David J. Kearney

Iron-deficiency anemia and Helicobacter pylori infection: a review of the evidence.

Iron deficiency is the most common cause of anemia in the world, affecting an estimated 500–600 million persons (1). It is also estimated to be the most common nutritional deficiency in both underdeveloped and developed nations, the most common cause of anemia, and possibly the most common organic disorder in clinical practice (2). The prevalence of iron-deficiency anemia (IDA) was evaluated in a large cross-sectional survey of the United States and found to affect 2.7–4.4% of adult males, with a progressive increase in frequency with increasing age (3). Established causes of iron deficiency include inadequate iron intake, chronic blood loss, malabsorption, hemolysis, or a combination of these factors. IDA is often an indication to evaluate the upper and lower gastrointestinal tract to exclude chronic blood loss secondary to cancers, ulcerations, angiodysplasias, or malabsorption from celiac disease. However, endoscopic studies are frequently unrevealing and the cause of iron deficiency remains unexplained in a significant proportion of cases. In a prospective study of 100 patients with IDA, endoscopy failed to discover a culprit lesion in 48% of subjects (4). In another study of adults who underwent endoscopic evaluation for IDA, a cause of anemia was found in only 55% of outpatients (5). The failure to identify a cause of iron deficiency in a substantial subset of patients with low iron stores raises the question of whether there are additional as of yet unexplained causes of iron depletion. Recently, there has been a growing body of evidence to suggest a relationship between Helicobacter pylori gastritis and IDA in the absence of peptic ulcer disease.

Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample

OBJECTIVES To assess outcomes of veterans who participated in mindfulness-based stress reduction (MBSR). DESIGN Posttraumatic stress disorder (PTSD) symptoms, depression, functional status, behavioral activation, experiential avoidance, and mindfulness were assessed at baseline, and 2 and 6 months after enrollment. RESULTS At 6 months, there were significant improvements in PTSD symptoms (standardized effect size, d = -0.64, p< 0.001); depression (d = -0.70, p<0.001); behavioral activation (d = 0.62, p<0.001); mental component summary score of the Short Form-8 (d = 0.72, p<0.001); acceptance (d = 0.67, p<0.001); and mindfulness (d = 0.78, p<0.001), and 47.7% of veterans had clinically significant improvements in PTSD symptoms. CONCLUSIONS MBSR shows promise as an intervention for PTSD and warrants further study in randomized controlled trials.

Effects of Participation in a Mindfulness Program for Veterans With Posttraumatic Stress Disorder: A Randomized Controlled Pilot Study

OBJECTIVE To assess outcomes associated with Mindfulness-Based Stress Reduction (MBSR) for veterans with PTSD. METHODS Forty-seven veterans with posttraumatic stress disorder (PTSD; 37 male, 32 Caucasian) were randomized to treatment as usual (TAU; n = 22), or MBSR plus TAU (n = 25). PTSD, depression, and mental health-related quality of life (HRQOL) were assessed at baseline, posttreatment, and 4-month follow-up. Standardized effect sizes and the proportion with clinically meaningful changes in outcomes were calculated. RESULTS Intention-to-treat analyses found no reliable effects of MBSR on PTSD or depression. Mental HRQOL improved posttreatment but there was no reliable effect at 4 months. At 4-month follow-up, more veterans randomized to MBSR had clinically meaningful change in mental HRQOL, and in both mental HRQOL and PTSD symptoms. Completer analyses (≥ 4 classes attended) showed medium to large between group effect sizes for depression, mental HRQOL, and mindfulness skills. CONCLUSIONS Additional studies are warranted to assess MBSR for veterans with PTSD.

Breath Ammonia Measurement in Helicobacter pylori Infection

Our aim was to define the utility of breath ammonia measurement in assessing Helicobacter pylori infection. Volunteers breathed into a device containing three fiberoptic NH3 sensors at baseline and after ingesting 300 mg of urea. Breath ammonia levels were compared to the [14C]urea breath test. Thirteen subjects were tested. Before urea ingestion, H. pylori-positive subjects had significantly lower breath ammonia levels than negative subjects (mean ± sd, 0.04 ppm ± 0.09 vs 0.49 ppm ± 0.24, P = 0.002) and had a significantly greater increases in breath ammonia after urea ingestion (range 198–1494% vs 6–98%). One H. pylori-positive subject underwent treatment and breath ammonia levels shifted from the pattern seen in positive subjects to that seen in negative subjects. In conclusion, breath ammonia measurement for H. Pylori-positive and negative subjects showed distinct patterns. Breath ammonia measurement may be feasible as a diagnostic test for H. pylori.

Loving‐Kindness Meditation for Posttraumatic Stress Disorder: A Pilot Study

Loving-kindness meditation is a practice designed to enhance feelings of kindness and compassion for self and others. Loving-kindness meditation involves repetition of phrases of positive intention for self and others. We undertook an open pilot trial of loving-kindness meditation for veterans with posttraumatic stress disorder (PTSD). Measures of PTSD, depression, self-compassion, and mindfulness were obtained at baseline, after a 12-week loving-kindness meditation course, and 3 months later. Effect sizes were calculated from baseline to each follow-up point, and self-compassion was assessed as a mediator. Attendance was high; 74% attended 9-12 classes. Self-compassion increased with large effect sizes and mindfulness increased with medium to large effect sizes. A large effect size was found for PTSD symptoms at 3-month follow-up (d = -0.89), and a medium effect size was found for depression at 3-month follow-up (d = -0.49). There was evidence of mediation of reductions in PTSD symptoms and depression by enhanced self-compassion. Overall, loving-kindness meditation appeared safe and acceptable and was associated with reduced symptoms of PTSD and depression. Additional study of loving-kindness meditation for PTSD is warranted to determine whether the changes seen are due to the loving-kindness meditation intervention versus other influences, including concurrent receipt of other treatments.

Breath ammonia testing for diagnosis of hepatic encephalopathy.

Measurement of arterial ammonia has been used as a diagnostic test for hepatic encephalopathy, but obtaining an arterial specimen is an invasive procedure. The aim of this study was to evaluate the ability of a minimally invasive, highly sensitive optical sensing device to detect ammonia in the breath of patients with end-stage liver disease and to evaluate the correlation of breath ammonia levels, arterial ammonia levels, and psychometric testing. Fifteen subjects with liver cirrhosis and clinical evidence of hepatic encephalopathy underwent mini-mental status examination, number connection test, focused neurological examination, and arterial ammonia testing. On the same day, breath ammonia testing was performed using an apparatus that consists of a sensor (a thin membrane embedded with a pH-sensitive dye) attached to a fiberoptic apparatus that detects optical absorption. Helicobacter pylori testing was performed using the 14C urea breath test. A positive correlation was found between arterial ammonia level and time to complete the number connection test (r = 0.31, P = 0.03). However, a negative correlation was found between breath ammonia level and number connection testing (r = −0.55, P = 0.03). Furthermore, no correlation was found between breath and arterial ammonia levels (r = −0.005, P = 0.98). There is a significant correlation between the trailmaking test and arterial ammonia levels in patients with cirrhosis. However, no correlation was found between breath and arterial ammonia levels using the fiberoptic ammonia sensor apparatus in this small study.

A prospective study of endoscopy in HIV-associated diarrhea

OBJECTIVE: Diarrhea commonly occurs in persons with human immunodeficiency virus (HIV) infection. The optimal use of endoscopic procedures remains poorly studied for patients with HIV-related diarrhea. The purpose of this study is to compare the diagnostic yield of a complete endoscopic work-up including an esophagogastroduodenoscopy and colonoscopy to a more limited approach of biopsies obtainable by flexible sigmoidoscopy. METHODS: A prospective study of 79 patients with HIV-related diarrhea. Upper endoscopy and colonoscopy were performed with tissue biopsies labelled according to location within the colon or small intestine. RESULTS: A new infection was diagnosed in 22 of 79 patients (28%). Biopsy of the left colon yielded an enteric pathogen in 17 of 22 patients (sensitivity: 77%) and in 15 of 15 patients with cytomegalovirus colitis (sensitivity: 100%). Combined left and right colonic biopsies had a sensitivity of 82%. Combined colonic and terminal ileum biopsies missed no pathogens. Duodenal biopsies yielded no additional pathogens beyond those identified by colonoscopy and terminal ileal biopsy. Patients with a new pathogen diagnosed had significantly lower CD4 lymphocyte counts as compared to patients without a new pathogen (p = 0.001). CONCLUSIONS: For patients with CD4 counts < 100/mm3 and unexplained AIDS-related diarrhea, flexible sigmoidoscopy with biopsy is a sufficiently thorough endoscopic evaluation.

Complementary and alternative medicine for IBS in adults: mind-body interventions.

Standard treatment for IBS focuses on the management or alleviation of the predominant gastrointestinal presenting symptoms, such as diarrhea or constipation, often using pharmacological therapy. For many patients, this approach is unsatisfactory, and patients frequently seek the advice of complementary and alternative medicine (CAM) practitioners in order to explore other treatment options. CAM practices include a broad range of modalities, and mind–body interventions hold particular promise as treatment modalities for IBS because psychological factors could have an important role in IBS symptomatology and quality of life. Psychological stressors are postulated to result in gastrointestinal symptoms through alteration of intestinal function mediated by the autonomic nervous system, hypothalamic–pituitary–adrenal axis and immune system. Hypnotherapy has the strongest supportive evidence as a beneficial mind–body intervention for IBS. Clinical studies of hypnotherapy have uniformly shown improvement of gastrointestinal symptoms, anxiety, depression and quality of life in patients with IBS. Mindfulness meditation remains unstudied for IBS, but is theoretically attractive as a stress-reduction technique. There is a suggestion that relaxation therapy or multimodal therapy (a combination of relaxation therapy, education and psychotherapy) is beneficial for IBS. The most generally accepted psychological mind–body intervention is cognitive behavioral therapy, and clinical trials support the beneficial effects of cognitive behavioral therapy in patients with IBS.

Participation in mindfulness-based stress reduction is not associated with reductions in emotional eating or uncontrolled eating

The adverse health effects and increasing prevalence of obesity in the United States make interventions for obesity a priority in health research. Diet-focused interventions generally do not result in lasting reductions in weight. Behavioral interventions that increase awareness of eating cues and satiety have been postulated to result in healthier eating habits. We hypothesized that participation in a program called mindfulness-based stress reduction (MBSR) would positively influence the eating behaviors and nutritional intake of participants through changes in emotional eating (EE), uncontrolled eating (UE), and type and quantity of food consumed. Forty-eight veterans at a large urban Veterans Administration medical center were assessed before MBSR, after MBSR, and 4 months later. For all participants (N = 48), MBSR participation was not associated with significant changes in EE or UE. In addition, there were no significant differences in the intake of energy, fat, sugar, fruit, or vegetables at either follow-up time point as compared with baseline. Enhanced mindfulness skills and reduced depressive symptoms were seen over time with medium to large effect sizes. Changes in mindfulness skills were significantly and negatively correlated with changes in EE and UE over time. Overall, there was no evidence that participation in MBSR was associated with beneficial changes in eating through reductions in disinhibited eating or significant changes in dietary intake. Randomized studies are needed to further define the relationship between mindfulness program participation and eating behaviors.

Treatment of Helicobacter pylori Infection in Clinical Practice in the United States Results from 224 Patients

Our objectives were to define treatment success, compliance, and side effects for treatment of Helicobacter pylori in clinical practice. In all, 224 consecutive patients received Helicobacter pylori treatment: 97 received two weeks of bismuth subsalicylate, metronidazole, tetracycline four times a day with a H2-receptor antagonist twice a day (BMT); 89 received one week of metronidazole, lansoprazole, and clarithromycin twice a day (MLC); and 38 received one week of BMT with lansoprazole twice a day (BMT-PPI). Cure rates were: BMT 81% (95% CI 74–89%), MLC 90% (95% CI 84–96%) BMT-PPI 87% (95% CI 81–92%). More patients prescribed a bismuth-based regimen discontinued medications due to side effects compared to MLC (P = 0.049). Nausea was more common for BMT compared to MLC (P = 0.04). In conclusion, treatment of Helicobacter pylori infection with a one-week course of MLC achieves a high rate of cure in clinical practice. Significantly fewer patients prescribed PPI-based therapy discontinue medications due to side effects as compared to bismuth-based triple therapy.