The effect of core stability training on balance and mobility in ambulant individuals with multiple sclerosis: a multi-centre series of single case studies.

BACKGROUND: Core stability training is popular in the management of people with multiple sclerosis (MS); however, scientific evidence to support its effectiveness is scarce. OBJECTIVE: To explore the effectiveness of core stability training on balance and mobility. METHOD: A multi-centre series of eight single case studies was undertaken. Eight ambulant individuals with stable MS participated in 16 face-to-face core stability training sessions, delivered by a neurophysiotherapist, plus a daily home exercise programme. A range of outcomes were measured: 10-m timed walk, 12-item MS walking scale, timed get up and go, functional reach tests, timed single leg stance, visual analogue scales of two activities, and the Activities-specific Balance Confidence Scale. RESULTS: Visual analysis of trend, level and slope demonstrated improvement in five subjects (62%) in seven measures. This was confirmed by the two standard deviation band method of analysis for six measures. Analysis of group data (repeated measures within subjects analysis of variance) indicated significant improvement between baseline and intervention phases for timed walk (p = 0.019), MSWS-12 Scale (p = 0.041), forward (p = 0.015) and lateral reach (p = 0.012). In general, no further improvements were made following withdrawal of the intervention. CONCLUSIONS: This study provides preliminary evidence of the effectiveness of an 8-week core stability training programme in improving balance and mobility in ambulant people with MS. Variations in response to intervention are evident. Assessor-blinded randomized controlled studies are required to confirm these findings and determine patient characteristics which identify those who benefit most from this intervention.

Regression of columnar lined (Barrett's) oesophagus with continuous omeprazole therapy.

Twenty-three adult patients with a columnar lined (Barrett's) oesophagus are being treated with long-term omeprazole, 40 mg daily. Twelve had never undergone anti-reflux surgery (Group 1), the other eleven having previously had insertion of an Angelchik anti-reflux prosthesis (Group 2). Endoscopy was carried out six months before, immediately before and six months, one year and two years into treatment. Multiple and standardized biopsies were taken at each endoscopy. Results from the two groups were similar. During the 6-month run-in period there was a statistically non-significant increase in the linear extent of the columnar mucosa, but this showed a progressive, statistically significant decrease during the two years of treatment. Other evidence for regression of the Barrett's mucosa includes the emergence of large numbers of macroscopic squamous islands within the abnormal mucosa, an increase in the number of microscopic squamous islands, and microscopic squamous encroachment of the abnormal mucosa at the squamo-columnar junction. Histological assessment showed a reduction in the proportion of sulphomucin-rich intestinal metaplasia, but this only achieved statistical significance in Group 1. The results substantiate the importance of acid in the pathogenesis of Barrett's oesophagus. Omeprazole may have a therapeutic role in bringing about regression of the metaplastic epithelium.

The histological diagnosis of chronic gastritis in fibreoptic gastroscope biopsy specimens.

The advent of the fibreoptic gastroscope with biopsy facilities has provided the means of obtaining biopsy specimens under direct vision from any part of the stomach. This creates new opportunities for the study of chronic gastritis, and, in particular, its evolution, topographical location, and causal relationships. On the basis of an experience with more than 2,500 biopsy specimens we have outlined a method for their systematic examination and have proposed a classification of chronic gastritis. This classification includes the type of mucosa, the type and stage of activity of the gastritis, and the presence and type of metaplasia. The classification is sufficiently flexible to allow within it quantitative assessment of individual histological features.

Five year follow-up study of gastritis.

This paper describes a five year follow-up study of the incidence and course of gastritis affecting the antrum and body of the stomach of 50 patients, most of whom presented with non-ulcer dyspepsia and a few with peptic ulceration. We have shown that antral gastritis, like gastritis affecting the fundus, becomes more severe in a proportion of patients as time goes by. Perhaps more important is the increased severity and progression of atrophic and metaplastic change in the antrum compared with the fundus. The significance of these changes with regard to the development of peptic ulceration and malignancy is discussed.

New spiral bacterium in gastric mucosa.

A new spiral bacterium, distinct from Campylobacter pylori, was found in the gastric mucosa of six patients with gastrointestinal symptoms. All patients had chronic active type B gastritis and four had oesophagitis. Culture and microscopy for C pylori infection was negative. These unculturable spiral organisms were probably an incidental finding in patients presenting for upper gastrointestinal endoscopy, but it is not possible to say from this small series whether these organisms cause chronic active gastritis. The organism is helical, 3.5-7.5 microns long and 0.9 micron in diameter with truncated ends flattened at the tips, and up to 12 sheathed flagella 28 nm in diameter at each pole. It is proposed that this spiral bacterium should be called "Gastrospirillum hominis Gen.nov., Sp.nov."

Esophageal dilatation using the Eder Puestow dilators.

We have performed fifty-one dilatations in twenty-six patients using an end-viewing fiberoptic endoscope and Eder Puestow dilators. All (except two) were performed using intravenous diazepam, the majority on an outpatient basis. The only complication has been a single case of aspiration pneumonia. We have found this method of esophageal dilatation particularly useful in the preoperative dilatation of benign strictures, and in those elderly frail patients who are unsuitable for surgery. Transthoracic resection of the stricture is avoided and thus transabdominal repair of the hiatus hernia may be undertaken.

Long-term follow up of patients with gastritis associated with Helicobacter pylori infection.

The aim of this study was to evaluate the long-term prognosis for patients suffering from gastritis associated with Helicobacter pylori infection, and in particular the proportion of cases progressing to peptic ulcer. The study was carried out in one urban general practice. One hundred and three patients who had presented with dyspepsia over the 1973-80 period and who were found to have a macroscopically normal endoscopy were reassessed between seven and 14 years later. Gastric antral biopsies had been taken routinely at endoscopy and were subsequently re-examined for the presence of H pylori. The patients' medical records were examined to establish their consulting rates over the follow-up period and whether they suffered from any other medical conditions. Patients were interviewed to assess the course of their dyspeptic symptoms. Comparison of patients who were unequivocally H pylori positive with those who were negative revealed no significant differences in the consultation rate for gastroenterological symptoms, in the proportion of patients referred to a hospital consultant or for further gastroenterological investigations or in the proportion reporting that their symptoms had improved. However, a statistically highly significant relationship was found between H pylori infection and hypertension. The results of this study have shown that there is a good prognosis for non-ulcer dyspepsia whether or not H pylori infection is present. The association between H pylori gastritis and hypertension clearly merits further investigation.

The results of Ramstedt's operation: room for complacency?

The results of 101 pyloromyotomies performed from 1972 to 1980 have been analysed; 34 operations were performed using local anaesthesia and 67 using general anaesthesia. The use of local anaesthesia was not associated with any advantage related to postoperative or other complications. A high postoperative complication rate of 20% was found (excluding postoperative vomiting), and there were 2 deaths; 11 patients suffered wound infection, with Staphylococcus aureus isolated from 5 of these wounds. The use of prophylactic antibiotics active against Staphylococcus aureus is suggested.

Duodenal diversion with vagotomy and antrectomy for severe or recurrent reflux oesophagitis and stricture: an alternative to operation at the hiatus.

In cases of mild symptomatic gastro-oesophageal reflux, standard antireflux surgery, such as fundoplication or the Angelchik prosthesis, produces satisfactory results. Duodenal diversion is recommended for use only in patients with severe oesophageal damage. This situation commonly arises where the gastro-oesophageal junction cannot be reduced into the abdomen, or where previous surgery has made reoperation at the hiatus difficult and hazardous. Fifty-seven patients with severe reflux oesophagitis have been treated by Roux-en-Y duodenal diversion and antrectomy. Thirty three patients had vagotomy in addition. Median follow-up after operation is 6.1 years. In 35 patients (61%), the technique was used as primary surgical treatment. These included 22 patients in a randomized trial of the method. Thirteen (23%) had previously had unsuccessful antireflux surgery. Nine (16%) had undergone previous operations for peptic ulcer or achalasia. There was no operative mortality. No patient in the series required stricture resection. Good or excellent overall results were achieved in 86% of patients. Eighteen of twenty seven patients with severe strictures required an average of three dilatations after operation before dysphagia was completely relieved. Heartburn was dramatically relieved and oesophagitis settled within an average period of 6 months. Poor or unsatisfactory overall results were observed in 8 (14%) patients. These included one tight fibrous stricture which required endoscopic intubation despite resolution of oesophagitis, and four patients who developed a stomal ulcer. No patients suffered from the dumping syndrome. Malignancy must be carefully excluded by biopsy in all cases of stricture.

Human embryo: a biological definition.

This paper defines a human embryo from a biological standpoint that takes into account emerging technologies in reproductive science. The paper does not consider legal, moral, religious or social views. As the definition of a human embryo must reflect the multifactorial processes of development, an approach has been adopted which combines recognition of observed events with potential for further development. This acknowledges that fertilization and development are not static processes, and as such embryo status can only be defined by observation of specific markers. The following biological definition of 'human embryo' is proposed. A human embryo is a discrete entity that has arisen from either: the first mitotic division when fertilization of a human oocyte by a human sperm is complete or any other process that initiates organized development of a biological entity with a human nuclear genome or altered human nuclear genome that has the potential to develop up to, or beyond, the stage at which the primitive streak appears, and has not yet reached 8 weeks of development since the first mitotic division.

Proximal gastric vagotomy versus long-term maintenance treatment with cimetidine for chronic duodenal ulcer: a prospective randomised trial.

Forty-four patients with chronic duodenal ulceration were allocated randomly to either long-term maintenance treatment with cimetidine or proximal gastric vagotomy. All were followed up both clinically and endoscopically for periods of one to four years. The rate of recurrence of ulcer during and after medical treatment was 54% while after surgery it was 10%. One patient developed severe allergic hepatitis while receiving maintenance treatment with cimetidine, and two others had to stop treatment because of possible drug reactions. Patients whose ulceration recurs while they are receiving treatment with cimetidine should be offered the possibility of operation.

Endoscopic studies of dyspepsia in a general practice.

In an urban general practice serving 7800 patients, all patients presenting over five and a half years with dyspepsia lasting more than two weeks were investigated by fibreoptic endoscopy and cholecystography, and many by barium meal. Of the 393 patients with dyspepsia, 346 completed the investigation: 180 had specific disease of the oesophagus, stomach, duodenum, or gall bladder, including six with carcinoma. Al further 67 had mucosal disease, and only 99 patients had no abnormality. After the first year the number of patients presenting annually and the percentage of patients with specific lesions remained constant. The annual incidence for patients with dyspepsia was about 1% and for patients with specific lesions 0.4%, suggesting that each year those who became symptom free (either spontaneously or because of treatment) were balanced by a similar number who developed symptoms. In contrast to the conclusions of other workers that an "open-access" endoscopy service could not be justified because the number of patients with specific lesins fell during their survey, we suggest that such endoscopy services are indeed worth while for providing an accurate diagnosis of dyspepsia.

Vagotomy and pyloroplasty for gastric ulcers.

Eighty patients with benign gastric ulcer treated by vagotomy and pyloroplasty in a district general hospital are reviewed. There were no postoperative deaths in the patients undergoing elective surgery but 8 deaths in those undergoing emergency surgery for massive bleeding (38 per cent). Eighty-three per cent of patients had a result that was classed as good or satisfactory. Recurrent gastric ulceration was found in 8 per cent and a tendency to late asymptomatic ulcer recurrence is identified. Careful long term follow-up, including endoscopic re-examination, is advocated for patients undergoing conservative operations for benign gastric ulcer.

Self-dilatation of oesophageal strictures.

A new technique for the management of upper and mid-oesophageal benign strictures is reported. A deflated oesophageal balloon catheter coated with steroid paste is passed by the patient through the stricture, the balloon is inflated and then withdrawn. This technique can be used for both strictures caused by tablet or corrosive damage that recur rapidly and where stricturing is the result of a chronic disease not amenable to medical or surgical treatments. Three patients in who this technique has been used with satisfactory patient tolerance and compliance and good relief of symptoms are reported.

Open-access upper alimentary endoscopy.

During 11 years of an open-access endoscopy service for general practitioners the proportion of positive diagnoses has remained relatively constant. There has been a progressive fall in the incidence of duodenal ulcers but an increase in oesophagitis which is now the single most commonly detected abnormality. The number of barium meal requests has fallen by approximately 50%. A study of cimetidine prescribing suggests that use of the open-access service results in fewer inappropriate prescriptions.

Randomized prospective trial of the Angelchik anti-reflux prosthesis.

Fifty-two patients with reflux oesophagitis resistant to medical treatment were randomized at operation to receive either the Angelchik prosthesis or a fundoplication. All patients were assessed postoperatively by a physician unaware of the nature of the operation. Forty-two patients have been followed up for 1-2 years; ten patients for 3-9 months. Ninety-six per cent of the Angelchik patients had satisfactory or excellent results compared with 81 per cent with a fundoplication. There were no failures to control reflux with the Angelchik prosthesis whereas 6 patients (23 per cent) of the fundoplication group have persisting reflux. Operating times for insertion of the prosthesis averaged a little over half that recorded for fundoplication. Complication rates were similar. The results of the trial encourage the use of the prosthesis in patients with gastro-oesophageal reflux, where medical treatment has failed. The prosthesis should not be used if the gut is opened during operation either inadvertently or deliberately, as in making a suture line or anastomosis, because of the risk of sepsis.

A life-threatening respiratory complication of gastro-oesophageal reflux in a patient with tetraplegia.

Recurrent attacks of life-threatening dyspnoea and choking occurred in a patient with tetraplegia. Conventional investigations for gastro-oesophageal reflux were normal, but 24-hour oesophageal pH recording revealed gross reflux in association with an attack of dyspnoea. Surgical correction of the reflux abolished the attacks. The possibility of autonomic dysreflexia as the mechanism linking reflux and respiratory symptoms in this patient is discussed.

A follow-up survey of patients with dyspepsia in one general practice.

Eighty-three patients who had been investigated by cholecystogram, barium meal and fibreoptic endoscopy more than two years previously were interviewed to enquire into their reactions to the investigations carried out, their present symptoms, and their present smoking and alcohol consumption. Comparisons were made with previously recorded observations. Those who still complained of severe dyspepsia were asked to attend for a repeat endoscopy. Sixty-three per cent of patients were asymptomatic; 13 per cent had recurrent dyspepsia, and 24 per cent had persistent dyspepsia. Thirty-nine per cent of smokers were found to have stopped altogether following medical advice.Both radiological and endoscopic methods of investigation proved acceptable. A majority of patients preferred endoscopy to barium meal.