Surreptitious Use Research Articles

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Introduction: Diagnosing factitious disorders can be expensive, time consuming, and challenging. We present a clinical conundrum of refractory hypotension that ultimately led to a diagnosis of surreptitious AV-nodal agent abuse. Case: A 41 year-old female with a diagnosis of idiopathic capillary leak syndrome (ICLS), s/p demand pacemaker for intermittent symptomatic bradycardia, was admitted for elective administration of intravenous immunoglobulin (IVIG). Development of hypoalbuminemia, bilateral pleural effusion, and peripheral edema on a background of refractory hypotension during a preceding hospital admission (6 months prior to the index admission) aided the diagnosis of ICLS [1]. A diagnosis of ICLS was made following an extensive 2-year evaluation by multiple specialties for a constellation of symptoms that had escaped clinical diagnosis. She was committed to IVIG, after failure of first line therapy (Terbutaline) [2] by an autonomic dysfunction expert, in consultation with an allergist, pulmonologist, general cardiologist, and electrophysiologist. On evaluation, her physical examination, biochemical profile, echocardiogram, pacemaker evaluation, and radiology were all unremarkable. Within one hour of admission, the patient developed acute refractory hypotension and bradycardia prompting pacemaker activation and vasopressors. Hemodynamic improvement noted during the course of the day was followed by a precipitous decline at night, only to improve dramatically again with short periods of vasopressor therapy. This was the pattern of her clinical course during her admission. Inconsistencies in her clinical presentation (no evidence of hemoconcentration or third spacing - a hallmark of ICLS) and intermittent pacemaker activation for bradycardia, prompted a reevaluation of her clinical diagnosis. The evanescent nature of the symptoms in an otherwise healthy individual was intriguing. Our belief in the medical adage 'All other things being equal the simplest answer is usually the best' prompted us to consider surreptitious AV-nodal blocker abuse. We requested serum beta and calcium-channel blocker levels during the throes of these acute hypotensive episodes while the patient was on norepinephrine. A two year search for a medical dilemma that escaped clinical diagnosis came to fruitition when a Metoprolol level of 95 ng/ml (therapeutic limit 20 to 340 ng/ml) and a Verapamil level of 380 ng/ml (therapeutic limit 70 to 350 ng/ml) was reported. A case for Munchausen's Syndrome - Factitious disorder was thus made. Patient was confronted with the data and reluctantly admitted to surreptitious use of Metoprolol and Verapamil. She elected to have her pacemaker removed and psychiatry services were consulted. Discussion: Factitious Disorder is a mental disorder in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created their symptoms. Idiopathic capillary leak syndrome is a rare disease of unknown cause. It results in reversible plasma extravasation and vascular collapse. Diagnosis is made clinically and by exclusion of other diseases that cause similar signs and symptoms [1]. Factitious disorders must also be considered as part of the differential diagnosis when there are inconsistencies in the patient's history, laboratory tests, and physical examination findings [3]. Conclusion: Factitious disorders could be the simplest explanation for medical conundrums that baffle physicians. "When you hear hoofbeats, think horses, not zebras." Reference #1: Druey KM et al. Narrative review: the systemic capillary leak syndrome. Ann Intern Med 2010; 153-90. Reference #2: Gousseff M, et al. The systemic capillary leak syndrome: a case series of 28 patients from a European registry. Ann Intern Med 2011; 154:464. Reference #3: Krahn LE, Li H, et al. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry. Jun 2003;160(6):1163-8

A hypokalaemic woman with nephrocalcinosis: rebirth of old knowledge

The coexistence of hypokalaemia and nephrocalcinosis poses a challenge in rapid diagnosis and appropriate management. We describe a 38-year-old woman who presented with thirst, intermittent carpopedal spasm, paresthaesia of both hands and progressive weakness of lower extremities for two years. She had a history of chronic hypokalaemia of unknown cause with intermittent potassium supplementation for 7-8 y and bilateral nephrocalcinosis notable for one year. She denied vomiting, diarrhoea or use of laxatives, alcohol or diuretics. Her blood pressure was normal. Laboratory investigations showed hypokalaemia (2.7 mmol/L) and metabolic alkalosis (HCO3(-) 32.6 mmol/L, pH 7.46). Two random urine samples both showed a consistently high urine K(+) excretion but with excretion rates of Na(+), Cl(-) and divalent cations which were high in one sample but not the other. Ingestion of furosemide 120 mg daily for body image for 7-8 y was uncovered. With furosemide cessation and potassium supplementation, her hypokalaemia with neuromuscular symptoms was corrected but nephrocalcinosis persisted. Surreptitious use of diuretics for various purposes should be kept in mind as an important cause of hypokalaemia and/or nephrocalcinosis. Measurement of electrolyte concentrations in at least two random urine samples is warranted to distinguish it from true renal tubular disorders and extrarenal causes.

Surreptitious use of disulfiram

Surreptitious use of disulfiram

An Integer Programming Quiz Picture Round

Pub quizzes have been a popular weekday evening activity in the United Kingdom for many years. These quizzes consist of a number of teams competing for a cash prize over several rounds of questions. Typical rounds may include general knowledge, music, science, sports, and current affairs. More recently, because of surreptitious use of smart phones it has become a challenge to quiz setters to devise questions that will confound the would-be cheat. As a result, rounds of picture questions have become increasingly prevalent and in this article I would like to present a particularly novel type of picture round based on the traveling salesman problem (TSP) or, more specifically, the TSP art pioneered by Bob Bosch and others. The TSP may be formulated using integer programming (IP) and is known to be NP-complete. The P versus NP problem is considered to be of such importance that the Clay Mathematics Institute included it as one of the millennium problems, offering a $1 million prize for its resolution. For an official description of the problem together with a video see http://www.claymath.org/millennium/P_vs_NP/. The TSP has generated a great deal of attention over the past few decades and researchers in this field have taken from and hugely contributed to the more general IP literature. William J. Cook’s terrific book In Pursuit of the Traveling Salesman (2012) gives a very detailed but accessible coverage of the problem and is essential reading for anyone with more than a passing interest in optimization. Cook (2012) includes a useful introduction to TSP art in a consciousness expanding chapter entitled Aesthetics. The basic idea is to generate TSP solutions that will approximate target images, usually portraits, when viewed at an appropriate distance. These are sometimes referred to as single line drawings and may be at the very least eye-catching and in some instances quite beautiful. In 2010 a sculpture called Embrace based on this idea gained Bosch the mathematical art exhibition first prize awarded by the American Mathematical Society and the Mathematics Association of America. This exquisite piece of mathematical artwork may be viewed at http://www .ams.org/mathimagery/displayimage.php?pid=274. Bosch, together with Craig Kaplan, has developed many sophisticated methods to enhance the aesthetic appeal of TSP images, see for example Kaplan and Bosch (2005) and their respective Web pages at http://www.oberlin.edu/math/faculty/bosch/tspartpage.html and http://www.cgl.uwaterloo.ca/~csk/ projects/tsp/. In this article I use the basic ideas to render images of iconic figures. My objective was to produce a range of images of varying clarity to be used as a basis for a quiz picture round. The process begins with a target image in the form of a black and white digital photograph as with the portrait of Marilyn Monroe in Figure 1. This target image is divided into rectangular panels and the average grayscale value of each panel is computed. The panels of the original photograph are each replaced by rectangles containing a number of points proportional to the grayscale value of the respective panel. An R language function (TspDotMap.r) to achieve this “stippling,” as it is known, is included as a supplementary file and I will refer to the output of this function as a dot map. The function stores the dot map in standard TSPLIB format, which is described in detail at http://plato.asu.edu/tsplib.pdf. An example (marilyn.tsp) is included with this article. Minor editing of the R function output is necessary as can be seen from inspection of this example. Figure 2 shows the stippled image generated from the target image in Figure 1. The TSP portrait may then be rendered using the Concorde software downloadable at http://www .tsp.gatech.edu/concorde.html. Searching for optimal tours in large problems can be time consuming

Ex vivo erythrocyte generation and blood doping.

Ex vivo erythrocyte generation and blood doping.

Surreptitious Antiretroviral Use as an Explanation for Apparent Elite HIV Control

Surreptitious Antiretroviral Use as an Explanation for Apparent Elite HIV Control

Issue Highlights

Issue Highlights

Identifying Plasma Glycerol Concentration Associated with Urinary Glycerol Excretion in Trained Humans*†

Glycerol has been used as a means to legitimately hyperhydrate the body in an attempt to offset the deleterious effects of dehydration. It has the potential to mask blood doping practices and as a result has been added to the WADA prohibited substance list. The purpose of this study was to identify the plasma glycerol concentration coinciding with urinary glycerol excretion. Twelve healthy, trained male subjects completed five separate trials under resting conditions. For each trial, subjects consumed a different glycerol dose (0.025, 0.05, 0.10, 0.15, or 0.20 g glycerol/kg LBM) of a 5% glycerol solution in order to determine at what plasma glycerol concentration an increase in urine glycerol concentration becomes apparent. Based on regression analysis, plasma glycerol concentrations > 0.327 ± 0.190 mmol/L and a glycerol dose > 0.032 ± 0.010 g glycerol/kg LBM would be associated with urinary glycerol excretion. There were significant linear relationships between peak plasma glycerol concentration and time to reach peak plasma glycerol concentration to the ingested glycerol doses. Our findings illustrate the importance of considering the effect of urinary glycerol excretion on legitimate hyperhydration regimens as well as suggesting that it is possible to detect surreptitious use of glycerol as a masking agent through urinary analysis.

Sexing the Fetus: Feminist Politics and Method across Cultures

Countries like India and China have become well known locally and internationally for their skewed girl-boy sex ratios, which have declined sharply in the very years marked by these countries' emergence as potential global economic giants. In India, these declines and the concomitant concern over the “missing” girl child have been associated with the spread of antenatal technologies such as ultrasound testing during pregnancy and their surreptitious use for sex determination and the selective abortion of female fetuses, which is banned by Indian law. This essay attempts to set up connections between Indian struggles over the problem and two U.S. feminist texts, Donna Haraway's essay “Fetus: The Virtual Speculum in the New World Order” and Rayna Rapp's ethnography Testing Women, Testing the Fetus. Many levels of disconnect across our respective “naturecultures” become visible in the process. A major argument throughout this essay is to pay closer attention to questions of method—the dominance of the language of statistics and numbers in India, for instance, compared with the ethnographic voices in Rapp's account. Rather than search for a global ethical answer to the question of the putative rights of the unborn, whether sexed or disabled, as the case may be, I argue that we need multiple modes of knowing how decisions are structured in different contexts. Only then can we acknowledge the feminist work that lies ahead in negotiating with women's diverse “choices”—as victims, criminals, and philosophically incoherent, but also as moral pioneers.

이동통신 단말기에서 데이터 보호 및 백업을 위한 원격 제어 시스템 설계

최근 이동통신 단말기들의 분실 또는 도난을 통해 개인 정보의 유출로 타인의 도용에 우려가 되는 바, 본 논문에서는 이동통신 단말기의 분실 시에 잠금 기능 설정을 설정하지 않은 경우에도 단말기 안의 정보를 원격으로 제어 할 수 있는 방법을 구현하고자 한다. 제안하는 시스템의 주요 가능은 크게 4가지 부분으로 구성되는 데 사용자가 단말기를 원격 제어할 수 있도록 인터페이스 역할을 하는 웹사이트 제공부, 사용자가 본인임을 확인하며 가입된 이동통신사 시스템으로부터 가입자확인 정보를 수행하는 사용자 확인부, 단말기의 실 소유자임이 확인되면 원격제어 프로그램을 가동시키기 위한 접속코드를 단말기로 전송하여 접속을 설정하는 접속 관리부, 단말기를 원격 제어하기 위한 원격 제어 서비스 코드 및 환경 설정 값을 단말기로 전송하고 단말기로부터 서비스 완료 코드를 수신하는 서비스 실행부를 포함한다. The change in performance of the mobile communication field took place due to jumping development of technology, so high performance terminals that anyone can directly search and amend desired information anywhere and anytime, namely, the mobile communication terminals called Smartphone were released to the market. The terminal can store informations that an individual stored, for example, call log, where to make contact and address of acquaintances, transmit/receive message and mail, photographs and videos, etc., but there are worries on surreptitious use of other people due to leaking of personal information through loss or theft of these terminals because of several reasons, so the present thesis aims to realize a method that remotely control information inside a terminal in case of loss of a mobile communication terminal.

PTH-095 Surreptitious use of non-steroidal anti-inflammatory drugs and aspirin may be responsible for small bowel injury seen by capsule endoscopy

Introduction Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin can cause small bowel injury and present with anaemia, bleeding or symptoms suggestive of Crohn9s disease, the most common indications for capsule endoscopy (CE). Previous studies have suggested that the surreptitious use of these drugs may be a common cause of unexplained peptic ulcer disease.1 We hypothesised that surreptitious NSAID or aspirin use occurred in patients undergoing CE and that this might be responsible for symptoms or abnormalities being investigated. Methods Demographic data, indications for CE and medications were recorded prospectively. A salicylate spot test and gas chromatography mass spectrometry for NSAID metabolites were performed on urine samples of consecutive patients undergoing routine CE. Videos were analysed by an experienced gastroenterologist who was blinded to the urinalysis results. Results Seventy-six patients (52 female; mean age 50 years) underwent CE for suspected small bowel pathology. Urinalysis was positive in 13.6% of patients (n=10/76), although only one of these patients declared the relevant drug (aspirin) in their drug history. The indication for CE in the 10 patients included iron deficiency anaemia (n=2), investigation of suspected active Crohn9s disease (n=7) and possible coeliac complications (n=1). The presence of salicylates was detected in 3.9% of patients (n=3) while NSAID metabolites were detected in 9.2% (n=7: 6 patients ibuprofen alone and both ibuprofen and diclofenac in 1 patient). While CE was normal in 2 patients, positive findings were seen in 80% of patients (n=8) which included the presence of erosions± red patches in 5 patients, small bowel ulceration in 2 patients and ulceration with early stricturing in one patient. Follow-up data revealed that the patient with small bowel stricturing was subsequently diagnosed as Crohn9s disease while a patient with small bowel ulceration underwent small bowel resection at a further presentation which confirmed NSAID enteropathy histologically. Conclusion 13.6% of patients undergoing capsule endoscopy were taking NSAIDs or aspirin, of which the majority were not declared in the clinical history. In 11.8% of patients, NSAIDs or aspirin could have been contributing to the symptoms or anaemia being investigated. Patients should be carefully questioned about their use of these drugs and over the counter medications which might contain them, prior to CE.

A Defense of Innovation: The Editor's Response to david [ sic ] McCraw's Review

A Defense of Innovation:The Editor's Response to david [sic] McCraw's Review Zong-qi Cai In How to Read Chinese Poetry: A Guided Anthology, my coauthors and I offer a new kind of comprehensive textbook for studying classical Chinese poetry. Our anthology differs from most of its predecessors in three important ways. It provides 1. a display of the Chinese text for each poem; 2. phoneticization of each poem in tone-marked pinyin; and 3. an interpretative commentary by a specialist in the relevant genre and period. Each of these innovative features has been harshly criticized by David McCraw in his review. For each point, I shall summarize his criticism and then offer a defense of our endeavors. Issues of Professional Ethics Before my defense, I must first deal with two issues of professional ethics: willful misrepresentation and the use of highly inappropriate language and tone in the review. Sloppiness is an issue addressed in great detail by my coauthors (see their responses above). A wide range of errors by the reviewer has been identified. He faults the authors for doing what they did not do and, conversely, not doing what they actually did. He cites ideas or arguments that have never been made by the identified scholars. He reverses an author's surname and middle name and refers to her by her middle name. He changes the spelling of the names of several renowned scholars in the field. The list goes on. Some of my coauthors who have [End Page 50] not made public their responses have also pointed out many errors of the same or other kinds in the review. It is ironic that the reviewer who shows little tolerance for others' errors and, in his own words, plays the game of "substituting reviewer as editor" (p. 28) has committed so many errors himself. Regrettably, the fact the reviewer cannot get (or does not bother to get) facts, quotes, and even names right undermines his trustworthiness as a critic. However, sloppiness is a minor fault compared to willful misrepresentation. Some of McCraw's errors are too egregious to be taken merely as evidence of sloppiness. In these cases, McCraw appears guilty of willful misrepresentation. Consider his criticism of my commentary on "The Zhongnan Mountain" by Wang Wei: Cai assures us that merge 合 refers to a Sanskrit word for "composite," while dispel/turn empty 無 refers to "negation of both sides" 無二. While as reader's association it remains just possible, this Buddhist over-reading wrongly limits students' understandings and inhibits precisely the evocative nature of Tang poetry and the full readers' co-participation Cai has previously recommended. Now he would have us respond: "Oh, they're just Buddhist technical terms," neither a likely nor a desirable effect (p. 30). One has to wonder what would motivate a reviewer to omit (and, in effect, deny the existence of) my detailed discussion of the poet's perceptual processes and illusions, painterly approach to poetry, his surreptitious use of Buddhist terms, and his ultimate evocation of a Buddhist vision of the world (Guided Anthology, pp. 177-179). Do those pages not do exactly what he is trying to fault me for not doing—demonstrating the "evocative nature of Tang poetry" and inviting the "readers' coparticipation?" With sleight of hand, he reduces my commentary to a gloss of two Buddhist terms in order to allege that the commentator "would have us respond: 'Oh, they're just Buddhist technical terms.'" On a larger scale, McCraw is willing to change/misrepresent the subject if it allows him to score on the authors of this anthology: "Throughout, Cai simply assumes, uncritically, that we have a corpus of 'orally performed' Han yuefu (e.g., p. 28); now he claims their hedonism finds a source in the views of 'Warring States' thinker Yang Zhu, as quoted in Liezi." McCraw has willfully changed the subject of chapter 5 from "nineteen old poems" (generally considered a corpus of literati compositions) to Han yuefu (a corpus with oral and folk origins). This manipulation allows him to ridicule the author for attempting to trace oral and folk compositions to the written text of an ancient philosopher. To bolster his accusation, McCraw...

Resistance and the underlife: Informal written literacies and their relationship to human information behavior

AbstractThis article presents findings from a research study (Trace, 2004) that looked at a particular aspect of human information behavior: children's information creation in a classroom setting. In the portion of the study described here, naturalism and ethnomethodology are used as theoretical frameworks to investigate informal documents as an information genre. Although previous studies have considered the role of informal documents within the classroom, little sustained attention has been paid to pre‐adolescents, particularly in terms of how they create unofficial or vernacular literacies both to navigate their growing awareness of the formal (albeit sometimes “hidden”) curriculum and, on occasion, to subvert it, positing an alternative economy that itself can be “hidden” via surreptitious use of informal documents. Making explicit the ties that exist between these objects and the worlds in which they are embedded demonstrates that informal documents hold a particular relevance for children within this social context (Garfinkel & Bittner, 1999). Furthermore, this article demonstrates that an ethnomethodologically informed viewpoint of information creation brings a level of dignity and determination to an individual's human information behavior, allowing us to appreciate the human ability to recontextualize or reenvisage sanctioned or official information genres to meet our own needs and purposes.

Salmonella Arizonae Bacteremia Associated with Septic Arthritis Following Consumption of Rattlesnake Capsules in a Patient with Idiopathic Thrombocytopenic Purpura (ITP) on Chronic Steroid Therapy.

Background: Folk medicine plays an important role in some populations in the United States. In particular, the use of rattle snake powder is becoming increasingly popular among the Mexican-American population along the US-Mexico border. Infections associated with the ingestion of this preparation have increasingly been reported in this country. We present a patient who presented with Salmonella Arizonae bacteremia and septic arthritis with underlying ITP on chronic treatment with steroids and surreptitious use of rattle snake powder.Case Report: A 53 year-old Mexican -American male with a past history of ITP on chronic oral prednisone with intact spleen was admitted with fever, chills, and an acute onset of pain, swelling and tenderness of his left knee. On admission to the hospital, his temperature was 101.5 F, blood pressure was 124/68, and pulse 102/min. The physical findings were significant for swelling and tenderness to the left knee with evidence of synovial effusion and restricted range of motion. The white blood cell count was 18,000cu/mm. Culture of the patient's left knee synovial fluid aspirate grew Salmonella Arizonae, as did his blood cultures. The pathogen was sensitive to 3rd generation cephalosporins and quinolones, and he was treated with intravenous ceftriaxone for 2 weeks with resolution of the bacteremia and improvement of the septic knee. He subsequently underwent a total knee arthroplasty, and follow up 1 year later revealed no evidence of persistent infection. After the pathogen identification, a careful alternative medicine history revealed the consumption of rattle snake powder preparation intended for treatment of his arthritis and ITP.Conclusion: Physicians should be aware of Salmonella Arizonae associated illnesses in both immunocompetent as well as immunosuppressed patients. Because the surge of interest in complementary and alternative medicine, a careful history should be elucidated, especially in immunocompromised patients who present with this syndrome.

HOW RELIABLE IS THE CLINICAL HISTORY OF NONSTEROIDAL ANTI-INFLAMMATORY DRUG USE IN PATIENTS WHO PRESENT WITH UPPER GASTROINTESTINAL HEMORRHAGE?

There is paucity of literature regarding the reliability of clinical history for assessing the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients presenting with upper gastrointestinal hemorrhage. Platelet function testing using the PFA-100 has been used to detect the effects of NSAIDs on platelets. We hypothesized that surreptitious use of NSAIDs occurs only in a small minority of such patients. Study Design Adult hospitalized patients undergoing endoscopy for evaluation of melena, hematemesis, or coffee-ground emesis were included in the study. Exclusion criteria included hematocrit less than 25% or platelet count less than 100,000/mm3 as these factors cause invalid measurements by the platelet function analyzer. Results Sixty-three patients met inclusion criteria. Sixteen patients were excluded due to anemia and thrombocytopenia as above. The average (SD) age of patients was 53.65 (15.55) years. Caucasians formed 40% of the study population, whereas the remaining were African Americans. Patients were predominantly males (64%). Twenty-one percent of the patients tested had positive PFA-100 measurements that suggested NSAID use. However, 60% of those with positive PFA-100 test had denied a history of prior NSAID use. Conclusions Clinical history is not a reliable indicator of prior NSAID use in patients presenting with upper gastrointestinal bleeding. Alternate testing to evaluate for surreptitious use of NSAIDs should be considered in patients with bleeding due to non-HP, non-NSAID ulcers.

Adolescent girls' communication with partners about microbicide use

Topical microbicides could be a female-controlled method of preventing sexually transmissible infections. Despite the possibility of surreptitious use, most women report that they would tell partners, and microbicides may be detectable. The purpose of the present study was to examine communication between adolescent girls and their partners regarding microbicides. Girls (aged 14-21 years) participated in a 6-month study in which they were given vaginal moisturisers to use when they had intercourse. Data was collected about their demographics, sexual histories and conversations with mothers and partners. Both quantitative and qualitative analyses were conducted. Girls (n = 171) were asked about conversations with their partners. Talking with mothers and using the product were significantly related to talking with partners. Reasons for not talking were intrapersonal or interpersonal variables, the context of the relationship did not warrant an explanation and the lack of a decision to communicate. There seemed to be no difference in conversations for those who used or did not use. Girls had conversations with their partners when deciding to be in the study, when they were engaged in study activities or when deciding to use the product. Conversations about using the product focused on needing to use the product because of study demands, the lubricating properties or wanting to experience product use. Most of the girls talked to their partners and had positive conversations. Girls may need help initiating conversations and managing reluctant partners.

Peptic ulcer disease today

Over the past few decades, since the introduction of histamine H(2)-receptor antagonists, proton-pump inhibitors, cyclo-oxygenase-2-selective anti-inflammatory drugs (coxibs), and eradication of Helicobacter pylori infection, the incidence of peptic ulcer disease and ulcer complications has decreased. There has, however, been an increase in ulcer bleeding, especially in elderly patients. At present, there are several management issues that need to be solved: how to manage H. pylori infection when eradication failure rates are high; how best to prevent ulcers developing and recurring in nonsteroidal anti-inflammatory drug (NSAID) and aspirin users; and how to treat non-NSAID, non-H. pylori-associated peptic ulcers. Looking for H. pylori infection, the overt or surreptitious use of NSAIDs and/or aspirin, and the possibility of an acid hypersecretory state are important diagnostic considerations that determine the therapeutic approach. Combined treatment with antisecretory therapy and antibiotics for 1-2 weeks is the first-line choice for H. pylori eradication therapy. For patients at risk of developing an ulcer or ulcer complications, it is important to choose carefully which anti-inflammatory drugs, nonselective NSAIDs or coxibs to use, based on a risk assessment of the patient, especially if the high-risk patient also requires aspirin. Testing for and eradicating H. pylori infection in patients is recommended before starting NSAID therapy, and for those currently taking NSAIDs, when there is a history of ulcers or ulcer complications. Understanding the pathophysiology and best treatment strategies for non-NSAID, non-H. pylori-associated peptic ulcers presents a challenge.

Long-term Outcome of Helicobacter pylori–Negative Idiopathic Bleeding Ulcers: A Prospective Cohort Study

Helicobacter pylori-negative idiopathic ulcers are increasingly recognized. The secular trend and long-term outcome of this condition are unknown. We prospectively studied consecutive patients with bleeding gastroduodenal ulcers from January to December 2000. The incidence and etiology of ulcers during this period were compared with that between September 1997 and August 1998. H. pylori-negative idiopathic ulcers were defined as negative tests for H. pylori, no exposure to analgesics within 4 weeks, and absence of other risk factors for ulcers. After the ulcers had healed, patients with H. pylori-negative idiopathic ulcers and patients with H. pylori ulcers who received eradication therapy were followed up for 12 months without anti-ulcer drugs. Six hundred thirty-eight patients had bleeding ulcers: 213 (33.4%) were H. pylori ulcers, and 120 (18.8%) were H. pylori-negative idiopathic ulcers (vs 480 [50.3%] H. pylori ulcers and 40 [4.2%] H. pylori-negative idiopathic ulcers in 1997-1998; P < .001). H. pylori-negative idiopathic ulcers accounted for 16.1% of patients who were admitted for bleeding and 42.4% of patients who bled while in the hospital (P < .0001); 28.3% of patients with H. pylori-negative idiopathic ulcers had histologic evidence of past H. pylori infection. The probability of recurrent ulcer complications in 12 months was 13.4% (95% CI: 7.3%-19.5%) in patients with H. pylori-negative idiopathic ulcers and 2.5% (95% CI: 0.4%-4.6%) in patients with H. pylori ulcers who received eradication therapy (P = .0002). The incidence of H. pylori-negative idiopathic bleeding ulcers is rising. These ulcers are prone to recurrent complications.

Genetic diversity and possible avenues of dissemination of porcine reproductive and respiratory syndrome virus in two geographic regions of Mexico

Objective: To determine the range of porcine reproductive and respiratory syndrome virus (PRRSV) genetic variation and possible avenues of dissemination in geographically separated swine herds in Mexico. Methods: Pooled serum samples (n=33) from suspected viremic sows and nursery and finisher pigs from 13 sites in the state of Sonora (northwest Mexico) and six sites in Puebla (south-central region) were subjected to PRRSV polymerase chain reaction amplification, purification, and sequencing. Results: Thirty-four PRRSV open reading frame 7 (ORF7) sequences were generated from a total of 31 isolates from 13 sites in Sonora and six in Puebla. The nucleotide similarity of ORF7 among isolates ranged from 86 to 100%. Phylogenetic analysis revealed no obvious geographic, temporal, or other characteristics that accounted for the observed distribution of isolates. Implications: DNA sequence analysis revealed unexpectedly high levels of genetic variation among and within swine-rearing regions in Mexico, suggesting independent PRRSV introductions. Re-isolation of a vaccinal strain of PRRSV suggests importation of vaccinated animals or semen or surreptitious use. The diversity and distribution of viral genotypes indicates that the mechanisms of geographic spread were complex, such that effective control may present a substantial epidemiological challenge.

Diagnosing Crohn's Disease (CD) with Capsule Endoscopy (CE): Careful Consideration Required

CD is a chronic inflammatory disorder that can affect the bowel at any point. Treatment entails immune suppression with agents that have potential for serious adverse effects. Traditionally the diagnosis is made in patients with a suggestive clinical scenario by radiologic imaging and/or performing endoscopic procedures to biopsy affected bowel to look for characteristic histologic features. CE has been shown to be more sensitive than contrasted small intestinal X-rays in small studies for detecting ulcers in CD. We reviewed all patients who had ulcers detected at CE done over an 11month period in order to define their characteristics and to evaluate the role of this device in the diagnosis of CD. Method: A database of the patients who underwent CE between 01/03 and 11/03 was reviewed. All patients who had ulcers in the small intestine were identified, and their basic characteristics, indication for CE, prior work up, and where available post-CE work-up and outcome evaluated. Results: Ulcers were seen in a total of 24 cases. 24 had had upper endoscopies, 22 colonoscopy, and 18 small bowel contrast X-Rays, all of which were normal. In 21 of these studies, many of the ulcers were aphthous lesions, and in 12, larger ulcers with discrete bases were noted. The commonest indication for the procedure was chronic abdominal pain (n=15), followed by chronic diarrhea (n=6), occult bleeding (n=4) and overt bleeding (n=4). 9 of these patients were on a daily aspirin or non-steroidal anti-inflammatory drugs (NSAIDs). Of the others, after careful consideration of the clinical features, the characteristics of their ulcers, and additional data such as inflammatory indices, serum ASCA and vitamin B12 levels, 4 were thought to have CD and treated conventionally. 3 of these patients appear to have responded well to date. In one of these cases, CE was repeated during an episode of melena, and large ulcers not noted in the earlier study were seen. Conclusion: When ulcers are detected at CE, admitted and surreptitious use of NSAIDs need to be considered. Large, linear or circumferentially arrayed ulcers may be more characteristic of CD. Endoscopy should be used to biopsy the accessible portions of the gastrointestinal tract. Surrogate laboratory and imaging data as well as clinical information also need to be taken into consideration before assigning patients the diagnosis of possible CD. Patients with ulcers who do not meet strict criteria should be followed closely, and repeating CE during more symptomatic periods may provide firmer evidence for CD.