The life and health challenges of young Malaysian couples: results from a stakeholder consensus and engagement study to support non-communicable disease prevention.

BACKGROUND: Malaysia faces burgeoning obesity and diabetes epidemics with a 250% and 88% increase respectively between 1996 and 2006. Identifying the health challenges of young adults in Malaysia, who constitute 27.5 % of the population, is critical for NCD prevention. The aim of the study was two-fold: (1) to achieve consensus amongst stakeholders on the most important challenge impacting the health of young adults, and (2) to engage with stakeholders to formulate a NCD prevention framework. METHODS: The Delphi Technique was utilised to achieve group consensus around the most important life and health challenges that young adults face in Malaysia. Subsequently, the results of the consensus component were shared with the stakeholders in an engagement workshop to obtain input on a NCD prevention framework. RESULTS: We found that life stress was a significant concern. It would seem that the apathy towards pursuing or maintaining a healthy lifestyle among young adults may be significantly influenced by the broader distal determinant of life stress. The high cost of living is suggested to be the main push factor for young working adults towards attaining better financial security to improve their livelihood. In turn, this leads to a more stressful lifestyle with less time to focus on healthier lifestyle choices. CONCLUSIONS: The findings highlight a pivotal barrier to healthier lifestyles. By assisting young adults to cope with daily living coupled with realistic opportunities to make healthier dietary choices, be more active, and less sedentary could assist in the development of NCD health promotion strategies.

Identifying responders to acid suppression in dyspepsia using a random starting day trial.

BACKGROUND: Functional dyspepsia is a heterogeneous condition and a uniform response to drug treatment is not likely. This may be the reason for the general failure of acid suppression in clinical trials in these patients. It may be more rewarding to identify true responders to drug treatment by a single subject trial. AIM: To develop and to test a novel single subject trial design (random starting day trial) in dyspeptic patients. PATIENTS AND METHODS: A total of 301 dyspeptic patients entered a 16-day trial. All patients received placebo for the first 4 days and switched to omeprazole at a randomized and blinded day between day 5 and day 14. Response was defined as a sustained >/= 50% decrease in symptom score occurring in relation to drug shifting. RESULTS: Spontaneous response varied between 0.3% and 10.6% per day, uniformly distributed over time. Overall, 53-61% of patients with organic dyspepsia had a symptom response in relation to shifting to active treatment, compared to only 23% of patients with functional dyspepsia. The only predictor of response was symptoms suggesting gastro-oesophageal reflux. CONCLUSIONS: A random starting day trial may be a valuable tool to identify response to acid suppression in dyspeptic patients.

Budesonide versus prednisolone retention enemas in active distal ulcerative colitis.

METHODS: Efficacy and safety of the topically acting glucocorticosteroid budesonide retention enema (2.3 mg/115 mL) were compared with prednisolone disodium phosphate enema (31.25 mg/125 mL) in patients with active distal ulcerative colitis. The study was a randomized, multicentre trial, with two parallel groups and single-blind to the investigator. One hundred patients with active ulcerative colitis, not reaching beyond the splenic flexure as determined by endoscopy, were treated for up to 8 weeks. RESULTS: Forty-five patients were randomized to receive budesonide and 55 to prednisolone. Both treatment groups improved significantly in terms of endoscopic and histological scoring during the study, but there were no statistically significant differences between the two groups. Clinical remission, defined as no more than three daily bowel movements without blood and endoscopically non-inflamed mucosa, was achieved in 16% of the patients in the budesonide group after four weeks and in 24% in the prednisolone group (N.S.). After 8 weeks treatment the clinical remission rate in the groups had increased to 36% for budesonide and 47% for prednisolone (N.S.). Mean morning plasma cortisol levels were unchanged in the budesonide group, whereas they were significantly suppressed in the prednisolone group after 2, 4 and 8 weeks (P < 0.0001). Side effects were mild and rare in both groups. CONCLUSIONS: Treatment with budesonide enema in active distal ulcerative colitis was comparable, regarding efficacy, to treatment with conventional prednisolone enema. A prolongation of the treatment time from 4 to 8 weeks doubled the clinical remission rate in both groups. However, budesonide may be preferable to prednisolone since it causes less systemic effects as reflected by a lack of plasma cortisol suppression.

Low-dose cyclosporin for Crohn's disease: implications for clinical trials.

Cyclosporin is a potent immunosuppressant, which has gained recent interest as a possible treatment for Crohn's disease. Chronic nephrotoxicity, however, has recently been demonstrated as a result of early treatment with high initial cyclosporin doses. We report the effect of a 3-month treatment with low-dose cyclosporin (5-7.5 mg kg-1 day-1) in 11 chronically active, therapy-resistant Crohn's disease patients. Eight of the 11 patients (72%) improved according to a clinical grading score and the Dutch Activity Index whereas 9/11 (82%) improved according to the Crohn's Disease Activity Index (P less than 0.05) after 1 month. Three patients were withdrawn despite clinical improvement. One developed arterial hypertension, one dropped out and one required surgical treatment due to a small bowel stricture. Five patients (45%) completed the treatment period with improved clinical scores. After tapering-off, two patients (18%) were better at follow-up. No serious side-effects were encountered and it is concluded that low-dose cyclosporin treatment should be further investigated in Crohn's disease.

Duodenal ulcer healing on 2 g of sucralfate daily at bedtime compared to 1 g four times daily.

Seventy-seven patients with endoscopically verified duodenal ulcers were randomized to treatment with either 2 g sucralfate daily at bedtime or 1 g sucralfate q.d.s. in a controlled double-blind comparative study. After a 4-week treatment period, the healing rate was 68% for the former and 69% for the latter treatment.

Evaluation of the ulcerogenic effect of potassium chloride by endoscopy and fecal blood loss.

In a blinded-observer crossover study, 16 volunteers ingested equimolar doses of three different potassium chloride preparations and placebo for nine days in a random order. The irritating effect on the mucosa was evaluated by means of upper gastrointestinal endoscopy and fecal blood loss, measured by reference to the amount of radioactivity in three 24-hour samples after previous injection of 51Cr-tagged autologous red cells. The microencapsulated KCl capsule preparation induced three ulcers, but the total endoscopic group score was not significantly higher than the score with placebo. The total endoscopic group score for the wax-matrix formulation was significantly higher than the score for placebo (P less than .05) and for a new microencapsulated KCl tablet preparation containing a potent disintegrant (P less than .10). We did not find any significant differences in mean fecal blood loss during the four different treatments. A correlation between endoscopic score and fecal blood loss was found in the placebo group (r = .54) and the microencapsulated KCl capsule preparation (r = .56) group.

Prognosis of acute nonspecific abdominal pain. A prospective study.

In a prospective study of 230 patients followed up for 5 years after hospital admission for acute non-specific abdominal pain, 21 patients (9 patients) could not be traced, and 11 (5 percent) had died. Only one death was related to symptoms from the first admission. Of the remaining 198 patients, 77 percent were healthy and free of any symptoms during the observation period. Fourteen patients (7 percent) had been hospitalized once more due to acute abdominal pain; 5 had acute appendicitis. The others had diagnosed recurrences of nonspecific abdominal pain. Sixteen percent complained of continuing of intermittent abdominal symptoms, mainly of benign colonic or gynecologic origin, while malignant disease developed in 1 percent (or 4 percent of patients over 50 years of age). It is concluded that control of these patients is generally unnecessary, but when symptoms recur further examinations, especially for colonic or gynecologic disease, should be carried out. In patients over 50 years old, the possibility of malignant disease should be kept in mind.

Quantitative hepatobiliary scintigraphy and endoscopic sphincter of Oddi manometry in patients with suspected sphincter of Oddi dysfunction: assessment of flow-pressure relationship in the biliary tract.

OBJECTIVE: In the present study, the diagnostic efficacy of quantitative hepatobiliary scintigraphy (QHBS) was compared with that of endoscopic sphincter of Oddi (SO) manometry (ESOM) in patients with a suspected SO dysfunction (SOD) of biliary type II or III. METHODS: Twenty cholecystectomized patients with SOD biliary types II and III were investigated by QHBS and by ESOM. Twenty asymptomatic cholecystectomized patients served as controls for scintigraphy. ESOM was performed by applying the station pull-through method. Then SO basal pressure and phasic contraction characteristics were determined. During QHBS, time-activity curves were generated, and the time-to-peak (Tmax), the half-time of excretion (T(1/2)), the duodenal appearance time (DAT) and the hilum-to-duodenum transit time (HDTT) were then calculated. At the 60th minute of QHBS, 5 ng/kg body weight/min caerulein was administered. RESULTS: In patients with SOD and elevated SO basal pressure (> 40 mmHg), QHBS parameters, such as Tmax and T(1/2) calculated from regions of interest over the hepatic hilum and common bile duct, HDTT and DAT proved to be significantly increased compared to controls: 28.7 +/- 4.3 versus 21.1 +/- 4.6 min, 39.7 +/- 15.4 versus 18.8 +/- 2.6 min, 9.0 +/- 3.6 versus 2.3 +/- 1.3 min and 27.1 +/- 4.9 versus 16.6 +/- 3.0 min, respectively. In contrast, in patients with SOD and normal SO basal pressure, QHBS parameters did not differ significantly from the controls. For the pooled data on the symptomatic patients with SOD, a statistically significant linear correlation was found between the SO basal pressure and the QHBS parameters. Although HDTT was the most sensitive scintigraphic parameter (89%), the combined sensitivity and specificity of Tmax and T(1/2) of the common bile duct reached 100%. No scintigraphic sign of a paradoxical response to cholecystokinin was detected. CONCLUSIONS: QHBS is a useful non-invasive diagnostic method for the selection of SOD patients with an elevated SO basal pressure. A significant correlation has been established between the trans-papillary bile flow measured by QHBS and the SO basal pressure determined by ESOM.

Analysis of the motor function of the human sphincter of Oddi by endoscopic retrograde cinecholangiography gated by manometry--a report of a case.

Although the motor function of the sphincter of Oddi (SO) has been clearly identified by endoscopic SO manometry (ESOM), the physiologic role of the phasic contractions of the SO remains unsettled in humans. The aim of this study was to correlate SO motor activity measured by ESOM with bile flow characteristics determined by simultaneously recorded endoscopic retrograde cinecholangiography. We investigated a 55-year-old female patient by means of ESOM. During the station pull-through recording, the ESOM catheter was withdrawn into the SO zone and retained there for 15 min. The pressures transmitted by the external transducers and the enlarged video picture of the choledochoduodenal junction from the X-ray fluoroscopic monitor (25 digital pictures/sec) were recorded simultaneously on the computer system with a time-correlated basis. During the analysis without taking note of the cinefluoroscopic events, we selected different manometric periods manually, such as the pressure wave of the SO phasic contraction, no SO phasic activity and the first second of the beginning of the next phasic contraction. Cumulative cinecholangiographic pictures were then constructed by the computer for each period, at a frequency of one frame/sec to create representative sum-of-pictures for each manometric period. By means of the application of manometrically gated cinecholangiography, we succeeded in demonstrating an exact time correlation between the SO systolic and diastolic movements on cinecholangiography and the pressure recording detected by ESOM in humans.

Precision requirements in a study of computer-aided diagnosis of jaundice (the COMIK study).

Some 700 icteric patients have now been investigated by the Copenhagen study group for computer-aided differential diagnosis of jaundice (the COMIK study). The paper presents experience based on preliminary test runs using selected subsets of the data. In particular, the effect of the number of intervals into which quantitative laboratory variables are grouped has been stuied. Computer performance depends little on such grouping and, by inference, on analytical imprecision. As the grouping becomes finer, performance is even seen to deteriorate. These findings are in accord with theory and experience from other areas of pattern recognition, the problem being one of sample size. It is concluded that we are in a paradoxical situation of knowing from studies of single analytes that precision matters; yet when it comes to assembling information about a patients's condition we cannot make effective use of the precision of today's laboratories. This would seem to hold good whether data are processed by a computer, by physician, or by the two in collaboration.

[Duodenal ulcer in systemic mastocytosis]. / Ulcus duodeni ved systemisk mastocytose.

Two cases of systemic mastocytosis are presented. Both patients had peptic ulceration. Greatly raised values on investigation of gastric acid secretion in patients with therapy-resistant peptic ulceration and normal serum gastrin should raise the suspicion of systemic mastocytosis.

[Laser epilation. A systematic review of evidence-based clinical results]. / Laserepilering. En systematisk oversigt over evidensbaserede kliniske resultater.

Unwanted hair growth remains a therapeutic challenge and an effective treatment modality without side effects is needed. Today, hair removal is offered with lasers and light sources and patients may expect long-lasting or permanent hair removal. Evidence-based clinical results have been considerably examined for ruby and alexandrite lasers, whereas there is little documentation on Nd:YAG and diode lasers. The results with the diode laser are, however, promising. No controlled clinical studies have been published with intense pulsed light sources. We conclude that there is scientific evidence of a short-term effect after hair removal with ruby, alexandrite, Nd:YAG, and diode lasers (three, six months). Ruby and diode lasers may have a long-lasting effect (one year), but this, however, must be further clarified. No studies have examined whether laser hair removal may be permanent. The occurrence of postoperative side effects is reported to be low for all laser systems. From this review of the literature, we conclude that laser hair removal does not at the moment have a permanent or convincing long-lasting effectiveness.

[Percutaneous endoscopic gastrostomy. A retrospective study of the course and complications]. / Perkutan endoskopisk gastrostomi. En retrospektiv opgørelse af forløb og komplikationer.

To assess mortality, morbidity and outcome of percutaneous endoscopic gastrostomy (PEG) we retrospectively studied 67 patients. PEG was successful in 65 patients (success rate, 97%). PEG was used as the procedure of choice when enteral feeding was needed. PEG was performed employing an introducer-technique and a Danish developed gastrostomy tube. The most common indication for PEG were neurological diseases (45 patients (69%)), trauma and malignant disorders (17 patients (26%)). Oral intake recovered in 18 patients (28%) who then had the tube removed, 25 patients (38%) were discharged with the gastrostomy, 13 patients (20%) died from their primary disease and five patients with PEG remained in hospital, PEG was removed in three patients due to intolerance to enteral feeding (two patients) or stomal leak (one patient). The total complication rate was 8% with three major complications (one procedure-related death). We recommend PEG for both short and long-term feeding.

[Endoscopic percutaneous transhepatic cholelithotripsy in the treatment of complicated stones in the deep biliary tracts]. / Endoskopisk perkutan transhepatisk kolelitotripsi til behandling af vanskelige sten i de dybe galdeveje.

The results of endoscopic percutaneous transhepatic cholelithotripsy in seven patients with stones in the deep biliary passages which could not be treated by endoscopic papillotomy (EST) or extracorporeal shock wave lithotripsy (ESWL) are presented. A new dilator technique combined with mechanical or laser-lithotripsy was employed. All of the patients were relieved of the stones after uncomplicated course. It is concluded that endoscopic percutaneous cholelithotripsy which can be carried out under local anaesthesia, should be offered to patients with stones in the deep biliary passages which are not accessible to conventional treatment with EST or ESWL.

[Pediatric colonoscopy]. / Paediatrisk koloskopi.

The procedure and results of 50 colonoscopies performed over a three-year period on a group of 43 children (range: 0.3-16 yr; median: 9 yr) are described. The main indications were evaluation for, or control of already known, chronic inflammatory bowel disease (n = 38) and rectal bleeding (n = 8). Following verbal and written information the children were admitted one to two days before the procedure for bowel preparation. Children < 10 years old received general anaesthesia during the colonoscopy (n = 25) and most children > or = 10 years old received an intravenous sedation with pethidine and midazolam (n = 25). In only one case was intravenous sedation not successful. The coecum was visualised in 96% and the terminal ileum intubated in 77% (when intended) of the endoscopies. The most important results obtained were establishment of the diagnosis of inflammatory bowel disease in 21 of 30 suspected cases and the removal of a polyp in two cases. At the time of colonoscopy a "best guess" diagnosis of either ulcerative colitis or Crohn's disease often predicted the histological diagnosis, but endoscopy tended to underestimate the severity and extent of the inflammation as compared to microscopy. There were no complications. We conclude that colonoscopy performed according to our recommendations is a safe and informative procedure for evaluation of the large bowel and terminal ileum in children with intestinal disease.

[What is evidence-based medicine?]. / Hvad er evidensbaseret medicin?

Evidence-based medicine is based on the best results from clinical and epidemiological research, which is combined with clinical experience and patient preferences. Questions of prognosis and harm are often best elucidated in large cohort studies. For other clinical questions the best evidence is usually found by systematic review of randomised trials, if possible in the form of meta-analyses. To make a diagnosis is, for example, not an aim in itself but a way to arrive at a prognosis and to suggest a treatment, provided this leads to a better prognosis. The most relevant, albeit rarely seen, test of a diagnostic method is a randomised trial. Evidence-based medicine will provide the best basis for evaluations of which interventions should be abandoned and which are effective and economically feasible. The use of evidence-based clinical guidelines will lead to more cost-effective treatments. It should be a national strategy that health care should be evidence-based.

[Extracorporeal shockwave crushing of gallstones. Preliminary report]. / Ekstrakorporal galdestensknusning. En praeliminaer rapport. Hvidovre Hospitals Galdestensgruppe.

Extracorporeal shock wave lithotripsy (ESWL) was used for treatment of symptomatic x-ray negative stones in 23 patients. The number of ESWL sessions per patient was 1.8 (range 1-4). In 18 patients (78%), adequate fragmentation was seen comparable to results obtained elsewhere. Oral bile acid therapy was used after ESWL in the 18 patients mentioned and the mean follow-up period was five months (range 3-8 months). Four patients had by now passed all stones while 12 patients still had remaining stone fragments and one patient a gallstone. After ESWL, one patient was and one patient a gallstone. After ESWL, one patient was referred for cholecystectomy at his own request. Of the remaining five patients, cholecystectomy was performed in two and was scheduled for in three. Complications after ESWL were seen in two patients who developed acute pancreatitis. Thus, our preliminary experience shows that ESWL resulted in fragmentation and passing of gallbladder stones, but not without complications. Like the gallstone groups in Lyon, Montreal and Munich we are convinced that ESWL should be performed in accordance with prospectively designed protocols in order to establish optimal planning of indications and strategies for future treatment.

[Esophago-gastro-duodenoscopy of pediatric patients]. / Osofago-gastro-duodenoskopi af paediatriske patienter.

In total 199 oesophago-gastro-duodenoscopies (OGD) were performed in 71 female and 71 male paediatric patients (three months-15 years, median 8 years 2 months). The endoscopy was performed in general anaesthesia in children less than five years old, and in an intravenous sedation in older patients. The indications for OGD were: recurrent abdominal pain and concomitant positive antibodies against Helicobacter pylori as a part of a scientific project, upper dyspepsia, upper gastrointestinal bleeding, failure to thrive, coeliac disease, suspicion of chronic inflammatory bowel disease and a percutaneous gastrostomy. Seventy-two OGD were carried out in general anaesthesia, 86 in intravenous sedation with midazolam and pethidine and 41 in intravenous midazolam sedation. Complications related to the sedation or to the endoscopy were not observed. Amnesia was reported in 94/95 children who were sedated intravenously with midazolam and pethidine or midazolam alone. Six endoscopies could not be carried out in intravenous sedation because of agitation. In the primary OGD endoscopy revealed a normal mucosa in 121/142 (85%), oesophagitis in four (3%), nodular mucosa in six (4%), gastritis in four (3%) and a duodenal ulcer in one (0.7%). Histology disclosed active or inactive chronic gastritis at the primary endoscopy in 35/69 (51%) of the children with recurrent abdominal pain and antibodies against H. pylori. In children with failure to thrive an avillous duodenal mucosa was seen in 3/32 (9%). A comparison between histological and stereomicroscopical evaluation of the duodenal biopsies revealed agreement in 41/47 (87%). We conclude that OGD is a safe and tolerable procedure in paediatric patients, in whom possible morphological changes are suspected. The indications for an OGD need further evaluation.