Gastric reflux is a significant causative factor of tooth erosion.

Dental erosion is caused by dietary or gastric acid. This study aimed to examine the location and severity of tooth erosion with respect to causative factors, and to determine whether the clinical pattern of erosion reflected the dominant etiological factor. The study involved 249 Icelandic individuals and included: a detailed medical history; clinical oral examination; salivary sampling, and analysis for flow rate, pH, and buffering capacity. Reflux was assessed in 91 individuals by gastroscopy, esophageal manometry, and 24-hour esophageal-pH monitoring. Reflux symptoms were reported by 36.5% individuals. Manometry results were abnormal in 8% of study participants, abnormal esophageal pH in 17.7%, and a pathological 24-hour pH recording in 21.3%. 3.6% were positive for Helicobacter pylori. Normal salivary flow was found in 92%, but low salivary buffering (10.4%) was associated with erosion into dentin (P < 0.05). Significant associations were found between erosion and diagnosed reflux disease (OR 2.772; P < 0.005) and daily consumption of acidic drinks (OR 2.232; P < 0.005).

Relationship between dental erosion, soft drink consumption, and gastroesophageal reflux among Icelanders.

The aim of this study was to determine the prevalence of dental erosion in young Icelandic adults (19-22 years old) and patients with gastroesophageal reflux disease (GERD), in relation to their soft drink consumption and gastroesophageal reflux. Eighty subjects (40 males and 40 females), comprising 57 young adults (mean age 21 +/- 2 years) and 23 GERD patients (mean age 35 +/- 10 years), were enrolled in this study. All subjects answered a detailed frequency questionnaire of soft drink consumption and participated in a clinical examination. Erosion was scored for incisor and molar teeth separately. No significant difference was observed in the prevalence of dental erosion between young adults and GERD patients. However, by combining the two study groups a three-fold higher risk of having erosion in molars or incisors was found for subjects drinking Coca-Cola three times a week or more often ( p < 0.05). Additionally, significantly higher erosion scores were found in molars among subjects drinking more than 1 litre of carbonated drinks (all brands) per week ( p < 0.05). It is concluded that the frequency of soft drink consumption is a strong risk factor in the development of dental erosion.

[Carcinoma of the colon in Iceland 1955-1989. A study on pathology.].

OBJECTIVE: The objective of this study was to investigate various pathological parameters of colon carcinoma in Iceland in the 35 year time period from 1955-1989, and changes in these parameters during the study period. MATERIAL AND METHODS: Information on all patients diagnosed with colon carcinoma in the study period was obtained from the Icelandic Cancer Registry. All pathology reports and autopsy reports were checked. All pathology samples were reviewed and the tumours reevaluated, reclassified, tumour location determined, the tumours graded and Dukes staged and age standardized incidence was calculated according to revised diagnosis. Cancers in polyps are included in the study. The study period was separated into seven five year periods and changes in pathological parameters investigated according to time periods. RESULTS: After reevaluation of the tumours 1205 fulfilled the criteria for the diagnosis of colon carcinoma, 572 in men and 633 in women. The incidence increased in the study period for men from 8.2 to 21.5/105 and for women from 7.9 to 15.8/105. The pathological parameters were determined for 1109 tumours. Adenocarcinoma NOS was the most common diagnosis or 90.1% of the tumours and mucinous carcinomas came second. Most of the tumours were located in the sigmoid colon (38.6%), 19.1% in the coecum and 14.5% in the ascending colon. No significant observed changes occurred in tumour location in the study period. The mucinous histological type and signet ring tumour type were more common in the right colon. In Dukes staging of the tumours 9.1% were in stage A, 32.1% in stage B, 24.6% in stage C and 22.7% in stage D, whereas 11.5% proved indeterminate. A minimal trend to increase in Dukes A tumours was observed in the latter half of the study period, overall no significant changes in Dukes classification could be pinpointed in the time period. Most of the tumours were of intermediate tumour grade or 70.1%, but 16.5% were well differentiated and 13.4% were poorly differentiated. A much higher percentage of poorly differentiated tumours were present in the right colon in comparison to the left colon. A poorer differentiation of the tumours went hand in hand with worse Dukes stage of tumours. CONCLUSIONS: We conclude that: 1. the incidence of colon carcinoma has much increased during the study period for both sexes, 2. observed changes in studied pathological parameters over the study period were minimal. Of interest is the minimal change in Dukes stages of colon cancer in the study period.

[Homocysteine, folate and cobalamin in Icelandic men and women.].

OBJECTIVE: To determine reference intervals and interquartile ranges for total homocysteine (Hcy) folate and cobalamin in Icelandic men and women and to evaluate the correlation of Hcy to serum levels of the vitamins folate and cobalamin. MATERIAL AND METHODS: Blood samples were collected from 449 individuals over a period of three months, 291 men (mean age 48.3 years) and 158 women (mean age 49.8 years). Plasma Hcy was measured by a HPLC method with fluorescence detection; folate and cobalamin levels in serum were measured by an electroimmunochemical method on an ELECSYS system from Roche. RESULTS: The reference interval for Hcy, between 2.5% and 97.5% fractiles, estimated by parametric statistics, are 6.2-17.5 micromol/L for men and 4.8-14.1 micromol/L for women. Similarly the 95% reference intervals for folate and cobalamin were estimated using parametric statistics. A significant negative correlation was found between concentrations of folate and Hcy for both men and women (p<0.01) with a correlation coefficient of -0.39 and also between cobalamin and Hcy where the correlation coefficient is -0.20. CONCLUSIONS: Reference interval for Hcy from the general presumed healthy population is estimated here for the first time in Icelandic men and women and will be of value in cardiovascular risk assessments. The negative correlation between Hcy and folate and also Hcy and cobalamin, is in agreement with results from other studies and suggests that an improved vitamin status might be beneficial in lowering Hcy in a section of the population as has been suggested in numerous studies in other countries.

[Diseases in the esophagus, stomach and duodenum: is Helicobacter pylori to blame?].

OBJECTIVE: To evaluate a) how many of symptomatic patients referred for upper endoscopy have active H. pylori infection, b) the correlation between the indications for upper endoscopy and endoscopic diagnosis and c) the association between H. pylori and organic disease in the upper gastrointestinal tract. MATERIAL AND METHODS: This is a prospective study on 562 symptomatic patients referred for upper gastrointestinal endoscopy. The criteria for inclusion were symptoms from the upper gastrointestinal tract but patients taking anticoagulation medication were excluded. All patients who had received H. pylori eradication therapy were excluded from the final analysis. Biopsies were obtained from both the antrum and body of the stomach for CLO testing as well as for histological evaluation for H. pylori. RESULTS: For final analysis 458 patients (81.5%) were evaluable, 76 patients (13.5%) were excluded who came for evaluation after H. pylori eradication and 28 patients (5%) were also excluded due to inadequate information. Of 458 patients, 220 (48%) tested CLO positive, there of 122 women (46%) and 98 men (50.5%). The correlation between indication for referral for upper endoscopy and final endoscopic diagnosis was poor, where peptic ulcer disease was clearly overrated. Active H. pylori infection was most often diagnosed among patients with peptic ulcer disease, particularly duodenal ulcer (82%) and less often gastric ulcer (60%). Patients with gastritis and duodenitis had H. pylori diagnosed in 57% of the cases. CONCLUSIONS: H. pylori was diagnosed in 48% of patients with symptoms from the upper gastrointestinal tract. Of all patients with peptic ulcer disease H. pylori was diagnosed in only 69% of the cases, which is lower than previous studies have indicated. The correlation between indication for endoscopy and the endoscopic diagnoses is rather poor. It is important to perform diagnostic endoscopy early in order to select the best initial treatment for the patient.

Lack of effect of treating Helicobacter pylori infection in patients with nonulcer dyspepsia. Omeprazole plus Clarithromycin and Amoxicillin Effect One Year after Treatment (OCAY) Study Group.

BACKGROUND: It is uncertain whether treatment of Helicobacter pylori infection relieves symptoms in patients with nonulcer, or functional, dyspepsia. METHODS: We conducted a double-blind, multicenter trial of patients with H. pylori infection and dyspeptic symptoms (moderate-to-very-severe pain and discomfort centered in the upper abdomen). Patients were excluded if they had a history of peptic ulcer disease or gastroesophageal reflux disease and had abnormal findings on upper endoscopy. Patients were randomly assigned to seven days of treatment with 20 mg of omeprazole twice daily, 1000 mg of amoxicillin twice daily, and 500 mg of clarithromycin twice daily or with omeprazole alone and then followed up for one year. Treatment success was defined as the absence of dyspeptic symptoms or the presence of minimal symptoms on any of the 7 days preceding the 12-month visit. RESULTS: Twenty of the 348 patients were excluded after randomization because they were not infected with H. pylori, were not treated, or had no data available. For the remaining 328 patients (164 in each group), treatment was successful for 27.4 percent of those assigned to receive omeprazole and antibiotics and 20.7 percent of those assigned to receive omeprazole alone (P=0.17; absolute difference between groups, 6.7 percent; 95 percent confidence interval, -2.6 to 16.0). After 12 months, gastritis had healed in 75.0 percent of the patients in the group given omeprazole and antibiotics and in 3.0 percent of the patients in the omeprazole group (P<0.001); the respective rates of H. pylori eradication were 79 percent and 2 percent. In the group given omeprazole and antibiotics, the rate of treatment success among patients with persistent H. pylori infection was similar to that among patients in whom the infection was eradicated (26 percent vs. 31 percent). There were no significant differences between the groups in the quality of life after treatment. CONCLUSIONS: In patients with nonulcer dyspepsia, the eradication of H. pylori infection is not likely to relieve symptoms.

Tooth erosion, gastroesophageal reflux, and salivary buffer capacity.

To obtain information on the connection between tooth erosion and acid gastroesophageal reflux, 14 patients (mean age, 15.7 years) with tooth erosion were investigated with simultaneous 24-hour pH monitoring in the esophagus and the oral cavity. Salivary parameters were also investigated in a larger group of 62 erosion patients (mean age, 21 years) and compared with a group of 50 controls (mean age, 28 years). No changes in oral pH were observed in a total of 339 acid reflux episodes, not even in long supine reflux episodes. Extended periods of lowered intra-oral pH to the level of 4 to 5 were observed but not connected with gastroesophageal reflux episodes. Significantly more (p < 0.001) erosion patients (34 of 62) had low salivary buffer capacity compared with controls (10 of 50).

[Peptic ulcer disease and Helicobacter pylori. A comparative study of two different three-drug regimens].

Helicobacter pylori (H. pylori) is now known to be strongly associated with gastritis type B, duodenal ulcer, gastric ulcer and perhaps gastric cancer. To cure peptic ulcer disease has become reality. This prospective study included 60 patients, 41 male and 19 females, with long history of peptic ulcer disease (1 - 41 yr, mean 16.5 yr), diagnosed with active duodenal ulcer (50) or gastric ulcer (10) during endoscopy of the upper gastrointestinal tract. After a positive CLO test and histologic confirmation as well as positive culture of H. pylori from the antral mucosa, patients were treated with conventional anti-ulcer therapy. After ulcers were healed (usually in 4 - 6 weeks) patients were randomized to take one of two regimens: 1) colloid bismuth sub-citrate 120 mg, four times a day for 28 days, metronidazole 400 mg, three times a day for 10 days and tetracyclin (DMT) 250 mg, four times a day for 14 days, 2) De-Nol 120 mg, four times a day for 28 days, metronidazole 400 mg, three times a day for 10 days and ampicillin 500 mg, four times a day for 14 days (DMA). Careful monitoring of compliance, symptoms, side effects, H. pylori status and ulcer recurrence by endoscopy was performed at one, two, six and 12 months after completion of triple therapy. Duodenal ulcer recurred in all six patients, that remained H. pylori positive (10%). Eradication of H. pylori was achieved in all patients (30) treated with DMT, and they remained H. pylori negative throughout the 12 months follow-up period. The compliance to the treatment regimens was excellent (<95%). Side effects were frequent (38%), but mild in most cases, mainly soft stool and nausea. One patient had to discontinue the treatment. Re-infection rate was 2% (one patient) during the 12 months follow-up period. A triple therapy with DMT was 100% effective in eradicating H. pylori and statistically superior (p = 0.0105) to DMA at 12 months follow-up. No ulcer recurrence occured in H. pylori negative patients. The importance of persistent and marked symptomatic improvement observed in this study as compared to conventional maintenance treatment has not been emphasized enough in the recent debates on ulcer treatment modalities. The ultimate benefit of H. pylori eradication in peptic ulcer disease should be evaluated by long term follow up studies..

Efficacy of sucralfate in treatment of non-ulcer dyspepsia. A double-blind placebo-controlled study.

The object of this study was to assess the efficacy of sucralfate in the treatment of non-ulcer dyspepsia (NUD). The diagnosis of NUD was made by exclusion. All patients underwent an upper gastrointestinal endoscopy and abdominal ultrasound, and blood tests were done as clinically indicated. Patients with a history of peptic ulcer disease were not included. Symptomatic assessment was made at the beginning and at the end of the study. The patients registered their most prominent dyspeptic symptoms and whether they improved, were unchanged, or worsened. The study was double-blind. Placebo or 1 g sucralfate four times daily was given for 3 weeks. Over a 2-year period 104 patients were included in the study; 56 received sucralfate and 48 placebo. Nine patients were excluded because of poor compliance or side effects, six from the sucralfate group and three from the placebo group. The sucralfate and placebo groups were comparable with regard to symptom and clinical variables. Global assessment of symptoms showed that in the sucralfate group 34 improved (68%), 11 were unchanged, and 5 were worse. In the placebo group 31 improved (69%), 11 were unchanged, and 3 were worse. There was no statistically significant difference between the groups. The 3-week course of sucralfate in patients with NUD did not show symptomatic improvement over placebo.

Cholecystectomy and colorectal carcinoma: a total-population historical prospective study.

The relationship between cholecystectomy and colorectal cancer in the Icelandic population was analyzed in a historical prospective study. A total of 3,425 individuals (857 males and 2,568 females) who underwent cholecystectomy during a 26-yr period (1955-1980) were followed for 8-33 yr. The risk of colonic cancer in Icelandic males increased significantly 11 yr or more after operation (relative risk, 2.73; 95% confidence interval, 1.25-5.19). This is the only study that shows a significantly increased risk of colonic cancer in males only. In spite of this increased risk, regular screening for colonic cancer in Icelandic males would probably not be warranted, since almost 70% of the males are 70 yr old or older at the time of diagnosis.

Cancer of the pancreas in Iceland. An epidemiologic and clinical study, 1974-85.

A retrospective study was performed of all patients diagnosed as having pancreatic cancer in Iceland during the period 1974-85 (12 years). The incidence of the disease during the period according to this study was 10.7 per 100,000 males and 9.8 per 100,000 females, with age-adjusted world standard incidences of 9.0 per 100,000 males and 6.7 per 100,000 females. A total of 301 patients were identified; adequate information could be obtained for 281 patients, and 225 (74.8%) had the diagnosis histologically confirmed. Two hundred and five patients with adenocarcinoma were accepted for detailed analysis. Of the patients with adenocarcinoma 139 (67.8%) were diagnosed at laparotomy, and 33 of them had the tumour resected, with an operative mortality of 12.1%. The cancer was located in the head of the pancreas in 102 patients (49.8%), and in 159 (77.6%) metastases were found at the time of diagnosis. The median survival time for the patients with adenocarcinoma was 95.4 days (SD +/- 11.1 days), although there were two patients in this group who were alive 5 years after diagnosis. The median survival for the total group of 281 patients was 98.3 days (SD +/- 11.0 days), although 6 of these patients lived for more than 5 years. The percentage of histologically confirmed tumours in Iceland is high compared with many previously reported studies.

Primary cytomegalovirus infection and gastric ulcers in normal host.

A 42-year-old woman presented with epigastric pain and vomiting. Upper gastrointestinal endoscopy revealed three gastric ulcers. Histologic examination of biopsies from the ulcers showed cytomegalovirus inclusion bodies. The appearance of IgM antibodies to cytomegalovirus indicated a recent and primary infection. Stored serum from her last pregnancy 17 months previously contained no cytomegalovirus antibodies. A thorough evaluation of her immune system revealed no abnormality. We are aware of only two other cases where seroconversion was documented in normal hosts. Cytomegalovirus infections in the gastrointestinal tract of normal hosts are very unusual but a common cause of morbidity in immunocompromised hosts. We believe that cytomegalovirus may have a role in the pathogenesis of gastrointestinal lesions in nonimmunocompromised patients.

Phase II trial of sequential chemotherapy and low-dose radiotherapy in advanced gastric adenocarcinoma. A Southwest Oncology Group Pilot Study.

Thirty-four patients with metastatic gastric adenocarcinoma were treated with the combination of chemotherapy and radiation therapy in a Phase II trial. Induction chemotherapy consisted of one cycle of 5-fluorouracil (5-FU), adriamycin, and BCNU (FAB), followed in 4 weeks by a cycle of 5-FU, adriamycin and mitomycin-C (FAM). In responding and stable patients, consolidation radiotherapy to major sites of disease, followed by maintenance FAM, was administered. Twelve of 30 (40%) patients with measurable disease responded (3 complete responses and 9 partial responses), with a median response duration of 6.0 months. Toxicity was moderate and consisted of nausea, vomiting, and myelosuppression. No additive effects for this combined modality approach could be demonstrated.

Combination chemotherapy for metastatic carcinoma of the ampulla of Vater--report of three cases.

Three patients with metastatic carcinoma of the ampulla of Vater received celiac artery infusion of 5-fluorouracil, adriamycin, mitomycin-C, and streptozotocin followed by intravenous administration of the same combination. In two patients with measurable disease, one partial (6.0 months) and one complete response (16.0 + months) occurred. Two out of three patients remain alive at 30.0+ and 21.0+ months. Carcinoma of the ampulla of Vater may be a neoplasm responsive to combination chemotherapy.

Intermittent regional infusion of chemotherapy for pancreatic adenocarcinoma. Phase I and II pilot study.

Nineteen patients with unresectable and metastatic adenocarcinoma of the pancreas and ampulla of Vater were treated with intermittent regional infusion of the celiac axis (CAI) with the combination of 5-fluorouracil, adriamycin, mitomycin-C, and streptozotocin (FAM-S). Three schedules with escalating doses were investigated. The arterial infusion was repeated at 4 weeks, and in responding and stable patients, I.V. FAM-S was continued at monthly intervals. Twelve patients had measurable disease, and in this group one complete response and seven partial responses occurred. Median duration of response was 6+ months and median survival for all patients was 5.2 months. Four patients had catheter-related complications (emboli, three, sepsis, one). Hematologic and gastrointestinal toxicity was minimal. Celiac artery infusion with FAM-S in locally extensive and metastatic adenocarcinoma of the pancreas and ampulla of Vater is a relatively simple procedure associated with low incidence of serious complications and toxicity but a higher response rate than previously reported. Induction of response with CAI and subsequent maintenance therapy with intravenous chemotherapy is under investigation.

Hepatic artery infusion with 5-fluorouracil and mitomycin-C in metastatic colorectal carcinoma phase II study.

Thirty-two patients with hepatic metastases colorectal carcinoma were treated with hepatic artery infusion (HAI) employing 5-fluorouracil (5-FU) and mitomycin-C (mito-C). Catheters were placed percutaneously via the femoral artery. Two schedules were employed: (I) 5-FU 1,200 mg/m2 IA (D1-4) and mito-C 8 mg/m2 IA (D1 + D4); (2) 5-FU 1,200 mg/m2 IA (D1-6) and mito-C 8 mg/m2 IA (D1 + D4). Courses were repeated every 4 weeks. Thirty patients with measurable disease were evaluable, 22 received schedule I and 8 patients schedule II. Complete response occurred in two patients (6.7%) and partial response in 13 patients (43.3%). Five patients (16.7%) had minimal regression. The overall response rate as 66.7%. Median survival of all patients from start of treatment was 11.2 months. Median survival of responders and nonresponders was 12.4 months and 4.6 months, respectively (P less than 0.05). No differences in response rates, duration of response, or survival was seen between the two schedules. Drug toxicity was moderate to severe, but morbidity of HAI per se was minimal. Intermittent HAI of 5-FU and mito-C is a well-tolerated treatment modality associated with few serious complications. The response rate, duration of response, and the survival is comparable to continuous HAI infusion of 5-FU or floxuridine (FUDR). As given in this study, mito-C did not appear to provide added benefit.

Colchicine in the treatment of Paget disease of bone: a new therapeutic approach.

Paget disease of the bone (PDB) has been treated effectively with various agents including calcitonins, diphosphonates, and mithramycin. Each agent has relatively serious toxic side effects or practical inconveniences associated with its use. An effective agent with fewer adverse reactions and a more convenient route of administration would be preferable. The purpose of this study was to evaluate the effect of colchicine for the treatment of PDB in five patients. All patients were symptomatic and had typical changes on roentgenograms and bone scans consistent with the disease. Serum alkaline phosphatase ranged from 408 to 1,311 mU/ml (normal, 30 to 115 mU/ml), and urinary excretion of total hydroxyproline ranged from 68 to 205 mg/24 hr (normal, 30 to 65 mg/24 hr). Colchicine, 0.6 mg, was given orally three times a day to each patient, who had subsequent follow-up with clinical and laboratory determinations evaluated at each visit. The duration of follow-up was eight to 28 weeks, with a mean of 20 weeks. Pain was relieved in all patients, and two became asymptomatic. Serum alkaline phosphatase decreased 18% to 38%, and urinary hydroxyproline decreased 26% to 53% from the pretreatment values. The biochemical values and and clinical symptoms changed markedly in two patients, correlating with withdrawal and reinstitution of colchicine. These results indicate that colchicine may be effective in the treatment of PDB. Although the mode of action and long-term efficacy of colchicine in this disorder remains to be evaluated, the antimitotic effect on osteoprogenitor cells, the adherence of colchicine to the microtubular structures in preexisting osteoblasts, and the nonspecific anti-inflammatory effect of this agent may explain the therapeutic response noted in this study.