Predicting the onset of major depression in primary care: international validation of a risk prediction algorithm from Spain.

BACKGROUND: The different incidence rates of, and risk factors for, depression in different countries argue for the need to have a specific risk algorithm for each country or a supranational risk algorithm. We aimed to develop and validate a predictD-Spain risk algorithm (PSRA) for the onset of major depression and to compare the performance of the PSRA with the predictD-Europe risk algorithm (PERA) in Spanish primary care. METHOD: A prospective cohort study with evaluations at baseline, 6 and 12 months. We measured 39 known risk factors and used multi-level logistic regression and inverse probability weighting to build the PSRA. In Spain (4574), Chile (2133) and another five European countries (5184), 11 891 non-depressed adult primary care attendees formed our at-risk population. The main outcome was DSM-IV major depression (CIDI). RESULTS: Six variables were patient characteristics or past events (sex, age, sex×age interaction, education, physical child abuse, and lifetime depression) and six were current status [Short Form 12 (SF-12) physical score, SF-12 mental score, dissatisfaction with unpaid work, number of serious problems in very close persons, dissatisfaction with living together at home, and taking medication for stress, anxiety or depression]. The C-index of the PSRA was 0.82 [95% confidence interval (CI) 0.79-0.84]. The Integrated Discrimination Improvement (IDI) was 0.0558 [standard error (s.e.)=0.0071, Zexp=7.88, p<0.0001] mainly due to the increase in sensitivity. Both the IDI and calibration plots showed that the PSRA functioned better than the PERA in Spain. CONCLUSIONS: The PSRA included new variables and afforded an improved performance over the PERA for predicting the onset of major depression in Spain. However, the PERA is still the best option in other European countries.

Iron deficiency and Helicobacter pylori infection in children.

AIM: To examine the relationship between iron deficiency (ID) and Helicobacter pylori infection in school-aged children. METHODS: Altogether 363 children from ambulatory admission were consecutively enrolled in the study. Haemoglobin (Hb), soluble transferrin receptor (sTfR), IgG against H. pylori and IgA against tissue transglutaminase were measured. The criteria for ID were sTfR > 5.7 mg/L in children aged 7-12 years and sTfR > 4.5 mg/L in older children, for anaemia Hb < 115 g/L in the younger group and Hb < 130 g/L for older boys and Hb < 120 g/L for girls. RESULTS: Iron deficiency was found in 17% of the children, 5% had also anaemia. H. pylori colonization was detected in 27% and serum markers for coeliac disease in 0.6% of the children. The prevalence of ID and H. pylori seropositivity was higher in older children (23% and 29%, vs 9% and 22%, respectively). Children with H. pylori were significantly shorter [length SDS 1.0 (0.98-1.01) vs 0.98 (0.97-0.99)]. Older children had risk for ID (OR 1.1, 95% CI 1.0-1.3, p = 0.03). Although the prevalence of H. pylori seropositivity was higher in the ID group, it was not significantly associated with ID in multivariate analysis. CONCLUSION: Helicobacter pylori seropositivity was not associated with ID. The associated factor for ID was age.

An international risk prediction algorithm for the onset of generalized anxiety and panic syndromes in general practice attendees: predictA.

BACKGROUND: There are no risk models for the prediction of anxiety that may help in prevention. We aimed to develop a risk algorithm for the onset of generalized anxiety and panic syndromes. METHOD: Family practice attendees were recruited between April 2003 and February 2005 and followed over 24 months in the UK, Spain, Portugal and Slovenia (Europe4 countries) and over 6 months in The Netherlands, Estonia and Chile. Our main outcome was generalized anxiety and panic syndromes as measured by the Patient Health Questionnaire. We entered 38 variables into a risk model using stepwise logistic regression in Europe4 data, corrected for over-fitting and tested it in The Netherlands, Estonia and Chile. RESULTS: There were 4905 attendees in Europe4, 1094 in Estonia, 1221 in The Netherlands and 2825 in Chile. In the algorithm four variables were fixed characteristics (sex, age, lifetime depression screen, family history of psychological difficulties); three current status (Short Form 12 physical health subscale and mental health subscale scores, and unsupported difficulties in paid and/or unpaid work); one concerned country; and one time of follow-up. The overall C-index in Europe4 was 0.752 [95% confidence interval (CI) 0.724-0.780]. The effect size for difference in predicted log odds between developing and not developing anxiety was 0.972 (95% CI 0.837-1.107). The validation of predictA resulted in C-indices of 0.731 (95% CI 0.654-0.809) in Estonia, 0.811 (95% CI 0.736-0.886) in The Netherlands and 0.707 (95% CI 0.671-0.742) in Chile. CONCLUSIONS: PredictA accurately predicts the risk of anxiety syndromes. The algorithm is strikingly similar to the predictD algorithm for major depression, suggesting considerable overlap in the concepts of anxiety and depression.

Risk factors associated with rosacea.

BACKGROUND: Although rosacea is a common disease, the cause of disease is still a mystery -Helicobacter pylori infection, genetic predisposition, climatic factors, and detrimental habits are implicated as triggers of rosacea. OBJECTIVE: The aim of current study is to evaluate several suspected risk factors coincidently. METHODS: Patients with rosacea from a dermatology clinic and skin-healthy controls from an randomly selected employees' population enrolled the study. Skin status were evaluated by one and same dermatologist. Participants were queried for age, gender, sun-reactive skin type, and detrimental habits using a questionnaire; blood samples for detecting Helicobacter pylori serostatus were collected. RESULTS: Totally 145 skin-healthy controls and 172 subjects either with flushing episodes or established rosacea included the study. In multivariate analysis, rosacea patients had significantly higher chance to have photosensitive skin types (OR 1.75; 95% CI 1.01-3.04; P < 0.05), positive family history to rosacea (OR 4.31; 95% CI 2.34-7.92; P < 0.0001) or previous smoking status (OR 2.01; 95% CI 1.07-3.80; P < 0.05) comparing with skin-healthy controls. There were no statistically significant differences either in gender, Helicobacter pylori serostatus, caffeine intake, alcohol consumption, occupational environment, or education level between rosacea patients and controls. CONCLUSION: Rosacea is foremost associated with familial predisposition. There is no association between Helicobacter pylori infection and rosacea in current study.

High prevalence of coeliac disease: need for increasing awareness among physicians.

BACKGROUND: Coeliac disease is a wheat gluten and related prolamines-induced disease with a prevalence that may be underestimated in many geographical regions and populations. AIM: To investigate the prevalence of coeliac disease in a population of schoolchildren of Estonia using tissue transglutaminase antibodies for screening. SUBJECTS AND METHODS: The study was designed as cross-sectional. Serum samples from 1160 randomly selected schoolchildren (636 female and 564 male, aged 9 or 15 years) were studied using a novel tissue transglutaminase antibody immunoassay (EliA Celikey IgA assay). Antibody-positive subjects were investigated for coeliac disease. RESULTS: A total of five subjects had antibodies. Four of them agreed for further investigations. By small-bowel biopsy they all were confirmed to have active coeliac disease, including three subjects with symptoms that were not considered by their family doctors. The prevalence of coeliac disease is at least 1 case per 290 (0.34% with CI 0.09-0.88%) in Estonia. It is much higher than that in our previous screening studies but is comparable with data from other European countries. CONCLUSION: The prevalence of coeliac disease might have increased during the last decade in Estonia. This study clearly shows that the awareness of coeliac disease among physicians is low. Thus, there is a need for more epidemiological studies and education related to coeliac disease.

Serum antibodies to enterohepatic Helicobacter spp. in patients with chronic liver diseases and in a population with high prevalence of H. pylori infection.

BACKGROUND: Enteric Helicobacter species might be a risk factor for chronic liver and biliary tract diseases. AIMS: To analyse serum antibody levels to three enteric Helicobacter species in patients with various biliary tract and chronic liver diseases and compare results with corresponding parameters for an adult population group, known to have a high prevalence of Helicobacter pylori infection, and with healthy blood donors, to explore a possible association of enteric Helicobacter with chronic liver diseases. SUBJECTS: Sera of 90 patients with various chronic liver diseases, 121 Estonian adult persons and 68 blood donors were analysed. METHODS: Sera, previously tested for H. pylori were analysed for IgG to Helicobacter hepaticus, Helicobacter bilis and Helicobacter pullorum. ELISA was initially used for screening and exclusion of negative cases. Sera with positive ELISA results were further analysed by immunoblot. To remove cross-reactive antibodies between H. pylori and the enteric species, sera were pre-absorbed with lysed H. pylori cells. RESULTS: Liver patients showed a significantly higher seroprevalence to H. hepaticus and H. bilis, compared with the adult population group (p=0.0001 and 0.04, respectively), and to H. hepaticus, compared with blood donors (p=0.01). Patients with autoimmune hepatitis showed no significant antibody reactivity to the enteric Helicobacter spp. in contrast to patients with other chronic liver diseases. CONCLUSION: Patients with chronic liver diseases, except autoimmune hepatitis patients, showed increased antibody levels to H. bilis/H. hepaticus compared with the population and blood donors indicating a possible role of enteric Helicobacter in the natural course of chronic liver diseases. Immunoblot seems to be a promising method for serodiagnosis of infections with these fastidious pathogens.

Long-term recurrence rate after treatment of Helicobacter pylori infection in children and adolescents in Estonia.

BACKGROUND: Helicobacter pylori infection is common in Estonia: 87% of adults and 56% of children aged 9-15 years have been found to be H. pylori seropositive. The aim of this study was to evaluate the long-term recurrence rate after treatment in children and adolescents in a setting of high H. pylori prevalence. METHODS: All children (n = 27) who underwent gastroscopy at the Children's Clinic of Tartu University Clinics during 1993--95 and in whom H. pylori infection was verified by histological examination and rapid urease test and who had completed a treatment course against H. pylori infection were invited for a post-treatment follow-up endoscopy 4-6 weeks after completion of therapy (1st follow-up visit) and to the follow-up control by [13C]-urea breath test in 1997 (2nd follow-up visit) and 2002 (3rd follow-up visit). RESULTS: Recurrence of H. pylori infection occurred in I patient out of 16 at the 2nd follow-up visit (mean 17.8+/-7.1 months after treatment), and in 5 patients out of 15 at the 3rd follow-up visit (mean 6.6+/-0.9 years after treatment). The recurrence rate calculated for the period between the 1st and the 2nd follow-up visits was 4.2% per patient-year, and between the 2nd and the 3rd follow-up visits the rate was 7.6% (95% CI 2.5%-17.6%) per patient-year. The recurrence rate calculated for the whole follow-up period was 6.7% (95% CI 2.5%-14.5%) per patient-year. CONCLUSION: The post-treatment recurrence rate of H. pylori infection in children and adolescents is higher in Estonia than in low prevalence settings.

Prevalence of antibiotic resistance of Helicobacter pylori isolates in Estonia during 1995-2000 in comparison to the consumption of antibiotics used in treatment regimens.

OBJECTIVE: To find a possible relation between the dynamics of antibiotic resistance of Helicobacter pylori isolates and the consumption of antibiotics during the last several years in Estonia. METHODS: Helicobacter pylori isolates were collected from the gastric mucosa of patients with peptic ulcer (153) and gastritis (68) and isolated on the Columbia Agar Base. From 1995 to 1997 the disk-diffusion method was used for testing of H. pylori susceptibility to metronidazole (115 isolates), erythromycin (119 isolates), tetracycline (119 isolates) and amoxicillin (119 isolates). From 1998 to 2000 the susceptibility of H. pylori to metronidazole (106 isolates), amoxicillin (30 isolates), clarithromycin (106 isolates) and ciprofloxacin (30 isolates) was assessed by E tests. Data from the Estonian State Agency of Medicines were used to determine the antibiotic consumption rate. RESULTS: Up to the year 2000 all the investigated H. pylori isolates were susceptible to ciprofloxacin; the resistance to clarithromycin, tetracycline, amoxicillin and erythromycin was 3%, 1.7%, 0.7% and 2.5%, respectively. Forty-six percent of H. pylori isolates were resistant to metronidazole. During 1995-2000 the consumption of amoxicillin, erythromycin and ciprofloxacin increased and the consumption of tetracycline decreased. The increasing consumption of amoxicillin reached a level 5.7 times than that of the consistent use of metronidazole. The resistance to amoxicillin appeared to be very low and resistance to metronidazole was continuously high. The increase of clarithromycin consumption (from 0.002 to 1.119 defined daily doses/1000) during three years was associated with the appearance of the first clarithromycin-resistant isolates in 2000. CONCLUSION: No relation was observed between the antibiotic consumption rate and the resistance pattern of H. pylori to metronidazole, amoxicillin, erythromycin, tetracycline and ciprofloxacin during recent years among the in population.

Apoptosis in different compartments of antrum and corpus mucosa in chronic Helicobacter pylori gastritis. An 18-year follow-up study.

BACKGROUND: The association of apoptosis was analysed in three different compartments (foveolar cells--FC, proliferating zone--PZ and glandular part--GP) of antrum and corpus mucosa specimens with development of atrophy and the extent of apoptosis as depending on grade of chronic inflammation, activity of gastritis and Helicobacter pylori colonization at two time points of an 18-year follow-up in an adult population from Saaremaa, Estonia, with a high prevalence of H. pylori infection were compared. METHODS: A total of 68 persons (31 men, 37 women; median age, 39 years in 1979) from a primary sample of 304 subjects, endoscoped in 1979 and reinvestigated by endoscopy and biopsy in 1997, were included in the study. The state of the gastric mucosa and the presence of H. pylori in the antrum and corpus mucosa were assessed in accordance with the Sydney system. The dynamics of apoptotic index (AI) between two time points in 1979 and 1997 was evaluated in antrum biopsies of 49 persons and in corpus biopsies of 64 persons. Apoptosis was measured using terminal deoxyuridine nucleotide nick end labelling (TUNEL) histochemistry. RESULTS: The antrum as well as the corpus of 2/68 persons were H. pylori negative at both time points. Atrophy developed in 9/68 persons in the antrum and in 23/68 in the corpus. In PZ and GP of the corpus mucosa as well as in GP of the antrum mucosa, AI decreased significantly during 18 years compared with initial values (P < 0.05), which was not associated with development of atrophy. In all compartments of the antrum and corpus mucosa, studied at the initial and end points of observation, AI did not reveal a difference in persons with and without development of atrophy (P > 0.05). In the samples of 1979 the highest independent effect on the value of AI in the FC compartment for the antrum was exerted by grade of activity of gastritis (P = 0.01) and in GP by degree of chronic inflammation (P = 0.03), while in the samples of 1997 the highest effect was exerted by grade of H. pylori colonization (P = 0.02 and 0.03 in FC and GP, respectively). For the corpus mucosa AI was most strongly affected also by grade of activity of gastritis in FC compartment (P = 0.02) and by degree of chronic inflammation in PZ (P = 0.04), but not by grade of H. pylori colonization. CONCLUSION: AI was not associated with development of atrophy, but was largely dependent on grade of activity of gastritis and degree of chronic inflammation; in the antrum mucosa AI depended also on grade of H. pylori colonization.

Significant increase in antigastric autoantibodies in a long-term follow-up study of H. pylori gastritis.

In 30% of H. pylori-infected patients a certain type of antigastric autoantibodies, reacting against canalicular structures within human parietal cells, is detectable. Furthermore, it has been shown that these autoantibodies are correlated with atrophy of the mucosa in the corpus. The aim of this study was to analyse the prevalence of these anticanalicular autoantibodies (ACAB) and their significance for development of gastric mucosa atrophy in a 12-year follow-up period. Gastric biopsy specimens from 62 persons in Saaremaa Island, Estonia, were collected in 1997 and assessed independently by two pathologists in accordance with the updated Sydney system. The sera of these persons were immunohistochemically screened for ACAB and for classic parietal cell antibodies (PCA). In addition, for 37 of the 62 persons, gastric biopsies and sera collected 12 years earlier (1985) were investigated in an analogous manner. ACAB increased significantly, from 8 out of 37 in 1985 to 17 out of 37 in 1997 (P=0.004; McNemar test). In 1997 a significant correlation existed between the presence of ACAB and corpus mucosa atrophy (19 out of 30 versus 10 out of 32 without atrophy; P=0.01; odds ratio (OR)=3.8, 95% CI 1.4-10.6). However, no correlation was found between ACAB and development of atrophy in the period from 1985 to 1997. All 37 persons were PCA negative in 1985, whereas in 1997, 2 turned out to be PCA positive. ACAB increased significantly with duration of H. pylori gastritis. The correlation between ACAB and presence of gastric corpus atrophy was confirmed. However, it is possible that ACAB are the consequence of and not a causative factor in gastric mucosa atrophy, insofar as the association of ACAB with progression of corpus atrophy was not significant.

Metronidazole and clarithromycin susceptibility and the subtypes of vacA of Helicobacter pylori isolates in Estonia.

The prevalence of metronidazole and clarithromycin resistance of Helicobacter pylori strains under different growth conditions (microaerophilic or anaerobic preincubation) was tested in 56 patients suffering from gastritis and peptic ulcer. vacA subtypes were detected in 46 H. pylori strains and were subsequently compared with the antibiotic resistance pattern. From 56 isolates, 26 proved resistant and 30 sensitive to metronidazole. The patients with peptic ulcer and gastritis were infected with both metronidazole-sensitive and metronidazole-resistant strains. In anaerobic preincubation all the strains were sensitive to metronidazole (MIC < 8 mg/l). All the strains were clarithromycin-sensitive (MIC < 2 mg/l). In the patients with gastritis and peptic ulcer s1 was the predominant vacA subtype. Comparison of vacA subtypes with the diagnoses revealed no correlation; different virulence factors such as vacA subtypes and antibiotic resistance to metronidazole in a microaerophilic milieu proved unrelated.

Seropositivity to Helicobacter pylori and CagA protein in schoolchildren of different ages living in urban and rural areas in southern Estonia.

OBJECTIVE: To evaluate Helicobacter pylori and CagA seropositivity in a non-selected group of schoolchildren in southern Estonia, with reference to previous studies where high seroprevalence to H. pylori (87%) and anti-CagA positivity (63%) in an adult population from the same region were found. STUDY POPULATION: A total of 421 schoolchildren selected haphazardly from a random population (n = 1018, ages 9, 12 or 15 years) and living in urban or rural areas. METHODS: H. pylori status was determined by evaluation of IgG antibodies against cell surface proteins of H. pylori, strain CCUG 17874, using standard ELISA. Anti-CagA IgGs were determined by ELISA using a recombinant fragment of CagA (CCUG 17874) as solid-phase antigen. Absorbance values > 0.3 (405 nm) were taken as a CagA-positive result based on a study of 25 sera from H. pylori-negative children. RESULTS: Of the 421 subjects, 235 (56%) were H. pylori-ELISA positive, and 109 out of the 235 (46%) were anti-CagA positive. Neither H. pylori nor CagA positivity were significantly different in girls and boys, or in children aged 9, 12 or 15 years. The H. pylori prevalence rate (118/181, 65%) as well as CagA positivity (64/181, 35%) in rural areas were higher compared with those in towns (117/240, 49% and 54/240, 22%, respectively; P = 0.001 and P = 0.005). CONCLUSION: Of schoolchildren living in southern Estonia, 56% were seropositive to H. pylori. Half of them had anti-CagA antibodies. Schoolchildren living in rural areas were infected significantly more often with CagA-seropositive strains compared with those living in towns.

An 18-year follow-up study of chronic gastritis and Helicobacter pylori association of CagA positivity with development of atrophy and activity of gastritis.

BACKGROUND: We wanted to evaluate the course of chronic gastritis and its association with Helicobacter pylori and CagA seropositivity in an adult sample from Saaremaa (Estonia) during an 18-year follow-up. METHODS: Seventy persons (31 men, 39 women; median age, 57.5 years) from a primary sample of 304 subjects endoscoped in 1979 were reinvestigated by endoscopy and biopsy in 1997. The state of the gastric mucosa and the presence of H. pylori in histologic sections from the antrum and corpus were assessed both in 1979 and 1997 in 66 subjects in accordance with the Sydney system, and H. pylori status in all 70 subjects was determined with the enzyme-linked immunosorbent assay (ELISA). Anti-CagA IgGs were determined with the ELISA, using the recombinant fragment of CagA. RESULTS: During an 18-year follow-up 11% of the subjects developed atrophy in the antrum, whereas 35% developed it in the corpus. Development of atrophy in the corpus and the appearance of intestinal metaplasia in the antrum were associated with increased activity of gastritis both in the initial and last follow-up biopsies. Anti-CagA positivity was found in 71% of H. pylori-seropositive persons (94% of subjects). There was a significant association between CagA positivity and the activity of gastritis, the presence of atrophy or damage to surface epithelial cells in the antrum and in corpus mucosal biopsy specimens at the last follow-up endoscopy. CONCLUSION: The CagA-positive strains of H. pylori enhance the development of atrophic gastritis compared with CagA-negative strains.

Completeness of vagotomy, Helicobacter pylori colonization and recurrent ulcer 9 and 14 years after operation in duodenal ulcer patients.

OBJECTIVE: To clarify the relationship between the completeness of vagotomy and Helicobacter pylori colonization in the development of recurrent ulcer (RU) during a long-term follow-up period after the operation in duodenal ulcer (DU) patients. DESIGN: 122 consecutive vagotomized DU patients were studied twice on average 9 and 14 years after vagotomy. METHODS: The presence of RU and completeness of vagotomy were assessed simultaneously endoscopically and by endoscopic Congo Red test (ECRT). The positive ECRT showed incomplete vagotomy. The amount of H. pylori in the biopsy specimens of the gastric antrum and corpus mucosa was detected histologically by microscopic counting. RESULTS: The cumulative increase in RU occurred from 4% (5/122) at 9 years to 18% (22/122) at 14 years (P < 0.001) and the rate of ECRT positive cases rose from 52 to 71%, respectively (P < 0.01). All RU cases were ECRT positive. H. pylori colonization occurred in 92% of cases at 9 years and in 98% of cases at 14 years. Vagotomy increased H. pylori prevalence in the corpus mucosa and the rate of the high intensity grade of H. pylori in the antrum and corpus mucosa. CONCLUSION: The number of RU after vagotomy increases with time and is limited to patients with incomplete vagotomy. H. pylori colonization and the increased rate of its high intensity in the gastric mucosa after vagotomy may promote the development of RU only in incomplete vagotomy cases.

Helicobacter pylori (H. pylori) in gastric mucosa of children with abdominal complaints: immunohistochemistry detects antigen-reactive corpus mucosa cells.

BACKGROUND: Previous morphological and serological studies of gastric Helicobacter pylori (H. pylori) colonization among Estonian children with abdominal complaints, as well as among populations of schoolchildren, have shown a high prevalence of H. pylori (49-60%). Based on published data concerning the high specificity and sensitivity of immunohistochemical detection of H. pylori, we examined the prevalence of H. pylori in gastric biopsy specimens of Estonian children by different localization and morphological type of gastritis comparing Giemsa staining with immunohistochemistry. MATERIAL AND METHODS: Formalin-fixed biopsies (107 antral, 108 corpus mucosa) of 112 children (41 boys, 71 girls, age range 1-16 years, median age 12 years) with abdominal complaints were stained with hematoxylin & eosin and Giemsa stains, as well as examined using the peroxidase antiperoxidase (PAP) method with polyclonal antibodies to H. pylori. RESULTS: Gastritis of any degree and localization was found in 84/112 (75%) children. Using Giemsa staining H. pylori were detected in 83/112 (74%) of all children, and by use of the PAP method in 55/112 (49%) (p = .001). Concordance of the results of immunohistochemical and Giemsa methods in antrum biopsies was 70%, in corpus biopsies 73%. In 12 out of 108 (11%) corpus mucosa specimens a positive staining with anti-H. pylori IgG was localized in the cytoplasma of corpus mucosal cells in the neck part of the glands. CONCLUSIONS: The prevalence of H. pylori was higher when employing the Giemsa stain in comparison with immunohistochemistry. Antibody reactivity of cells in the neck part of the corpus glands may either be due to cross-reactivity of anti-H. pylori IgG with epithelial cell epitopes, or to internalization of H. pylori by these cells, suggesting a pathogenic role of neck cells in an anti-H. pylori immune response.

Follow-up of Helicobacter pylori positive gastritis and argyrophil cells pattern during the natural course of gastric ulcer.

BACKGROUND: A follow-up of argyrophil cell hyperplasia in Helicobacter pylori-positive corpus gastritis in gastric ulcer patients during the natural course of ulcer disease. METHODS: Endoscopic biopsies (4 specimens) were obtained step-wise from the posterior wall of the corpus mucosa in 55 gastric ulcer (GU) patients. The natural course of GU was followed up in 38 patients during more than 10 years (maximum 19 years), and altogether 115 endoscopic examinations were made: 20 patients were re-examined once, 14 twice, and 4 three times. A total of 364 biopsies from 307 biopsy sites were stained by Grimelius' silver, hematoxylin-eosin, and Giemsa method for the analysis of the argyrophil endocrine cells, chronic gastritis, and H. pylori colonization, respectively, according to the Sydney System. RESULTS: Of 307 biopsy sites, 153 (50%) showed some grade of ACH. Focal (linear/micronodular) hyperplasia was found in 118 (77%) of biopsy sites; it was detected in 78 (66%) cases of atrophic corpus mucosa, but was present in only 14 (12%) cases of gastritis without atrophy or in the normal mucosa. In the follow-up patients, ACH evolved in 17 and progressed in 6 cases, and a simultaneous development of atrophic corpus gastritis was found in 20 cases. CONCLUSION: This study demonstrates that ACH evolves during the natural course of GU, alongside the development of chronic atrophic gastritis.

CagA protein seropositivity in a random sample of adult population and gastric cancer patients in Estonia.

OBJECTIVE: The prevalence of antibodies to CagA protein, associated with the risk of developing gastric cancer (GC), was studied in an Estonian adult population with a high prevalence of Helicobacter pylori (HP) infection and in a group of GC patients. DESIGN: In a representative sample of a random adult population from the South Estonian town of Karksi-Nuia, containing 199 subjects (86 M, 113 F, mean age 42.4) and in 45 (22 M, 23 F, mean age 64.5) consecutive patients with gastric adenocarcinoma, recruited during the periods 1986-87 and 1995-96 in the Hospital of Oncology, University of Tartu, anti-CagA IgG antibodies were determined by enzyme-linked immunosorbent assay (ELISA) using a recombinant fragment of CagA protein. The occurrence of anti-CagA IgG in ELISA was compared with immunoblot results for 141 subjects. RESULTS: Seropositivity to acid glycine extracted cell surface proteins of HP was 85% in the population and 91% in GC patients (p = 0.39). Anti-CagA IgG antibodies were present in 63% of the population and in 87% of GC patients (p = 0.004). The highest prevalence of anti-CagA IgG in the population sample occurred in the age group 20-29 (76%). A comparison of anti-CagA positivity evaluated by using ELISA and immunoblot showed an agreement of results in 80% of cases. CONCLUSION: HP seropositivity was similarly high in the Estonian random adult population sample and in GC patients, however, the prevalence of anti-CagA IgG was significantly higher in GC patients. Moreover, persons aged 20-29 years in the population possess the highest prevalence of anti-CagA IgG and should be given further attention with respect to the development of GC later in life.

Helicobacter pylori infection in Estonian population: is it a health problem?

The role of Helicobacter pylori infection in traditionally noncommunicable diseases as chronic gastritis, peptic ulcer and gastric carcinoma became more evident during the first decade of H. pylori studies. To analyse and evaluate the prevalence of H. pylori infection in Estonia as a population health problem, the data of three randomly selected samples of Estonian population aged over 15 years were used. The infection rate assessments in two representative samples of the population (Kambja 157 persons and Kuressaare 224 persons) were based on H. pylori colonization in the gastric mucosa, and in one sample (Karksi-Nuia 1467 persons) on seroconversion of H. pylori IgG antibodies. The persons studied were divided into groups according to birth cohorts. The population studies in Estonia showed a high prevalence of H. pylori infection among Estonians: 73% in the Kuressaare sample, 78% in the Kambja sample, and 87% in the Karksi-Nuia sample. From the Kuressaare population sample 38 families with 290 persons were included in a family H. pylori infection study and 92.5% of the persons in these families were found to be H. pylori positive. H. pylori infection was frequent in persons who were born at the beginning of this century as well as in those born after World War II up to 30 years ago. It was concluded that H. pylori infection is common in Estonia, both in random persons and their families. It is probable that the infection rate of H. pylori depends to a great extent on the socioeconomic conditions of this country and that acquisition of H. pylori in Estonia starts at an early age.

A 12-year follow-up study of chronic gastritis and Helicobacter pylori in a population-based random sample.

BACKGROUND: The study is a 12-year endoscopic follow-up investigation on the course of chronic gastritis and Helicobacter pylori infection in a sample of 81 Estonian people. METHODS: The series is a subset from a random sample of 227 subjects in whom a gastroduodenal endoscopy had been done. The grade of superficial gastritis (SG), atrophy, and colonization of the mucosa by H. pylori was evaluated in biopsy specimens from both antrum and corpus in accordance with the principles of the Sydney System. RESULTS: The healing rate of the H. pylori and gastritis was 0.3% (3 of 81); H. pylori colonization with gastritis developed in 5 of 81 during the follow-up. The mean prevalence of atrophic gastritis (AG) was three times more common in the corpus than in the antrum on the average. The formation of new cases of AG and the disappearance of AG were quite equal during the follow-up, and the overall changes in the grade of SG and atrophy were slow. The mean life span of corpus AG was nearly three times as long as that of antrum AG. In the antrum the grade of chronic inflammation correlated positively with the grade of H. pylori colonization. In cases of SG a low grade of colonization of H. pylori in the antral mucosa in connection with moderate inflammation predicted a reduction or even a healing of gastritis in the long term. CONCLUSIONS: New H. pylori infections with subsequent gastritis may occur in adulthood; a healing of gastritis occurs but is a quite rare event in the course of the 12-year follow-up. Further, in the present random sample of Estonian people atrophic corpus gastritis did not show an overall progression, in contrast to our earlier findings.

Risk of recurrence of gastric ulcer, chronic gastritis, and grade of Helicobacter pylori colonization. A long-term follow-up study of 25 patients.

BACKGROUND: We describe here our observations on colonization of the gastric mucosa by Helicobacter pylori in a long-term follow-up of 25 patients with gastric ulcer (GU). METHODS: All patients were followed-up endoscopically for more than 10 years (mean, 16 years) and endoscopically verified to have GU in the angular or corpus area of the stomach. None had received treatment with H2 blockers or omeprazole or had undergone any maintenance therapy or surgery. On the basis of the endoscopic findings on the activity of GU at follow-up endoscopies, the patients were divided into a group of subjects with 'low risk' of recurrence (15 patients who either had no (7 patients) or only a single recurrence (8 patients) at the first follow-up endoscopy but not thereafter) and into those with a 'high risk' of recurrence (10 patients who had at least 2 episodes of recurrence at follow-up endoscopies). RESULTS: A severe bilateral (antrum and corpus) colonization of the gastric mucosa by H. pylori at the first re-examination (1-6 years after the initial diagnosis of GU) was the most important characteristic feature in the patients with high risk of recurrence as compared with those with low risk. In the course of the follow-up, colonization of the corpus mucosa by H. pylori remained rather unchanged in both high- and low-risk subjects but decreased in grade in antrum particularly in those with low risk (no bacteria at the last endoscopy in 13 of 16 low-risk patients and in 2 of 8 high-risk patients). In both low- and high-risk groups corpus gastritis developed progressively into atrophic gastritis (11 of 25 patients had severe corpus atrophy at the last endoscopy). On the other hand, antral gastritis showed a tendency to heal (13 of 24 patients had normal or only slightly gastric antrum at the last endoscopy). CONCLUSIONS: The observations indicate that the H. pylori plays a role in and associates closely with the long-term course of angular or corpus GU disease and is related to the tendency of these ulcers to recur.