Culture-based selection therapy for patients who did not respond to previous treatment for Helicobacter pylori infection

BACKGROUND & AIMS

Eradication of Helicobacter pylori using empiric therapy has become difficult as a result of increasing resistance to antibiotics. We evaluated the efficacy of specific treatments, selected based on response of bacterial samples to culture with clarithromycin, levofloxacin, and metronidazole, for patients infected with resistant strains of H pylori.

METHODS

We performed a prospective study at a single center of 236 consecutive patients with persistent H pylori infection, despite 1 or more treatment attempts, and documented resistance to at least 1 antimicrobial agent (based on bacterial culture tests). Biopsy samples were collected by endoscopy and cultured in selective media. Patients received either 10 days of levofloxacin (250 mg twice daily for 131 patients with susceptible infections) or 12 days of rifabutin (150 mg once daily for 105 patients resistant to levofloxacin) in combination with amoxicillin (1 g twice daily) and esomeprazole (40 mg twice daily). Efficacy of eradication was determined by the (13)C-urea breath test, 6 to 8 weeks after therapy. Compliance and side effects were determined via personal interviews at the end of therapy. Rifabutin toxicity was monitored by analysis of blood samples.

RESULTS

H pylori infection was cured in 118 of the patients who received levofloxacin triple therapy (90%; 95% confidence interval, 85%-95%) and 93 of the patients who received rifabutin triple therapy (88.6%; 95% confidence interval, 82%-95%). In each group, the cure rate did not differ significantly between patients infected with H pylori strains resistant to single or multiple antibiotics. Mild side effects occurred in 15.5% and 14.9% of patients resistant to single or multiple antibiotics, respectively, and self-limiting neutropenia was observed in 1 (0.7%) case.

CONCLUSIONS

Selection of triple therapy with either levofloxacin or rifabutin, based on results from bacterial culture tests, cures H pylori infection in about 90% who did not previously respond to antibiotics.

Newer agents for Helicobacter pylori eradication

Helicobacter pylori infection remains widespread internationally, with a definite morbidity and mortality. The efficacy of standard 7–14 day triple therapies is decreasing, mainly due to increasing primary bacterial resistance to antibiotics. Currently, the most effective treatments are either the sequential regimen or the concomitant therapy. Different patents have been registered showing high bactericidal effects in vitro, some of which are active against clarithromycin- and metronidazole-resistant strains, even at low pH values. Among these novel molecules, benzimidazole-derivatives, polycyclic compounds, pyloricidin, and arylthiazole analogues seem to be the more promising. The identification of essential genes for either bacterial colonization or growth represents a route for potential target therapies in the near future.

Gastroesophageal reflux disease and Barrett's esophagus

Gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. The spectrum of injury includes esophagitis, stricture, the development of columnar metaplasia in place of the normal squamous epithelium (Barrett's esophagus), and adenocarcinoma. Barrett's esophagus is a premalignant lesion detected in the majority of patients with esophageal and gastroesophageal adenocarcinoma. The incidence of these cancers has been increasing in the United States and they are associated with a low rate of survival (5-year survival rate, 15-20%). When symptoms of gastroesophageal reflux disease are typical and the patient responds to therapy, no diagnostic tests are necessary to verify the diagnosis. Endoscopy is the primary test in patients whose condition is resistant to empirical therapy but its yield in this setting is low because of the poor correlation between symptoms attributed to the condition and endoscopic features of the disease. Clinical experience suggests that lifestyle modifications may be beneficial for gastroesophageal reflux disease although trials of the clinical efficacy of dietary or behavioral changes are lacking. Abundant data from randomized trials show benefits of inhibiting gastric acid secretion and suggest that proton-pump inhibitors are superior to H2-blockers and that both are superior to placebo. In patients with Barrett's esophagus, antireflux interventions are intended to control symptoms of reflux and promote healing of the esophageal mucosa. If a patient has symptoms refractory to proton-pump inhibitors or cannot tolerate such therapy, antireflux surgery, most commonly Nissen fundoplication, may be an alternative management approach. In patients with high-grade dysplasia, endoscopic therapies or surgical resection must be considered.

PDE10A and PDE10A-dependent cAMP catabolism are dysregulated oppositely in striatum and nucleus accumbens after lesion of midbrain dopamine neurons in rat: a key step in parkinsonism physiopathology

Loss of dopamine neurons in experimental parkinsonism results in altered cyclic nucleotide cAMP and cGMP levels throughout the basal ganglia. Our objective was to examine whether expression of phosphodiesterase 10A (PDE10A), an isozyme presenting a unique distribution in basal ganglia, is altered after unilateral injection of 6-hydroxydopamine in the medial forebrain bundle, eliminating all midbrain dopaminergic neurons, such that cyclic nucleotide catabolism and steady state could be affected. Our study demonstrates that PDE10A mRNA levels were decreased in striatal neurons 10 weeks after 6-hydroxydopamine midbrain lesion. Such changes occurred in the striatum ipsilateral to lesion and were paralleled by decreased PDE10A protein levels and activity in striatal neurons and in striato-pallidal and striato-nigral projections. However, PDE10A protein and activity were increased while PDE10A mRNA was unchanged in the nucleus accumbens ipsilateral to the 6-hydroxydopamine midbrain lesion. Accordingly, cAMP levels were down-regulated in the nucleus accumbens, and up-regulated in the striatum ipsilateral to the lesion, but they were not significantly changed in substantia nigra and globus pallidus. Unlike cAMP, cGMP levels were decreased in all dopamine-deafferented regions. The opposite variations of cAMP steady state in striatum and nucleus accumbens are concordant and likely dependent, at least in part, on the down-regulation of PDE10A expression and activity in the former and its up-regulation in the latter. On the other hand, the down-regulation of cGMP steady state in the striato-nigral and striato-pallidal complex is not consistent with and is likely independent from the concomitant down-regulation of PDE10A. Therefore, dopamine loss inversely regulates PDE10A gene expression in the striatum and PDE10A post-transcription in the nucleus accumbens, therein differentially modulating PDE10A-dependent cAMP catabolism.

Helicobacter pylori eradication: are we really all equal? A controlled study in native and immigrant population

Italy's shift to a tertiary economy has modified the working market, concentrating demand also on unqualified one, which includes most immigrants. It is also well established that low socio-economical conditions are associated with an increased prevalence of H. pylori infection. The aims of this study were to compare: (1) the efficacy of a 7 days triple therapy in immigrant and in Italian patients; (2) the prevalence of PUD between these two groups of patients. A total of 116 consecutive immigrant and 112 Italian H. pylori infected patients were recruited between 2007 and 2008. Patients underwent (13)C-UBT, endoscopy with biopsies, and were offered a 7-day triple therapy. Eradication rate (ER) was assessed 8 weeks after the end of the treatment using (13)C-UBT. The two populations differed for median age (p < 0.01), prevalence of PUD (p < 0.01), and smoking status (p < 0.01). The ER according to the ITT analysis was 70% for Italian and 48.3% for immigrant (p < 0.01). Multivariate analysis including country of origin, sex, age, PUD, smoking, and alcohol status found that immigrant had an adjusted OR for not eradicating of 2.14 (p = 0.03). In immigrant patients resident in Italy, performance of triple therapy was lower than expected. Further studies are demanded to confirm and clarify these intriguing results.

A validation study of the Italian Short-Form Leeds Dyspepsia Questionnaire

Assessment of symptoms should be one of the main outcome measures in dyspepsia clinical trials. This requires a reliable, valid and responsive questionnaire that measures the frequency and severity of dyspeptic symptoms. The Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ) has been proven to fulfil these criteria in its original version in the English language. The aim of the study was to assess the internal consistency, reliability, validity and responsiveness of the Italian version of the SF-LDQ in primary and secondary care. Unselected primary and secondary care patients completed the Italian version of the SF-LDQ. Test-retest reliability was assessed after 2 days. Validity was measured by comparison with diagnosis made by physicians. Responsiveness was determined before and after treatment for endoscopically proven disease. The SF-LDQ was administered to 311 patients in primary care and 179 in secondary care patients. Internal consistency, as judged by the Cronbach's α, was 0.90. Pearson's correlation coefficient for test-retest reliability was 0.92. The SF-LDQ had a sensitivity of 80% and a specificity of 82%. A highly significant response to change was also observed (p = 0.001). The Italian SF-LDQ is a reliable, valid and responsive self-completed outcome measure for quantifying the frequency and severity of dyspeptic symptoms.

A comparison amongst three rapid urease tests to diagnose Helicobacter pylori infection in 375 consecutive dyspeptic

Rapid diagnostic tools for Helicobacter pylori are important in endoscopy. To assess the accuracy of a new 5-min rapid urease test (UFT300, ABS Cernusco, sul Naviglio, Italy) compared with the 1-h Pyloritek (Serim Laboratories, Elkhart, IN) and the 24-h CLO test (Kimberly-Clark Ballard Medical Products, Roswell, GA), consecutive dyspeptic patients referred to our unit for endoscopy were prospectively studied. All patients underwent a 13C-urea-breath test, histology and the UFT300 (ABS; Cernusco, sul Naviglio, Italy). Two additional rapid urease tests were performed. Patients were deemed infected when both 13C-UBT and histology were positive. Rapid urease tests were read at 1, 5, and 60 min, respectively. Of the 375 enrolled patients, 45.3% were infected with H. pylori. The sensitivity of the new 5-min rapid urease test 300 was 90.3, 94.5, and 96.2% at 1, 5, and 60 min, respectively (specificity 100%). The Pyloritek and the new 5-min rapid urease test were comparable, but the CLO test was not reliable at 5 and 60 min. In conclusion, the new 5-min rapid urease test is comparable to the Pyloritek test, but the CLO test is significantly less sensitive at early time points. Reading the test results at 1 min may increase false-negative results with decreasing sensitivity.

[Cat scratch pneumonia: a case report]

Pasteurella multocida infections can be caused by scratches or bites of many animals including pets. An unrecognized infection can lead to severe complications such as arthritis, osteomyelitis, respiratory infections and even meningitis or endocarditis. We present the case of a woman affected by soft tissue infection caused by Pasteurella multocida complicated by bacteremia and pneumonia.

Response of bovine endothelial cells to FGF-2 and VEGF is dependent on their site of origin: Relevance to the regulation of angiogenesis

Angiogenesis, the formation of new capillary blood vessels, occurs almost exclusively in the microcirculation. This process is controlled by the interaction between factors with positive and negative regulatory activity. In this study, we have compared the effect of two well described positive regulators, vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (FGF-2) on bovine adrenal cortex-derived microvascular endothelial (BME) and bovine aortic endothelial (BAE) cells. The parameters we assessed included (a) cellular reorganization and lumen formation following exposure of the apical cell surface to a three-dimensional collagen gel; (b) organization of the actin cytoskeleton; (c) expression of thrombospondin-1 (TSP-1), an endogenous negative regulator of angiogenesis; and (d) extracellular proteolytic activity mediated by the plasminogen activator (PA)/plasmin system. We found that (a) collagen gel overlay induces rapid reorganization and lumen formation in BME but not BAE cells; (b) FGF-2 but not VEGF induced dramatic reorganization of actin microfilaments in BME cells, with neither cytokine affecting BAE cells; (c) FGF-2 decreased TSP-1 protein and mRNA expression in BME cells, an effect which was specific for FGF-2 and BME cells, since TSP-1 protein levels were unaffected by VEGF in BME cells, or by FGF-2 or VEGF in BAE cells; (d) FGF-2 induced urokinase-type PA (uPA) in BME and BAE cells, while VEGF induced uPA and tissue-type PA in BME cells with no effect on BAE cells. Taken together, these findings reveal endothelial cell-type specific responses to FGF-2 and VEGF, and point to the greater specificity of these cytokines for endothelial cells of the microvasculature than for large vessel (aortic) endothelial cells. Furthermore, when viewed in the context of our previous observation on the synergistic interaction between VEGF and FGF-2, our present findings provide evidence for complementary mechanisms which, when acting in concert, might account for the synergistic effect.

Phenotypic alterations in senescent large-vessel and microvascular endothelial cells

Endothelial cell senescence likely plays a key role in age-associated vascular diseases. A close relationship between in vitro and in vivo senescence of endothelial cells has been established. Therefore, elucidating the structural and functional changes occurring during long-term cultures of endothelial cells would contribute to clarifying the pathogenesis of vascular disorders in the elderly. We investigated the effects of replicative senescence on the architecture of bovine aortic vs microvascular endothelial cells. A marked increase in cell area was observed in both cell types, whereas dramatic morphological alterations were detected in microvascular endothelial cells only. The latter also showed age-associated reorganization of the actin cytoskeleton. Finally, both aortic and microvascular endothelial cells lost their migratory response to basic fibroblast growth factor with age. Our results highlight dramatic structural and functional alterations in senescent endothelial cells. Such rearrangements might account for in vivo endothelial cell alterations involved in age-associated vascular dysfunction.

Characterization of novel clonal murine endothelial cell lines with an extended life span

A murine endothelial cell line was recently established from microvessels that had invaded a subcutaneous sponge implant (Dong, Q. G.; Bernasconi, S.; Lostaglio, S., et al. Arterioscl. Thromb. Vasc. Biol. 17:1599-1604; 1997). From these sponge-induced endothelial (SIE) cells, we have isolated two subpopulations endowed with different phenotypic properties. Clone SIE-F consists of large, highly spread cells that have a relatively slow growth rate, form contact-inhibited monolayers, do not grow under anchorage-independent conditions, express elevated levels of thrombospondin-1 (TSP-1) and are not tumorigenic in vivo. In contrast, clone SIE-S2 consists of small, spindle-shaped cells that have a high proliferation rate, do not show contact-inhibition, grow under anchorage-independent conditions, express very low levels of TSP-1 and are tumorigenic in vivo. Both clones express the endothelial markers vascular endothelial-cadherin and vascular intercellular adhesion molecule-1, but do not express CD31 and E-selectin. In addition, SIE-S2 cells, but not SIE-F cells, express the alpha-smooth muscle actin isoform. SIE-S2 cells, but not SIE-F cells, are able to form branching tubes in fibrin gels. The SIE-F and SIE-S2 clones, which have properties of nontransformed and transformed cells, respectively, should provide useful tools to investigate physiological and pathological processes involving vascular endothelium.

Occurrence of papillary carcinoma in a hyperfunctioning thyroid nodule: report of a case and diagnostic considerations

Papillary carcinoma of the thyroid occurring within a hyperfunctioning nodule is an extremely rare disorder. A case in a woman is reported. We believe that diagnostic and therapeutic procedures to be used in the case of a hot thyroid nodule must take this possible occurrence into account.

[Hypothyroidism and simple goiter in pregnancy]

The incidence of hypothyroidism during pregnancy is 2.5%. Failure to diagnose the problem causes serious complications both to the mater and to the fetus. This pathological condition is verified on the basis of clinical analysis and above all in the laboratory. Autoimmunity is frequently the cause of hypothyroidism whereas this condition is rarely provoked as a result of surgery and therapy with I131. Pregnancy causes a definite deterioration of a pre-existing euthyroid goiter, so as it requires a careful monitoring of woman at risk. If the goiter is found to be neoplastic, its histotype and size must be studied carefully in order to provide for surgery. Therapy with L-thyroxine is essential to avoid damage to both mater and fetus and to monitor the glandular growth in the euthyroid goiter.

[Hyperthyroidism during pregnancy]

The authors review the current knowledge of fetus and woman thyroid physiology during pregnancy. They analyze the abnormalities related to hyperthyroidism, and clinical and therapeutic aspects of thyrotoxicosis; in detail possible fetal complications. They suggest the practical management of thyrotoxicosis during pregnancy.

[Echocardiographic changes in primary autoimmune hypothyroidism]

Echocardiographic features in patients with autoimmune hypothyroidism have been described. Plasma levels of T3, T4 and TSH have been compared with the severity of the echocardiographic alterations. Echocardiography demonstrated abnormalities more frequently in patients with severe hypothyroidism. No pericardial effusion has been detected. We discuss the possible etiopathogenic mechanisms.

Treatment of solitary bone cysts with intramedullary nailing

The article describes the treatment of solitary bone cysts of the upper and lower limbs by means of elastic intramedullary nailing. In the 11 cases treated, bone rehabilitation was complete, probably due to the defluction of the intracystic fluid by means of the drainage caused by the nails.

Digital angiography in evaluation of orthopedic tumors

Preoperative evaluation of orthopedic tumors using digital subtraction angiography (DSA) proved useful to ascertain the nature of the lesion, its extension to soft tissues and joints, and the presence of arteriovenous (AV) shunts. We report that overall accuracy varied from 89% to 92%, depending on the feature evaluated. The importance of angiographic examination of this entity is discussed as well as the advantages of DSA over conventional angiography.

High Speed Cylindrical Rolling Element Bearing Analysis “CYBEAN”—Analytic Formulation

This paper documents the analytic foundation and software architecture for the computerized mathematical simulation of high speed cylindrical rolling element bearing behavior. The software, CYBEAN (CYlindrical BEaring ANalysis), considers a flexible, variable geometry outer ring, EHD films, roller centrifugal and quasidynamic loads, roller tilt and skew, mounting fits, cage and flange interactions. The representation includes both steady state and time transient simulation of thermal interactions internal to and coupled with the surroundings of the bearing. A sample problem illustrating program use is presented.

A Theoretical Investigation of Compliant Surface Journal Bearings

The problem of the compliant surface journal bearing is investigated. The mathematical problem is divided into two parts, the elasticity problem and the fluid problem. The equations of linear elasticity, which represent the elasticity problem, are solved; (a) by expansion of the solution in eigenfunctions (b) by the Raleigh Ritz method, and (c) by a collocation method. Reynolds’ equation, which represents the fluid problem, is then coupled with the solution to the elasticity problem. The corresponding finite difference representation of Reynolds’ equation, which is a set of fourth-order nonlinear algebraic equations, is inverted by Newton iteration. Finally, numerical results are presented.

Performance Characteristics of Spiral-Groove and Shrouded Rayleigh Step Profiles for High-Speed Noncontacting Gas Seals

Current methods in gas lubrication have been used in this paper to analyze the gas-film characteristics in a high-speed, face-type gas seal. Detailed analyses are presented for two different surface geometries, the spiral-groove-orifice seal and the shrouded Rayleigh step seal. Results are presented in three parts. The first part shows the performance of a spiral-groove seal without the orifices, and also the difference in performance when the grooves are located at the high pressure, low pressure, or both sides. The second part gives typical performance of a nonparallel film profile for the spiral-groove-orifice seal as well as for the shrouded Rayleigh step seal. In the last part, a comparison is made between the two seal geometries on their tolerance to coning or dishing under a constant seal load.

On the Analytical and Experimental Investigation of a Hydrostatic, Axisymmetric Compliant-Surface Thrust Bearing

The paper presents experimental and theoretical data on the axisymmetric hydrostatic thrust bearing with one bonded compliant surface. The theoretical results are exact and are based on linear elasticity theory. The effects of compliance on the behavior of the thrust bearing are discussed and illustrated.