patients with persistent dyspeptic symptoms. AIM: To compare the long-term results of two treatment strategies: empirical treatment followed by the Helicobacter pylori test and treat strategy (treat and test group) and prompt upper gastrointestinal endoscopy followed by directed medical treatment (endoscopy group). METHODS: In this study we describe the long-term follow-up data from a previously published randomized clinical trial. At least 6 years after randomization all participating general practitioners and patients were asked to give information about medication use, diagnostic testing, symptoms and quality of life by questionnaire. RESULTS: Information about a total of 77 out of the 80 patients initially included (96%) was retrieved. Overall, 16 patients from the treat and test group (41%) underwent 18 diagnostic investigations. The 34 patients (100%) from the endoscopy group underwent 38 investigations (P < 0.01). The number of patients of the treat and test group and endoscopy group using acid inhibition therapy was 15 (38%) and 19 (56%), respectively (P = 0.14). There were also no differences in symptom prevalence and quality of life between the groups. CONCLUSIONS: Treat and test management for patients with dyspeptic symptoms is safe and does not lead to additional diagnostic testing or use of medication when compared to prompt endoscopy.     

Health-related quality of life in patients with cardiovascular disease--the effect of upper gastrointestinal symptom treatment

BACKGROUND: Upper gastrointestinal discomfort decreases the already impaired health status of patients with cardiovascular disease. AIM: To evaluate whether acid suppressive therapy improves health-related quality of life in patients who developed upper gastrointestinal symptoms after starting low-dose acetylsalicylic acid. METHODS: In a double-blind, placebo-controlled randomized trail, cardiac patients using low-dose (80 mg) acetylsalicylic acid with (n = 142) and without (n = 90) upper gastrointestinal symptoms were included. Patients with symptoms were treated with rabeprazole or placebo for 4 weeks. At baseline and 4 weeks information about gastrointestinal symptoms and health-related quality of life was assessed. RESULTS: The 73 patients assigned to rabeprazole when compared with 69 patients given placebo reported the same quality of life scores 4 weeks after randomization. The differences in quality of life scores between patients with and without symptoms at baseline remained after 4 weeks. Patients in whom treatment led to complete symptom relief or those who remained symptom-free reported significantly higher scores for Physical Component Summary (P < 0.01) and Mental Component Summary (P < 0.01), when compared to those with persistent symptoms or new onset symptoms. CONCLUSION: Proton-pump inhibitor therapy did not improve quality of life. Upper gastrointestinal symptom relief in itself considerably increased quality of life.     

Gastric acid-suppressive therapy and community-acquired respiratory infections

BACKGROUND: Bacteria and viruses have been detected in the stomach of patients during acid-suppressive therapy. AIM: To investigate whether subjects using acid-suppressive drugs more often develop community-acquired respiratory infections when compared to those who do not use acid-suppressive drugs. METHODS: 700 study subjects were recruited during a single week in December 2002. Information on the prevalence of clinical manifestations of infections and complications in the preceding month was assessed by questionnaire. Furthermore, subjects were asked to report antibiotic therapy and physician visits related to possible infection. RESULTS: Questionnaires were returned by 405 subjects (58%). Consumption of acid-suppressive drugs was reported by 91 individuals, of whom 79 used proton-pump inhibitors (20%) and 12 H2-receptor antagonists (3%). Overall, 101 (25%) responders reported clinical manifestations of respiratory infection in the preceding month. Subjects using acid-suppressive drugs were 2.34 times [95% confidence interval (CI) 1.4-4.1] more likely to have clinical manifestations of infection than individuals not using acid-suppressive drugs. Subjects using acid-suppressive drugs visited a physician 3.72 times more often (95% CI 2.1-6.8) for an infection and received antibiotic therapy 4.19 times more often (95% CI 2.2-8.1) in comparison to individuals not using acid-suppressive drugs. CONCLUSIONS: Subjects using acid-suppressive drugs more often reported community-acquired respiratory infections in comparison to those who did not use acid-suppressive drugs.