toxin became infected after


large dose of live gastric

helicobacters. This result indicates that intervention

against H pylori is a real

possibility. Much needs to be done to define further the best protocol and to identify less potentially toxic adjuvants, such as cholera toxoid rather than toxin.7 Formulation of equivalent safe vaccines of H pylori would make possible the immunisation of children in countries such as China and Columbia and so prevent the establishment of long-term inflammation, and its possible consequences.


School of Microbiology and Immunology, University of New South Wales, Kensington, NSW 2033, Australia

1. Forman D, Newell DG, Fullerton F, et al. Association between infection with Helicobacter pylori and risk of gastric cancer: evidence from a prospective investigation. Br Med J 1991; 302: 1302-05. 2. Sharma AW, Mayrhofer G. A comparative study of infections with rodent isolates of Giardia duodenalis in inbred strains of rats and mice. Parasite Immunol 1988; 10: 169-79. 3. Czinn SJ, Nedrud JG. Oral immunization against Helicobacter pylori. Infect Immun 1991; 59: 2359-63. 4. Lee A, Hazell SL, O’Rourke J, Kouprach S. Isolation of a spiral-shaped bacterium from the cat stomach. Infect Immun 1988; 56: 2843-50. 5. Lee A, Fox JG, Otto G, Murphy J. A small animal model of human Helicobacter pylori active chronic gastritis. Gastroenterology 1990; 99: 1315-23. 6. Dick-Hegedus E, Lee A. Use of mouse model to examine anti-Helicobacter pylori 1991; 26: 909-15. agents. Scand Gastroenterol J 7 Liang X, Lamm ME, Nedrud JG. Cholera toxin as a mucosal adjuvant: glutaraldehyde treatment dissociates adjuvanticity from toxicity. J Immunol 1989; 143: 484-90.

respiratory quality-of-life questionnaires that are applicable to patients with COPD.2.3 Although the frequency of this urgency has not been investigated formally we have been finding a frequency of about 50% in outpatients. We decided to try and find out what burden this excretion urgency places on patients. A symptom may be medically interesting but of little consequence to quality of life if it is not distressing. 55 COPD outpatients were sent a questionnaire asking the degree of "bother" caused by five problems commonly found in COPD patients. The paired comparison method (in which problems are shown in pairs and the patient is asked which causes the most bother) was used. Of the 25 patients who returned completed questionnaires, all reported "being unable to do things because you get too breathless" and 14 reported "Having to go to the toilet when you get breathless". Of those who experienced excretion urgency, 6 rated it as causing more bother than being unable to do things and 8 rated being unable to do things as more bother than excretion urgency. These findings show that when COPD patients experience excretion urgency, this can sometimes have a substantial effect on quality of life. 1 patient told us that urgency was reduced after a change in therapy led to less breathessness. One possibility was that the excretion urgency was iatrogenic, associated with theophylline; however, we found no association between this drug and excretion urgency. Department of Psychology, Polytechnic South West, Plymouth PL4 8AA, UK


Department of Thoracic Medicine,

Helicobacter pylori infection with age SIR,-Dr Mendall and colleagues (April 11, p 896) give an important insight into the epidemiology of Helicobacter pylori infection as determined by serology. However, they repeat the received wisdom that Hpylori infection increases progressively with age. This is not necessarily true if direct tests are done, since serology may merely represent past infection. We studied 462 patients, not on antibiotics or ulcer-healing therapy, who had normal upper digestive endoscopy. A gastric antral forceps biopsy was taken for urea gel/indicator testing (CLO-test). There was no sex difference. Though a progressive rise in infection age:

rates was

noted up



Age (yr)

70, there was a fall after that Proportion positive 4/17 (24%) 20/63 (32 % ) 25/67 (37%) 28/78 (36 % ) 24/50 (48%J

14-19 20-29 30-39 40-49 50-59 60-69 70-79 80-92 All

43/67(64%) 30/84 ( 36 %J 11/36 (31 %J

185/462 (40%) Various explanations might account for this finding, but it does suggest that older people return to the lower infection rates seen under age 30. Certainly the relation between H pylori infection and age is not simply a progressive one. Bishop Auckland General Hospital, Bishop Auckland DL14 6AD, UK


Excretion urgency in chronic obstructive pulmonary disease


research into the

quality of life of patients with

chronic obstructive pulmonary disease (COPD), we held four focus groups where patients talked to each other about how their

respiratory disorder affected their lives. It emerged that some patients experience excretion urgency associated with the sensation of increased breathlessness. Some repeatedly feel the urge to urinate or to defaecate, or both. The feeling of urgency does not appear to be related to the amount of excretion which subsequently takes place. Such difficulties are not reported in previous accounts of quality of life deficit in COPD patients,l nor does this topic feature in general

King’s College School and Dentistry,

of Medicine


London SE5

McSweeny AJ, Labuhn KT. Chronic obstructive pulmonary disease. In: Spilker B, ed. Quality of life assessments in clinical trials. New York: Raven, 1990: 391-417. 2. Guyatt GH, Berman LB, Townsend M, Pugsley SO, Chambers LW. A measure of quality of life for clinical trials in chronic lung disease. Thorax 1987; 42: 773-78. 3. Jones PW, Quirk FH, Basveystock CM, Littlejohns P. A self-complete measure for chronic airflow limitation—the St George’s respiratory questionnaire. Am Rev Respir Dis (in press). 1.

Intramuscular medroxyprogesterone acetate for sexual aggression in elderly men SIR,-Sexual aggression in male dementia patients responds poorly to behavioural management or to psychotropic drugs. Anti-androgens have few side-effects (rise in blood pressure, mild pedal oedema) and they reduce sexual drive and sexually aggressive acts in cognitively intact and brain-damaged hypersexual men of all ages.l-4 Treatment thus far reported in old men has been with daily or weekly dosing. In the two cases described here, inappropriate sexual aggression was eliminated with small doses of intramuscular medroxyprogesterone acetate (MPA) every two weeks. A 72-year-old man’s hypersexuality began with molestation of his 12-year-old stepdaughter 25 years earlier. For many years, he had frequent contact with prostitutes, and in the most recent 2 years had begun fondling women of all ages, had exposed himself to children, and openly masturbated anally. He had been discharged from military service at age 25 with 10% psychiatric disability and had been admitted to hospital and treated with electroconvulsive therapy two or three times because of violence, auditory hallucinations, and grandiose delusions. He became unable to work vehicle accident which resulted in loss of a ruptured spleen. His aberrant sexual behaviour increased after his head injury. Insidious onset of cognitive impairment began at age 70. Evaluation at age 71 established organic mental disorder. A computed tomographic brain scan revealed only mild cerebral atrophy. A small dose of thioridazine produced severe extrapyramidal effects. MPA 100 mg every 2 weeks was started on Oct 15, 1991. On Oct 28, his testosterone level had dropped from 2-9 ng/ml to 1 ’7 ng/ml and his sexual behaviour had improved in that he no longer made inappropriate sexual comments to staff and patients. However, the patient continued inappropriate behaviours such as inserting objects (shampoo bottles, soap) into his rectum. The MPA dose was at


62, after

a motor

consciousness, multiple fractures, and

Helicobacter pylori infection with age.

1121 plus toxin became infected after a large dose of live gastric helicobacters. This result indicates that intervention against H pylori is a...
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