Helicobacter pylori and diminished growth in children: is it simply a marker of deprivation?

Helicobacter pylori is an accepted gastroduodenal pathogen and has recently been investigated for possible implications in non gastroenterological diseases such as growth impairment coronary heart disease and diabetes. Infection by cytotoxic, i.e., CagA or VacA positive strains seems more likely to lead to more serious gastroduodenal diseases compared to infection by non cytotoxic strains, but the possible role of CagA or VacA positive strains in non gastroenterological diseases has not been investigated. Aim of the present study was to evaluate the prevalence of Helicobacter pylori infection as well as CagA and VacA positivity in three paediatric populations auxologically normal, hyposomic and diabetic children. Sera from a total of 522 children (auxologically normal: 246, hyposomic: 164, diabetic: 112) were analyzed by a novel Recombinant ImmunoBlot Assay-Strip Immunoblot Assay--RIBA SIA--which contain individual band for whole Helicobacter pylori lysate and recombinant CagA and VacA. The overall seroprevalence of reactivities against Helicobacter pylori lysate, CagA and VacA were: 7.3%, 9.3%, 6.9% vs 11.6%, 7.9%, 8.5% vs 14.3%, 13.4%, 8% (p = NS) in auxologically normal, hyposomic and diabetic children, respectively. Summarizing, we found a similar prevalence of reactivity against both whole Helicobacter pylori lysate as well as recombinant CagA and VacA between auxologically normal, hyposomic and diabetic children. Our data do not support a possible role of Helicobacter pylori in diminished growth in children.

What is the role of Helicobacter pylori in complicated ulcer disease?

The role of Helicobacter pylori in the pathogenesis of duodenal and gastric ulcer and ulcer recurrence is widely known. Bleeding, perforation, and obstruction represent the most serious, potentially life-threatening manifestations of ulcer disease (hemorrhage in 15%-20%). The lifetime prevalence of perforation and obstruction is much lower (approximately 5% and 2%, respectively). Despite improved diagnostic and therapeutic options, bleeding-related mortality rates remain at 6%-7% in the United States and between 4% and 14% in Europe. H. pylori and nonsteroidal anti-inflammatory drugs are now recognized as the two primary causes of ulcer disease. Eradication of H. pylori in patients with uncomplicated ulcers results in recurrence rates of < 10%, suggesting that eradication of H. pylori in patients with bleeding ulcers may virtually prevent recurrence of both the disease and its complications. Although the prevalence of H. pylori infection is almost 100% in duodenal and 80%-90% in gastric ulcer patients not using nonsteroidal anti-inflammatory drugs, the prevalence of the organism in bleeding duodenal and gastric ulcers does not reach 70% and 60%, respectively, which may be due to false-negative test results.

Family treatment of symptomatic children with Helicobacter pylori infection

BACKGROUND

Familial clustering of Helicobacter pylori infection has been reported. We tested the hypothesis that simultaneously treating all Helicobacter pylori positive family contacts of infected symptomatic children results in lower treatment failure.

METHODS

Relatives of 47 children (index) with Helicobacter pylori gastritis had endoscopy to assess prevalence of infection in first degree cohabiting relatives. Controls included 60 children with dyspepsia and Helicobacter pylori gastritis whose infected family contacts were not treated. Index children, siblings younger than 18 years of age and control children received a 2-week course of amoxicillin and tinidazole. Parents of index children and their siblings over 18 years of age received a 2-week course of Colloidal Bismuth Subcytrate and tinidazole. The eradication rate in index children and their relatives was compared to controls whose infected family contacts were not treated.

RESULTS

Helicobacter pylori was found in 67% of 31 siblings younger than 18, in 82% of 22 siblings older than 18 years, and in 87% of 92 parents. Endoscopy, repeated four to six weeks after the end of treatment, showed Helicobacter pylori eradication in 94% of children and siblings younger than 18, and in 70% of parents and siblings over 18 years in the family treatment group, compared with 75% of control children (p < .01).

CONCLUSIONS

The high prevalence of the infection in family members suggests that person-to-person spread of Helicobacter pylori takes place. Furthermore our results show that if (or when) required, simultaneous treatment given to the whole family results in lower treatment failure, since it may promote compliance to treatment.

High prevalence of Helicobacter pylori in liver cirrhosis: relationship with clinical and endoscopic features and the risk of peptic ulcer

In 153 consecutive patients with cirrhosis we assessed: (1) the prevalence of IgG to Helicobacter pylori and compared it with that found in 1010 blood donors resident in the same area; and (2) the relationships of IgG to Helicobacter pylori with clinical and endoscopic features and with the risk of peptic ulcer. The IgG to Helicobacter pylori prevalence of cirrhotics was significantly higher than in blood donors (76.5% vs 41.8%; P < 0.0005) and was not associated with sex, cirrhosis etiology, Child class, gammaglobulins and hypertensive gastropathy. In both groups, the prevalence of IgG to Helicobacter pylori was significantly higher in subjects over 40. Among patients with cirrhosis a significantly higher prevalence of Helicobacter pylori was found in patients with previous hospital admission (P = 0.02) and/or upper gastrointestinal endoscopy (P = 0.01) and patients with peptic ulcer (P = 0.0004). Multivariate analysis identified increasing age and male sex as risk factors for a positive Helicobacter pylori serology and no independent risk factors for peptic ulcer. The high prevalence of Helicobacter pylori-positive serology found in the present series is related to age and sex and might also be explained by previous hospital admissions and/or upper gastrointestinal endoscopy. Our results do not confirm the role of Helicobacter pylori as risk factor for peptic ulcer in patients with liver cirrhosis.

Prospective screening of dyspeptic patients by Helicobacter pylori serology: a safe policy? The Italian Helicobacter pylori Study Group

BACKGROUND AND STUDY AIMS

Endoscopic screening of all dyspeptic patients is not cost-effective, nor is it feasible in many health-care delivery systems. To select the most appropriate candidates, various preendoscopic screening strategies have been proposed, some of which include Helicobacter pylori serology and patient age. We assessed the value of these two criteria in preendoscopic screening of a large series of dyspeptic patients, and compared the results obtained in a referral hospital (university center with an extensive H. pylori research program) with those in nonreferral hospital (participating centers that did not have such a program).

PATIENTS AND METHODS

Blood samples for determination of anti-H. pylori IgG antibody were collected from patients with uninvestigated dyspepsia undergoing endoscopy at one referral hospital and in 93 nonreferral hospitals throughout Italy. For IgG antibody assay, an in-house enzyme-linked immunosorbent assay (ELISA) technique was used in the referral hospital, while a commercial kit was used in the nonreferral hospitals.

RESULTS

A total of 1638 patients were evaluated at the referral hospital (845 men and 793 women, mean age 46.1 years, range 18-89), and 3281 at the nonreferral hospitals (1718 men and 1563 women, mean age 48.8, range 18-96), respectively. If endoscopy had not been performed in patients who were seronegative for H. pylori and younger than 45 years, 19% versus 17.5% of the tests would have been avoided in the referral and nonreferral hospitals, respectively, while six of 304 ulcers (2%) and no cancers would have been missed versus 35 of 557 ulcers (6.3%) and two of 557 cancers (0.3%).

CONCLUSIONS

A screening strategy based on age and H. pylori serology is a valid means of selecting dyspeptic patients for endoscopy; however, the policy needs further refinement for use in nonreferral hospitals.

A serologic survey of Helicobacter pylori infection in 3281 Italian patients endoscoped for upper gastrointestinal symptoms. The Italian Helicobacter Pylori Study Group

AIM

To assess the seroprevalence of Helicobacter pylori infection in a large series of patients with upper gastrointestinal symptoms referred for their first upper gastrointestinal endoscopy, and to evaluate any association with disease.

METHODS

A large survey of 3281 dyspeptic patients undergoing their first endoscopic examination was undertaken, involving 93 centres in Italy. A blood sample was taken from each participant, for measuring IgG antibodies against H. pylori using a commercially available kit, and two biopsies of the antral gastric mucosa were obtained for evaluating a Giemsa-stained specimen.

RESULTS

Endoscopic macroscopic diagnoses included normal mucosa (25.3%), gustroduodenitis (51.6%), gastric and duodenal ulcers (3.7 and 14.9%, respectively) and other conditions, including gastric cancer (0.8%). Overall, the seroprevalence result was 71.3% with a strong positive association with increasing age and male sex and a negative one with educational level. According to endoscopic diagnoses, the association with H. pylori seropositivity was highest for duodenal and gastric ulcer (multivariate odds ratio: 6.1 and 2.2) and lowest for carcinoma. The comparison between the results of serology and the single Giemsa-stained specimen showed good reliability of H. pylori IgG, particularly in a subgroup (n = 2056) for which the interpretation was performed by a single dedicated pathologist: sensitivity and specificity were 92 and 78%, respectively.

CONCLUSION

Commercial IgG serology is a reliable tool for the assessment of H. pylori infection in large-scale multicentre surveys. A very high seroprevalence among dyspeptic patients was confirmed, particularly in the presence of peptic disease. Factors associated with the infection were very similar to those usually reported in the general population, but male patients showed a significantly higher prevalence.

Usefulness of serology in preendoscopic screening. The Italian Helicobacter pylori Study Group

BACKGROUND

Over the last 20 years, upper gastrointestinal endoscopy has become the investigation of choice for patients with symptoms referrable to the upper gastrointestinal tract. As the increasing number of patients referred for endoscopy has led to enlarged waiting lists and medical expenses, it has been recommended that preendoscopic screening strategies might identify patients at low risk of having major pathology. These patients could avoid prompt endoscopy and might safely undergo different management. Since the recognition of the major role played by Helicobacter pylori in gastroduodenal pathology, H. pylori serological and demographical features have been proposed as part of preendoscopic screening strategies in dyspeptic patients referred to endoscopy, in an attempt to reduce endoscopic workload and medical expenses.

METHODS

We evaluate data presented in the literature and aim to give interpretations possibly helpful in the clinical practice.

RESULTS

The analysis of the endoscopic findings showed that applying a preendoscopic strategy based on age and H. pylori status in local hospitals without a specific interest in H. pylori research would have meant missing a proportion of relevant pathology: 35 of 557 (6.3%) peptic ulcers (24 duodenal and 11 gastric ulcers) and two gastric cancers (0.3%).

CONCLUSIONS

Although we do understand the need to increase the cost-effectiveness of endoscopy and realize that considering age and H. pylori status could help to get to this target, we conclude that similar preendoscopic screening strategies must be refined further before being adopted on a large scale.

Prevention with sucralfate gel of NSAID-induced gastroduodenal damage in arthritic patients

OBJECTIVES

To evaluate the efficacy of a new formulation of sucralfate as gel (Gastrogel) in the short-term prevention of gastroduodenal lesions in arthritic patients receiving nonsteroidal anti-inflammatory drugs.

METHODS

One hundred seven patients with arthritis (M/F 18/89, mean age 55.2 +/- 9.7 yr) enrolled in two centers were considered eligible for the study if initial endoscopy showed the absence of any relevant mucosal damage. Patients were randomly allocated to receive diclofenac 200 mg/day or naproxen 1 g/day plus either sucralfate gel 1 g b.i.d. (N = 53) or identical placebo (N = 54) for 14 days in a randomized double-blind study. Repeated assessment of GI symptoms and endoscopy were performed at the end of the study period.

RESULTS

At final endoscopy the incidence of erosion and the mean endoscopic score for both stomach and duodenum were significantly lower in the sucralfate gel group compared with placebo group (p < 0.05). Both heartburn and epigastric pain were significantly less frequent in patients receiving sucralfate gel than placebo (51 vs 30% and 49 vs 28% for heartburn and epigastric pain, respectively, p < 0.05). No differences were observed in the incidence or in the mean score for nausea. An unexplained difference in the incidence of ulcers was found between the two centers, but in both a similar reduction in the incidence of ulcers was observed between patients receiving sucralfate gel compared with those receiving placebo. The overall difference (8% in sucralfate-treated patients, 28% in patients receiving placebo) of gastroduodenal ulcers was statistically significant (p < 0.05).

CONCLUSIONS

Sucralfate gel reduces both the incidence of acute gastroduodenal mucosal lesions and symptoms in patients with arthritis receiving short-term nonsteroidal anti-inflammatory drugs.

Antigenic mimicry between Helicobacter pylori and gastric mucosa in the pathogenesis of body atrophic gastritis

BACKGROUND & AIMS

The majority of patients with Helicobacter pylori infection have autoantibodies cross-reacting with gastric antigens. In this study, the relation between autoantibody status, histopathology of body mucosa, and antigenic profile of H. pylori was investigated.

METHODS

One hundred patients were examined for H. pylori infection, body gastritis, and gastric autoantibodies. Balb/c mice were analyzed for serum autoantibodies after immunization with H. pylori from patients with and without atrophic gastritis.

RESULTS

Immunoglobulin G autoantibodies were detected in 57 of the 87 infected patients (65.5%) but in none of the 13 patients without infection and gastritis. The autoreaction involved mainly the luminal surface of glandular cells and secretory canaliculi of parietal cells. The autoantibody status correlated with the presence and degree of inflammation and atrophy of the glands. H. pylori from patients with atrophic gastritis showed a higher capacity to induce autoantibodies than H. pylori from patients with a minimal superficial gastritis. Monoclonal antibodies showed differences in the bacterial expression of cross-reacting determinants.

CONCLUSIONS

H. pylori-mediated autoimmunity is involved in the pathogenesis of chronic atrophic gastritis. The grade of antigenic mimicry of the infecting H. pylori strain plays a role in the progression of chronic gastritis to atrophy.

Serological response to Helicobacter pylori in gastric and non-gastric cancer

1. We aimed to evaluate the seroprevalence of Helicobacter pylori (H. pylori) in gastric cancer, non-gastric cancer and outpatients by ELISA and iso-electric focusing, and to compare histology and serology for H. pylori in gastric cancer and outpatients. 2. In 124 patients with gastric cancer, 78 patients with non-gastric cancer and 110 outpatients, H. pylori seroprevalence was assessed by ELISA and isoelectric focusing. Gastric cancer and outpatients underwent endoscopy with biopsies. 3. Seroprevalence by ELISA was significantly higher in gastric cancer compared with non-gastric cancer (84% versus 56%, P < 0.001) but not with outpatients (84% versus 74%). Iso-electric focusing detection of H. pylori was comparable to ELISA: 85, 51 and 75% in gastric cancer, non-gastric cancer and outpatients respectively. Oligoclonal iso-electric focusing was significantly more frequent in gastric cancer compared with non-gastric cancer and outpatients: 69% versus 45 and 46% respectively, P < 0.01. The reliability of H. pylori detection by antral biopsy was significantly lower in gastric cancer compared with outpatients: 36% versus 74% (P < 0.001). In gastric cancer, ELISA and iso-electric focusing were significantly more reliable than histology in H. pylori detection (84 and 85% versus 36% respectively) (P < 0.001). 4. Serological immune response to H. pylori in gastric cancer, non-gastric cancer and outpatients seems different both quantitatively and qualitatively; serology was more reliable than histology in detection of H. pylori in gastric cancer.

Spectrotypic analysis of antibodies to Helicobacter pylori in patients with antral gastritis and duodenal ulcer

AIMS

To investigate the anti Helicobacter pylori (H pylori) spectrotype associated with (a) antral gastritis and duodenal ulcer; (b) the H pylori eradicating treatment.

METHODS

Spectrotypic analysis was performed by isoelectric focusing and reverse blotting (IEFRB) in a cross sectional study on sera from 70 patients with antral gastritis and duodenal ulcer. In addition, a longitudinal study was performed on 40 of these patients (20 with antral gastritis and 20 with duodenal ulcer) who underwent eradicating treatment.

RESULTS

The cross sectional study showed that the oligoclonal spectrotype was present in 74% of antral gastritis patients and in 85% of duodenal ulcer patients. In only a minority of subjects (23% with antral gastritis and 3% with duodenal ulcer) was a polyclonal spectrotype observed. The longitudinal study showed a reduction in the intensity of the spectrotypic bands in 5/10 antral gastritis patients with eradicated H pylori as opposed to only 2/10 patients without eradication. A reduction was also observed in 6/11 eradicated v 0/9 non-eradicated patients with duodenal ulcer. Collectively, a reduction in the spectrotype was observed in 11/21 patients (52%) who--independently of the disease--underwent H pylori eradication, as opposed to 2/19 of the non-responder patients (10.5%). The polyclonal spectrotype was found exclusively in four patients with antral gastritis, all belonging to the group without eradication of H pylori after eradicating treatment.

CONCLUSIONS

The anti H pylori oligoclonal spectrotype is the most common pattern observed in patients with antral gastritis and duodenal ulcer. After H pylori eradicating treatment the spectrotype does not change qualitatively, but the polyclonal pattern seems to be predictive of a poor response to eradication.

DNA probe hybridisation in microwells using a new bioluminescent system for the detection of PCR-amplified HIV-1 proviral DNA

A new bioluminescent detection system combined with a sandwich DNA hybridisation reaction in microwells has been developed for the detection of human immunodeficiency virus type 1 (HIV-1) provirus DNA amplified by the polymerase chain reaction (PCR). First, a fragment of the HIV-1 gag gene was amplified. The amplified DNA fragments were denatured and hybridised to a capture probe immobilised in microwells and to a biotinylated detection probe. A streptavidin-pyruvate kinase conjugate could then react on the biotinylated probe and the kinase activity detected by means of the luciferin-luciferase system, with production of a bioluminescent signal. This sandwich assay followed by a bioluminescent reaction detected as little as 7 amol of target DNA. The bioluminescent assay detected 5 HIV copies generated after one round of PCR, even if no band was seen on an agarose gel. The assay was applied to the detection of HIV-proviral DNA in peripheral blood mononuclear cells after one round of PCR and allowed to clearly identify a positive sample as compared to nested PCR.

Helicobacter pylori in patients with gastric and nongastric cancer

OBJECTIVES

To compare the seroprevalence of Helicobacter pylori in gastric and nongastric carcinoma patients and to investigate the relationship between H. pylori, gastric cancer site, and histological type.

METHODS

In a 24-month period, 307 gastric cancer patients (male/female: 185/122; age range 19-94 yr, mean 69 yr) were investigated by serology (IgG to H. pylori), histology, and urease test for H. pylori. One hundred and seventy-seven gastric cancers were in the antrum, 98 were in the corpus, and 32 were in the fundus; 227 were intestinal and 80 were diffuse type. In the same study period, we assessed the H. pylori seroprevalence in 162 patients with nongastric carcinoma (lung n = 41, breast n = 42, genitourinary n = 41, GI tract n = 22, others n = 16) (male/female: 84/78; age range 31-81 yr, mean 56 yr).

RESULTS

The overall seroprevalence of H. pylori in gastric cancer and in nongastric cancer was 82 and 56%, respectively (p < 0.001). In asymptomatic blood donors (age range 55-65 yr) and in dyspeptic patients older than 60 yr, a seroprevalence of 55 and 58% was found, respectively, which is significantly lower (p > 0.001) than the gastric cancer patients but similar to the nongastric cancer population. No difference was found in the H. pylori status according to the gastric cancer site (83, 82, and 81% in the antrum, corpus, and fundus, respectively). Two hundred and twenty-seven gastric cancers [185 (81%) H. pylori-positive] were found to be of an intestinal type and 80 [66 (82%) H. pylori-positive] of a diffuse type (not significant). No age-related difference (below and above 60 yr) in H. pylori prevalence was observed within each cancer population, and, in both age groups, the seroprevalence of infection was higher in gastric cancer patients (86 and 81%) than in nongastric cancer patients (56 and 56%) (below and above 60 yr, respectively).

CONCLUSION

H. pylori seroprevalence is significantly higher in gastric cancer compared with nongastric cancer patients. No differences were observed in H. pylori seroprevalence according to gastric cancer site or histological type. The higher H. pylori seroprevalence in gastric cancer patients is not age related.

Helicobacter pylori status, endoscopic findings, and serology in HIV-1-positive patients

We have carried out a large prospective study of the frequency of H. pylori infection and HIV-1 status in a community of ex-drug abusers including subjects with (N = 210) and without (N = 259) upper gastrointestinal symptoms, endoscopy and serology. Control groups were patients with upper gastrointestinal symptoms not at high risk of HIV-1 infection (N = 219) and asymptomatic blood donors (n = 322). H. pylori was present in 52% of symptomatic community residents having endoscopy and 55% of the control patients with symptoms but not at high risk of HIV-1 infection. H. pylori was less common in HIV-1-positive patients (40%) than those who were negative (66%; P < 0.001). In patients with AIDS (33%), the frequency of H. pylori infection was reduced compared to HIV-1-positive patients without AIDS (53%; P = 0.05). All the residents with AIDS had upper gastrointestinal symptoms. In community residents, peptic ulcer was always associated with H. pylori infection. By H. pylori serology, there was no difference in the frequency of infection in asymptomatic residents (56%) whether HIV-1 positive (55%) or HIV-1 negative (58%) compared with those residents with symptoms. Overall, H. pylori was less common in HIV-1-positive residents (49%) than those who were HIV-1 negative (61%; p < 0.05). This difference was due mainly to the low frequency of infection in residents with AIDS (33%). H. pylori infection is common in HIV-1 positive patients, and only slightly reduced when compared with at-risk HIV-1-negative subjects. Peptic ulcer is associated with H. pylori in HIV-1 infection.(ABSTRACT TRUNCATED AT 250 WORDS)

The susceptibility of Helicobacter pylori to the rifamycin, rifaximin

Forty strains of Helicobacter pylori had an MIC(50) of 4 mg/L of the non-absorbably antibiotic, rifaximin. Neither synergy nor antagonism was demonstrated when the drug was combined with ampicillin, metronidazole and omeprazole and the rate of spontaneous mutation was less than 1 in 10(8). With these in-vitro characteristics, rifaximin should now be assessed for clinical efficacy.

Standardisation of primers and an algorithm for HIV-1 diagnostic PCR evaluated in patients harbouring strains of diverse geographical origin. The Belgian AIDS Reference Laboratories

Eight Belgian AIDS Reference Laboratories established a multicentre quality control to evaluate the performance of their diagnostic human immunodeficiency virus type 1 (HIV-1) DNA polymerase chain reaction (PCR). A set of Belgian and African HIV-1 seropositive and seronegative patient samples, collected in Belgium, and the British Medical Research Council (MRC) HIV-1 PCR reference reagent kit, containing plasmid HIV-1 DNA at several dilutions in human carrier DNA with appropriate negative controls, were tested by the laboratories. No false positive results were reported. All laboratories were able to detect one to two copies of HIV-1 DNA. Among the 17 Belgian and African HIV-1 seropositives, some laboratories reported up to four indeterminate results, mainly due to failure of the SK38-39, SK68-69 (Ou et al. (1988) Science 239, 295-297) and/or gag881-882 (Simmonds et al. (1990) J. Virol. 64, 864-872) primers and a poorly performing algorithm. Only the H1POL4235-4538 nested pol primer set, developed by one of the laboratories, correctly identified all the tested HIV-1 positive and negative samples. Consequently, the laboratories decided to evaluate these pol primers as a reference primer set and to standardise the testing algorithm. All laboratories achieved a sensitivity and specificity of 100% on testing 10 additional Belgian and African patient samples, when adapting a standardised algorithm based on three HIV-1 primer sets, one of which is the H1POL4235-4538 primer set.

Duodenal ulcer, Helicobacter pylori, and gastric secretion

Patients with chronic dyspepsia were categorised by macroscopic appearance at oesophagogastroduodenoscopy as having duodenal ulceration (DU), other diagnosed lesions such as reflux oesophagitis, carcinoma of stomach, etc, or no organic lesion (non-ulcer dyspepsia, NUD). Material was collected to identify gastric infection with Helicobacter pylori (H pylori) by CP urease test, culture, and histological examination and to make the microscopic diagnosis of active chronic gastritis. Each patient in the DU and NUD categories was then invited to volunteer for a gastric secretion study in which maximal gastric secretion in response to histamine was measured. Sixty two gastric secretion tests were performed (31 DU, 31 NUD). The presence of H pylori was associated with active chronic gastritis (100%). DU patients secreted more acid than the NUD patients. H pylori positivity was associated with decreased maximal gastric secretion in both groups. There was a positive correlation between smoking and maximal acid output shown only in H pylori negative but not in H pylori positive patients. These findings were clear cut when all corrections of maximal gastric secretion were made for pyloric loss, duodenogastric reflux, and stature. This study failed to show any aetiological link between H pylori and DU by increased maximal gastric secretion.

Enhanced mucosal interleukin-6 and -8 in Helicobacter pylori-positive dyspeptic patients

OBJECTIVES

To determine the concentrations of interleukin-1 beta, interleukin-6, and interleukin-8 in tissue homogenates of mucosal biopsy specimens from Helicobacter pylori-positive and -negative patients.

METHODS

In 43 consecutive patients who underwent upper gastrointestinal endoscopy, seven antral biopsies were taken; three specimens were used for cytokine determination and the remaining four biopsies were processed for H. pylori detection. Peripheral venous blood was collected and IgG to H. pylori was assayed by an ELISA technique.

RESULTS

Twenty-nine of 43 patients (67%) were histologically positive for H. pylori; all had chronic gastritis. The mucosal levels of interleukin-6 and interleukin-8 were significantly higher in H. pylori-positive patients than in the negative patients (p < 0.001). A significantly higher percentage of interleukin-8 was found in patients colonized by H. pylori with active superficial chronic gastritis (85.7%), compared to quiescent superficial gastritis (12.5%) (p < 0.01), and the median and range were, respectively, 400 (0-1000) and 0 (0-200) pg/mg protein (p < 0.001). In patients with active superficial gastritis, a significant correlation between interleukin-6 and -8 was found (p 0.01). No difference was found regarding the mucosal levels of interleukin-1 beta according to the presence of H. pylori.

CONCLUSIONS

These results suggest a possible pathogenetic role for interleukin-6 and interleukin-8 in H. pylori-associated gastritis.

Seroconversion for Helicobacter pylori

Images

Prevalence of peptic ulcer in Helicobacter pylori positive blood donors

This study aimed to determine the importance of raised antibodies to Helicobacter pylori in an asymptomatic population. A total of 128 asymptomatic blood donors who were seropositive for H pylori and consented to endoscopy were investigated. These subjects were from a population of 1010 blood donors screened for antibodies to H pylori. A questionnaire was completed to determine if any subjects had complained of symptoms, and they subsequently had endoscopy. Altogether 121 of 128 were positive for H pylori by histology and urease test and/or culture and all 121 had chronic active gastritis on histology. Twenty five of these subjects had peptic ulcer (20 duodenal, five gastric), a further 21 had erosive duodenitis, and two were found to have gastric cancer. H pylori associated peptic ulcer disease and duodenitis occur more frequently than previously recognised and this suggests that H pylori infection, even if asymptomatic, is of far greater clinical relevance than originally thought.

Gastric retention of sucralfate gel and suspension in upper gastrointestinal diseases

This study was designed to compare by scintigraphy the gastric retention of a new dosage form of sucralfate as gel (Gastrogel) with that of sucralfate suspension in 25 patients with upper gastrointestinal symptoms referred for routine endoscopy. After endoscopy 4 subgroups were defined: macroscopically normal mucosa (n = 7), antral gastritis and/or erosions (n = 6), gastric ulcer (n = 6) and duodenal ulcer (n = 6). Each patient received either sucralfate gel or sucralfate suspension in equivalent doses (5 ml containing 1 g sucralfate). Both formulations were labelled with 111 MBq 99mTc-DTPA before administration. The mean value of t1/2 in the total group was significantly longer when patients were taking sucralfate gel (61.6 min) compared to sucralfate suspension (33.8 min) (P < 0.001). The mean values of t1/2 were significantly longer for sucralfate gel compared to sucralfate suspension also among the subgroups (macroscopically normal P < 0.02, antral gastritis P < 0.05, gastric ulcer P < 0.02 and duodenal ulcer P < 0.05). After 2 and 3 hours, the percentage residual activity in the gastric area was significantly higher following administration of sucralfate gel compared to sucralfate suspension. This study has shown that, compared to sucralfate suspension, sucralfate gel persists longer in the stomach of patients with gastritis and peptic ulcer.

Serum pepsinogen I and II concentrations and IgG antibody to Helicobacter pylori in dyspeptic patients

AIMS

To investigate the association between histologically confirmed gastritis, carriage of Helicobacter pylori and pepsinogen (PG) I and PG II concentrations.

METHODS

Prospective study of 81 dyspeptic patients undergoing upper gastrointestinal endoscopy was made. The extent of gastric mucosal inflammation and the presence of H pylori was determined, and serology to evaluate PG I and II concentrations and IgG titres to H pylori was carried out.

RESULTS

The presence of H pylori was strongly correlated with high IgG antibody titres to H pylori and gastritis. Patients who were H pylori positive had significantly higher PG I and PG II concentrations and a significantly lower PG I:PG II ratio than patients who were negative for H pylori. In 13 patients with duodenal ulcer and H pylori positive gastritis serum PG I concentrations were significantly higher than in H pylori positive patients without duodenal ulcer. Significant correlations were found between the age of patients and serum PG II, the PG I:PG II ratio, IgG antibodies to H pylori, the severity of body gastritis and H pylori infection, and between the degree of gastritis in the body of the stomach and the PG II concentration.

CONCLUSIONS

Serum PG I and II concentrations, together with a fall in the PG I:PG II ratio, could be used as predictors of H pylori infection as well as serum IgG antibody response to H pylori.

HIV-1 promoter activation following an oxidative stress mediated by singlet oxygen

Various biological processes, such as photosensitization or inflammatory reactions, can generate singlet oxygen (1O2) as one of the major oxidative species. Because this oxidant can be generated either extracellularly or intracellularly, it can cause severe damage to various biological macromolecules, even to those deeply embedded inside the cells such as DNA. Sublethal biological modifications induced by different DNA-damaging agents can promote various cellular responses initiated by the activation of various cellular genes and certain heterologous viruses. Since 1O2 fulfils essential prerequisites for a genotoxic substance, we have examined the effects of an oxidative stress, mediated by this species, on cells harbouring a heterologous promoter-leader sequence derived from the human immunodeficiency virus type 1 (HIV-1). Our results demonstrate that HIV-1 long terminal repeat (LTR), integrated into the cellular DNA of epithelial cells, can be transactivated following an oxidative stress mediated by 1O2. In addition, using HIV-1 latently infected promonocytes or lymphocytes, it can be shown that virus reactivation can be induced through a sublethal dose of 1O2 generated intracellularly. An extracellular generation of 1O2 can promote a substantial lethal effect without HIV-1 reactivation. These data may be relevant to the understanding of the events converting a latent infection into a productive one and to the appearance of the acquired immune deficiency syndrome.

Biliary surgery without the surgeon!

Since the introduction of endoscopic retrograde cholangiopancreatography in the 1970s and of endoscopic sphincterotomy (EST) in 1974, endoscopic techniques for the diagnosis and therapy of biliary and pancreatic disorders have proliferated. Although some procedures have become part of routine practice, for example EST for postcholecystectomy bile duct stones and stent insertion for inoperable biliary strictures, the place of others is unclear at present and should be evaluated by prospective randomized clinical trials. The choice of either an endoscopic or a transhepatic approach for biliary disease is usually dictated by local expertise, but these should be regarded as complementary rather than competing techniques, and complex biliary problems should be managed jointly by the endoscopist, interventional radiologist and hepatobiliary surgeon.

Eighteen month follow up of Helicobacter pylori positive children treated with amoxycillin and tinidazole

Sixty three children with dyspepsia (mean age 12 years, range one to 18, M/F 41/22) were Helicobacter pylori positive by histology of gastric antral biopsy specimens and were treated with a six week course of amoxycillin (50 mg/kg) and tinidazole (20 mg/kg). The endoscopic diagnoses were: normal (16), nodular gastritis (19), oesophagitis (four), duodenal ulcer (13), and gastric ulcer (11). H pylori was eradicated in 54 (87%) and histological gastritis resolved in 51 and was improved in the other three. Repeat investigation was offered at six monthly intervals. Reinfection was found in three of 34 (9%) at six months, in none of 22 at 12 months, and in two of 18 (11%) at 18 months, yielding an 18 month cumulative relapse rate of 20%. Children with persisting infection despite treatment remained positive during follow up. Serum H pylori IgG concentrations fell after treatment (p < 0.001), and for individual children during follow up there was a progressive decline, but an increased concentration indicated recurrence. After eradication of H pylori by combined amoxycillin and tinidazole treatment, only a minority of children relapse during the ensuing 18 months.

Double blind trial of colloidal bismuth subcitrate versus placebo in Helicobacter pylori positive patients with non-ulcer dyspepsia

We have carried out a double blind placebo controlled trial to assess the effects of treatment with colloidal bismuth subcitrate in Helicobacter pylori associated non-ulcer dyspepsia. Eighty patients with dyspepsia, normal upper gastrointestinal appearances at endoscopy and H pylori associated active chronic gastritis on histology of gastric antral biopsies were included in the trial. The patients were randomised to receive colloidal bismuth subcitrate 240mg twice daily for four weeks or matching placebo and were reassessed four weeks after completing treatment. Twenty-six patients (67%) receiving colloidal bismuth subcitrate had normal histology or improved inflammation compared with five (13%) receiving placebo (p less than 0.001), and symptoms were absent or improved in 32 (82%) and two (5%) respectively (p less than 0.001). Serum IgG level was a marker of infection, and fell with successful treatment. Colloidal bismuth subcitrate is effective treatment for H pylori associated non-ulcer dyspepsia with improved gastric antral histological appearances and has a beneficial effect on symptoms.

Eicosanoid synthesis and Helicobacter pylori associated gastritis: increase in leukotriene C4 generation associated with H. pylori colonization

The importance of pro-inflammatory leukotriene C4 in Helicobacter pylori (H. pylori) associated gastritis in man is unknown. Fresh gastric biopsy specimens from 28 dyspeptic patients were obtained: 10 showed normal antral histology with no evidence of H. pylori, the remaining 18 patients exhibited histological gastritis and were H. pylori positive as assessed by histology, culture and urease test. Twelve of these 18 patients received 240 mg twice daily colloidal bismuth subcitrate for four weeks before re-endoscopy. Gastric biopsies from H. pylori positive patients were incubated under basal and Ca(2+)-ionophore mediated conditions: Radioimmunoassay analysis of the supernatant showed basal release of prostaglandin E2 and leukotriene C4 was slightly but not significantly elevated in H. pylori positive mucosa. However in H. pylori positive mucosa there was an 85% increase in leukotriene C4 synthesis when biopsies were incubated with ionophore, compared to only 13% increase in H. pylori negative mucosa (p less than 0.02). After eradication of H. pylori by colloidal bismuth subcitrate, there was a clearance of inflammatory cell infiltrate as assessed by histology and a significant reduction in ionophore-mediated leukotriene C4 formation compared with before treatment (p less than 0.02). These results suggest that H. pylori gastritis is associated with increased capacity to generate leukotriene C4, which may amplify the damaging effects of the bacteria on gastric mucosa.

Endoscopic therapy for bile duct stones in a geriatric population

During the 5 year period to May 1988, 137 consecutive patients (age range, 65-102 years; median 84 years) with a diagnosis of choledocholithiasis, were referred to The Middlesex Hospital Geriatric Department. Endoscopic sphincterotomy was successful in 96.2% of cases and immediate biliary drainage was achieved in all but one of these patients. Stones were cleared endoscopically in 73.3% and surgically in 4.7% of cases. Long-term stenting was employed in 14.3% of patients. The 30 day mortality after endoscopic or surgical treatment was 4.7% (six deaths), although death was probably unrelated to therapy in half the cases. Deaths were due to procedural cardiorespiratory arrest (1), pancreatitis (1), pneumonia (2) and cerebrovascular accident (2). Endoscopic treatment is effective even in a high-risk geriatric population. After sphincterotomy patients with intact gall bladders should be managed expectantly.

Detection of Helicobacter pylori-like organisms in the stomach of some food-source animals using a monoclonal antibody

To investigate a possible animal reservoir of Helicobacter pylori, 15 pigs, 15 rabbits and 5 cows slaughtered for consumption were studied. Raised serum IgG levels were found in 93% of the pigs and 87% of the rabbits, but levels were normal in the cattle. In the controlled testings three of 22 humans had elevated IgG to H pylori and in all three H pylori was detected by the use of monoclonal antibody. Helicobacter pylori were identified in gastric brushings by a monoclonal antibody in 8 out of 10 pigs and 7 out of 10 rabbits. This study suggests an animal reservoir of Helicobacter pylori which may be of importance in human infection.

A 10 year single centre experience of percutaneous and endoscopic extraction of bile duct stones with T tube in situ

A non-randomised single centre study of 226 consecutive patients referred over 10 years with retained common bile duct stones and a T tube in situ or a cholecystostomy tube are reported. Percutaneous extraction was attempted in 204 and endoscopic extraction in 68 patients. Percutaneous clearance was achieved in 158 (77.5%) patients and endoscopic clearance in 52 (76.5%) patients. Six of 153 (3.9%) patients followed after percutaneous treatment suffered major complications (pancreatitis, cholangitis, or tract perforation). Three of 67 (44%) patients followed after endoscopic treatment suffered major complications (pancreatitis, cholangitis, or bleeding). When the initial method of treatment failed, the alternative was used, resulting in an overall success rate of bile duct clearance of 94.3%. It is concluded that percutaneous and endoscopic methods of bile duct clearance in patients with a T tube in situ are equally effective, carrying similar complication rates. This study has helped to clarify the indications and efficacy of these alternative treatments.

Postnatal transmission of human immunodeficiency virus type 1 from mother to infant. A prospective cohort study in Kigali, Rwanda

BACKGROUND

Although transmission of human immunodeficiency virus type 1 (HIV-1) from mother to infant has been well documented during pregnancy and delivery, little is known about the possible transmission of HIV-1 during the postnatal period.

METHODS

We conducted a prospective cohort study in Kigali, Rwanda, of 212 mother-infant pairs who were seronegative for HIV-1 at delivery. All the infants were breast-fed. The subjects were followed at three-month intervals, with Western blot assays for antibodies to HIV-1 and testing of mononuclear cells by a double polymerase chain reaction (PCR) using three sets of primers. To evaluate potential risk factors, each mother who seroconverted was matched with three seronegative control women.

RESULTS

After a mean follow-up of 16.6 months, 16 of the 212 mothers became seropositive for HIV-1. Of their 16 infants, 9 became seropositive. One infant was excluded from the analysis because of a positive test by PCR on the blood sample obtained at birth. Postnatal seroconversion to HIV-1 occurred in four of the five infants born to the mothers who seroconverted during the first 3 months post partum, and in four infants of the 10 mothers who seroconverted between month 4 and month 21. In all cases, the infant seroconverted during the same three-month period as the mother. The main risk factor for maternal seroconversion was being single.

CONCLUSIONS

HIV-1 infection can be transmitted from mothers to infants during the postnatal period. Colostrum and breast milk may be efficient routes for the transmission of HIV-1 from recently infected mothers to their infants.

Helicobacter pylori in children with peptic ulcer and their families

Little is known about the source and spread of Helicobacter pylori, but transmission from infected family contacts has been suggested. We have therefore investigated 15 children with peptic ulcer and their first-degree relatives for H. pylori. Serum anti-H. pylori IgG, pepsinogen I, and gastrin levels were measured. Endoscopy was carried out on the children and relatives, and biopsies were taken from the gastric antrum for histology, microbiology, and urease testing. Six of 11 children with duodenal ulcer (55%) and two of four children with gastric ulcer (50%) were positive for H. pylori. Fourteen of 16 parents (87%) and eight of 13 siblings (61%) of H. pylori-positive children with peptic ulcer were also infected compared with eight of 14 parents (57%) and none of four siblings of H. pylori-negative children with peptic ulcer (P less than 0.10, greater than 0.05, and NS, respectively). The children with H. pylori-negative peptic ulcer and negative siblings combined were younger than positive children with peptic ulcer and positive siblings (P less than 0.001). The reliability of serum anti-H. pylori IgG level as a screening test for infection was confirmed. These findings call into question a pathogenetic role for H. pylori in some childhood peptic ulceration, but do suggest that person-to-person spread of infection occurs.

Activation of human immunodeficiency virus type 1 by oxidative stress

An important aspect of the infection by the human immunodeficiency virus (HIV-1) type 1 is its clinical latency, suggesting that the virus itself or the provirus may remain latent for extended periods of time after primary infection. Certain heterologous viral proteins or chemical and physical agents are able to reactivate latent virus. Since a common denominator shared by these agents is the ability to cause stress response in cells, we have examined the effects of oxidative stress mediated by hydrogen peroxide (H2O2) on HIV-1 latently infected promonocytic cell line termed U1. After exposure to H2O2 in concentrations ranging from 0.1 to 2 mM, the viability of the U1 cells decreased during 24 h before recovery. At 24 h post stress, the U1 cells began to express virus as assessed by elevated reverse transcriptase activities in culture supernatants. Immunofluorescence carried out on stressed U1 cells using anti-HIV-1 polyclonal antibodies showed that H2O2 leads to HIV-1 gene expression activation, but not to a release of viral particles from damaged cells. Additionally, using a HeLa cell line containing integrated the bacterial chloramphenicol acetyl transferase (CAT) gene under the control of the HIV-1 long terminal repeat (LTR), we have shown that oxidative stress mediated by H2O2 allows transactivation of the viral LTR revealed by intracellular CAT activity. A stimulation factor of around 4 of CAT activity can be reached when these cells are treated with 0.5 mM H2O2.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum pepsinogen I and gastrin concentrations in children positive for Helicobacter pylori

Serum pepsinogen I, serum gastrin concentration, and inflammatory scores were measured in a population of 71 children undergoing upper gastrointestinal endoscopy for investigation of upper abdominal pain. Forty four were initially colonised with Helicobacter pylori. The indices were measured before treatment (in 71 children), one month (in 41 children), and six months (in 21 children) after stopping treatment. Before treatment there was a significant correlation between serum pepsinogen concentration, total inflammatory score, and H pylori state, but no correlation between serum gastrin concentrations and H pylori state. Similarly, the total inflammatory score and serum pepsinogen concentrations were significantly correlated. There was no such correlation in children negative for H pylori. After treatment the inflammatory score improved in those patients in whom H pylori had been eradicated. There was also a significant fall in serum pepsinogen I and serum gastrin concentration in those patients in whom H pylori had been eradicated. These results were similar to those found six months after treatment had been stopped. These findings suggest that the serum pepsinogen I concentration could be considered a useful marker for gastritis and can be used as an index of severity of gastritis in H pylori positive subjects. The measurement of serum gastrin concentrations does not give useful information.

Needle knife papillotomy: how safe and how effective?

Between January 1986 and July 1988 needle knife papillotomy was attempted in 103 patients after failure of conventional access for endoscopic sphincterotomy (96 cases) or diagnostic cholangiography (seven cases). Access was obtained at the same session in 36 cases and at a subsequent attempt within 2 to 5 days in a further 43, an overall success rate of 77%. The procedure related morbidity and mortality in the therapeutic group were 5.2% and 2.0% respectively. There were no deaths or complications in the diagnostic group. Needle knife papillotomy is a valuable adjunct to conventional techniques of biliary access.

Endoscopy in dyspeptic patients: is gastric mucosal biopsy useful?

Should dyspeptic patients coming to endoscopy with "normal" findings also be biopsied? To assess this, we studied the sensitivity and specificity of endoscopic examination compared with histology, microscopic evidence of Helicobacter pylori, CP-TEST, culture, and serum IgG and IgA antibody titers to H. pylori to determine whether endoscopy and antral biopsies really are useful. One hundred seven consecutive dyspeptic patients (mean age 43 yr) were entered. Four antral biopsies were taken routinely for evaluation by histology, microscopy, CP-TEST, and culture. Serum IgG and IgA antibody levels were measured in all patients. Of symptoms, postprandial bloating was statistically more common in H. pylori-positive than in negative patients. Endoscopy had the poorest sensitivity (37.1%) and specificity (53.3%). Patients with normal endoscopic appearances but histologically confirmed gastritis had significantly higher IgG and IgA titers than the patients normal by both endoscopy and histology and without evidence of H. pylori. This study has shown that endoscopy is unhelpful in dyspeptic patients if endoscopic biopsies are not routinely taken.

Mouse mammary tumor virus (MMTV) infection in SWISS and RIII mice. Correlation between resistance to exogenous infection and anti-MMTV serum response

Host-virus relationships were examined in mice from the two mouse mammary tumor virus (MMTV)-infected strains SWISS MB+ and RIII, which harbour the same MMTV variant, and from the derived sublines Swiss MB- and RIIIf, which were freed of milk-borne MMTV by foster-nursing. These two strains are not phylogenetically related, the SWISS strain bearing the endogenous Mtv-3 locus in its DNA. In RIII and SWISS MB+ mice, the incidence of early mammary tumors, which was of 96% and 8%, respectively, was correlated to the level of MMTV expression in milk. In the SWISS MB-line, a non-coordinate expression of the provirus associated with the Mtv-3 locus was observed in the mammary glands, the salivary glands and the spleen. This expression was not tumorigenic and was characterized by the presence of the p28 gag antigen and the absence of the gp52 env antigen, except, however, in mammary glands of elder mice where traces of gp52 were found. In the mammary glands of SWISS MB+ mice, the expression of the Mtv-3 locus was masked by large amounts of antigens resulting from exogenous virus expression. RIIIf mice were MMTV-negative. Viral antigens coexisted with anti-MMTV antibodies in the serum of infected and tumor-bearing mice, but not in the form of immune complexes as verified by a method that allowed to detect specific antigen-containing-soluble immune complexes. An anti-MMTV serum reactivity was also detected in SWISS MB- and RIIIf mice. However, the serum response was higher in the two SWISS lines than in the two RIII lines. Except in tumor-bearing mice, the anti-MMTV response was not significantly modified by the presence of exogenous virus and thus resulted essentially from exposure to endogenous MMTV expression. In experimental infection studies, RIII mice were more susceptible to MMTV infection than SWISS mice. The correlation between resistance to MMTV infection and serum response to endogenous MMTV expression, suggests that the non-tumorigenic expression of an endogenous provirus can protect at least partially, against exogenous MMTV infection.

The diagnosis of small bowel bacterial overgrowth. Reliability of jejunal culture and inadequacy of breath hydrogen testing

The reliability of a single jejunal culture in the diagnosis of small bowel bacterial overgrowth has recently been questioned. Seventy-seven patients thought to have bacterial overgrowth, defined as a jejunal culture yielding at least 10(6) organisms per milliliter of aspirate, took part in the study. Bacterial overgrowth was found in 74% of the patients with predisposing conditions and in 32% of those with no clear causes of bacterial colonization. The intestinal juice of some patients was taken at two different levels of the proximal jejunum, using both the closed- and open-tube systems. Highly significant correlations (rs = 0.90, p less than 0.001) were found between the numbers of bacteria per milliliter at the 2 jejunal levels and between the numbers of bacteria per milliliter of jejunal aspirate obtained from the closed and open tubes (rs = 0.84, p less than 0.001). Compared with the jejunal culture, the gas chromatography of volatile fatty acids in jejunal aspirate and the glucose- and lactulose-hydrogen breath tests showed sensitivities of 56%, 62%, and 68% and specificities of 100%, 83%, and 44%, respectively. This work demonstrates the reliability of jejunal cultures and the inadequacy of breath hydrogen testing in the prediction of positive jejunal cultures. When results of testing for volatile fatty acids in jejunal aspirates are positive, this always indicates the presence of bacterial overgrowth; thus, this procedure would avoid the more complicated, time-consuming, and costly bacteriological analysis of jejunal samples.