1. JOURNAL REVIEW Questionnaire study and audit of use of ACEI and monitoring in general practice BMJ 1999;318:234-237

2. Objectives To determine the current pattern of use of angiotensin converting enzyme inhibitor and monitoring of renal function in general practice To audit all admissions to a regional renal unit for uraemia related to use of these drugs

3. Design Postal questionnaire sent to 400 general practitioners Audit of clinical notes of all patients receiving these drugs in one large general practice Audit all notes of uraemia (Cr > 500umol/L) related to treatment presenting to hispital renal services over 12 months

4. Setting General practices in North Wales health authority and one in central Manchester Regional renal unit in Salford

5. Outcome Measures Proportion of general practitioners who regularly monitored renal function before and after initiation of ACEI Indications for treatment and details of monitoring of renal function in patients receiving these drugs Incidence of related uraemia and evidence of co-morbid disease, other etiological factors, delayed detection, and patient outcome

6. Results 277 (69%) GP’s replied, 235 (85%) checked renal function before But only 93 (34%) after the start of treatment 42 (15%) never checked

7. Results 2 162 out of total 3625 patients aged >35 were prescribed ACEI 45% checked renal function before the start 29% checked after starting treatment

8. Results 3 From the renal units: - 9 (7%) of 135 patients admitted to renal units for uraemia could be causally related to the use of ACEI - 3 had renovascular disease - 6 had congestive heart failure with another intercurrent illness - mean length of admission was 20.9 days - 1 died

9. Conclusion Cases of uraemia related to treatment with angiotensin converting enzyme inhibitor are still encountered These are often detected late because of lack of judicious monitoring of renal function in vulnerable, often elderly patients, especially at times of intercurrent illness Adoption of simple guidelines for monitoring of renal function would reduce this cause of morbidity and may reduce cost in long run

10. ORCHID STUDY Optimal Regimen Cures Helicobactor Induced Dyspepsia Study Group BMJ 1999;318:833-837

11. Introduction Most patients with dyspepsia do not have any peptic ulceration or other disease, they are classified as having Functional Dyspepsia About 50% of these patients have co-existent H.Pylori gastritis, but it was unclear whether H.Pylori causes symptoms in the absence of peptic ulceration. If so, eradication of H.Pylori should abate the symptoms.

12. Subjects Multicentre trial involving 40 centres from Australia, New Zealand, and nine from European countries. 244 patients were from secondary care, 31 from primary care Adult patients with dyspepsia (definition: pain or discomfort in upper abdomen) for 3 months with normal OGD findings, and a positive H.Pylori results. Excluded: ulcers, erosion, reflux, tumour, been on H2RA, prokinetics, PG in past 1 week.

13. Method Fill in symptom score card before, only patients with at least 3 days of at least moderate symptoms were included All patients underwent Urea Breath Tests to confirm status They were then randomised to either Triple therapy (Losec 20mg/Amoxil 1gm/Klacid 500mg bid) or Placebo tablet for 1 week Patients were considered compliant only if >12 doses taken

14. Follow up Diary cards (symptoms score and quality of life) were collected at 1, 3, 6, 9, 12 months after cessation of therapy No. of weak antacids consumption were recorded Urea breath test and OGD were performed at 3 &12 month

15. Outcome measures Diary cards – severity of dyspeptic symptoms (validated Likert scale with 7 grades: none, minimal, mild …, very severe) Endoscopic evaluation with biopsies and histological gradings GI symptom rating score – to further divide patients with positive dyspepsia into Ulcer-like or Dysmotility-like Successfully cured was defined as no more than minimal symptoms Chronic gastritis was considered healed when both biopsies specimen were free from inflammation.

16. Results 135 patients – to treatment arm, 143 patients -- to placebo Only 3 patients from all groups withdrawn because of unavailability of data The 2 groups were balanced with similar geographical and clinical features At 12 months, 85% in the treatment arm had been successfully cured of H.Pylori, whereas only 4% in placebo arm

17. Results 2 At 12 month, 81% of treatment arm had no or mild only gastritis, compared with 13% in placebo arm However, 24% only in the treatment arm were successfully treated, compared with 22% in the placebo arm at 12 month No significant difference in treatment success among those who were negative for H.Pylori (29%) and positives for H.Pylori (21%) at 12 month.

18. Results summary A similar proportion of patients in each treatment arm had no or minimal dyspepsia symptoms at each follow up. The mean symptom score were not significantly different at each time point. Mean antacid consumption over 12 months did not differ significantly b/w treatment (0.53) and placebo (0.65) groups.

19. Discussion Few large trials have vigorously evaluated the role of H.Pylori eradication in functional dyspepsia, and the results are conflicting. In this study, there was no convincing evidence that successful eradication of H.Pylori infection relieves or reduces symptoms in patients with functional dyspepsia over 12 months

20. Management implication A popular strategy in otherwise healthy young patients with uninvestigated dyspepsia is to test (non-invasively) for H. Pylori and treat all infected cases. In this study, it shows that such strategy may only help a minority of these patients to gain long-term symptomatic relief.