From dyspepsia to Helicobacter: a history of peptic ulcer disease

Abstract This thesis is a historical study of peptic ulcer disease from the sixth decade of the eighteenth century until the end of the twentieth. Symptoms of dyspepsia or indigestion have affected more than twenty percent of the British population for most of that period and attracted the involvement of many medical practitioners and others with the provision of health care. Within this group of symptomatic dyspeptic patients were to be found gastric and duodenal ulcers which were capable of causing serious health problems. However the prevalence of stomach and duodenal peptic ulcers has declined markedly during the time course of this thesis and now they are relatively uncommon. Although peptic ulcers may still have a fatal outcome, they now are considered to be curable conditions for the majority of patients who suffer from them in the developed world. This thematic history of gastric and duodenal ulcer examines how medical practitioners worked in a changing climate of novel ideas about disease, often aided or driven by technological developments, from the nineteenth century onwards. It begins with a humoural approach to the understanding of disease, which concentrated upon a patient’s personality, lifestyle choices and circumstances but this was gradually displaced from the end of the eighteenth century by the clinico-anatomical approach, which sought to identify a specific lesion as the ‘seat’ of the disease. In the nineteenth century, the discoveries of pathology, physiology, chemistry and bacteriology became incorporated in clinical medical practice, involving the laboratory in the investigation and treatment of many diseases. In the twentieth century, medical research became rooted in experimentation using scientific technology and engineering to equip investigators with new methods which changed the ways in which diseases were understood and treated. Although there were many innovations in theoretical concepts of disease aetiology and empirical treatments, many were subsequently rejected for reasons of ineffectiveness or possible harm to the patient, sometimes after long periods of use. In its first part, the thesis draws upon publications from 1769 until 1950, mostly in the form of scientific articles and books. In the second part, the oral testimonies of health care professionals involved with the management and treatment of gastric and duodenal ulcers are added. The recorded testimonies of 28 witnesses have been preserved in written form as a supplement to this dissertation. Peptic ulcer disease was initially perceived as a whole-body ailment which was centred on the stomach as its symptomatic location and its treatment was intended to alter humoural imbalance or relieve symptoms. However after post-mortem examinations were increasingly performed from the seventeen-nineties, medical practitioners could see its complications in death and combine their findings with the clinical presentations of what was becoming recognised as a relatively common disorder. In the nineteenth century, physiologists investigated the workings of the stomach using vivisection and chemistry to analyse the stomach contents. The acid produced by the stomach was seen to play a part in ulcer genesis but there was no agreement as to what its precise contribution was for many years thereafter. Bacteriologists who found micro-organisms in the stomach assumed that they were pathogenically involved and subsequent experiments confirmed this. As a result of effective anaesthesia and antisepsis in the last decades of the nineteenth century, surgeons intervened increasingly in life-threatening complications of gastric and duodenal ulcers and their observations changed their perceptions of the diseases. In the twentieth century, opaque meal X-ray techniques began to allow doctors to see lesions inside the living stomach, as did improved endoscopes. In 1952, research suggested that stomach bacteria played no part in causing ulcers and further bacteriological research in the stomach was abandoned. By this time, surgeons had designed operations to reduce stomach acid production which healed most gastric and duodenal ulcers. Good therapeutic results were also achieved using medication and dietetic regimens, but it was recognised that only the surgeon could help patients who had failed to respond to medical treatments. In 1962 it was noted that deaths rates for gastric and duodenal ulcer were falling and fewer people were suffering from them, but they remained a serious cause of morbidity and mortality. A new acid-reducing operation was devised in 1969 that offered the hope that surgery could adequately treat ulcers without causing iatrogenic damage, and in 1976, a new drug was marketed which healed them if continuously taken. Then in 1983 it was asserted that peptic ulcers were caused by a bacterium which was later called Helicobacter pylori. In time and in the face of much opposition, it was shown that if this organism was eradicated in the stomach by medication then gastric ulcers and duodenal ulcers could be cured for the first time. This account of the history of peptic ulcer disease shows how medical practitioners adapted the theoretical basis of their medical practice as its evolved under the influence of scientific or societal changes and later abandoned concepts and therapeutic regimens which no longer were in accord with current thinking. Important issues which have arisen out of the testimonies include: medical involvement with the pharmaceutical industry, how doctors co-operate in the care of patients and how they respond to new theories and equipment and techniques as they became available. The history of peptic ulcer disease over the past two hundred years as described in this thesis follows a broadly similar course to that of other diseases such as tuberculosis, syphilis and chronic renal disease which once dominated the lives of those who suffered from them and have largely become curable in recent years. This thesis is offered as an account of an equally fascinating and complex disease

Development of an injection therapy module.

The title of my project is 'the Development of an Injection therapy Module'. I undertook this project because I had been charged to develop an injection therapy module for the Society of Orthopaedic Medicine (SOM) (see below), as part of a postgraduate pathway towards an MSc in Orthopaedic Medicine at Middlesex University (MU). The project has three clear parts that link to form the cohérent project as shown in the table below. This 'wrap around' reflective commentary forms the final component to demónstrate the cohésion both within the project itself and its place in my doctoral programme. Within this commentary the term 'project' is reserved for the whole project only

An investigation of the difficulties faced by practitioner researchers in publication

This work based study is not only a stand alone project but can also be read in conjunction with other work based studies carried out by members of the Society of Practising Veterinary Surgeons (SPVS) Doctorate Group. This group worked through the National Centre for Work Based Learning Partnerships (NCWBLP) based at Middlesex University. The customisation of the studies was carried out by the Professional Development Foundation (PDF). The purpose of the group was to facilitate the development of postgraduate veterinary education in general practice in order to maintain lifelong learning within the profession. Within this framework this study sets out to investigate the difficulties faced by practitioner researchers in publication. The aim of the study is to increase not only the number of manuscripts published by practitioners but also to increase the number of practitioners carrying out publication. To achieve these aims the author has evaluated the existing veterinary peer reviewed journal journals with a view to answering the question “does the veterinary profession in the UK need a new peer reviewed journal?” The author of the study has written a book to aid practitioners with publication. The sparse veterinary literature is reviewed together with the relevant medical literature. A historical analysis was carried out on the four most commonly read veterinary peer reviewed journals, the Veterinary Record (VR), the Equine Veterinary Journal (EVJ), Equine Veterinary Education (EV) and the Journal of Small Animal Practice (JSAP). Five separate case studies were carried out on successful practitioner authors, successful practitioner authors, editors of peer reviewed veterinary journals, newly qualified veterinary surgeons and final year veterinary students. The quantitative and qualitative results were recorded ethically and analysed. These results were then critically discussed and commented on. The methods of learning, experienced by the practitioner author were reflected upon. Conclusions were then reached. These showed that the main reason for lack of publication by practitioners was the relatively few manuscripts submitted by relatively few practitioners. There was no bias shown by editors against practitioner authors. Some improvements were suggested for the journals but it was concluded that at the present time there was no need for a new veterinary peer reviewed journal. However EVJ, EVE and JSAP have agreed to have a major drive to increase practitioner input. The benefits of the project to the profession were recorded. They included a regular updated list of successful practitioner authors willing to help less experienced colleagues, with publication, to be shown on the web page of the Royal College of Veterinary Surgeons (RCVS). The agreement of the RCVS scientific committee to encourage in-practice research by co-ordinating funding. The agreement of DEFRA to regularly fund a residential course on in-practice research for practitioners at Cambridge Veterinary School and to fund resulting pieces of practitioner research. The agreement of the editor of the VR to appoint a sub-editor to help with publication of these projects. The whole doctorate group project, of designing an award for advanced veterinary general practice, was accomplished. The modular certificate was accepted by the RCVS. This certificate was designed to have other modules added. The project by the author included the designing and acceptance of three additional modules to allow an award in equine dentistry. Lastly a secondary finding of the project, that newly qualified veterinary graduates were under considerable pressure in practice, was exposed. The author at a local level took action. The British Veterinary Association observed this. Consultations were carried out. A new graduate mentoring project was then successfully launched nationally. The author played a key role in this initiative both nationally and locally

German and Austrian refugee dentists : the response of the British authorities 1933-1945

The dental émigrés who chose to leave Germany and Austria between 1932 and 1939 were required to make that decision after being deprived of their livelihoods and their economic and social existences, and were ultimately in fear of their lives. The primitive statistics on dental disease in Britain recorded in the 1930s show that disease was rampant and the commonest form of treatment was full mouth extractions and full dentures. The theory of focal infection underlined the primitive treatment that was available. Out of the total 15,000 dentists on the Dentists Register, only 8000 had been trained at a dental school. An analysis of the teaching in both German and Austrian dental schools showed that it was at a far higher level than that available in Britain. There were three main barriers to refugee dentists entering Britain. Firstly the misuse of the 1878 Dental Act. The General Medical Council searched for any variation from the basic British requirement of four years’ study to reject candidates. Secondly, the Home Office operated a ban on practice from February 1936. Thirdly, prior to 1939, the dental refugees were only allowed a limited amount of time in Britain, from four weeks to ten months. A positive side to this sad period of history were the various refugee organisations, of whom the Jewish Refugee Committee was the most important, providing financial help for those refugee dentists who were unable to work after the February 1936 ban and who were living in poverty. In the 1930s Britain was offered the gift of over 1000 well-trained dentists from Germany and Austria. 300 were accepted and over 700 rejected. The British response was ungenerous, bearing in mind the appalling dental health and standard of dental teaching and research at this time. This thesis has been able to turn the spotlight onto this specialist group of refugees forgotten by history

What are the informational needs of patients with ANCA Associated Vasculitis? a Mixed Methods Study

Background: The ANCA –associated vasculitides (AAVs) are a group of rare, potentially life-threatening conditions which if untreated can be fatal. Little is known about the information needs of people with AAV. Objectives: To explore what it is like to be diagnosed with AAV and to find out the informational needs of this group. Study design: A mixed methods approach using focus groups and one-to-one interviews, then a questionnaire surveying the membership of Vasculitis UK (VUK) and the Vasculitis Clinical Research Consortium (VCRC). Results: Emergent themes from the first phase were: reaction to diagnosis, need for information on disease management and access to knowledgeable practitioners. There were 314 VUK, 273 VCRC respondents. Respondents rated information on diagnosis, prognosis, investigations, treatment, and side effects as extremely important. Information on patient support groups and psychosocial care was less important. There was no difference in the ratings of information needs based on group, sex, age, disease duration, disease, or method of questionnaire delivery. Conclusion: Receiving the diagnosis of a rare, potentially life-threatening disease causes anxiety and fear and can impede information retention and recall. People with AAV seek specific information concerning their disease, treatment regimes and side effects, and the results of investigations. Individuals preferred to receive this information from a doctor. Recommendations: Patients with AAV should be treated in a similar manner to patients with other chronic illnesses in which patient education is a fundamental part of care

Perceptions of general health and root canal treatment in New Zealand general dental practice

There are common risk factors between general health and oral health. General dental practitioners (GDPs) are seeing increasing numbers of patients presenting with multiple complex medical conditions. In parallel to managing more medically compromised patients, GDPs must provide holistic and technically challenging root canal treatment (RCT) for teeth that are heavily restored. There is little evidence surrounding the health status and preferences of patients undergoing RCT, and the confidence of GDPs in managing them. This mixed method research engaged both dentists and their patients in a translational approach within a practice-based research network (PBRN). The goals of this study were to examine the self-perceived confidence and competence of New Zealand (NZ) GDPs managing patients for RCT presenting with a range of medical conditions; and their engagement in continuing professional development (CPD) related to endodontics. It also considered the dental experiences and self-perceived general health status of patients requiring RCT. This study had three parts: A Pilot study, a PBRN survey of GDPs and patients, and Focus Group interviews of GDPs. Quantitative data from the surveys were entered directly into IBM SPSS Statistics Software, and following descriptive analysis, bivariate analysis was used to quantify differences in proportions using Pearson’s Chi square test. Qualitative data was analysed thematically. Focus Group interviews were transcribed verbatim and transferred to NVivo 12 for detailed analysis. The Pilot study validated the reliability of the survey for use in a larger group. The PBRN survey was implemented in a range of general practices throughout NZ and provided self-reported demographic and health data from patients, as well as perceptions of their oral health and wellbeing. A positive patient experience of RCT was mostly influenced by clear, empathetic communication, and a professional approach by the practitioner. GDP confidence in providing RCT was strongly related to procedural and patient-related factors rather than specific medical conditions such as those readily controlled with medications including cardiovascular diseases, and diabetes mellitus. The development of CPD related to medical conditions and pharmacology in dentistry was perceived as important. With the help of both dentists and patients, this study has provided new knowledge, and improves our understanding of patients’ medical status when they present for RCT and how equipped our workforce is to manage endodontic patients. Together this information can inform development of CPD activities and assist NZ GDPs managing patients requiring RCT

Red flag screening for serious pathology presenting in cervical spine musculoskeletal disorders

Aim To develop a list of red flag clinical indicators for possible serious pathology masquerading as, or presenting alongside, neck related musculoskeletal disorders in the adult population. Background Musculoskeletal physiotherapists provide assessment and treatment for pain and functional impairments relating to musculoskeletal disorders, such as back and neck pain. In order to apply safe and effective treatment to these conditions it is vitally important that any underlying serious complaints have been excluded. Clinical indicators known as 'red flags' have been developed for diagnostic triage in back pain to help identify serious underlying conditions, such as cancer and infection. Red flags for serious pathology in neck pain or neck related pathology has not received the same level of attention as red flags in back pain. A literature review identified inconsistent evidence for clinical tests and clinical indicators for serious pathology in neck related musculoskeletal disorders. This presents a serious clinical challenge for musculoskeletal physiotherapists. Method A mixed method study design was developed involving: a) Qualitative descriptive method through Physiotherapy focus group; and, b) Three round Delphi survey method involving consultant neurologists and consultant neurosurgeons. The Delphi method involves combined qualitative and quantitative data phases. Thematic content analysis was used to analyse the qualitative data. A combined descriptive and inferential (non-parametric) statistical analysis was used to analyse the quantitative data. Kendall's W (Kendall's coefficient of concordance) was used to evaluate the level of consensus across all participants for the quantitative phase of the Delphi method. Findings A list of neck related red flag clinical indicators within five specific categories were developed: 1. progressive pain; 2. cancer, infection, trauma; 3. neurological deficit (spinal cord compromise); 4. headache (associated with neck pain/stiffness); 5. brainstem, cervical arterial and cranial nerve dysfunctions. An increase in Kendall's W was demonstrated between Rounds 2 and 3 in four out of five categories, indicating an increase in consensus levels between participants. This process highlights the complexity of interpreting clinical features within musculoskeletal presentations.awd_pdtunpub1810_ethesesunpu