Gastro-oesophageal reflux and respiratory symptoms in Busselton adults: the effects of bodyweight and sleep apnoea.

BACKGROUND/AIM: Respiratory symptoms and gastro-oesophageal reflux disease (GORD) are common within the general population. Although a number of epidemiological studies have addressed their relationship, none has investigated the confounding effects of body mass index (BMI) and obstructive sleep apnoea (OSA), both of which are associated with reflux. METHODS: Men and women (2700) from the 2005-2007 cross-sectional Busselton health survey were included. Questionnaire data included demography, information on general health, asthma, cough, wheeze, dyspnoea and reflux symptoms (never, monthly or less often and weekly or more often). BMI, risk of OSA (Berlin questionnaire definition), spirometry and airway hyperresponsiveness (AHR) were recorded. The effects of BMI and OSA on the relationship between respiratory and reflux symptoms were examined using logistic regression models, expressed as adjusted odds ratios for risk of respiratory symptoms by reflux symptom category. RESULTS: Fifty per cent had reflux symptoms (5-10% weekly or more often). Reflux symptoms had strong positive, dose-related associations with cough/phlegm, breathlessness, chest tightness and wheeze in the last 12 months (P < 0.001), but were not related to diagnosed asthma or AHR. Twenty-three per cent were at high risk of OSA and 63% had a BMI of >25 (22% > 30). Increased weight or high risk of OSA did not affect the relationship between respiratory symptoms and reflux symptoms. CONCLUSION: The relationship between reflux and respiratory symptoms was independent of BMI, high risk of OSA or AHR. These findings suggest that reflux contributes directly to respiratory symptoms.

Complication rates of colonoscopy in an Australian teaching hospital environment.

BACKGROUND: Quality assurance is an important part of health-care delivery. With the high level of awareness relating to adverse events from medical care, demonstration of a high standard of practice in gastroenterology is desirable. AIMS: To determine the incidence of significant complications or death within 30 days of an outpatient colonoscopy, and confirm that these are in keeping with international standards. METHODS: A retrospective audit of linked endoscopy and other hospital databases and selected medical records was carried out, based on reports of 30,463 colonoscopies performed between 5 September 1989 and 31 December 1999 in the three Western Australian public teaching hospitals. RESULTS: A total of 23,508 colonoscopies was performed on an outpatient basis between 5 September 1989 and 31 December 1999. Post-procedural complications identified (and incidence) were: bleeding episodes 49 (0.21%), colonic perforation 23 (0.1%), abdominal pain 22 (0.09%), and others 19 (0.08%). A total of 196 patients died within 30 days of undergoing colonoscopy (0.83%), although only three deaths were attributable to the procedure itself (incidence 0.01%). Two were inpatients at the time of the procedure (outpatient mortality rate 0.004%). The combined incidence of bleeding and perforation was not significantly different between consultant endoscopists and unassisted trainees (incidence 0.21% vs 0.20%, P=0.98). CONCLUSIONS: The incidence of bleeding and perforation is similar to other reported series and reflects procedures performed by personnel with a wide range of endoscopic experience. The incidence of complications was not greater for trainees compared with consultant endoscopists. All bleeding episodes and the majority of perforations were associated with a therapeutic intervention. Diagnostic colonoscopy in particular is a very safe procedure.

Serum ferritin and cardiovascular disease: a 17-year follow-up study in Busselton, Western Australia.

The association between serum ferritin level and coronary heart disease (CHD) and stroke events was evaluated in a long-term Western Australia prospective study in 1981-1998. The cohort consisted of the 1612 men and women aged 40-89 years who participated in the 1981 Busselton Health Survey and who were free of cardiovascular disease at that time. Serum ferritin levels were obtained from serum samples stored frozen since 1981. The outcomes of interest were time to first CHD event (hospital admission or death) and time to first stroke event. Case-cohort sampling was used to reduce costs and preserve serum but still allow efficient analysis. Ferritin assays were performed for 217 CHD cases, 118 stroke cases, and a random sample of 450 of the total cohort. Proportional hazards regression models were used to obtain age-adjusted and multivariate-adjusted hazard ratios for ferritin level in relation to CHD and stroke. The hazard ratio for the highest tertile group compared with the lowest group was 0.96 (95% confidence interval: 0.60, 1.53) for CHD and 1.43 (95% confidence interval: 0.78, 2.64) for stroke. Little or no evidence was found that ferritin level was a risk factor for cardiovascular disease.

High prevalence of coeliac disease in a population-based study from Western Australia: a case for screening?

OBJECTIVES: To determine the prevalence of coeliac disease in an Australian rural community. DESIGN: Retrospective analysis of stored serum samples from 3,011 random subjects from the Busselton Health Study. IgA antiendomysial antibodies (AEA) were detected by indirect immunofluorescence, and subjects testing positive were contacted and offered small-bowel biopsy. MAIN OUTCOME MEASURES: Prevalence of AEA positivity and biopsy-proven coeliac disease in the community with reference to the proportion of symptomatic to asymptomatic patients. RESULTS: 10 of 3,011 subjects were AEA positive. One subject had died, one subject could not be traced and one refused small-bowel biopsy. All subjects with detectable AEA who consented to biopsy had pathological changes consistent with coeliac disease. The prevalence of newly diagnosed biopsyproven coeliac disease is 7 in 3,011 (1 in 430). Two further subjects had a diagnosis of coeliac disease before this study. When all AEA-positive patients and those previously diagnosed are included, the prevalence is 12/3,011 (1 in 251). There was a significant clustering of cases in the 30-50-years age range, with 10/12 (83%; 95% CI, 52%-98%) aged between 30 and 50 years, compared with 1,092/3,011 (36%; 95% CI, 35%-38%) of the total population (P<0.03). Of the eight AEA-positive subjects who could be contacted, four had symptoms consistent with coeliac disease and four were asymptomatic. Three subjects were iron-deficient, four subjects had first-degree relatives with coeliac disease and one subject had type 1 diabetes mellitus. CONCLUSIONS: The prevalence of coeliac disease is high in a rural Australian community. Most patients are undiagnosed, and asymptomatic.

Effect of hemochromatosis genotype and lifestyle factors on iron and red cell indices in a community population.

BACKGROUND: Heterozygotes for the C282Y mutation of the HFE gene may have altered hematology indices and higher iron stores than wild-type subjects. METHODS: We performed a cross-sectional analysis of 1488 females and 1522 males 20-79 years of age drawn from the Busselton (Australia) population study to assess the effects of HFE genotype, age, gender, and lifestyle on serum iron and hematology indices. RESULTS: Male C282Y heterozygotes had increased transferrin saturation compared with the wild-type genotype. Neither male nor female heterozygotes had significantly increased ferritin values compared with the wild-type genotype. Younger (20-29 years) wild-type males, but not heterozygous males, had significantly lower ferritin values than wild-type males in the older age groups. Compound heterozygous subjects had increased means for serum iron, transferrin saturation, corpuscular volume, and corpuscular hemoglobin compared with the wild-type genotype, and the males also had increased ferritin values (medians 323 vs 177 microg/L; P = 0.003). In both male and female wild-type subjects, an increased body mass index was associated with decreased serum iron and transferrin saturation and increased ferritin values. There was a significant increase in ferritin concentrations in both genders with increasing frequency of red meat consumption above a baseline of 1-2 times per week and alcohol intakes >10 g/day. CONCLUSIONS: Male C282Y heterozygotes had significantly increased transferrin saturation values. Compound heterozygous (C282Y/H63D) subjects formed a separate category of C282Y heterozygotes in whom both iron and red cell indices were significantly increased compared with the wild-type genotype.

Pancreatic vasoactive intestinal polypeptide-oma as a cause of secretory diarrhoea.

A 42-year-old woman presented with a 4-year history of worsening diarrhoea that was watery, profuse and confirmed to be secretory in nature. She had tested positive for phenolphthalein on urinary laxative screening but continued to deny laxative usage. Her vasoactive intestinal polypeptide (VIP) level was subsequently found to be markedly elevated. Despite a normal abdominal ultrasound, a computed tomography scan revealed a 5-cm pancreatic tail mass. Octreotide scanning was used to exclude metastatic disease and she went on to have surgical removal of a localized pancreatic vasoactive intestinal polypeptide-oma which resulted in the complete resolution of her diarrhoea.

Compound heterozygous hemochromatosis genotype predicts increased iron and erythrocyte indices in women.

BACKGROUND: Women who inherit heterozygosity for the C282Y mutation of the HFE gene may have increased serum iron indices and hemoglobin and are less likely to develop iron deficiency compared with women with the wild-type genotype. METHODS: We performed a cross-sectional analysis of 497 women 20-44 years of age and 830 women >51 years of age drawn from the Busselton (Australia) population study to assess the effects of the HFE genotype on serum iron and hematology indices. RESULTS: Heterozygosity for the C282Y mutation occurred in 13.8% of the study population, comprising 11.8% C282Y wild-type heterozygotes and 2.0% C282Y/H63D compound heterozygotes. In the younger age group, C282Y wild-type women did not have significantly increased serum iron, transferrin saturation, or hemoglobin values, and were not protected from developing iron deficiency, compared with women of the same age with the wild-type genotype. Young compound heterozygous women had higher means for serum iron (25.0 vs 16.9 micromol/L; P <0.001), transferrin saturation (42.0% vs 25.6%; P <0. 05), hemoglobin (139.4 vs 132.3 g/L; P <0.05), and corpuscular volume (91.1 vs 87.7 fL; P <0.05), and a higher median ferritin (53 vs 44 microg/L; P <0.05) compared with the wild-type genotype. Similar results were observed for compound heterozygotes in the >51 years age group. CONCLUSIONS: Women with the compound heterozygous HFE genotype C282Y/H63D, but not the C282Y wild-type genotype, had increased values for serum iron and transferrin saturation, and the younger age group also had increased hemoglobin values. We conclude that the compound heterozygous genotype may have a beneficial effect in protecting women from iron deficiency.

Ibuprofen versus other non-steroidal anti-inflammatory drugs: use in general practice and patient perception.

OBJECTIVE: To investigate whether ibuprofen was as well-regarded by patients as other non-steroidal anti-inflammatory drugs (NSAIDs). DESIGN: Questionnaire sent to 1137 consecutive recipients of an NSAID prescription from 21 doctors in six general practices with computerized records. Patient responses were subsequently linked to data held on the practice records. SETTING: General practices in and around Nottingham, selected to reflect local variations in number of partners, list size, geographical location, deprivation, prescribing burden and prescribing rate. SUBJECTS: Unselected patients receiving NSAIDs prescribed for all indications for use. MAIN OUTCOME MEASURES: Effectiveness of ibuprofen and other NSAIDs, possible drug related adverse events, patients' overall satisfaction with ibuprofen and other NSAIDs, factors associated with choice of ibuprofen, drug costs of ibuprofen and other NSAIDs. RESULTS: The main NSAIDs used were ibuprofen, diclofenac and naproxen. Ibuprofen use ranged from 1.0% of prescriptions in one practice to 69.1% in another. Although ibuprofen was generally prescribed in low doses, it was perceived by patients as being as effective as the other NSAIDs used, even after allowing for severity of the pre-treatment condition. Overall, 50.5% of patients rated their NSAID the best treatment they had received for their condition with no differences between individual drugs. CONCLUSIONS: Ibuprofen is as highly regarded as other NSAIDs when used in similar circumstances. Switching patients to ibuprofen may be a realistic way of reducing financial and medical costs associated with NSAIDs.

Antibiotic resistance in Helicobacter pylori.

OBJECTIVE: To describe antibiotic resistance patterns in Helicobacter pylori. DESIGN: Culture and antibiotic sensitivity testing of antral and gastric body biopsy samples from patients having gastroscopy. PARTICIPANTS: Consecutive consenting patients aged 18 years or more presenting for gastroscopy from 1 July 1998 to 30 June 1999. SETTING: An open-access gastroscopy service at an urban university tertiary hospital. MAIN OUTCOME MEASURES: Number of H. pylori isolates showing resistance to antibiotics; correlates of such resistance with demographic and clinical information. RESULTS: Of 1580 patients undergoing endoscopy, 434 agreed to participate in the study. 108 (24.9%) had positive cultures for H. pylori, and 88 of these isolates (81%) were available for further testing. Resistance to metronidazole and clarithromycin was detected in 36% and 11%, respectively. No resistance was found to tetracycline or amoxycillin. Metronidazole resistance was commoner in younger patients (P = 0.0004) and macrolide resistance was commoner in those born outside Australia or New Zealand (P = 0.03). CONCLUSIONS: We found substantial resistance to metronidazole, and emerging clarithromycin resistance, but complete susceptibility to amoxycillin, tetracycline, gentamicin and cefaclor. These factors may influence the effectiveness of presently recommended eradication regimens.

Rapid opioid detoxification during general anesthesia: a review of 20 patients.

BACKGROUND: Opioid addiction therapy includes successful detoxification, rehabilitation, and sometimes methadone maintenance. However, the patient may have physical, mental, and emotional pain while trying to achieve abstinence. A new detoxification technique that incorporates general anesthesia uses a high-dose opioid antagonist to compress detoxification to within 6 h while avoiding the withdrawal. METHODS: After Institutional Review Board approval and detailed informed consent, 20 patients, American Society of Anesthesiologists status I-II, addicted to various opioids underwent anesthesia-assisted rapid opioid detoxification. After baseline hemodynamics and withdrawal scores were obtained, anesthesia was induced. After testing with 0.4 mg intravenous naloxone, 4 mg nalmefene, was infused over 2 to 3 h. After emergence, severity of withdrawal was scored before and after administration of 0.4 mg intravenous naloxone. After 24 h, patients began outpatient follow-up treatment while taking oral naltrexone. RESULTS: All 20 patients were successfully detoxified with no adverse anesthetic events. After the first post-treatment test dose of 0.4 mg naloxone, 13 of 20 patients had no signs of withdrawal and hemodynamic changes were minimal. Withdrawal scores were always very low and similar before and after detoxification. Three of 17 patients (18%) available for follow-up have remained abstinent from opioids since treatment (< or = 18 months). Four other patients are clean after brief relapses. CONCLUSIONS: Anesthesia-assisted opioid detoxification is an alternative to conventional detoxification.

Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group.

BACKGROUND: Adverse drug events (ADEs) are common in hospitalized patients, but few empirical data are available regarding the strength of patient risk factors for ADEs. METHODS: We performed a nested case-control study within a cohort that included 4108 admissions to a stratified random sample of 11 medical and surgical units in 2 tertiary care hospitals during a 6-month period. Analyses were conducted on 2 levels: (1) using a limited set of variables available for all patients using computerized data available from 1 hospital and (2) using a larger set of variables for the case patients and matched controls from both hospitals. Case patients were patients with an ADE, and the matched control for each case patient was the patient on the same unit as the case patient with the most similar prevent length of stay. Main outcome measures were presence of an ADE, preventable ADE, or severe ADE. RESULTS: In the cohort analysis, electrolyte concentrates (odds ratio [OR], 1.7), diuretics (OR, 1.7), and medical admission (OR, 1.6) were independent correlates of ADEs. Independent correlates of preventable ADEs in the cohort analysis were low platelet count (OR, 4.5), antidepressants (OR, 3.3), antihypertensive agents (OR, 2.9), medical admission (OR, 2.2), and electrolyte concentrates (OR, 2.1). In the case-control analysis, exposure to psychoactive drugs (OR, 2.1) was an independent correlate of an ADE, and use of cardiovascular drugs (OR, 2.4) was independently correlated with severe ADEs. For preventable ADEs, no independent predictors were retained after multivariate analysis. CONCLUSIONS: Adverse drug events occurred more frequently in sicker patients who stayed in the hospital longer. However, after controlling for level of care and preevent length of stay, few risk factors emerged. These results suggest that, rather than targeting ADE-prone individuals, prevention strategies should focus on improving medication systems.

A population-based study of the clinical expression of the hemochromatosis gene.

BACKGROUND AND METHODS: Hereditary hemochromatosis is associated with homozygosity for the C282Y mutation in the hemochromatosis (HFE) gene on chromosome 6, elevated serum transferrin saturation, and excess iron deposits throughout the body. To assess the prevalence and clinical expression of the HFE gene, we conducted a population-based study in Busselton, Australia. In 1994, we obtained blood samples for the determination of serum transferrin saturation and ferritin levels and the presence or absence of the C282Y mutation and the H63D mutation (which may contribute to increased hepatic iron levels) in 3011 unrelated white adults. We evaluated all subjects who had persistently elevated transferrin-saturation values (45 percent or higher) or were homozygous for the C282Y mutation. We recommended liver biopsy for subjects with serum ferritin levels of 300 ng per milliliter or higher. The subjects were followed for up to four years. RESULTS: Sixteen of the subjects (0.5 percent) were homozygous for the C282Y mutation, and 424 (14.1 percent) were heterozygous. The serum transferrin saturation was 45 percent or higher in 15 of the 16 who were homozygous; in 1 subject it was 43 percent. Four of the homozygous subjects had previously been given a diagnosis of hemochromatosis, and 12 had not. Seven of these 12 patients had elevated serum ferritin levels in 1994; 6 of the 7 had further increases in 1998, and 1 had a decrease, although the value remained elevated. The serum ferritin levels in the four other homozygous patients remained in the normal range. Eleven of the 16 homozygous subjects underwent liver biopsy; 3 had hepatic fibrosis, and 1, who had a history of excessive alcohol consumption, had cirrhosis and mild microvesicular steatosis. Eight of the 16 homozygous subjects had clinical findings that were consistent with the presence of hereditary hemochromatosis, such as hepatomegaly, skin pigmentation, and arthritis. CONCLUSIONS: In a population of white adults of northern European ancestry, 0.5 percent were homozygous for the C282Y mutation in the HFE gene. However, only half of those who were homozygous had clinical features of hemochromatosis, and one quarter had serum ferritin levels that remained normal over a four-year period.

Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.

CONTEXT: Pharmacist review of medication orders in the intensive care unit (ICU) has been shown to prevent errors, and pharmacist consultation has reduced drug costs. However, whether pharmacist participation in the ICU at the time of drug prescribing reduces adverse events has not been studied. OBJECTIVE: To measure the effect of pharmacist participation on medical rounds in the ICU on the rate of preventable adverse drug events (ADEs) caused by ordering errors. DESIGN: Before-after comparison between phase 1 (baseline) and phase 2 (after intervention implemented) and phase 2 comparison with a control unit that did not receive the intervention. SETTING: A medical ICU (study unit) and a coronary care unit (control unit) in a large urban teaching hospital. PATIENTS: Seventy-five patients randomly selected from each of 3 groups: all admissions to the study unit from February 1, 1993, through July 31, 1993 (baseline) and all admissions to the study unit (postintervention) and control unit from October 1, 1994, through July 7, 1995. In addition, 50 patients were selected at random from the control unit during the baseline period. INTERVENTION: A senior pharmacist made rounds with the ICU team and remained in the ICU for consultation in the morning, and was available on call throughout the day. MAIN OUTCOME MEASURES: Preventable ADEs due to ordering (prescribing) errors and the number, type, and acceptance of interventions made by the pharmacist. Preventable ADEs were identified by review of medical records of the randomly selected patients during both preintervention and postintervention phases. Pharmacists recorded all recommendations, which were then analyzed by type and acceptance. RESULTS: The rate of preventable ordering ADEs decreased by 66% from 10.4 per 1000 patient-days (95% confidence interval [CI], 7-14) before the intervention to 3.5 (95% CI, 1-5; P<.001) after the intervention. In the control unit, the rate was essentially unchanged during the same time periods: 10.9 (95% CI, 6-16) and 12.4 (95% CI, 8-17) per 1000 patient-days. The pharmacist made 366 recommendations related to drug ordering, of which 362 (99%) were accepted by physicians. CONCLUSIONS: The presence of a pharmacist on rounds as a full member of the patient care team in a medical ICU was associated with a substantially lower rate of ADEs caused by prescribing errors. Nearly all the changes were readily accepted by physicians.

Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

CONTEXT: Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. OBJECTIVES: To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient. DESIGN: Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physician computer order entry (POE) and the combination of POE plus a team intervention. SETTING: Large tertiary care hospital. PARTICIPANTS: For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period. INTERVENTIONS: A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units. MAIN OUTCOME MEASURE: Nonintercepted serious medication errors. RESULTS: Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additional benefit over POE. CONCLUSIONS: Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.

Peptic ulcer bleeding in the elderly: relative roles of Helicobacter pylori and non-steroidal anti-inflammatory drugs.

BACKGROUND: Most ulcers are caused, one can deduce, by Helicobacter pylori or by use of non-steroidal anti-inflammatory drugs (NSAIDs). Whether both together are worse than one alone is something that is quite unknown. AIM: To study both factors in order to see wither they interact together positively. METHOD: A case control study of ulcer bleeding in elderly patients chosen without weeding. RESULTS: NSAID usage increased risk substantially. So did H pylori infection (but relative risk less than three). Neither seemed to interact. Their actions were discretely intact. CONCLUSION: H pylori effects ulcer bleeding in an adverse manner but does not make the risk of NSAIDs worse.