Daclatasvir/asunaprevir/beclabuvir, all-oral, fixed-dose combination for patients with chronic hepatitis C virus genotype 1

BACKGROUND AND AIM

This multinational (Taiwan, South Korea, Russia) phase 3 study evaluated the all-oral, ribavirin-free, fixed-dose combination (DCV-TRIO) of daclatasvir (NS5A inhibitor) 30 mg, asunaprevir (NS3 inhibitor) 200 mg, and beclabuvir (NS5B inhibitor) 75 mg, in patients with chronic hepatitis C virus genotype-1 infection, with or without compensated cirrhosis.

METHODS

UNITY-4 (NCT02170727) was an open-label, two-cohort study in which 169 patients, treatment-naive (n = 138) or treatment-experienced (n = 31), received twice-daily DCV-TRIO for 12 weeks with 24 weeks of post-treatment follow-up. The primary efficacy end point was sustained virologic response at post-treatment week 12 (SVR12) in treatment-naive patients.

RESULTS

Eighty-eight (52%) patients were men, 81 (48%) Taiwanese, 78 (46%) Korean, and 10 (6%) Russian; 23 (14%) had compensated cirrhosis, and 52 (31%) were IL28B (rs1297860) non-CC genotype. Baseline resistance-associated NS5A polymorphisms (L31 and/or Y93) were detected in 25/165 (15%) patients with available genotype-1 sequencing data. SVR12 was achieved by 98.6% (136/138; 95% confidence interval: 94.9-99.8%) of treatment-naive and 100% (31/31; 95% confidence interval: 88.8-100%) of treatment-experienced patients. Both virologic failures were found to be infected with hepatitis C virus genotype-6g; 100% SVR12 was observed for genotype-1a (n = 8) and genotype-1b (n = 157). Two patients experienced serious adverse events. Eight (5%) patients experienced reversible grade 3/4 alanine aminotransferase or aspartate aminotransferase elevations, leading to discontinuation in four (2%); all achieved SVR12. There were no grade 3/4 total bilirubin increases and no deaths.

CONCLUSIONS

Twelve weeks of DCV-TRIO was well tolerated and provided 100% SVR12 in treatment-naive and treatment-experienced patients with genotype-1 infection, with or without cirrhosis, including those with baseline NS5A-L31 or NS5A-Y93 resistance-associated substitutions.

Time to viral suppression is not related to achievement of SVR12 in HCV GT1-infected patients treated with ombitasvir/paritaprevir/ritonavir and dasabuvir with or without ribavirin

High rates of sustained virologic response at post-treatment week 12 (SVR12) were achieved in six phase 3 trials of ombitasvir (OBV, an NS5A inhibitor), paritaprevir (an NS3/4A protease inhibitor) co-dosed with ritonavir (PTV/r) + dasabuvir (DSV, an NS5B RNA polymerase inhibitor) (ie, 3D regimen) with or without ribavirin (RBV) in adults with chronic genotype (GT) 1 hepatitis C virus (HCV) infection. We assessed whether time to first HCV RNA value below the lower limit of quantification in patients with and without cirrhosis was associated with achievement of SVR12. Data were analysed from GT1-infected patients enrolled in six phase 3 studies of 3D ± RBV. Patients who experienced non-virologic failure were excluded from analysis. HCV RNA was determined using the Roche COBAS TaqMan RT-PCR assay (lower limit of quantification, LLOQ =25 IU/mL). SVR12 was analysed by week of first HCV RNA suppression, defined as HCV RNA <LLOQ. The analysis included a total of 2027 patients. Cumulative proportions of subjects with initial HCV RNA suppression <LLOQ at weeks 1, 2, 4 and 6 were 31%, 81%, 99% and 100%, respectively. SVR12 was achieved by 98%, 97%, 98% and 92% of patients with initial suppression at Weeks 1, 2, 4 and 6, respectively (P=.42, trend test). Across six phase 3 trials of 3D ± RBV, most patients achieved viral suppression by week 2. Time to viral suppression was not associated with subsequent achievement of SVR12, suggesting that on-treatment virologic monitoring may not be necessary with this regimen.

[Assessment of clinical efficacy and tolerability of meat-containing canned food for enteral nutrition]

AIM OF STUDY

to evaluate the efficacy and tolerability of meat-containing canned food for enteral nutrition in clinical settings in patients with gastrectomy. The product was made from animal protein (beef) with the addition of vegetable oils, soy protein, maltodextrin, stabilizer, vitamins and minerals. 40 patients with gastrectomy were included to the study and randomly formed 2 groups of 20 persons: the main group (8 men and 12 women, mean age 64.4±12.4 years) on the background of standard mashed diet for 14 days received 2 portions of the tested product (240 ml), the control group (5 men and 15 women, mean age 64.8±12.9 years) was treated with standard diet. Daily registration of the symptoms was carried out filling the 5-point scale of the Likert (the presence and severity of abdominal pain, flatulence, heartburn, nausea, a feeling of heaviness after eating, incomplete evacuation of the intestine). The Bristol stool scale was used to assess the dynamics of the stool. Laboratory parameters (hemoglobin, blood serum level of total protein, albumin and iron) and body composition parameters were evaluated before and after treatment. Consumption of meat-containing canned food for enteral nutrition was accompanied by significant decrease in the severity of nausea (from 1.20±0.29 to 1.02±0.05 points of the Likert scale, p=0.017), a decrease in abdomen heaviness (from 1.8±0.8 to 1.4±0.6 points, p<0.05), contributed to an improvement in stool consistency, an increase in all body composition parameters, a positive dynamic of protein metabolism (increase of hemoglobin level from 119.2±9.6 to 122.6±6.8 g/l, p>0.05, blood serum protein and albumin). A tendency to increase the mental component of the quality of life (+4.2%) was found. Thus, meat-containing canned foods for enteral nutrition can be used in the diet of patients in the postoperative period, they are well tolerated in conditions with loss of appetite, are effective in patients with protein-energy malnutrition.

Pharmacokinetics of the New Hepatitis C Virus NS3 Protease Inhibitor Narlaprevir following Single-Dose Use with or without Ritonavir in Patients with Liver Cirrhosis

In this study we sought to evaluate narlaprevir (NVR) pharmacokinetics (PK) after a single dose with or without ritonavir (RTV) in cirrhotic versus healthy subjects. NVR at 200 mg was administered to 8 healthy and 8 cirrhotic subjects, and NVR at 100 mg with RTV at 100 mg was administered to 8 healthy and 8 cirrhotic subjects. PK analysis was performed. The geometric mean maximum concentration of a drug in serum (Cmax) and the area under the concentration-time curve from 0 to infinity (AUC0-∞) were 563.1 ng/ml and 4,701.8 ng · h/ml in cirrhotic patients versus 364.8 ng/ml and 1,917.1 ng · h/ml in healthy volunteers, respectively. The geometric mean ratios of the PK parameters of cirrhotic subjects to healthy volunteers were 1.54-fold (90% confidence interval [CI] = 1.05 to 2.27) for Cmax and 2.45-fold (90% CI = 1.56 to 3.85) for AUC0-∞ The geometric mean Cmax and AUC0-∞ in cirrhotic and healthy subjects were similar: 1,225.7 ng/ml for Cmax and 15,213.1 ng · h/ml for AUC0-∞ in cirrhotic subjects and 1,178.9 ng/ml for Cmax and 14,257.2 ng · h/ml for AUC0-∞ in healthy volunteers. The corresponding geometric mean ratios were 1.04 (90% CI = 0.67 to 1.62) for Cmax and 1.07 (90% CI = 0.72 to 1.58) for AUC0-∞ Higher exposures in cirrhotic subjects were safe and well tolerated. We found that NVR exposures after a 200-mg single dose were higher in cirrhotic subjects than in healthy subjects and that a 100-mg single dose of NVR boosted with RTV at 100 mg resulted in no significant PK differences between cirrhotic and healthy subjects.

Late Relapse Versus Hepatitis C Virus Reinfection in Patients With Sustained Virologic Response After Sofosbuvir-Based Therapies

BACKGROUND

 The development of direct-acting antivirals in recent years has dramatically enhanced rates of viral eradication to >90% in patients with chronic hepatitis C virus (HCV) infection. To determine true treatment efficacy and define the most appropriate retreatment, it is important to distinguish virologic relapse from reinfection when patients in whom HCV is eradicated during treatment become infected with a new HCV strain after treatment.

METHODS

 We investigated the prevalence of late recurrent viremia (patients with sustained virologic response 12 weeks after the end of treatment but detectable HCV RNA at follow-up week 24) and used refined phylogenetic analysis of multiple HCV genes to distinguish virologic relapse from reinfection.

RESULTS

 Across 11 phase 3 clinical trials of ledipasvir-sofosbuvir (SOF) and SOF, only 12 of 3004 patients had detectable HCV RNA following sustained virologic response 12 weeks after the end of treatment. Of these 12 patients with late recurrent viremia, 11 had the same HCV genotype/subtype at baseline and at recurrence. Phylogenetic analysis demonstrated that 58% (7 of 12) of these patients were successfully treated with the SOF-based regimen, with HCV eradication achieved, but became reinfected with a different HCV strain after treatment. The remaining 5 patients with late recurrent viremia had virologic relapse in which the HCV present at baseline persisted in the liver or another compartment and reemerged in the blood 24 weeks after treatment.

CONCLUSIONS

 The incidence of late recurrent viremia was low. Distinguishing reinfection from virologic relapse has implications for determining true treatment efficiency and selecting optimal retreatment strategies.

Boceprevir plus peginterferon/ribavirin for treatment of chronic hepatitis C in Russia

AIM: To evaluate addition of boceprevir to peginterferon/ribavirin (PR) in Russian patients with chronic hepatitis C virus (HCV).

METHODS: Treatment-naive (TN) and treatment-experienced (TE) patients (who had failed prior treatment with PR for ≥ 12 wk) with chronic HCV genotype 1 infection were enrolled in this placebo-controlled, double-blind study. All patients initially received PR for 4 wk. Patients randomized to control treatment then received PR for an additional 44 wk. TN patients randomized to triple therapy received boceprevir (800 mg three times daily) plus PR for 24 wk and then further therapy according to treatment week 8 (TW8) HCV RNA levels. TE patients received boceprevir plus PR for 32 wk and then further therapy according to TW8 HCV RNA levels. Treatment was discontinued for TN patients with detectable HCV RNA at TW24 and TE patients with detectable HCV RNA at TW12 because of futility. The primary efficacy end point was sustained virologic response (SVR) defined as undetectable HCV RNA 24 wk after completing all study therapy.

RESULTS: SVR was 74.8% in the boceprevir plus PR arm compared with 46.2% in the control arm, with a stratification-adjusted treatment difference of 29.2% (95%CI: 16.4-41.5; P < 0.0001). Rates of SVR were higher in the boceprevir arm in both TN and TE patient groups (TN 78.4% vs 56.3%; TE 69.4% vs 30.0%). Within TE patients, the rates of SVR were higher with boceprevir plus PR compared with PR, regardless of treatment failure type (null responder, partial responder, and relapser). Most patients receiving boceprevir plus PR in both TN (86%) and TE (71%) populations were eligible for reduced treatment duration. Anemia was increased in patients receiving boceprevir plus PR vs PR alone (47.2% vs 24.4%); there was a corresponding increase in ribavirin dose reduction and erythropoietin use. Among patients receiving boceprevir plus PR, SVR rates were similar in patients with anemia (< 10 g/dL) and those without anemia (71.2% vs 77.4%).

CONCLUSION: Regulatory approval has been obtained for boceprevir plus PR in Russian patients with HCV genotype 1 infection based on the results of this study.

[Using a multicomponent functional food in IBS patients with constipation a comparative controlled study]

Irritable bowel syndrome (IBS) is highly prevalent functional gastrointestinal disorder associated with decrease in quality of life and a high social cost. Diet is one of several therapeutic options in IBS treatment; therefore the development and clinical evaluation of innovative functional food for IBS patients are actual. Instant drink containing 4 g inulin, 4 mg menthol and 2 mg of pyridoxine (in daily dose) has been evaluated. 49 patients 18-68 (41.5±16.5) years old fulfilling the Rome III criteria for IBS-C were randomly assigned into two groups: one received standard diet plus two drinks per day for 2 weeks and control group received standard diet. Response to therapy was recorded daily using Likert scale of abdominal pain, bloating and feeling of incomplete bowel emptying, frequency of bowel movement, Bristol stool scale, and quality of life was assessed by IBSQoL questionnaire before and after the treatment. The consumption of the drink with inulin and menthol contributed to a significant positive effect on the stool parameters (from 0.91±0.73 to 1.12±0.45 bowel movements per day in stool frequency, p=0.05, from 2.68±1.63 to 3.43±1.27 index Bristol scale, p=0.05), reduced the severity of abdominal pain (from 1.78±0.58 to 1.47?0.61 Likert scale points, p=0.05), bloating (from 2.22±0.83 to 1.53±0.71 points ofLikertscale,p= 0.01) and a sense of incomplete bowelemptying (from 2.22 ± 0.88 to 1.61± 0.81 points of Likert scale, p=0.001), as well as increased the quality of life (from 75.3± 12.0 to 83.3±6.7%, p=0.05), but a significant part of patients (10 of 25) complained the appearance of heartburn after the start of the treatment. In conclusion, the consumption of the functional drink containing inulin, menthol and pyridoxine is associated with improve in stool parameters, abdominal pain, Bristol scale index and increase in quality of life in patients with IBS-C, but produce noticeable heartburn. Changes in functional drink composition are needed to reduce adverse effects.

[Nutritional status of patients with different types of gastroesophageal reflux disease]

The aim of the study was to assess dietary intake in patients with erosive (ERD) and non-erosive reflux disease (NERD). One hundred and sixty seven patients (103 women and 64 men, mean age 47±13,6 years) were divided according to symptoms and endoscopic findings into three groups: 88 patients with NERD, 38 patients with ERD and 41 healthy controls. Symptoms were scored by validated GERDQ questionnaire, dietary intake was assessed by validated food questionnaire and 24-h pH/impedance monitoring was used for confirmation of pathological reflux. All groups were homogenous by age and sex, both NERD and ERD patients demonstrated higher BMI (28.1±6.5 vs 28.4±6.1 kg/m2) in compare to the patients from control group (24.3±2.8 kg/m2). Average daily calorie intake was higher in patients with NERD and ERD (2579±854 vs 2467±710 kcal/day) in compare to the control group (2093±696 kcal/day) due to increased consumption of fat (121±52 vs 112±52 g/day) and carbohydrates (244±88 vs 216±64 g/day) consequently. Consumption of dietary fiber was low in all groups in compare to recommended daily allowance, but even lower in NERD and ERD patients in compare to control (6.0±3.8 g/day vs 5.2±4.8 g/day vs 9.45±5.6 g/day). There was direct correlation between gastroesophageal reflux disease (GERD) and average energy consumption (R=0.23, p<0.05) and daily total fat consumption (R=0.21, p<0.05), but inverse correlation with consumption of dietary fiber (R=-0.23, p<0.05). Consumption of alcohol was higher in NERD patients in compare with ERD patients and control group (1.2±4.9 vs 0.2±2.6 vs 0±0.87 g/day), but generally it was low. Total daily number of refluxes as well as number of acid refluxes were highly correlated with daily consumption of energy (R=0.35, p<0.05; R=0.35, p<0.05), fat (R=0.33, p<0.05; R=0.32, p<0.05) and protein (R=0.3, p<0.05; R=0.25, p<0.05), however inverse correlation was found between total number of refluxes and consumption of fibers (R=-0.22, p<0.05). There was no correlation between consumption of carbohydrates or alcohol and total number of refluxes or acid refluxes. In conclusion, GERD is associated with higher BMI, increased consumption of calories and fat and low consumption of dietary fiber. Total number of refluxes is related to consumption of fat and fibers. No association with consumption of carbohydrates or alcohol was found. These findings need to be taken in account for prescription of diet to GERD patients.

[Genomic, proteomic and metabolomic predictors of nonalcoholic fatty liver disease development in obese patients. Part I]

The prevention, diagnosis and treatment of diseases associated to obesity require a qualitative increase of efficiency. There are still disputable questions about diagnostic significance of some molecules, including genomic, proteomic and metabolomic biomarkers. We observed 72 obese patients (20 men and 52 women, mean age--41.3 +/- 2.5) and performed ultrasound elastography and ultrasound of liver. We have identified two groups of patients: Group 1 consisted of 50 obese patients without complications (BMI 43.2 +/- 0.6), group 2 consisted of 22 patients with obesity complicated with nonalcoholic fatty liver disease (BMI 45.8 +/- 2.3). Determination of the adipokines (adiponectin, ghrelin, resistin, visfatin, and apelin), cytokine (interleukin--6, TNFalpha) oxidized lipoproteins (oxLDL), adhesion molecule sICAM (soluble intercellular cell adhesion molecule), fatty acid transporter L-FABP in serum was performed by ELISA. The study of the lipid metabolism involved determination of the concentration of total cholesterols, triglycerides, low and high density lipoproteins (LDL and HDL) by turbidimetry and spectrophotometry by analyzer. In addition, we conducted analysis of polymorphic alleles epsilon2, epsilon3, episolon4 of ApoE gene using polymerase chain reaction. Our data indicate that reducing the concentration of adiponectin (0.46-1.71 mcg/ml), increasing the level of glucose (5.57-6.25 mmol/l), triglycerides (2.06-3.94 mmol/l), TNFalpha (5.07-16.68 pg/ml) and L-FABP (11.62-23.76 pg/ml) are predictors of nonalcoholic fatty liver disease in obese patients, and the presence of genotype epsilon3/epsilon4 of ApoE gene is a poor prognostic marker of severity of nonalcoholic fatty liver disease.

[Immune status estimation algorithm in irritable bowel syndrome patients with food intolerance]

OBJECTIVE

To develop an algorithm for evaluation of the immune status in IBS patients with food intolerance.

MATERIALS AND METHODS

42 patients with IBS were observed. The diagnosis is based Rome III criteria. Determination of the concentration of serum allergen-IgG-antibodies to food allergens, IgG, IgA, IgM, IgE and immunoregulatory substances IL-5, TGF β1, IL-10, IL-4 IL-2, IL-13 were determined by enzyme immunoassay. All the patients received rotational diet therapy based on immunoassay data in addition to medical treatment of the basis disease. The control group comprised 15 healthy individuals.

RESULTS

Food intolerances basically to foods proteinaceous was diagnosed in 25 patients with IBS (59.5% of cases). The effectiveness of diet therapy was 68% (17 patients). Analysis of clinical and laboratory data revealed that the implementation of food intolerance in patients with IBS reducing the levels of IL-10 and TGFβ1. An effective rotational diet of food intolerance in IBS patients had significantly (p < 0.05) increase IgA levels.

CONCLUSION

Food intolerance in IBS patients characterized an increased synthesis of allergen-specific IgG antibodies, insufficient production of anti-inflammatory immunoregulatory substances IL-10 and TGFβ1, and intact cytokines IL-2, - 4, - 5, - 13, IgG and IgM in serum. Efficiency rotary diet in patients with IBS is accompanied by positive clinical dynamics, increase levels of anti-inflammatory substances and serum IgA.

[Isomeric specific analysis of hydroxyeicosatetraenoic acid in blood samples from obese patients with non-alcoholic and alcoholic steatohepatitis]

The aim of the study was to perform isomeric analysis of hydroxyeicosatetraenoic acid (HETE) in blood samples from obese patients with non-alcoholic (NASH) and alcoholic (ASH) steatohepatitis. Sixty nine obese patients with liver steatosis according to abdominal US data and chronic ALT elevation were assign into two groups aecoriing to the evaluation of alcohol consumption by GAGE and AUDIT questionnaires: NASH - 39 patients and ASH - 30 patients. The identification and quantification of 5(S)-hydroxyeicosatetraenoic acid (5-HETE), 15-HETE and also non-enzymatic oxidation product 11-HETE in blood plasma were carried out by HPLC-MS-TOF with using 2-hydroxyoctanoic acid as internal standard. The position of hydroxyl group in HETE was elucidated by HPLC-MS/MS. The MS/MS transitions were for 15-HETE m/z 319 ---> m/z 219; for 11-HETE m/z 319 --> m/z 167; for5-HETE m/z 319 --> m/z 115. Patients' body composition was evaluated by bioelectrical impedance, resting energy expenditures (REE) were assessed by indirect calorimetry and nutrition pattern was examined by foodfrequency questionnaire. Mean age, BMI and ALT serum level were similar in patients from ASH and NASH groups. Blood plasma 8+12-HETE concentration was also similar in both groups of patients, but concentration of 15-HETE (21,6±20,2 vs 11,9±13,7µg/ml, p =0,02) and 11-HETE (20,8±21,3 vs 11,2+12,9 ug/ml, p =0,03) was significantly higher in NASH patients. ASHpatients demonstrated higher lean body mass (68,1±10,6 vs 57,9±9,8 kg, p<0,001) and muscle mass (39,3±6,1 vs 33,2±6,8 kg, p<0,04) and higher rate of protein oxidation (98,5±3 1 vs 76,2±21,1 g/day, p= 0,02) recalculated from REE. There were no differences found in blood lipids content as well as in consumption of total dietary fat, however, there was a trend to difference in saturated/unsaturated fatty acids ratio between groups (2,3±0,2.in NASH and 1,4±0,3 in ASH patients). In conclusion, the rate of production of eicosatetraenoic acid metabolites by lipoxygenase pathway is different in NASH and ASH overweight patients. It means that possibly different mechanisms are responsible for formation of potentially toxic fatty acids metabolites in these two types of patients. It seems likely that differences in fatty acids consumption pattern are related to this metabolic pathway.

[An analysis of the efficacy of low-calorie and isocaloric diets in obese patients with nonalcoholic steatohepatitis]

Diet modification is widely used for the treatment of non.alcoholic steatohepatitis (NASH). Caloric restriction was shown to be effective in normalizing bldod lipid profile, increasing insulin sensitivity and subsequent normalization of aminotrasferases blood level. The aim of the study was to compare low-calorie diet (LCD) with isocaloric diet (ICD) in patients w,ith NASH. 174 NASH patients [86 females (39,43±1,53 years old) and 88 males (41,7±2,0), BMI 36,8±0,8 kg/m2] were randomly assigned (as 1:2) for LCD (1600-1700 kcal/day) or ICD (2500-2700 kcal/day) calculated according to patients'sex, age, resting energy expenditures and daily physical activity. Caloric restriction was achieved by decreasing consumption of carbohydrates and fat in LCD, whereas for ICD the caloric consumption was established according to the recommended daily values for proteins, fat and carbohydrates for ideal BMI for every patient. Blood chemistry and body composition were assessed at baseline and after 1 mo of prescribed diets. Compliance for the diet was also evaluated using previously validated questionnaire. After 1 mo of dietetic interventions total body mass and lean mass significantly decreased in both groups, but in LCD group it was significantly more prominent decrease in compare to ICD group (9,3±1,8 vs 6,2±1,7 kg and 6,6±0,4 vs 1,4±0,6 kg, p<0,05), whereas fat mass decreased better in ICD group (4,8±0,7 vs 2, 7±0,8kg, p<0,05). Mean ALT level was decreased in ICD group (77,5±41,7 vs 98,8±45,7, p<0,01), but not in LCD group (81,2±50,6 vs 77,2±31,8, p=NS) whereas blood cholesterol, triglycerides, high density lipoprotein woere significantly decreased in both groups. Moreover during the diet intervention in 72% of patients from LCD group ALT increased. Compliance index was much higher in ICD group, than in LCD group (85% vs 54%). Thus, one month of lCD leads to decrease in ALT activity in majority of NASH patients, higher loss of fat mass, lower loss of lean mass and associated with better compliance in compare to LCD.

[Normal values for high-resolution anorectal manometry in a healthy women: effects of age and maternity]

BACKGROUND

High-resolution manometry (HRM) is increasingly used in the evaluation of anorectal disorders. However, the normal values of HRM have not been widely evaluated. Anorectal pressure patterns are known to be possibly influenced by maternity status in women, but the normal values of HRM in parous and non-parous asymptomatic women have not been studied. The aim of the present study was to evaluate, for the first time, the normal values HRM in asymptomatic parous and non-parous women.

METHODS

Sixteen asymptomatic healthy females (age: 18-63 years) were enrolled into this study, and among them, 11 were parous women. HRM was performed using solid-state manometric assembly with 9 circumferential pressure sensors (MMS, Netherlands). Measurements of external and internal anal sphincter pressure at rest, during voluntary contraction and during rectal balloon distension were compared..

RESULTS

In asymptomatic parous women mean external anal sphincter resting pressure (69.9 ± 13.2) was significantly lower then anal pressure (101.2 ± 22.9) in healthy non-parous women. No differences were found between groups in internal sphincter pressure, voluntary contraction or during balloon distension.

CONCLUSIONS

The found difference in resting external sphincter pressure between parous and non-parous women have to be taken in account when HRM is used for evaluation of functional defecatory disorders. Further studies for establishing of normal values of anorectal HRM in larger group of healthy controls are badly needed.

[Contemporary dietotherapy of the irritable bowel syndrome]

Irritable bowel syndrome (IBS) is the most prevalent functional disease of the gastrointestinal tract. This highly prevalent condition is best diagnosed by assessing the constellation of symptoms with which patients present to their physicians. Because some critics have previously questioned whether irritable bowel syndrome and other functional gastrointestinal disorders truly exist because they do not have defining structural features, the Rome Foundation fostered the use of symptom-based criteria for universal use. In most cases treatment is reduced to symptomatic therapy because a lot of unknown in pathogenesis by irritable bowel syndrome. Irritable bowel syndrome leads to decrease of quality of life of the patients and could be one of the reasons of patients' disability. Food is believed by patients promotes symptoms and the diet or avoiding specific food can reduce symptoms. Possible role of different food and microbiota in the pathophysiology of irritable bowel syndrome, as well as the data from randomized, controlled clinical trials dedicated to the effects of diet in irritable bowel syndrome are summarized and discussed in this review. The efficacy of the diet, enriched by fiber, prebiotics, probiotics, peppermint oil, curcumin and vitamin B6 in irritable bowel syndrome patients was shown in numerous studies. In some studies restriction in consumption of fermented carbohydrates, coffee and alcohol, as well as diet with elimination IgG-sensed food was also shown to be effective in irritable bowel syndrome. Food intolerances, defined as non-toxic non-immune adverse reactions to food, include reactions to bioactive chemicals in foods and metabolic reactions to poorly absorbed dietary carbohydrates. New dietary approaches like polyunsaturated fatty acids intake correction and the low tryptophan intake are discussed.

Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report

Management of Helicobacter pylori infection is evolving and in this 4th edition of the Maastricht consensus report aspects related to the clinical role of H pylori were looked at again in 2010. In the 4th Maastricht/Florence Consensus Conference 44 experts from 24 countries took active part and examined key clinical aspects in three subdivided workshops: (1) Indications and contraindications for diagnosis and treatment, focusing on dyspepsia, non-steroidal anti-inflammatory drugs or aspirin use, gastro-oesophageal reflux disease and extraintestinal manifestations of the infection. (2) Diagnostic tests and treatment of infection. (3) Prevention of gastric cancer and other complications. The results of the individual workshops were submitted to a final consensus voting to all participants. Recommendations are provided on the basis of the best current evidence and plausibility to guide doctors involved in the management of this infection associated with various clinical conditions.