Various ancillary investigations can assist clinicians in the differential diagnosis of patients with parkinsonism. It is unknown which test offers greatest diagnostic value in clinical practice. We ...included 156 consecutive patients with parkinsonism, but with an initially uncertain diagnosis. At baseline, all patients underwent extensive clinical testing and the following ancillary investigations: brain magnetic resonance imaging (MRI);
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I-iodobenzamide single photon-emission computed tomography (IBZM-SPECT); analysis of cerebrospinal fluid (CSF); and anal sphincter electromyography (EMG). The final diagnosis was established after 3-year follow-up by two movement disorder specialists, according to international consensus criteria. We determined the diagnostic value by comparing the baseline clinical parameters and ancillary studies with the final diagnosis. Out of a potential 138 parameters, univariate analysis identified 35 parameters that discriminated Parkinson’s disease (PD,
n
= 62) and atypical parkinsonism (AP,
n
= 94), with AUC of 0.55–0.81. Stepwise logistic regression showed that the combination of tandem gait, axial UPDRS subscore, slow saccadic eye movements and dysphagia yielded an AUC of 0.93, adjusted for optimism. The combination of tandem gait and axial UDPRS subscore yielded an AUC of 0.90. None of the ancillary investigations alone or in combination with clinical testing improved this clinically based diagnostic accuracy, not even in a subgroup of patients with the greatest diagnostic uncertainty at baseline. Our study demonstrates that a comprehensive set of clinical tests provides good accuracy to differentiate PD from AP. Our results also suggest that routine MRI, IBZM-SPECT, CSF analysis and anal sphincter EMG do not improve this diagnostic accuracy. Future work should evaluate the possible diagnostic value of more advanced diagnostic tests.
Questionnaires are widely used instruments to monitor gastrointestinal (GI) symptoms. However, few of these questionnaires have been formally evaluated. We sought to evaluate our GI symptoms ...questionnaire in terms of clarity and reproducibility. Primary care patients referred for open access Helicobacter pylori urea breath testing reported GI symptoms (type+severity) and demographic information by written questionnaire. In an interview, patients gave a personal description of the meaning of the GI symptoms on the questionnaire. Patients' descriptions of GI symptoms were compared with current definitions. Symptom severity scores were compared before and after, interview versus questionnaire. Of the 45 patients included, 19 (42%) described all symptoms correctly, whereas 17 (38%) described one symptom incorrectly. None of the patients made more than three mistakes. Regurgitation was the most common incorrectly described symptom (16 patients 36%), whereas the other individual symptoms were well explained. Symptom severities before the interview, after the interview and reported by questionnaire (mean value+/-SEM) were 2.1 +/- 0.2, 2.1 +/- 0.2, and 1.5 +/- 0.2 points on a 7-point Likert scale (0-6), respectively. Mean severity reported by interview (95% CI) was 1.4 (1.3-1.5) times higher than reported by questionnaire (P < .05). In conclusion, the GI symptom questionnaire is understandable and has good reproducibility for measuring the presence of GI symptoms, although symptom severity is consistently rated higher when reported by interview.
Summary
Background : With the advent of empirical treatment strategies for patients with dyspeptic symptoms, it becomes increasingly important to select patients with a high risk of having cancer for ...immediate endoscopy. Usually alarming symptoms are used for this matter, but their diagnostic value is by no means clear.
Aim : To investigate the diagnostic value of alarm symptoms for upper gastrointestinal malignancy.
Methods : Meta‐analysis of studies describing prevalence of alarm symptoms in patients with and without endoscopically verified upper gastrointestinal malignancy were identified through a Medline search. The prevalence, pooled sensitivity, specificity, positive and negative predictive values were calculated.
Results : About 17 case studies and nine cohort studies were selected. The mean prevalence of gastrointestinal malignancies in the cohort studies was 2.8% of 16 161 patients. Five cohort studies indicated that 25% of the patients diagnosed with upper gastrointestinal malignancy had no alarm symptoms. The pooled sensitivities of individual alarm symptoms varied from 9 to 41%, the pooled positive predictive value ranged from 4.6 to 7.9%, and was 5.9% for ‘having any alarm symptom’. The pooled negative predictive value was 99.4% for ‘having any alarm symptom’.
Conclusion : The risk of upper gastrointestinal malignancy in any individual without alarm symptoms is very low, but approximately one in four patients with upper gastrointestinal cancer have no alarm symptoms at the time of diagnosis.
Summary
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.
Background:
Triple therapies with proton pump inhibitor/ranitidine bismuth citrate (RBC), clarithromycin (C) and either amoxicillin (A) or a nitroimidazole (I) are widely accepted as treatment for ...Helicobacter pylori infection. However, it is not clear which of these antibiotic combinations should be preferred.
Aim:
To evaluate whether there is a difference in efficacy between triple therapies with proton pump inhibitor/RBC, clarithromycin and either amoxicillin or a nitroimidazole.
Methods:
The literature was examined for randomized trials comparing proton pump inhibitor/RBC‐C‐A and proton pump inhibitor/RBC‐C‐I. Studies were grouped according to the type of acid inhibitor used (proton pump inhibitor or RBC) and differences between pooled cure rates were calculated.
Results:
Forty‐seven studies were identified: seven using RBC, 39 using proton pump inhibitor, one using both. RBC‐C‐I was somewhat superior to RBC‐C‐A, although this difference only reached statistical significance in intention‐to‐treat analysis. Overall, proton pump inhibitor‐C‐I and proton pump inhibitor‐C‐A were equally effective, but in nitroimidazole‐susceptible strains, proton pump inhibitor‐C‐I performed better, in nitroimidazole‐resistant strains, proton pump inhibitor‐C‐A performed better. No serious side‐effects were reported and pooled drop‐out rates were equal.
Conclusions:
In general, proton pump inhibitor‐C‐I and proton pump inhibitor‐C‐A are equally effective and therefore other factors such as local prevalence of resistant strains, cost of therapy and options for second‐line treatment should determine which regimen should be preferred. When using RBC, the RBC‐C‐I combination is somewhat superior to RBC‐C‐A.
Summary
Background : There is much debate about the influence of pre‐treatment with a proton pump inhibitor on Helicobacter pylori eradication. The few studies investigating the influence of ...pre‐treatment on triple and quadruple therapies did not find differences in eradication rates. However, the high eradication rates make it difficult to study factors associated with therapy failure in small populations. In order to overcome this problem we performed a meta‐analysis.
Methods : The literature was searched in order to identify randomized clinical trials comparing modern triple/quadruple therapies for H. pylori eradication without pre‐treatment with a proton pump inhibitor with exactly the same regimen with pre‐treatment. The overall risk difference (with − without pre‐treatment) was calculated by pooling the risk differences of the individual studies weighted by the inverse of their variances.
Results : Nine studies, investigating a total of 773 patients, were identified. There was considerable variation regarding therapy regimen and duration. Pooled eradication rates were 81.3% (312 of 384) for patients with pre‐treatment and 81.2% (316 of 389) for patients without pre‐treatment. The (weighted) overall risk difference was 0.1% (95% CI: −5%; 5%).
Conclusion : Pre‐treatment with a proton pump inhibitor does not influence H. pylori eradication.
Background. Questionnaires are frequently used to measure the severity of gastrointestinal (GI) complaints. These questionnaires can either be filled out by the physicians or by the patients, but it ...is not clear whether these scores correspond. This study aimed to investigate the interrater agreement between physician-reported severity and patient-reported severity concerning the patients’ upper GI complaints. Methods. In a prospective observational study, the severity of eight GI complaints was registered by both patients and GPs independently on a seven-point scale (n = 316) before and after treatment with esomeprazole. Weighted kappa values for the agreement on the severity and simple kappa values for the agreement on the absence or presence of symptoms were calculated. Results. The weighted kappa values ranged from 0.14 to 0.68 indicating poor to moderate agreement. The agreement on the presence or absence of symptoms was similar. Several systematic differences in scoring were found: the GPs tended to underestimate the severity of belching, nausea, early satiety, vomiting and upper and lower abdominal pain. Furthermore, the treatment effect for belching and lower abdominal pain was more often overestimated, while the treatment effect for nausea was more often underestimated by the GP. Conclusion. The agreement between GP and patient is low. The differences in scoring should be kept in mind when comparing physician-reported outcomes with patient-reported outcomes.
The discovery of
Helicobacter pylori has had a major clinical impact. Clinical research is now focused on the role of
H. pylori and
H. pylori eradication in the treatment of several upper ...gastrointestinal disorders such as non-ulcer dyspepsia, ulceration during therapy with aspirin or other anti-inflammatory drugs, the treatment of precancerous conditions of the stomach, and the prevention of gastric cancer. Triple and quadruple therapies have become the standard for
H. pylori eradication. The expansion of knowledge and the development of new therapeutic modalities are likely to lead to a further implementation of
H. pylori-related methods in strategies for the prevention and treatment of upper gastrointestinal disorders.
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.
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.
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)).
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.
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