Randomised controlled trial of Helicobacter pylori testing and endoscopy for dyspepsia in primary care

ObjectiveTo determine the cost effectiveness of a strategy of near patient Helicobacter pylori testing and endoscopy for managing dyspepsia.DesignRandomised controlled trial.Setting31 UK primary care centres.Participants478 patients under 50 years old presenting with dyspepsia of longer than four weeks duration.InterventionsNear patient testing for H pylori and open access endoscopy for patients with positive results. Control patients received acid suppressing drugs or specialist referral at general practitioner''s discretion.Results40% of the study group tested positive for H pylori. 45% of study patients had endoscopy compared with 25% of controls. More peptic ulcers were diagnosed in the study group (7.4% v 2.1%, P=0.011). Paired comparison of symptom scores and quality of life showed that all patients improved over time with no difference between study and control groups. No significant differences were observed in rates of prescribing, consultation, or referral. Costs were higher in the study group (£367.85 v £253.16 per patient).ConclusionsThe test and endoscopy strategy increases endoscopy rates over usual practice in primary care. The additional cost is not offset by benefits in symptom relief or quality of life.

What is already known on this topic

Patients younger than 50 without H pylori infection are unlikely to have treatable disease detected at endoscopySuch patients can be managed by acid suppression and reassurance aloneTest and endoscopy (referral of patients testing positive for H pylori in primary care) has been recommended as a way to reduce endoscopic workload

What this paper adds

Applying a test and endoscopy strategy increased the endoscopy referral rate from 25% to 40%The strategy produced no significant differences in symptoms or quality of life compared with usual managementThe increased costs of this strategy cannot be justified     

Trend breaks in incidence of non-cardia gastric cancer in the Netherlands

IntroductionThe incidence of gastric cancer declined over the past decades. Recently, unfavorable trend breaks (i.e. rise in incidence) were seen for non-cardia cancer in younger age groups in the US. It is unclear whether these also occur in other Western countries. We aimed to analyze the gastric cancer incidence trends by age, sex, subsite and stage in the Netherlands.MethodsData on all patients with gastric adenocarcinoma diagnosed from 1973 to 2011 (n = 9093) were obtained from the population-based Eindhoven cancer registry. Incidence time trends (European standardized rates per 100,000) were separately analyzed by sex, age group (<60, 60–74, and >75 years), subsite, and pathological stage. Joinpoint analyses were performed to discern trend breaks, age–period–cohort analyses to examine the influence of longitudinal and cross-sectional changes.ResultsThe incidence of non-cardia cancer declined annually by 3.5% (95% CI −3.8; −3.3). However, in males <60 years, the incidence flattened since 2006, and tended to rise in those >74 years. This pertained to corpus cancers. The incidence of cardia cancer peaked in 1985 and decreased subsequently by 2.4% (95% CI −3.2; −1.5) yearly. The absolute incidence of stage IV disease at first diagnosis initially decreased, but then remained stable over the past 15–20 years.ConclusionsThe incidence of non-cardia cancer declined over the past four decades in the Netherlands, but now seems to be stabilizing particularly in males. Unfavorable trend breaks are seen for corpus cancer in younger and older males. The trend breaks in the Netherlands are however not similar to those observed in the US.     

Recommendations for introducing genetics services in developing countries

Many concerned scientists believe that developments in the medical application of genomics will widen the gap between the developed and the developing world. We argue that most developing countries now urgently need to incorporate genetic approaches (including DNA diagnosis) into their health services, and that many are able to do so. DNA diagnosis is relatively inexpensive, helps to develop skills in molecular biology and provides a basis for developing national expertise in genomics.     

Appropriate biotechnology for sustainable agriculture in developing countries

Many transnational organizations are investing heavily in biotechnological research¹. They are primarily interested in activities such as the sale of chemicals and/or food processing. Consequently, research leading to an expansion in the use of chemicals or a reduction of commodity prices is advantageous to those companies. An increase in the sale of chemicals can, for instance, be expected as a result of research on herbicide resistance², a further reduction of commodity prices can be stimulated by biotechnological research directed at cost reduction or finding cheaper substitutes³. Western governmental research institutes and universities contribute to these research directions by cooperating closely with these companies^4,5.In view of these developments, it can be expected that biotechnological research will contribute to a further decrease in commodity prices and further instability of the agricultural structure in many developing countries and, consequently, an acceleration of migration to the already overcrowded cities.The question is, can biotechnology also contribute to sustainable development in rural areas by assisting small-scale and semi-subsistence farmers? I suggest it can.     

Immune responses to tuberculosis in developing countries: implications for new vaccines

Tuberculosis is out of control in developing countries, where it is killing millions of people every year. In these areas, the present vaccine - Mycobacterium bovis bacillus Calmette-Guérin (BCG) - is failing. Progressive tuberculosis occurs because the potentially protective T helper 1 (T(H)1)-cell response is converted to an immunopathological response that fails to eliminate the bacteria. Here, we discuss the data indicating that the problem in developing countries is not a lack of adequate T(H)1-cell responses but, instead, an exaggerated tendency to switch to immunopathological responses. We propose that a successful vaccine needs to block this immunopathology, because it is not the quantity of T(H)1-cell activity that matters but, rather, its context.