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Source: Uemura N, et al. N Engl J Med. 2001;345:784-789.
Knowledge that Helicobacter pylori (HP) is involved in the pathogenesis of gastrointestinal (GI) disorders began in the early 1980s. In addition to nonmalignant GI syndromes, such as peptic ulcer disease, the World Health Organization (among others) has recognized HP as a definite carcinogen for gastric cancer. Uemura and colleagues have performed a prospective study of a large population of patients (n = 1526) in Japan who underwent endoscopy and confirmatory testing for the presence of HP, including tissue biopsy. Patients were followed up with repeat endoscopy at 1 and 3 years later.
Eighty-five percent of patients were HP positive at baseline. Gastric cancer developed in 2.9% of HP-infected patients, but in none of the uninfected patients. Gastric cancer did not develop in any of the HP-positive patients who had undergone treatment to eradicate HP.
In their discussion of this information, Uemura et al point out that previous studies that demonstrated carcinoma in HP-negative individuals may have used tests more likely to be false-negative than the battery of diagnostic tests used in this study. HP infection appears to be related to gastric cancer; in the relatively short-term observation reported here (up to 3 years), HP treatment was associated with an absence of the occurrence of gastric cancer.
Source: The Writing Group for the Activity Counseling Trial Research Group. JAMA. 2001;286:677-687.
The benefits of physical activity on health and well-being outcomes are well documented and diverse. Patients have indicated that they would like to receive counsel from their clinician about exercise, but there are little data on the frequency, adequacy, and efficacy with which health professionals offer advice about physical activity.
This trial was sponsored by the National Heart, Lung, and Blood Institute (NHLBI) to ascertain which of 2 education and counseling interventions was superior, and compare 2 interventions with "usual care" in the community. To evaluate this, 874 patients were randomized to receive either advice (physicians advised patients to increase activity, select a long-term goal, and visit with a health educator for educational materials on physical activity); assistance (same intervention as advice plus behavioral counseling intervention and a single phone contact at 1 week); and counseling (same as advice and assistance, but including biweekly telephone counseling for 6 weeks, followed by monthly contact; weekly classes on obtaining and maintaining healthy lifestyles were also included).
For increasing cardiorespiratory fitness, men differed from women in their responses to tailored interventions. Women responded more favorably to assistance and counseling than advice, but there was no difference in response to any one method over another. This study suggests that specially designed programmatic interventions may enhance the ability of women to achieve cardiovascular fitness, though additional benefits in men (over simple advice) are not apparent.
Source: Tepaske R, et al. Lancet. 2001;358:696-701.
Postoperative morbidity and mortality (PMM) is increased among the elderly and persons with impaired ventricular function. Some of this adverse event profile may be due to nutritional inadequacies; studies of nutritional supplements such as L-arginine (the immediate precursor to nitric oxide), omega-3 polyunsaturated fatty acids (PUFA), and dietary nucleotides (eg, yeast RNA) have shown some favorable effects in postsurgical settings.
L-arginine, PUFA, and yeast RNA have been combined into a single oral entity (Oral Impact, Novartis Nutrition). This supplement, or a placebo control of equal volume and caloric content, was administered to 50 patients undergoing cardiac surgery for 5-10 days preoperatively.
Patients who received the supplement had statistically fewer infections postoperatively (4 vs 12). Other surrogate markers of immune status (eg, delayed-type hypersensitivity response, interleukin 6 levels) were also more favorably affected in the active treatment group. The study was not powered to show a difference in length of hospital stay. There were no adverse effects attributable to the supplementation. Nutritional supplementation with Oral Impact may favorably affect postoperative outcomes in cardiac surgery patients.
Source: Hirsch AT, et al. JAMA. 2001;286:1317-1324.
Peripheral arterial disease (PAD) causes substantial morbidity, and is associated with significant mortality, particularly referable to cardiovascular events. Compared to other vasculopathies like stroke and myocardial infarction (MI), which are associated with high levels of public awareness and commonplace incorporation of risk factor reduction on the part of the clinical community, PAD is relatively neglected. The PARTNERS program evaluated detection of PAD in the office setting, hypothesizing that PAD is underdiagnosed and undertreated in primary care.
Patients (n = 6979) from 350 primary care sites older than age 70 (> age 50, if a smoker or diabetic) were screened for PAD using a Doppler device to obtain the ankle-brachial index (ankle systolic blood pressure divided by brachial systolic blood pressure). Since ankle blood pressure should be equal to or greater than brachial, an ABI less than 0.9 is indicative of clinically relevant PAD.
PAD was found in 29% of study subjects, of which the majority had not been previously diagnosed. Less than 10% of PAD subjects were symptomatic. Only half of physicians were aware of the PAD diagnosis in persons previously diagnosed.
Attending to cardiovascular risk factor analysis, Hirsch and colleagues note that smoking cessation had been applied to only half of PAD subjects, and management of both hypertension and hyperlipidemia were less intensive than in comparable patients with cardiovascular disease. PAD, a harbinger of other cardiovascular mortal and morbid end points, has been demonstrated to be underdiagnosed and less intensively managed than other comparable vasculopathies.
Source: Manges AR, et al. N Engl J Med. 2001;345:1007-1013.
The majority of American women will experience a urinary tract infection (UTI) in their lifetime, and as many as 11% of women report at least 1 UTI per year. Although most Escherichia coli strains involved in UTI are susceptible to trimethroprim-sulfamethoxazole, currently more than 15% of isolates are resistant. Since certain clonal strains of E coli have caused outbreaks of cystitis and pyleonephritis in Europe, the question has been raised whether there is a specific clone of E coli in the United States that has been etiologic in TMP-SMX-resistant UTI.
Study subjects were obtained from a population of California women with symptoms of UTI who cultured positive for E coli resistant to TMP-SMX over a 14-week period beginning October 1999; the results were compared with analyses of E coli from women with UTI in Michigan and Minnesota.
Considering isolates from all 3 states, 38-50% TMP-SMX resistant E coli belonged to a single clonal group. The method of spread of this clonal group is unknown, but the suggestion has been made that contaminated food could harbor such strains.
Source: Taguchi A, et al. N Engl J Med. 2001;345:935-940.
Major abdominal surgery consistently produces some degree of ileus, which not only may cause pain, nausea, and vomiting, but also delays return to oral feeding. Ultimately, ileus prolongs hospitalization. The common causes of ileus include the mechanical effects of surgical bowel manipulation, and opioids used in pain management. Opioid analgesia results in anticholinergically derived reductions in bowel motility.
ADL 8-2698 (ADL) is an investigational agent that blocks the gastrointestinal effects of opioid analgesics; because it is poorly absorbed when administered orally, and does not cross the blood-brain, coadministration with opioid analgesics is possible without blockade of opioid-induced centrally-mediated analgesia. The current study included 78 patients who underwent significant abdominal surgery. Patients were randomly assigned to ADL or placebo, both administered orally twice daily.
Participants who received ADL enjoyed shorter time to first passage of flatus (49 vs 70 hours), earlier first bowel movement (70 vs 111 hours), and earlier discharge from the hospital (68 vs 91 hrs). No serious adverse events were reported; indeed, ADL was associated with reduced nausea and vomiting. ADL offers promise as a tool to circumvent anticholinergic effects of postoperative opioid analgesia.