Eradication Therapies for H. pylori
(Canada—Canadian Family Physician, July 1998, p. 1481.) Helicobacter pylori infection is associated with more than 90 percent of duodenal ulcers and 80 percent of gastric ulcers. If the organism is successfully eradicated, the 12-month rate of ulcer recurrence is approximately 6 percent, compared with 67 percent if eradication is unsuccessful. Recommended first-line eradication therapies include proton pump inhibitors such as omeprazole and lansoprazole to relieve symptoms and promote ulcer healing. Two current regimens combine a proton pump inhibitor with clarithromycin and metronidazole or clarithromycin and amoxicillin. In both regimens, medications are given twice daily for 10 to 14 days and have efficacy rates of approximately 90 percent. The only significant side effects reported are taste disturbances and diarrhea. Alternative therapies combine proton pump inhibitors with bismuth, metronidazole and tetracycline. Serologic tests for H. pylori remain positive after successful eradication, but new breath tests can confirm eradication based on detection of carbon dioxide metabolized from labeled urea.
Urinary Incontinence in the Elderly
(New Zealand—New Zealand Family Physician, August 1998, p. 31.) Up to one third of elderly patients living in the community report involuntary loss of urine with consequent social and hygiene problems. Many conditions can cause or exacerbate urinary incontinence, and the acronym DRIP is suggested to guide investigations. The letter “D” refers to both delirium and drugs, such as those causing polyuria, frequency, urgency, anticholinergic effects and fecal constipation. The other letters refer to retention; immobility, inflammation of the bladder and impaction of feces; and polyuria. The clinical history, examination and initial tests are directed toward identifying one of the three basic mechanisms of incontinence. In cases of overactive detrusor muscle, typical symptoms include frequency, nocturia, urgency, urge incontinence and nocturnal enuresis. When the basic mechanism of incontinence is underactive urinary sphincter, increased intra-abdominal pressure commonly results in small to moderate urine loss. This situation commonly follows surgery of the prostate in men or childbirth-related weakness of the pelvic muscles in women. Incontinence that is due to overactive sphincter is usually overflow incontinence from urinary retention. This may result from lesions of the spinal cord or outflow obstruction.
Imaging for Postmenopausal Bleeding
(Hong Kong—Hong Kong Practitioner, August 1998, p. 421.) Imaging studies may be useful to guide the management of selected patients with postmenopausal bleeding but low risk of neoplasm. In most non-Oriental women, transvaginal ultrasonography can accurately identify pathology if the endometrial thickness is 5 mm or greater. The sensitivity of the test can be improved by instilling fluid contrast material into the vaginal cavity (hydrosonography). According to one estimate, up to 68 percent of invasive diagnostic tests for postmenopausal bleeding could be avoided by use of ultrasonographic screening of selected patients. Magnetic resonance imaging has not been widely studied in cases of postmenopausal bleeding but is expensive and lacks the specificity for diagnosis of endometrial pathology. Research using color Doppler ultrasonography of the uterine arteries to correlate vascular changes with the etiology of clinical symptoms shows promising results but is not yet clinically applicable.
Features of Antiphospholipid Syndrome
(Australia—Australian Family Physician, August 1998, p. 709.) The antiphospholipid syndrome (APLS) is characterized by recurrent venous and arterial thromboses, recurrent pregnancy loss, thrombocytopenia and detectable antibodies such as anticardiolipin, lupus anticoagulant, phosphatidylserine and phosphatidylethanolamine. The condition may be primary or may occur in association with autoimmune disorders such as systemic lupus erythematosus. Clinically, arterial thromboses are most common in the brain, whereas venous thromboses occur most frequently in the legs and abdomen. APLS may be responsible for up to one quarter of recurrent miscarriages, and these usually occur early in pregnancy. There is little consensus about diagnostic criteria or guidelines for management of APLS. Acute thrombosis is managed by intravenous and oral therapy to maintain an International Normalized Ratio (INR) greater than 3. Patients with recurrent thromboses that are caused by APLS require lifelong prophylactic anticoagulation.