The impact of enzyme replacement therapy on the oral health manifestations of hypophosphatasia among children: a scoping review.

PURPOSE: A scoping review to describe the use of enzyme replacement therapy (ERT) in the form of asfotase alfa to decrease the severity of oral manifestations in children with hypophosphatasia (HPP). METHODS: Six databases were searched using keywords and index terms related to "hypophosphatasia," "children," and "enzyme replacement therapy." Duplicates were removed and two independent reviewers screened the titles and abstracts to identify articles for full-text review. Extracted data was summarised narratively. RESULTS: The systematic search identified 3548 articles, with 171 suitable for full-text review and a final 22 that met inclusion criteria. Enzyme replacement therapy generally resulted in a reduction in the presence and severity of oral manifestations of HPP. However, numerous studies failed to report specific details regarding the nature of oral health outcomes and there were reported cases of further loss of primary teeth. CONCLUSIONS: The available evidence suggests that that ERT in the form of asfotase alfa for HPP in infants and young children leads to improved oral health outcomes. It is recommended that the outcomes are improved with earlier initiation of ERT. Further, well-designed clinical research is required to assess oral health improvements and decreased morbidity associated with the early loss of teeth.

Molar-incisor hypomineralisation prevalence in a cohort of Australian children with type 1 diabetes.

PURPOSE: Systemic diseases or drugs administered early in life may cause a disruption in amelogenesis and contribute to the qualitative defect of enamel described as molar-incisor hypomineralisation (MIH). Therefore, an increase in prevalence of MIH in children with type 1 diabetes (T1D) may be expected as this systemic disorder is commonly diagnosed in early childhood. The aim of this study was to determine the prevalence of MIH in a cohort of children with T1D and investigate diagnosis of MIH with T1D factors. METHODS: Cross-sectional study of children with T1D recruited from paediatric diabetes clinics at the Women's and Children's Hospital (South Australia). A detailed medical history, comprehensive dental and MIH examination according to the European Academy of Paediatric Dentistry (EAPD) long form classification was collected for each child. All upper and lower first permanent molars and central incisors were scored. RESULTS: A total number of 73 participants; 35 (47.95%) males were examined including 584 teeth. The mean age of the participants was 13.25 ± 2.58 years, with a mean age of diagnosis 7.75 ± 3.58 years, and a mean HbA1c of 8.5 ± 1.6%. 42 out of 73 children (54.8%) had enamel defects on at least one of the teeth examined. However, 19.2% met the criteria for MIH. Univariate and bivariate analyses were conducted but no significant associations were noted between MIH and risk factors including diabetes control (p > 0.1). CONCLUSION: There was a high prevalence of enamel defects and MIH amongst children with T1D. More research is required to establish association between T1D and MIH.

A mathematical model to study the effect of hepatitis B virus vaccine and antivirus treatment among the Canadian Inuit population.

The prevalence of hepatitis B among the Canadian Inuit population is 4%. This study will use a mathematical model to compare the roles of vaccination and therapy to predict future prevalence and incidence among the Canadian Inuit population for the next 50 years. We applied a mathematical model developed by Medley et al. (Nat Med 7(5):619-624, 2001), combined with data on hepatitis B incidence, prevalence, and vaccination coverage, to predict trends of hepatitis B virus (HBV) among the Inuit population over the next 50 years. The current estimated prevalence of HBV is 6.04% and the incidence is 3.4/100,000 persons among Canadian Inuit. If HBV vaccination coverage levels of 47.2% remain unchanged, the prevalence of HBV will decrease to 1.91% and the incidence will decrease to 0.81/100,000 persons by 2058. If vaccination coverage levels are increased to 57.2%, the prevalence and incidence of HBV will decrease to 1.74% and 0.63/100,000 persons, respectively. If we increase both immunization and therapy by 10%, this will produce the greatest reduction in prevalence and incidence, to 1.56% and 0.54/100,000 persons, respectively. The combination of immunization and treatment programs seems to have the best result in decreasing the prevalence and incidence of HBV among the Inuit population.

Hepatitis C infection and survivals of liver transplant patients in Canada, 1997-2003.

INTRODUCTION: Liver transplantation is an important health and health care issue for Canadians. Very few studies have estimated the survival results among liver transplant patients infected with hepatitis C virus (HCV) in Canada. METHODS: We carried out a retrospective cohort study to analyze 1- to 5-year survival rates among liver transplant patients, using Canadian Organ Replacement Registry data (1997-2003). Patients less than 19 years old were excluded from the study. The patients were categorized according to previous HCV infection status. The HCV-positive and HCV-negative groups were compared in the following characteristics: age group, gender, ethnicity, blood groups, donor type, pretransplantation medical status. Survival curves were plotted by Kaplan-Meier method. Stepwise regression model was applied to control the confounding impact related to gender, age, and HCV infection status. RESULTS: A total of 1842 liver transplant patients were included in the analysis. One-year survival rate for all patients was 85.4%. There were 319 HCV-positive recipients in the exposed group and 813 in the HCV-negative group. The HCV-positive and HCV-negative groups were comparable in age groups, ethnicity, ABO blood group, pretransplantation medical status, and donor organ type. The HCV-positive group had the higher male:female ratio (2.32:1) than the HCV-negative recipients (1.49:1) (Mantel Haenszel (MH) chi2 = 10.0311, P = .0015). There was no significant difference in 1-year survival rate between HCV-positive and HCV-negative groups, but the differences in the 2-year and 5-year survival rates were significant even after adjusting gender factor by stepwise regression analysis (MH chi2 = 4.4203, P = .0355). CONCLUSION: In Canada, the first-year survival rate is about 85.4%, which is comparable with other industrialized countries. The exaggerated survival disadvantage for HCV-positive recipients seems to be middle and long term, not short term.

Survival analysis of liver transplant patients in Canada 1997-2002.

UNLABELLED: Liver transplantation is an important health care issue for Canadians. Very few studies have assessed survival and determinants of survival in liver transplant patients in Canada. METHODS: We carried out an epidemiological analysis of 1 year survival and determinants of 1 year survival in liver transplant patients, using Canadian Organ Replacement Registry data (1997-2002). Survival curves were plotted by the Kaplan-Meier method. Cox proportional hazards analysis was applied to evaluate hazard ratios with different age groups, gender, ethnicity, blood groups, donor type, pretransplantation medical status, and HBV infection status. RESULTS: A total of 1164 liver transplant patients were included in the analysis. One-year survival rate was 84.7%. Male recipients had a 21% higher risk of developing organ failure than females. Recipients over 60 years of age had a 5% lower survival probability in comparison with recipients below 20 years of age. Pacific Islanders and Aboriginals had 32% and 9% lower survival probabilities, respectively, in comparison with Caucasians. Type B blood recipients had a 12% higher survival probability, whereas type AB blood recipients had a 7% lower survival probability compared with type O blood recipients. Twenty-six live organ recipients had 40% higher survival probabilities than 1138 cadaveric organ recipients. Patients with fulminant hepatitis (status 3F) had the highest survival, while patients with fulminant failure in ICU with intubation/ventilation (status 4F) had the lowest survival. One hundred sixty-seven recipients with positive HBsAg antigen showed 10% lower survival probability than 997 cases with negative HBsAg antigen. CONCLUSION: In Canada, the first year survival rate is about 85%, which is comparable with other industrialized countries. Type of donor organs and recipient gender, ethnicity, ABO blood group, pretransplantation medical status, and HBV infection status had significant affects on the recipient survival.

Epidemiological study of hepatitis B virus infection in Manitoba, Canada, 1992-2003.

In comparison with other Canadian provinces and most Western countries, the province of Manitoba maintains a different vaccination policy for hepatitis B. This policy provides selective antenatal screening for hepatitis B in women and an inoculation program for hepatitis B vaccination for fourth-grade pupils. There has been increasing concern for this policy with regard to its influence on secular trends of acute hepatitis B incidence in Manitoba. This created a need to summarise the epidemiological characteristics of hepatitis B virus (HBV) infection in Manitoba and to allocate finances and human resources for future prevention programs. The Cadham Provincial Laboratory in Winnipeg, a Canadian Public Health Laboratory, is responsible for testing all specimens for diagnosis of various common infectious diseases in Manitoba. During the period from 1 January 1992 to 31 December 2003, a total of 285,946 clinical specimens were submitted to this laboratory, which confirmed 310 cases of acute HBV and 7,556 cases of chronic HBV infection. A total of 18,168 individuals were identified as having vaccine-induced immune status. The incidence rate of acute HBV infection has significantly decreased from 6.52/100,000 person-years in 1996 to 0.86/100,000 person-years in 2003. Annual prevalence rates of chronic HBV infection in Manitoba increased slightly from 42.96 cases/100,000 population in 1992 to 71.47 cases/100,000 population in 2003. Incidence rates were generally higher in men than in women at all age groups, with values of 2.65 and 1.65 per 100,000 population, respectively (chi-square=15.768, p value <0.001). The highest incidence rate for both males and females was observed in the age group 30-34 years. The North Eastman and Winnipeg Regional Health Authorities showed significantly higher incidence rates of acute hepatitis B compared with the other nine Regional Health Authorities. Selective hepatitis B vaccination programs for children in Manitoba had achieved the greatest success in the prevention of vertical and horizontal transmission. There is an urgent need to develop cost-effective harm-reduction strategies for hepatitis B prevention among adults (aged 30-34) and groups at risk in Manitoba.

The effects of a supervised toothbrushing programme on the caries increment of primary school children, initially aged 5-6 years.

Children in the London Boroughs of Kensington, Chelsea and Westminster have one of the highest levels of caries in England and Wales. In 1997/98, the mean dmft for 5-year-old children was 2.83 with only 45.9% of the children being caries free. The aim of this study was to determine whether teacher-supervised toothbrushing, once a day, at school, during term time, with commercial toothpaste containing 1,450 ppm fluoride, could reduce dental caries in primary school children when compared with children from the same community who did not receive this intervention. A total of 517 children (mean age 5.63 years) were recruited for the study. Class teachers were trained individually by the same dental hygienist in an appropriate toothbrushing technique for young children. Children in the intervention group brushed once a day at school. All examinations were by visual assessment only. All teeth present were assessed using the BASCD criteria. For children in the intervention group, the overall caries increment (2.60) was significantly less (10.9%; p < 0.001) than for children in the non-intervention group (2.92). Among different tooth surfaces, the difference in caries increment between the intervention group (0.78) and the non-intervention group (1.03) was greatest for the proximal surfaces (21.4%; p < 0.01). In conclusion, this study suggests that a programme of daily teacher-supervised toothbrushing with fluoride toothpaste can be effectively targeted into socially deprived communities and a significant reduction in dental caries can thereby be achieved especially among caries-susceptible children.

Serological studies of West Nile virus in a liver transplant population.

BACKGROUND: Solid organ transplant populations are at increased risk for serious clinical manifestations of West Nile virus (WNV) infection. OBJECTIVE: To monitor liver transplant recipients during the 2003 WNV season in Manitoba and to identify incidence, clinical presentation and serology. METHODS: Serial blood specimens were obtained from adult patients followed at the liver transplant outpatient clinic between May 2003 and October 2003. Studies for WNV infection included immunoglobulin (Ig) G and IgM enzyme immunoassay (EIA), hemagglutination inhibition (HI), plaque reduction neutralization test and reverse transcriptase-polymerase chain reaction. RESULTS: None of the 79 patients had clinical presentations suggestive of WNV infection. On testing of the final serum specimen obtained, 14 patients (18%) had positive IgG anti-WNV by EIA and six patients (7%) had indeterminate IgG anti-WNV by EIA, although all were negative by IgM EIA. Four (20%) of the EIA-positive samples were reactive by HI, but all of these were negative by WNV plaque reduction neutralization test; this is consistent with the presence of non-West Nile flavivirus antibody in these sera. Blood specimens obtained throughout the season from EIA- and HI-positive individuals were uniformly negative for WNV-RNA by reverse transcriptasepolymerase chain reaction. Age, sex, hematology and biochemistry findings, hepatitis B or C virus status, immunosuppressive regimen (cyclosporin or tacrolimus) and pretransplant diagnosis of liver disease were similar for EIA-positive and EIA-negative patients. For the 10 patients with a positive IgG EIA maintained on cyclosporin, the cyclosporin level was 129.1+/-28.6 microg/L compared with 85.6+/-36.7 microg/L in 26 patients who were EIA-negative (P=0.002). CONCLUSIONS: False-positive IgG EIA serology for WNV was common in this cohort of liver transplant recipients, and was associated with elevated serum cyclosporin levels.

The use of 188Re to treat in-stent re-stenosis of coronary arteries.

A pilot study has been conducted in which coronary arteries subject to re-stenosis after angioplasty and stenting have been irradiated following further angioplasty. The method of irradiation has been to use radioactive 188Re in an angioplasty balloon. This paper considers all aspects of the procedure including elution of the rhenium from a tungsten/rhenium generator, its concentration, dispensing and safe delivery to the patient using specially designed equipment to reduce staff doses and radioactive spills. In the pilot study of 28 lesions in 26 patients only 1 was recorded as having angiographic re-stenosis in the treated region at 6 months although 4 other patients had edge re-stenosis. This represents less than 18% re-stenosis in a population that would have been expected to exhibit at least 50% re-stenosis at 6 months. A total of 72 patients have been treated either in the pilot study or a subsequent trial. In only one case has a minor spill of radioactivity occurred and in no case has the balloon burst. Radiation doses to staff are approximately 20 microSv per procedure and are therefore not of serious consequence. It is concluded that this procedure is safe, feasible and effective in reducing in-stent re-stenosis.

Early changes in hepatitis C virus (HCV) RNA levels predict response to interferon treatment in noncirrhotic HCV patients.

UNLABELLED: The role of hepatitis C virus (HCV) RNA quantification in determining ideal interferon (IFN) treatment of noncirrhotic HCV liver disease is uncertain. The specific aim of this study was to determine whether measurement of baseline HCV RNA or changes in HCV RNA levels (DHCV RNA) early during therapy predict response to IFN alpha in noncirrhotic HCV patients. PATIENTS AND METHODS: Twenty-one noncirrhotic patients with chronic HCV were treated with 3 MU IFN alpha-2a three times per week. HCV RNA levels were determined at baseline and after two, four, six, eight and 12 weeks of treatment. Baseline HCV RNA and DHCV RNA during therapy were compared with treatment response results at six months. Data were expressed as mean +/- SE, and differences were assessed using Student's t test. RESULTS: Twenty-one patients initiated IFN alpha therapy. Two patients were noncompliant and lost to follow-up. One patient discontinued IFN alpha due to side effects. Apart from age, where responders tended to be younger than nonresponders, the baseline clinical characteristics and alanine aminotransferase (ALT), aspartate aminotransferase, bilirubin and HCV RNA levels did not differ between IFN alpha responders and nonresponders. Levels of HCV RNA were significantly lower after both two and four weeks of therapy in IFN alpha responders compared with nonresponders (P<0.001). Changes in log HCV RNA levels after both two and four weeks of therapy were significantly greater in IFN alpha responders compared with nonresponders (P<0.001). Changes in log HCV RNA of more than 1.0 after two weeks of IFN alpha therapy identified all six-month responders, with a sensitivity of 100% and a specificity of 89%. Potential financial impact of these findings on patients' management was also calculated. Decisions regarding discontinuation of therapy based on early changes in HCV RNA levels would result in a 40% to 50% reduction in IFN alpha cost. CONCLUSIONS: In noncirrhotic HCV patients, the change in quantitative HCV RNA after the first two weeks of IFN alpha therapy identifies responders. This finding would result in a 40% to 50% cost savings if decisions about continuing IFN alpha were based on early changes in HCV RNA levels rather than ALT or HCV RNA assessment after the completion of three months of IFN alpha treatment.

Comparison of clinical outcomes following treatment of chronic adult periodontitis with subgingival scaling or subgingival scaling plus metronidazole gel.

BACKGROUND, AIMS: Conventional treatment of chronic periodontitis involves mechanical debridement of periodontal pockets. Recently, subgingival antimicrobials have been used adjunctively following such debridement. This 2-centre study compared the clinical effects of subgingival scaling (SRP) with SRP plus subgingival application of 25% metronidazole gel, Elyzol (SRP+gel), in patients with chronic adult periodontitis. METHOD: Voluntary informed written consent was obtained from 45 subjects at the Eastman (mean age 46, range 34-63) and 43 subjects at RAF Halton (mean age 47, range 34-71) who participated in this blind, randomised split-mouth design study. All had at least 2 sites in each quadrant with probing pocket depth (PPD) > or = 5 mm. PPD, bleeding on probing (BOP), and clinical probing attachment levels (CAL) measured using a stent, were recorded at baseline and at 1, 3, 6 and 9 months post-therapy. After subgingival scaling of all quadrants, 2 quadrants were randomly selected to be treated with metronidazole gel. RESULTS: A paired t-test on baseline values showed no bias between groups. Both treatments effectively reduced the signs of periodontitis. At each follow-up visit, reduction in PPD, CAL and BOP after the combined treatment was greater than for SRP alone. Paired t-tests showed that the improvement in the SRP+gel group was statistically significantly better (p<0.001) than for SRP alone (mean 0.5 +/- 0.6 mm. 95% CI 0.4-0.6 mm.) Similarly, the % of sites which improved to a final pocket depth of < or = 3 mm and the % of sites which improved over the 9 months of the study by as much as > or = 2 mm were greater for SRP+gel than for SRP alone. CONCLUSIONS: At the end of the study, the mean reductions for PPD were 1.0 mm (SRP) compared to 1.5 mm (SRP+gel), and for CAL they were 0.4 mm (SRP) compared to 0.8 mm (SRP+gel), with mean difference for CAL between treatments of 0.4 +/- 0.6 mm (95% confidence intervals of 0.3-0.6 mm). The combination therapy of SRP+gel was superior to the conventional treatment of SRP alone, and these differences were maintained for 9 months.

Gnotobiological study of infective juveniles and symbionts of Steinernema scapterisci: A model to clarify the concept of the natural occurrence of monoxenic associations in entomopathogenic nematodes.

Gnotobiology of Steinernema scapterisci and bacteriological study of its symbiont confirmed that this nematode harbors a symbiotic species of Xenorhabdus, as do other Steinermena species. Based on phenotypic and 16S rDNA data, this Xenorhabdus strain UY61 could be distinguished from other Xenorhabdus species. Bacteria reported previously as being associated with this nematode and belonging to several other genera were probably contaminating bacteria located in the intercuticular space of the infective juveniles (IJs). These bacteria were detrimental to nematode reproduction in Galleria mellonella. Axenic S. scapterisci and its symbiont Xenorhabdus strain UY61 alone were not pathogenic to G. mellonella. The combination of both partners reestablished the pathogenicity of the complex toward G. mellonella. This combination also gave the best yields of IJs when produced in this insect and in vitro production on artificial diet.

Helicobacter pylori in the Canadian arctic: seroprevalence and detection in community water samples.

OBJECTIVE: Many North American arctic communities are characterized by risk markers associated with Helicobacter pylori (H. pylori) infection, including overcrowded housing and inadequate water supply and sanitation systems. Our aim was to determine the seroprevalence of H. pylori infection in two traditional Inuit communities in the central Canadian arctic and to test for the presence of H. pylori, by polymerase chain reaction (PCR), in local water supplies. METHODS: Samples of venous whole blood from adults and capillary blood from children were collected and analyzed by enzyme immunoassay and Helisal Rapid Test, respectively, for IgG antibody to H. pylori. Antibodies to CagA were detected by enzyme immunoassay, and ABO and Lewis antigens were also determined. Demographic and clinical information were collected by questionnaire. Water samples from each community were tested for H. pylori by PCR. RESULTS: One hundred-thirty (50.8%) of 256 subjects from the two communities were positive for H. pylori IgG antibodies. Seropositive subjects were more likely to be male, compared with seronegative individuals (p = 0.01). Antibody status did not differ with respect to age, community, alcohol or cigarette use, number of persons per household, gastrointestinal complaints or previous investigations, medications, or presence of blood group O, Lewis a-b+. CagA antibodies were detected in 78 (61.9%) of 126 H. pylori-seropositive subjects tested; however, 41 (35.3%) of 116 H. pylori-seronegative subjects were also CagA positive. Water samples taken from the water delivery truck in Chesterfield Inlet and two lakes near Repulse Bay were positive for H. pylori. CONCLUSION: The seroprevalence of H. pylori in the study group was higher than rates in southern Canadian populations, but lower than the seroprevalence previously documented in a Canadian subarctic Indian (First Nations) community. The detection of H. pylori in local water supplies may indicate a natural reservoir for the organism or possible contamination from human sewage.

The use of GAFchromic film to determine the absolute activity of beta emitters.

A method of using GAFchromic film to determine the absolute activity of beta emitters by immersing the film in a bath of activity is described. This includes calculations of the effect of part of the radioactive solution being displaced by the film that is performing the measurement. Calculations have been performed for 90Y, 32P and 188Re. It is shown that for the film used in this study, this effect will cause a correction of the order of 15-20% for the three radionuclides studied. The results of the GAFchromic film measurement are compared with results obtained from liquid scintillation counting and from a commercial dose calibrator. It is shown that for 32P all methods were in reasonable agreement, but for 188Re, although the GAFchromic film and the liquid scintillation counting methods give similar results, the dose calibrator measurement differed by more than 20%. The GAFchromic film was also used to perform a direct measurement of the radiation dose at a distance of 0.5 mm from the surface of a cylindrical source of 188Re activity. This gave good agreement with the value of the dose predicted from theoretical calculations.

Seroprevalence of Helicobacter pylori, incidence of gastric cancer, and peptic ulcer-associated hospitalizations in a Canadian Indian population.

The living conditions of many aboriginal communities in Canada may place their residents at risk for H. pylori infection. Our aims were to determine: (1) the seroprevalence of H. pylori in a traditional Indian community, (2) the clinical relevance of H. pylori infection in this population, and (3) if H. pylori could be identified by polymerase chain reaction from the local water. A demographic questionnaire was administered, and blood was collected from subjects in an Indian community in northwestern Manitoba. The serum was analyzed by ELISA for IgG to H. pylori and to CagA. ABO and Lewis antigens were tested. Age-adjusted incidence of gastric cancer and of hospitalizations associated with diagnoses of peptic ulcer were determined for the Indian and non-Indian Manitoba population in the years 1989-1993. Nested PCR was performed on lake water using H. pylori-specific primers and the amplicons probed with an internal Dig-labeled probe. Three hundred six (59%) of approximately 518 individuals who were resident in the community at the time of the study were enrolled. The ELISA for H. pylori was positive in 291 (95%). There was no association between H. pylori seropositivity and age, sex, gastrointestinal complaints, medications, housing characteristics, and ABO or Lewis antigen status. CagA was positive in 84.5% of infected subjects. The average annual age-adjusted incidence of hospitalizations associated with diagnoses of peptic ulcer disease in Manitoba was higher for treaty-status Indians (394.3/100,000) than for non-Indians (203.8/100,000), but gastric cancer rates were similar (11.2/100,000 vs 11.6/100,000). No H. pylori DNA was detected in the lake water. In conclusion, the seroprevalence of CagA-positive H. pylori is high in this representative Manitoban Indian community. This may be associated with an increased risk for peptic ulcer disease but is not associated with an increased risk for gastric cancer.

Thripenema fuscum n. sp. (Tylenchida: Allantonematidae), a Parasite of the Tobacco Thrips, Frankliniella fusca (Thysanoptera).

Thripenema fuscum n. sp., a parasite of the tobacco thrips, Frankliniella fusca, is described and illustrated from material collected from peanut (Arachis hypogaea) in Marianna, Florida. Thripenema fuscura can be distinguished from all other previously described Thripenema spp. by the dorsal curvature of the male and the presence of a stylet in the male. Highest parasitism rates of F. fusca by T. fuscum in peanuts were 51% in 1995 and 68% in 1996.

Comparison of salivary and serum enzyme immunoassays for the diagnosis of Helicobacter pylori infection.

Infection with Helicobacter pylori has been established as an important risk factor for the development of peptic ulcer disease, gastritis and gastric cancer. The diagnosis of H pylori infection can be established by invasive or noninvasive techniques. Two noninvasive enzyme immunoassays (EIAs) for antibody detection - HeliSal and Pylori Stat - were compared with histology. Both assays detect immunoglobulin (Ig) G directed against purified H pylori antigen. The test populations consisted of 104 consecutive patients scheduled for upper gastrointestinal endoscopy. Of these patients, 97 (93%) had symptoms compatible with peptic ulcer disease. Saliva and serum were collected simultaneously at the time of endoscopy. Salivary EIA had a sensitivity of 66%, specificity of 67%, positive predictive value of 67% and negative predictive value of 66% compared with the serum EIA, where the results were 98%, 48%, 64% and 96%, respectively. Although the salivary EIA is an appealing noninvasive test, it was not a sensitive and specific assay. The serum EIA also lacked specificity, but was highly sensitive with a good negative predictive value. Although a negative serum EIA rules out H pylori infection, a positive result must be interpreted in the clinical context and confirmed with a more specific measure.

Endoluminal brachytherapy for recurrent laryngeal carcinoma.

Early-stage squamous cell carcinoma of the larynx is usually treated with local field radiotherapy. Surgery is used for salvage following recurrence. Further recurrences present a more difficult therapeutic problem which requires individualized management. The aims of local control, survival, maintenance of function and minimizing side effects all need to be balanced according to the site and extent of disease. The present case study looks at the management of a 54-year-old man with multiple recurrences from a squamous cell carcinoma of the larynx. It describes a technique of endoluminal brachytherapy using an iridium-192 wire spiralled around the outer part of a tracheostomy tube that achieves good local control while enabling self-insertion and self-cleaning during the procedure. The dose given was 2500 cGy at 5 mm over 25.2 h and was achieved with minimal early or delayed side effects. The patient had no further symptoms relating to the stomal recurrence until his death from metastatic disease 6 months later.