Efficacy and safety of TC-325 (HemosprayTM) for non-variceal upper gastrointestinal bleeding at Middlemore Hospital: the early New Zealand experience.

AIMS: A case series to review early experiences with HemosprayTM for a variety of non-variceal upper gastrointestinal bleeding (UGIB) at Middlemore Hospital. METHODS: HemosprayTM was administered therapeutically as first line or rescue at the discretion of the endoscopist. All cases of UGIB requiring HemosprayTM at Middlemore Hospital were identified to the investigator who undertook analysis of electronic and hard copy notes. RESULTS: Between October 2013 and July 2016, 36 patients were treated endoscopically with HemosprayTM. Source of bleeding was predominantly gastric in 17, 15 were duodenal and four oesophageal. The majority of lesions were peptic ulcer or post-intervention (78%), with others being Mallory Weiss tear (MWT), gastric mass, Dieulafoy lesion, portal hypertensive gastropathy and post-biopsy. Thirty-one were actively bleeding with mostly oozing haemorrhage (75%). Twenty-three patients were on antithrombotic therapy (ATT), two each on warfarin and low molecular weight heparin (LMWH) and 19 on antiplatelet agents. HemosprayTM was administered therapeutically in all cases, as first line or rescue. Acute haemostasis was achieved in all patients; four (11%) episodes of re-bleeding occurred within seven days, with average follow-up of 16 months. There were no instances of equipment malfunction or adverse events specific to use of HemosprayTM. CONCLUSIONS: Our early experience with HemosprayTM is very promising and there is clear role for HemosprayTM as a rescue therapy when standard methods have failed to achieve haemostasis and possibly as first line in cases of diffuse bleeding not amenable to standard interventions. However, HemosprayTM is not recommended as a standalone therapy for spurting haemorrhage due to the increased frequency of re-bleeding.

Personalized hypertension management in practice.

The revolution occurring in genomic and personalized medicine is likely to have a significant impact on the management of hypertension. However, from the perspective of translating new knowledge into clinical practice, progress has been slow. This review article summarizes recent advances in hypertension-related diagnostics while also offering new perspective on hypertension management for the future. Such new perspectives will likely require a paradigm shift toward more integrated and holistic approaches for better prevention and treatment of hypertension in both individuals and the population as a whole.

A win for the patient: Direct patient notification improves treatment rates of active Helicobacter pylori infection.

BACKGROUND: Current international guidelines recommend the commencement of effective eradication therapy as soon as active Helicobacter pylori (H. pylori) infection is confirmed. At our institution, all positive Campylobacter-like Organism (CLO) test results were automatically communicated to general practitioners (GPs) via a standardised letter, which also advised the commencement of eradication therapy. Despite this endeavour, a clinical audit conducted in 2011 demonstrated that only 66 per cent of confirmed H. pylori-positive South Auckland patients received eradication treatment and only 83 per cent of these patients received treatment within one month. AIMS: Improve the timely initiation of H. pylori eradication therapy through direct patient notification. METHOD: A prospective clinical audit of 109 consecutive outpatients with a positive CLO test identified at gastroscopy. In addition to standard general practitioner notification, patients were also directly notified of their positive CLO test result via a standardised letter, which provided information about H. pylori and its disease associations as well as advising patients to seek consultation with their GP to commence eradication therapy. Dispensing data was examined using Test Safe electronic records to determine the total uptake and timing of treatment compared to data from a preliminary 2011 audit. RESULTS: Ninety-five per cent of H. pylori-positive patients received standard triple therapy; therefore, treatment of active H. pylori infection was significantly higher when patients were directly notified in addition to standard GP notification, when compared to GP notification alone (95 per cent vs 66 per cent, p<0.001). All patients who received eradication therapy did so within one month of notification, a significant improvement compared to data from the previous audit in 2011 (100 per cent vs. 83 per cent, p<0.001). CONCLUSION: Direct patient notification using a standardised letter is a simple and economical strategy that significantly improves the timely initiation of eradication therapy for active H. pylori infection. This has since been integrated into standard practice at our District Health Board (DHB).

Increasing primary antibiotic resistance and ethnic differences in eradication rates of Helicobacter pylori infection in New Zealand--a new look at an old enemy.

AIMS: To determine the current prevalence, primary antibiotic resistance and eradication rate with standard triple therapy of Helicobacter pylori (H. pylori) infection in South Auckland, New Zealand (NZ). METHODS: Consecutive patients undergoing gastroscopy in 2012 were prospectively enrolled. The prevalence of primary H. pylori infection was determined from all Campylobacter-like organism (CLO) tests performed. Antibiotic susceptibility testing was performed for a range of relevant antibiotics and the success of eradication therapy was determined by stool antigen clearance. RESULTS: The prevalence of H. pylori infection by ethnic group; European (7.7%), Maori (34.8%), Pacific People (31.3%) and Orientals (23.8%). Metronidazole resistance was found in 49.3% of isolates, clarithromycin resistance in 16.4%, and moxifloxacin resistance in 9.5%. No isolates were resistant to tetracycline. Clarithromycin resistance (greater than and equal to 15%) was prevalent among Maori, Pacific People and Orientals. Metronidazole resistance has increased significantly from 32.7% in 1999 to 49.3% in 2012 (p=0.011), and clarithromycin resistance from 7% in 1999 to 16.4% in 2012 (p=0.021). The eradication rate (intention to treat) with standard omeprazole, amoxicillin and clarithromycin (OAC) therapy in ethnic groups where clarithromycin resistance was <15% was 85.7% versus 64.9% in groups where clarithromycin resistance was greater than and equal to 15% (p=0.024). CONCLUSION: H. pylori infection is very common among certain ethnic groups living in South Auckland. Resistance to clarithromycin and metronidazole have increased significantly among treatment naive patients compared to historical NZ data. Ethnic groups with clarithromycin resistance of greater than and equal to 15% were associated with lower eradication rates with OAC therapy. This suggests a need to review the current NZ H. pylori eradication guidelines to accommodate ethnic differences in the response to first-line regimens.

Spontaneous low-pressure headache complicating bag-piping.

We describe an interesting case of a 40-year-old lady who developed a spontaneous low-pressure headache whilst playing the bag-pipes. Playing wind instruments requires the generation of significant intra-thoracic pressure, which may have contributed to this musician's condition.