Library

Notes: Background : Triple therapy with proton pump inhibitor, clarithromycin and amoxicillin and, in the event of eradication failure, quadruple therapy with proton pump inhibitor, bismuth, tetracycline and metronidazole have been proposed in Maastricht as the optimal sequential treatment of Helicobacter pylori infection.Aim : To compare two second-line regimens with quadruple therapy.Methods : One hundred and eighty patients with a previous failed course of standard therapy were randomly given one of the following 7-day treatments: ranitidine bismuth citrate 400 mg b.d. plus amoxicillin 1 g b.d. and tinidazole 500 mg b.d. (RBCAT), pantoprazole 40 mg b.d. plus amoxicillin 1 g b.d. and levofloxacin 500 mg/day (PAL) and pantoprazole 40 mg b.d., bismuth citrate 240 mg b.d., tetracycline 500 mg q.d.s. and metronidazole 500 mg b.d. (PBTM). The eradication rate was assessed by 13C-urea breath test. Side-effects and compliance were evaluated by a standardized questionnaire and by counting returned medication.Results : The RBCAT, PAL and PBTM groups achieved mean intention-to-treat eradication rates of 85%, 63% and 83%, respectively (P 〈 0.05 for PAL vs. either RBCAT or PBTM). Compliance was optimal in all patients, although side-effects were more commonly observed in the PBTM group than in the other two patient groups (P 〈 0.0001).Conclusions : Both RBCAT and PBTM can be used as second-line therapies. Conversely, PAL did not achieve satisfactory eradication rates.

Notes: Triple therapy with proton pump inhibitor, clarythromycin, and amoxicillin has been proposed in Maastricht as the first-line treatment of H. pylori infection.〈section xml:id="abs1-2"〉〈title type="main"〉Aim:To determine whether ranitidine bismuth citrate (RBC) based regimens may be used as second-line treatments after ‘Maastricht therapy’ failure.〈section xml:id="abs1-3"〉〈title type="main"〉Methods:A total of 285 patients with H. pylori infection were given a 7-day treatment with pantoprazole 40 mg b.d., clarythromycin 500 mg b.d., and amoxicillin 1 g b.d. Patients who were still infected were randomly given one of the following 14-day treatments: RBC 400 mg b.d. plus amoxicillin 1 g b.d. and tinidazole 500 mg b.d. (RAT group), RBC 400 mg b.d. plus amoxicillin 1 g b.d. and clarythromycin 500 mg b.d. (RAC group), and RBC 400 mg b.d. plus clarythromycin 500 mg b.d. and tinidazole 500 mg b.d. (RCT group).〈section xml:id="abs1-4"〉〈title type="main"〉Results:The ‘Maastricht therapy’ achieved an eradication rate of 59% (95% CI: 54–65) on intention-to-treat analysis. The RAT, RAC, and RCT regimens achieved eradication rates of 81% (95% CI: 67–94), 43% (95% CI: 26–60), and 62% (95% CI: 44–80), respectively, on intention-to-treat analysis. Patient compliance was optimal in RAT and RAC groups.〈section xml:id="abs1-5"〉〈title type="main"〉Conclusion:RBC plus tinidazole and either amoxicillin or clarythromycin can be used as second-line therapies after failure of the Maastricht triple therapy.

Notes: Triple therapy with proton pump inhibitor, clarithromycin and amoxicillin has recently been proposed in Maastricht as first-line treatment for H. pylori infection.〈section xml:id="abs1-2"〉〈title type="main"〉Aim:To determine predictors of unsuccessful eradication.〈section xml:id="abs1-3"〉〈title type="main"〉Methods:Two hundred and forty-eight patients underwent endoscopy with biopsies for rapid urease test, histology and culture with antibiotic susceptibility tests, and 13C-UBT. All infected patients were given pantoprazole (40 mg b.d.), clarithromycin (500 mg b.d.) and amoxicillin (1 g b.d.) for 1 week. Eradication was assessed by UBT at 4–6 weeks after therapy.〈section xml:id="abs1-4"〉〈title type="main"〉Results:One hundred and sixty-two of 248 patients (65%) were infected. Culture was positive in 144 (89%). Prevalence rates of metronidazole, clarithromycin and amoxicillin resistance were 14, 8 and 3%, respectively. Eradication rates (95% CI) were 63% (54.7–70.6) by intention-to-treat analysis and 67% (59.4–75.4) by per protocol analysis. Drug compliance was excellent and side-effects were mild. Age ≥ 45 years (OR: 2.35, CI: 1.30–4.25), smoking (OR: 1.37, CI 1.01–1.87) and high pre-treatment UBT results (OR: 1.36, CI: 1.08–1.72) were independent predictors of eradication failure. Gender, endoscopic findings, alcohol intake, and clarithromycin and amoxicillin resistance did not predict treatment failure.〈section xml:id="abs1-5"〉〈title type="main"〉Conclusion:Despite the low prevalence of primary antibiotic resistance in our geographical area, triple therapy with pantoprazole, amoxicillin and clarithromycin achieves low eradication rates. Smoking, age and pre-treatment UBT results are predictors of potential eradication failure.

Notes: Background : The urea breath test is routinely used for diagnosing or confirming the eradication of Helicobacter pylori.Aim : To evaluate the appropriateness of urea breath test referrals.Methods : The age, sex, symptoms, endoscopic findings, use of non-steroidal anti-inflammatory drugs, family history of gastric cancer or H. pylori infection and concomitant diseases of patients referred for urea breath testing in a 1-year period were recorded. The appropriateness of urea breath test referrals was judged according to Maastricht guidelines.Results : One thousand, three hundred and twenty subjects (47 ± 16 years) were referred in 2001: 578 (43.8%) for the diagnosis and 742 (56.2%) for confirmation of the eradication of H. pylori. The urea breath test was considered to be appropriate in 836 (63.3%) patients, inappropriate in 192 (14.5%) and appropriate but avoidable in 292 (22.1%). The appropriateness ratios of urea breath test referrals were 4.6 and 9.0 (P 〈 0.0001) for general practitioners and gastroenterologists, respectively. Of the patients (n=230) with uninvestigated dyspepsia, who underwent urea breath testing according to a ‘test and treat’ strategy, 98 (42.6%) presented at least one risk factor for organic disease.Conclusions : In Italy, nearly 36% of urea breath test referrals are inappropriate or could be avoided if all dyspeptic patients with risk factors were referred for endoscopy or all dyspeptic patients undergoing endoscopy were tested for H. pylori infection with biopsy methods. Both general practitioners and, to a lesser extent, gastroenterologists require educational programmes to deal effectively with H. pylori.

Notes: Erythromycin, a macrolide antibiotic, has been shown to have gastric prokinetic effects and has been proposed as an alternative therapeutic option for diabetic gastroparesis. However, its efficacy has not yet been compared with that of other prokinetic drugs.〈section xml:id="abs1-2"〉〈title type="main"〉Aims:The purpose of the present study was to compare the effects of erythromycin (250 mg 60 min before meals) and cisapride (10 mg 30 min before meals) on gastric emptying of healthy subjects and insulin-dependent diabetics.〈section xml:id="abs1-3"〉〈title type="main"〉Patients and methods:Six type 1 diabetic patients with a previous scintigraphic demonstration of gastroparesis and five healthy subjects were recruited for the study. Gastric emptying was scintigraphically studied by labelling the solid component of a standard test meal. Three scintigraphic studies, spaced at least 3 days apart, were carried out on each subject, basally and after erythromycin or cisapride.〈section xml:id="abs1-4"〉〈title type="main"〉Results:Cisapride significantly accelerated gastric emptying in both the healthy subjects and the diabetic patients without any significant effect on the lag-time, whereas erythromycin in addition to a significant improvement of the overall gastric emptying also showed a pronounced effect on the lag-time in both groups (controls 25 ± 5 vs. 37 ± 8 min, P≤0.04; diabetics 65 ± 11 vs. 112 ± 16 min, P〈0.03).〈section xml:id="abs1-5"〉〈title type="main"〉Conclusions:Erythromycin may represent an effective therapeutic alternative to more established forms of treatment in patients with diabetic gastroparesis, especially when other drugs have failed.

Notes: Aim : To evaluate the efficacy of a long-term course of lamivudine monotherapy in patients with anti-HBe-positive chronic hepatitis B who relapsed after the first course of either lamivudine/interferon (n = 16; Group 1) or lamivudine (n = 20; Group 2).Methods : Biochemical and virological tests were performed every 3 months. At baseline and breakthrough, the region coding for the YMDD amino acid motif was sequenced.Results : The length of re-treatment averaged 24 months. The virological response peaked at 6 months (94.4%), and declined to 66.7% and 50% at 12 and 24 months, respectively. The rates of breakthrough were 2.9%, 31.4% and 48.6% at 6, 12 and 24 months, respectively. By the second year, responders amounted to 62.5% and 40% in Groups 1 and 2, respectively (P = 0.10). The 18 responders at month 24 are still on therapy after 25–51 months of treatment: 14 still maintain a response, nine from Group 1 and five from Group 2.Conclusions : Re-treatment with lamivudine can control viral replication. This effect is maintained for the initial 12 months in two-thirds of patients, but afterwards the duration of response lessens due to the development of viral resistance.

Notes: Pharmacological prophylaxis of post-ERCP pancreatitis is costly and not useful in most non-selected patients, in whom the incidence of pancreatitis is 5% or less. However, it could be useful and probably cost-effective, in patients at high risk for this complication, where the post-procedure pancreatitis rate is 10% and more.〈section xml:id="abs1-2"〉〈title type="main"〉Aim:To assess the efficacy of octreotide in reducing the incidence and severity of post-ERCP pancreatitis and procedure-related hospital stay, in subjects with known patient-related risk factors.〈section xml:id="abs1-3"〉〈title type="main"〉Methods:A total of 120 patients were randomly allocated to receive octreotide or not, in a multicentre, randomized, controlled trial. The drug was given subcutaneously, 200 μg t.d.s., starting 24 h before the ERCP procedure, in patients with either sphincter of Oddi dysfunction, or a history of relapsing pancreatitis or post-ERCP pancreatitis, or who were aged under 35 years, or who had a small common bile duct diameter (〈 8 mm).〈section xml:id="abs1-4"〉〈title type="main"〉Results:A total of 114 patients (58 in the octreotide group and 56 in the control group) completed the trial. Post-procedure pancreatitis occurred in seven octreotide-treated patients (12.0%) and eight controls (14.3%). The two groups showed no significant differences in the incidence or severity of pancreatitis. Twenty-four hours after the procedure, severe hyperamylasemia (more than five times the upper normal limit) without pancreatic-like pain was recorded in three octreotide-treated patients (5.2%) and six controls (10.7%), the difference being not significant.〈section xml:id="abs1-5"〉〈title type="main"〉Conclusion:Twenty-four-hour prophylaxis with octreotide proved ineffective in preventing post-ERCP pancreatitis and in avoiding 24-h severe hyperamylasemia in high-risk patients.

Notes: Background : Prior studies suggest that platelet counts of 〈140 000/μL can discriminate patients with different stages of fibrosis.Aim : To determine the added value of abdominal ultrasound analysis of morphological liver features in increasing the diagnostic accuracy of platelet counts for the prediction of liver fibrosis at histology.Methods : In a retrospective study, clinical records of 1143 chronic hepatitis C patients at their first presentation, naives to both liver biopsy and anti-viral treatment, were reviewed. Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios of following indices were evaluated singularly or in combination: platelet counts 〈140 000/μL; nodular liver surface, spleen and portal vein size.Results : All indices had specificity rate of ≥90% in excluding bridging fibrosis/cirrhosis, whereas sensitivity was acceptable (51%) for only platelet counts 〈140 000/μL. None of the ultrasonographic parameters singularly evaluated and reached an acceptable sensitivity rate. For ruling cirrhosis in or out, specificity rate was ≥82% for all tests, with the highest value reported by portal vein size. Low platelet counts plus nodular liver surface had the best sensitivity.Conclusions : No additional significant predictive value was given by adding ultrasonographic parameters to low platelet counts, whereas only a mild non-significant improvement in sensitivity was obtained combining platelet counts 〈140 000/μL with the presence of nodular liver surface. The platelet counts 〈140 000/μL showed the best predictive value for including both significant fibrosis and cirrhosis.

Notes: Background : Host genetic factors may be important in determining not only disease susceptibility, but also disease behaviour and response to therapy in inflammatory bowel disease. Two polymorphisms (C3435T and G2677T/A) of the multidrug resistance 1 gene have been correlated with the altered P-glycoprotein expression and function in humans, and associated with predisposition to ulcerative colitis and Crohn's disease.Aim : To investigate the contribution of these polymorphisms to disease susceptibility and response to medical therapy.Methods : A total of 946 inflammatory bowel disease patients (478 Crohn's disease, 272 males, mean age 43 ± 14 years and 468 ulcerative colitis, 290 males, mean age 48 ± 15 years) and 450 healthy controls were genotyped for the single nucleotide polymorphisms C3435T and G2677T/A. Patients were also classified on the basis of response to medical therapy (mesalazine, steroids, immunosuppressives and infliximab).Results : Both single nucleotide polymorphisms were in Hardy–Weinberg equilibrium and significant linkage disequilibrium. No significant difference in the allele, genotype, and haplotype frequencies was found in both Crohn's disease and ulcerative colitis patients compared with the controls. No correlation with clinical features was found, except for a reduced frequency of extra-intestinal manifestations in Crohn's disease patients with the G2677T genotype (40%) compared with GG2677 and 2677TT genotypes (54% and 58%, respectively) (P = 〈0.02). No significant difference was also found after stratifying the patients on the basis of their response to medical therapy.Conclusion : The investigated polymorphisms of the multidrug resistance 1 gene have no significant role in disease susceptibility and response to medical therapy in our Italian population of inflammatory bowel disease patients.

Notes: Background : Anti-Saccharomyces cerevisiae mannan antibodies have been proposed as a new serological marker associated with Crohn's disease. However, their clinical value is still unclear; furthermore, a standardization of anti-S. cerevisiae mannan measurements is lacking.Aim : In this study, we aimed to assess the correlation between anti-S. cerevisiae mannan detection and specific clinical features in Crohn's disease and ulcerative colitis. Moreover, we tested the concordance of four different anti-S. cerevisiae mannan assays.Materials and methods : Serum samples from 196 patients with Crohn's disease, 197 patients with ulcerative colitis and 100 unrelated healthy controls were tested for anti-S. cerevisiae mannan with a standard enzyme-linked immunosorbent assay method (Lille) by one of the authors (VP). Subsequently, 60 randomly selected serum samples (27 Crohn's disease, 28 ulcerative colitis and five healthy controls) were tested for anti-S. cerevisiae mannan with three different commercial kits.Results : With the Lille assay, anti-S. cerevisiae mannan were detected in 100 of 196 patients with Crohn's disease (51%; P 〈 0.0001 vs. controls), 32 of 197 patients with ulcerative colitis (16%; P 〈 0.02 vs. controls), and six of 100 controls (6%). No correlation between presence of anti-S. cerevisiae mannan and specific clinical features was found in both ulcerative colitis and Crohn's disease patients. The percentages of anti-S. cerevisiae mannan detected with four different assays ranged from 28 (Bouty) up to 43% (Inova), but these differences did not reach statistical significance. The concordance rate of anti-S. cerevisiae mannan detection in the four assays was very low (11 concordant results of 60 samples, 18.3%) (k = 0.15). No improvement of the concordance rate wasobtained by modifying the suggested cut-off values (k = 0.20).Conclusion : In this study, we confirm that anti-S. cerevisiae mannan are significantly more frequent in Crohn's disease patients compared with ulcerative colitis patients (P 〈 0.0001) and controls. However, no correlation with clinical features was found in both ulcerative colitis and Crohn's disease. The low prevalence of anti-S. cerevisiae mannan, at least in our population, and the low concordance rate between different assays, makes the clinical role of this marker questionable.