Eradication of Helicobacter pylori infection with proton pump inhibitor-based triple therapy. A randomised study.

BACKGROUND: Helicobacter pylori (H. pylori) infection plays an important role in the pathogenesis of duodenal ulcer (DU) disease. Low DU recurrences and reinfection rates were universally described, when treatment was effective. It has been suggested that short-term triple therapy, comprising a proton pump inhibitor plus 2 antibiotics (clarithromycin, amoxycillin or a nitroimidazole), should be used as first choice in treating H. pylori infection. Nevertheless, conflicting results have been reported on using these treatment regimens in different countries. Our aim was to compare cure rates of H. pylori infection, with a 1-week triple therapy versus 10 and 15 day triple schedules, in patients with DU. METHODS: A total of 172 patients (91 males, mean age 56.2+/- 3.2 years) were randomly treated with a triple therapy including a standard dose of proton pump inhibitor, amoxicillin at a dose of 1 g twice daily and clarithromycin 500 mg twice a day. Sixty-six patients received a 1-week triple therapy (group I), 42 subjects were treated with a 10-day triple therapy (group II) and 64 others with a 14-day triple therapy (group III). H. pylori infection at entry and after eradication, at least 4 weeks after therapy had ended, were assessed by 13C urea breath test and histology on biopsies from the antrum and the corpus. RESULTS: At the end of the course of treatment, the overall H. pylori eradication rate was 68.2% (45/66) in group I, 76.2% (32/42) in group II and 71.9% (46/64) in group III, without any statistically significant difference between the 3 differing period regimens, although a trend for better results with the 10-day triple therapy was observed. Compliance was good and side effects infrequent and mild. CONCLUSIONS: None of the 3 periods of triple therapy achieved 80% eradication rate recommended by the Maastricht Consen-sus Conference. The 10-day triple therapy, although not significantly, provided a satisfactory treatment against H. pylori infection.

Decreasing eradicaton rate of Helicobacter pylori infection with metronidazole-based triple therapy. A randomised study.

BACKGROUND: Helicobacter pylori (H. pylori) infection plays an important role in the pathogenesis of duodenal ulcer (DU) disease. Low DU recurrences and reinfection rates were universally described, when treatment was effective. It has been suggested that short-term triple therapy, comprising a proton pump inhibitor plus two antibiotics (clarithromycin, amoxicillin or a nitroimidazole), should be used as first choice in treating H. pylori infection. Nevertheless, conflicting results have been reported on using these treatment regimens in different countries, due to the resistance of H. pylori against one or more antibiotics. Our aim was to compare the efficacy, for H. pylori eradication, of 1-week triple therapy versus 10 and 14-day triple schedules, in patients with a history of recurrent DU. METHODS: A total of 159 patients (85 males, mean age 59.2+/-3.2 years) was randomly treated with a triple therapy including a standard dose of omeprazole twice daily, amoxicillin 1 g twice daily and metronidazole 500 mg twice daily. Fifty-three patients received 1-week triple therapy (Group I), 53 subjects were treated with 10-day triple therapy (Group II) and 53 others with 14-day triple therapy (Group III). H. pylori infection at entry and eradication, at least 4 weeks after therapy had ended, was assessed by 13C urea breath test and histology on biopsies from the antrum and the corpus. RESULTS: Of the 159 subjects randomised into the study, 6 (3 in group II and 3 in group III) were excluded from the per protocol (PP) analysis because of discontinuations. At the end of the course of treatment, the overall H. pylori eradication rate in the intention-to-treat analysis, was 73.5% (39/53) in group I, 71.6% (38/53) in group II and 73.5% (39/53) in group III, without any statistically significant difference. Moreover, the PP analysis also showed no statistical differences, with an eradication rate of 73.5% (39/53) in group I, 76% (38/50) in group II and 78% (39/50) in group III. The reported frequency of side-effects was evenly distributed between the groups, but 6 patients (3.7%) stopped because of adverse events only in groups II and III. CONCLUSIONS: The present study shows that there is no significant difference between the three regimens although the 14-day triple therapy shows a slightly higher H. pylori eradication rate. There is a strong need, in our region, to put forward surveillance programmes to monitor the prevalence of local resistant strains and to guide treatment on the basis of resistance patterns.

Yeast populations in Sardinian feta cheese.

In this study, the yeast populations in feta cheese from two different Sardinian dairies were examined. Samples of good quality feta (32) and samples of feta with a slimy surface defect (10) were examined from Dairy A. Similar, samples of good quality feta (23), feta with slimy surface defects (14) and samples with swelling defects (6) were examined from Dairy B. Kluyveromyces lactis was the dominating species in feta from Dairy A (95.2% of samples) followed by Debaryomyces hansenii (76.2%), Dekkera anomala (28.6%) and Dek. bruxellensis (19%). D. hansenii was dominant in samples from Dairy B (93%), followed by K. lactis (23.3%), Geotrichum candidum (23.3%) and Dek. anomala (18.6%). No significant difference was observed between the occurrence of yeast species in feta of good quality and in feta with slimy surface defects, thus confirming that slimy production is not associated with yeast contaminations. The swelling of samples observed in Dairy B seems to be caused by Dek. anomala. In fact, this strong fermenting species was present in all swelled samples in numbers exceeding 10(6) CFU g(-1), while it was isolated in very low concentration in only 5.4% of good samples.

Yeasts associated with Sardinian ewe's dairy products.

In the present work, the occurrence of yeasts in different types of typical Sardinian ewe's cheeses (32 samples of pecorino, 32 of caciotta, 40 of feta, 56 of ricotta) was determined. For the strains isolated the following properties were studied: proteolytic and lipolytic activities, the ability to grow at different temperatures, different concentrations of salt, and to assimilate and/or ferment compounds like lactate, citrate, lactose, glucose, galactose, lactic acid. Of 160 samples analysed, 76.2% yielded growth of yeasts. Yeast counts showed a certain variability among the samples. The highest levels were observed in caciotta and feta cheeses. A total of 281 strains belonging to 16 genera and 25 species were identified. In general, Debaryomyces hansenii was the dominant species, representing 28.8% of the total isolates. Other frequently appearing species were Geotrichum candidum, Kluyveromyces lactis and K. marxianus. Other genera encountered were Pichia, Candida, Dekkera, Yarrowia and Rhodotorula. With regard to the biochemical and technological properties of the yeasts, only K. lactis, K. marxianus and Dek. anomala assimilated and fermented lactose, whereas the majority of the species assimilated lactic acid. The assimilation of citrate was a characteristic of D. hansenii, R. rubra and Y. lipolytica. On the whole, the yeasts were weakly proteolytic while lipolytic activity was present in several species. A high percentage of strains showed a certain tolerance to low temperatures while only some strains of D. hansenii and K. lactis were able to grow at a 10% NaCl concentration.

Sexual transmission of hepatitis C virus: the Turin study.

BACKGROUND: Hepatitis C virus infection (HCV) is a major cause of chronic liver disease with the risk of evolution towards hepatic cirrhosis and hepatocellular carcinoma. Numerous studies have documented the possibility of HCV transmission through blood transfusions during surgery or during intravenous drug use. The percentage of the risk of sexual transmission, in the general population not presenting the aforesaid risks is still very controversial. The aim of this study was to evaluate the concomitant levels of seropositivity for anti-HCV, in the partners of patients with chronic HCV liver disease, but no history of previous transfusions or use of intravenous drugs. METHODS: The study included 196 anti-HCV positive spouses with a clinical diagnosis of active chronic hepatitis, aged between 20 and 75 years (mean age 53 years, SD+/-11 years). HCV infection was diagnosed by positivity of serum samples for anti HCV (EIA), confirmed by RIBA II and by circulating HCV-RNA detected by polymerase chain reaction (PCR). All partners underwent anti-HCV assay (EIA), confirmed by RIBA II in the event of positivity. RESULTS: The mean period of cohabitation was 27 years (range 3-37, SD+/-9.8 years). The positivity of anti HCV in both subjects affected 11 couples (5.6%). Of these couples, the viral genotype was also available in 3 cases which proved to be identical in the index patient and the partner, whereas it was not possible to identify the genotype in other couples owing to scarce compliance. CONCLUSIONS: The data obtained from this study confirm the possibility of the sexual transmission of HCV. However, in the context of subjects not belonging to "high risk" groups, this method of transmission does not appear to be important if compared with that of other viruses (HBV and HIV).

[Lithiasis of the gallbladder and biliary ducts: from epidemiology to therapy]. / Litiasi della colecisti e delle vie biliari: dall'epidemiologia alla terapia.

The diagnosis of cholelitiasis, more and more common with the wide diffusion of abdominal ultrasound, is often a surprise for the patient as well as for the physician who is sometimes forced to take a therapeutical decision. In the case of dilatation of the biliary duct, the cholangioRM is assuming an increasingly important role, especially before a therapeutical ERCP. The best therapeutical approach seems to be the surgical ablation in laparoscopy in presence of specific signs and symptoms. Indication to surgical ablation is a symptomatic or complicated cholelithiasis, or the history of obstructive pancreatitis. A preventive cholecystectomy can be useful for precancerous lesions.

[Gastroenterologists in ambulatory care. The experience in Turin in the year 2000]. / Poliambulatori specialisti di gastroenterologia. L'esperienza di Torino nell'anno 2000.

BACKGROUND: Digestive diseases (GI) have a major impact on public health in Italy. Hospital stay for digestive pathologies parallels that due to cardiovascular causes. Total mortality for GI causes is also very high. The management of GI pathologies is therefore a major task for the National Health System. To the experienced gastroenterologist it is clear that a large number of hospitalisation is linked to a lack of careful outpatient follow-up of diseases such as cirrhosis, ulcerative colitis and peptic ulcer. METHODS: One year of activity of our Gastro-entero-Hepatology outpatient service is examined. The management of the majority of GI diseases is organized in working teams of physicians and surgeons following cohorts of patients suffering of a specific disease. RESULTS: During the year 2000 not only a statistically significant higher number of patients has been examined (p<0.05), in comparison with 1994, but also the hospitalisation rate was lowered resulting in a very significative cost-containment. CONCLUSIONS: The specialization of outpatient activities into working teams offers advantages in terms of more appropriate medical care and cost reduction, partly due to a less frequent hospitalisation. The obvious counterpart was an increase of request of such form of follow-up from patients, resulting in longer delay to the access.

Diagnosis of Helicobacter pylori infection: validation of a commercial non invasive salivary test against urea breath test and serology.

BACKGROUND: Helicobacter pylori (H. pylori) infection plays an important role in the pathogenesis of chronic gastritis, peptic ulcer disease, MALT lymphoma and gastric cancer. Recently Helicobacter spp. infection has been correlated with cirrhosis, hepatocellular carcinoma and acute myocardial infarction. Several invasive and non-invasive tests have been proposed for the detection of the bacterium. In clinical practice, the selection of the appropriate test will depend on the disease and on cost-effectiveness. Aim of the study was to validate a rapid, salivary test for detecting the presence of antibodies against H. pylori in a population of patients undergoing to the 13C-urea breath test (13C-UBT). METHODS: Saliva and serum samples were obtained from 91 patients (47 females, mean age 53+/-6.7 years) attending the 13C-UBT service between 15 September and 31 November 1999. Thirty-five of them had had a previous diagnosis of peptic ulcer at endoscopy and 46 out of 91 had a diagnosis of histologically confirmed chronic gastritis. 39 out of 91 were dyspeptic patients with no symptoms suspect for peptic ulcer or cancer. Patients were excluded from the 13C-UBT if they had been treated with inhibitors of acid secretion and antibiotics within 30 days before testing. Breath sample were collected at baseline and 30 minutes after the ingestion of orange juice and a 75 mg dose of 13C-labeled urea. The presence in serum of antibodies (IgG) against the bacterium was assessed by means of a commercial enzyme immunosorbent assay with a reported sensitivity of 94% and specificity of 87%. Saliva was collected using a sterile absorbent pad placed between the mandibular gum and the cheek in the mouth and assayed for H. pylori antibodies by an immunochromatographic rapid method. RESULTS: Thirty-seven of the 91 patients were defined positive by 13C-UBT and serological test. Twenty-nine of these 37 were identified as positive by the salivary test. Fifty-four patients were defined as negative but the salivary test identified 13 of them as positive, thereby sensitivity and specificity were 78.3 and 75.9% respectively. The accuracy was 76.9%. Positive predictive value was 69% and negative predictive value 83.6%. CONCLUSIONS: The salivary test could be considered in the ambulatory setting, as a non-invasive tool for the screening of H. pylori infection, when more accurate methods are not available.

[Microbial environmental surveillance in a bone marrow transplant unit]. / Sorveglianza microbiologica ambientale in un centro per il trapianto di midollo osseo.

The aim of this study was to evaluate, after several years of application, in a bone marrow transplant (BMT) center of a Cagliari Hospital, the effectiveness of the disinfection protocol in minimizing the risk of environmentally transmitted infections. Microbial contamination of the air was evaluated every two months during normal activity using an SAS sampler. The contamination of surfaces was determined weekly, 2hrs after sanitation, using disposable surface contact plates. The results of environmental monitoring generally showed low values of microbial contamination of air and surfaces. Only two service rooms and two patient's rooms without own bathroom showed levels of microbial contamination slightly exceeding, in a few samplings, the values considered acceptable for environments at high risk of infections. From a qualitative point of view, the microrganisms isolated generally belonged to environmental species. In conclusion our study confirms the importance of microbial monitoring in the control and prevention of outbreaks of infections in BMT Units. This approach allows significant reduction in the level of contamination not only by improving cleaning procedures, but also by motivating the cleaning staff trough making them aware of their responsibilities.

[Microbial circulation and control in two Intensive Care Units]. / Circolazione microbica e controllo microbiologico in due Unit di Terapia Intensiva.

A microbiological survey was carried out in two medical Intensive Care Units from January to June 2000. The patients, staff (hands and upper respiratory tract) and environment were monitored. The results obtained in both Care Units give cause for concern. They showed particularly high cultural positivities in bronchoaspirates collected from artificially ventilated patients, a high percentage of positive environmental samples, and frequently contaminated hands in hospital staff, conditions which may facilitate microbial circulation in the medical Intensive Care Units. It would therefore seem necessary to promptly apply specific preventive measures for both the environment and patients.

Previous tuberculosis, hepatitis C virus and lichen planus. A report of 10 cases, a causal or casual link?

We report 10 cases of lichen planus (LP) and chronic liver disease linked to HCV. The mean age was 63.4 +/- 5.1 years (range 51-73), five were female; six patients had an established cirrhosis of the liver, as shown by either a liver biopsy or the ultrasonographic and biohumoral evidence. The remaining four patients had chronic hepatitis. Histological examination confirmed the presence of LP: the localization of the dermatosis was restricted to the skin in four patients, to the mucous membranes in five (4 atrophic erosive and one erosive) while the remaining had mucous-cutaneous localization. A type II cryoglobulinemia was demonstrated in two and a type III in one of the patients, while no one had otherwise circulating autoantibodies (anti-nuclear, anti-smooth muscle, anti-liver kidney microsomal type 1 and anti-mitochondrial antigens) such as other etiological factors of liver disease. In six of the patients the history was positive for previous Mycobacterium tuberculosis infection. In clinical practice the patients with chronic liver disease and HCV infection can also suffer from severe extrahepatic manifestations, including lichen planus.

Mixed cryoglobulinaemia associated with hepatitis C virus infection: a predictor factor for treatment with interferon?

BACKGROUND AND AIMS: Mixed cryoglobulinaemia (MC) is a frequent finding among patients infected with hepatitis C virus (HCV). The response to treatment with alpha-interferon (alpha-IFN) in these patients is linked to predictive factors. The aim of this study was to ascertain whether the presence of MC was a predictive factor of response in patients treated with alpha-IFN for chronic hepatitis due to HCV. METHODS: Thirty-two patients with MC and HCV infection (24 with chronic hepatitis and eight with cirrhosis) were compared with 30 patients with HCV infection without MC (23 chronic hepatitis, seven cirrhosis) of a similar mean age. All were treated with lymphoblastoid alpha-IFN, at 3 MU, t.i.w., for 6-12 months and then followed up. RESULTS: No statistical difference was observed between the two groups in terms of sustained response (P = 0.83), relapse (P = 0.88) and non-response (P = 0.92). The mean follow up was 24.3 months (range 17-28) for patients with sustained response and for the patients with MC and 22.6 months (range 15-26) for patients without MC. CONCLUSIONS: The presence of cryoglobulinaemia does not influence the response to alpha-IFN in patients with chronic HCV infection.

In-vitro antimicrobial activity and chemical composition of Sardinian Thymus essential oils.

Essential oils and their components are becoming increasingly popular as naturally occurring antimicrobial agents. In this work the chemical composition and the antimicrobial properties of Thymus essential oils and of their main components were determined. Three essential oils obtained from different species of Thymus growing wild in Sardinia and a commercial sample of Thymus capitatus oil were analysed. The essential oil components were identified by GC/MS analysis. The antimicrobial activity of the oils and components was determined against a panel of standard reference strains and multiple strains of food-derived spoilage and pathogenic bacteria, using a broth microdilution method. The GC/MS analysis showed that the major constituents of the oils were monoterpene hydrocarbons and phenolic monoterpenes, but the concentration of these compounds varied greatly among the oils examined. The results of the antimicrobial assay showed that essential oils extracted from Sardinian Thymus species have an antimicrobial activity comparable to the one observed in other thyme oils. It seems also confirmed that the antimicrobial properties of thyme essential oils are mainly related to their high phenolic content. Among the single compounds tested carvacrol and thymol turned out to be the most efficient against both reference strains and food-derived bacteria. The results of this study confirmed the possibility of using thyme essential oils or some of their components in food systems to prevent the growth of foodborne bacteria and extend the shelf-life of processed foods.

[Chronic HCV hepatopathy and cryoglobulinemia. The associated clinical spectrum]. / Epatopatia cronica da HCV e crioglobulinemia. Lo spettro clinico associato.

BACKGROUND AND AIM: The hepatitis C infection (HCV) has numerous extrahepatic manifestations owing to the systemic nature of the infection itself. HCV infects the cells that carry a CD 81 receptor and show a marked tropism for hepatocytes, bone marrow staminal cells and circulating lymphomonocytes. One consequence of this tropism is the activation of B lymphocyte clones with the consequent production of autoantibodies and cryoglobulins. The secondary event is the formation of circulating immune complexes which, having precipitated at an intravascular level, may cause part of the extrahepatic manifestations associated with these infections. METHODS: This retrospective study evaluated the manifestations correlated and/or associated with HCV hepatitis and mixed cryoglobulinaemia. RESULTS: This analysis showed that 75% of consecutively studied patients reveal clinically important extrahepatic manifestations. CONCLUSIONS: This underlines the "broad spectrum" action played by the hepatitis C virus in the host organism.

Management of duodenal ulcer disease in the era of H. pylori.

BACKGROUND: Today it is expected that the great majority of patients with duodenal ulcer (DU) respond to H. pylori eradication treatment without DU recurrence. The aim of the research is to identify patients who need a different therapeutic approach and the best management of their disease. METHODS: We examined retrospectively the medical history of 474 patients (326 males, mean age 61 years), followed up in 5 years in the outpatients department of a third level GI Center. From our research, 5 subgroups of patients emerged: 1) 63.5% carrying H. pylori infection, with successful eradication treatment and without DU recurrence; 2) 4% failing 3 courses of H.pylori eradication treatment; 3) 11% with DU lacking evidence of H. pylori infection or relapsing after verified eradication; 4) 8% being treated with NSAIDs; 5) 13% with DU complicated by hemorrhage or perforation. RESULTS: 23% of patients with DU need long-term therapy after H. pylori eradication treatment. Concerning this, the percentage of ulcerous recurrences in patients receiving anti-H2 therapy is 18.5%, but decreases considerably to 2% when PPI were used. CONCLUSIONS: Although representing the mainstay of DU therapy, H. pylori eradication treatment may not abolish all issue in DU management. Actually, of DU patients referred to a third level GI Center, 23% need a different therapeutic approach, which results from a thorough analysis of the medical history of the patient.

Incidence and biochemical characteristics of Bacillus flora in Sardinian dairy products.

This study was planned to assess the frequency and level of Bacillus spp. contamination in Sardinian dairy products and to evaluate some food-spoilage-related characteristics of the strains isolated. Of the 378 dairy products tested, 265 (70%) were found to contain Bacillus spp. The overall level of contamination ranged from less than 10 cfu per ml or gram up to a maximum of 1200 cfu. A total of 483 strains, belonging to 14 species, have been isolated from the 265 positive samples. The most frequently isolated psychotropic species were B. cereus (18.6% of total isolates), B. coagulans and B. mycoides. B. subtilis, B. licheniformis and B. pumilis were the most common mesophilic strains and B. stearotermophilus was the dominant thermophilic species. Most strains showed strong enzymatic activity, as indicated by the high percentage of isolates capable of hydrolysing casein, gelatin, starch and liquids. As regards possible health hazards. 72% of the B. cereus strains tested showed evidence of toxin production using a reversed passive latex agglutination assay.

[Recurring duodenal ulcer. Evaluation of previous complications as a predictive factor of ulcer recurrence after eradication of Helicobacter pylori]. / Ulcera duodenale recidivante. Valutazione della pregressa complicanza come fattore predittivo di recidiva ulcerosa dopo eradicazione dell'Helicobacter pylori.

Duodenal ulcer is a chronic disease, punctuated by acute relapses. The pathogenic mechanism in 90-100% of cases is infection by Helicobacter pylori. Two major strains exist of this bacterium: I strain, which secretes a vacuolating cytotoxin (Vac-A), and another protein named cytotoxin-associated (Cag-A) and type II strain, unable to produce both proteins and unable to produce duodenal pathology. We sought to identify the natural history of relapsing duodenal ulcer after cure of the bacterial infection. In particular, we followed the outcome of patients who repeatedly had bled from their recurrent ulcer disease, after success in eliminating the microorganism from the stomach. None of 12 repeated bleeders had an ulcer recurrence after the cure of Helicobacter pylori infection. Only 3 (5%) of 60 frequent relapser had a new episode of duodenal ulcer during a follow-up reinfection by Helicobacter pylori. We demonstrated that the cure of bacterial infection is also the cure of duodenal ulcer recurrence, but for a few cases, in the latter, event one could hypothesize a defect in the production of growth factors (Epidermal Growth Factor, Fibroblast Growth Factor) or of cellular polyamines synthesis. It is important to improve the diagnosis of reinfection by implementing the urea breath test.

Day Bed Unit at the Department of Gastro-enterology. Experience of a study group.

Day Bed Unit at the Department of Gastroenterology. Experience of a study group. We analyzed the activity of the Day-Bed Unit at the Department of Gastroenterology of Turin Hospital (Molinette). The quality of the service provided and the days of stay in hospital for each admission were evaluated in terms of cost benefit ratio. The average stay in hospital for each admission was 2.57 days as opposed to 9.3 in the in patient ward. Patients were divided in subsets according to the cause of admission. Stratifying the patients according to diagnosis showed a hospital stay of 2.73 days for liver disease and of 2.81 for pancreas and biliary disease. Among the admissions for liver disease, pre or posttranspiant patients required 2.89 days as opposed to 2.62 days of those who were treated for esophageal varices. Thus, the cause of admission was a factor influencing length of hospital stay. Patients needing non surgical treatment for liver cancer took 2.22 days if treated with percutaneous ethanol injection; those undergoing chemoembolization required 2.93 days. In conclusion, the day bed unit has proven to be able to provide a service with a good cost benefit ratio. Patients admitted to this service may be withdrawn from the waiting list of the in patient ward, thus reducing the waiting time. Optimization of this service needs integration with the surroudings Units within the Department and in the Hospital.