Impaired movement control in Alzheimer's disease

Movement accuracy in normal subjects depends on feedforward commands based on representation in memory of spatial and biomechanical features. Here we ask whether memory deficits in Alzheimer's disease (AD) interfere with movement planning and execution. Nine AD patients and nine age-matched controls moved a cursor to targets without seeing their limb. Starting and target positions were always visible on a screen, while, during movement, cursor position was either visible or blanked. Patients' paths showed discontinuous segments and prolonged movement time; movement inaccuracy, which increased without visual feedback, correlated significantly with scores of disease severity, working memory and attention.

Rapid improvement of symptomatology with pantoprazole, amoxycillin and metronidazole in Helicobacter pylori-positive duodenal ulcer patients

BACKGROUND/AIMS

To evaluate the efficacy and tolerability of a new 1-week triple therapy regimen consisting of pantoprazole, amoxycillin and metronidazole.

METHODOLOGY

The study involved 51 Helicobacter pylori (H. pylori) positive patients (M:30, F:21, mean age: 52.5 years, range: 24-75) affected with duodenal ulcer in active phase. At baseline and 6 weeks after the completion of treatment, clinical assessment, endoscopy with gastric biopsies, rapid urease test, 13C urea breath test, and serum laboratory analyses were performed. All patients were treated with pantoprazole 40 mg once daily, plus amoxycillin 1 gram tid and metronidazole 250 mg tid for 1 week, and pantoprazole 40 mg once daily for a second week. A clinical diary for daily assessment of symptoms and side effects was completed by patients during the treatment period.

RESULTS

Three patients were discontinued from the study. Six weeks after therapy, the ulcer was healed in 47 of 48 patients (97.9%, 95% CI = 93.9-100). The cure rates of H. pylori infection, expressed using both the intention-to-treat and per protocol analyses, were 80.4% (95% CI = 69.5-91.3) and 85.4% (95% CI = 75.4-95.4), respectively. The therapy led to a significant, rapid disappearance or reduction in daytime epigastric pain, from 68.8% on day 1 to 82.2% on day 3 (p < 0.001) and in nocturnal epigastric pain, from 80.6% on day 1 to 93.3% on day 3 (p < 0.001). After 2 weeks of treatment, the percentage of patients completely free of pain was 82.2% for daytime pain and 90.3% for nocturnal pain. A rapid improvement in acid regurgitation, heartburn, nausea and vomiting was also observed with a median value of symptom disappearance of 2 days. The percentages of patients completely symptom-free were 37.5% after 1 day, 54.1% after 3 days, 75% after 2 weeks, and 83.3% after 2 months. H. pylori-cured patients showed a significant decrease in the histological activity of both antral (p = 0.0001) and body (p < 0.008) gastritis. Mild to moderate adverse events were reported by 15 patients.

CONCLUSIONS

One week triple therapy with pantoprazole in combination with amoxycillin and metronidazole, followed by a second week of pantoprazole, was well tolerated and highly effective for the 1) rapid improvement or resolution of symptoms; 2) healing of the DU; 3) eradication of H. pylori infection; and, 4) reduction of histological signs of chronic gastritis activity.

Differential distribution of striatal [123I]beta-CIT in Parkinson's disease and progressive supranuclear palsy, evaluated with single-photon emission tomography

Functional imaging of the presynaptic dopaminergic activity using single-photon emission tomography (SPET) and iodine-123 labelled 2-beta-carboxymethoxy-3-beta-(4-iodophenyl)tropane ([123I]beta-CIT) is important for the assessment of disease severity and progression in patients with Parkinson's disease (PD). However, its capability to discriminate between different extrapyramidal disorders has not yet been assessed. The aim of this study was to evaluate the possibility of differentiating patients with PD and with progressive supranuclear palsy (PSP) by means of this method. The distribution of [123I]beta-CIT in the basal ganglia was assessed in six normal subjects, 13 petients with PD and five patients with PSP in whom the disease was mild. SPET images were obtained 24+/-2 h after i.v. injection of the tracer using a brain-dedicated system (CERASPECT). MR and SPET images were co-registered in four normal subjects and used to define a standard set of 16 circular regions of interest (ROIs) on the slice showing the highest striatal activity. The basal ganglia ROIs corresponded to (1) the head of caudate, (2) a region of transition between the head of caudate and the anterior putamen, (3) the anterior putamen and (4) the posterior putamen. A ratio of specific to non-displaceable striatal uptake was calculated normalising the activity of the basal ganglia ROIs to that of the occipital cortex (V3"). ANOVA revealed a global reduction of V3" in all ROIs of PD and PSP patients compared with normal controls (P<0. 0001). A Mann-Whitney U test showed that the difference between PD and PSP patients was statistically significant for the caudate region only (Z value: 2.6; P<0.01). By subtracting V3" caudate values from those of the putamen, differentiation from PSP was possible in 10/13 PD patients. In conclusion, analysis of [123I]beta-CIT distribution in discrete striatal areas provides information on the relative caudate-putamen damage, with different values being obtained in patients clinically diagnosed as having either PD or PSP.

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment

BACKGROUND/AIMS

Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy.

METHODOLOGY

In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy.

RESULTS

The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third.

CONCLUSION

The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.

Cardiovascular adaptations to endurance training and detraining in young and older athletes

In order to evaluate the influence of aging on cardiovascular adaptations to endurance training and detraining, 12 young (range 19-25 years) and 12 older (range 50-65 years) male cyclists were examined during the training and after 2 months of detraining. Twelve young and 12 older healthy sedentary males matched for age and body surface area were used as control groups. Each subject underwent a maximal exercise test using a cycle-ergometer in order to measure maximum oxygen consumption, an M-mode and 2D echocardiography in order to assess left ventricle morphology and systolic function, and a Doppler echocardiography for evaluating the diastolic filling pattern. During the training period both groups of athletes showed higher values of maximum oxygen consumption, left ventricular wall thicknesses, end-diastolic diameter and volume, as well as left ventricular mass, than their control subjects; in the older subjects the adaptation of the heart to aerobic training seems to be obtained mainly through a higher increase in left ventricular diastolic filling. In both groups no significant modifications in the ejection fraction and diastolic function parameters were recorded. After the detraining period the wall thicknesses decreased only in young athletes, while left ventricular mass and end-diastolic diameter and volume reduced only in older athletes. In conclusion, training and detraining induced nearly similar left ventricular morphological modifications in the two age groups, even though greater in the older athletes with respect to the ventricular mass and volume. No relevant differences were observed in the Doppler filling pattern between athletes and sedentary controls.

Omeprazole in patients with mild or moderate reflux esophagitis induces lower relapse rates than ranitidine during maintenance treatment

BACKGROUND/AIMS

Patients with reflux esophagitis have rapid relapses after treatment withdrawal. This study was designed to investigate the relapse rate of symptomatic esophagitis during maintenance treatment with omeprazole versus ranitidine after the induction of acute healing with omeprazole.

METHODOLOGY

Patients with endoscopically verified acute erosive or ulcerative esophagitis (grade 2 or 3) were initially treated with 20 mg of omeprazole daily for 4, 8, or 12 weeks. After healing, the patients were randomized to maintenance treatment with omeprazole (20 mg every morning) or ranitidine (150 mg twice daily). A control endoscopy was performed at the end of the healing phase and after 6 months of maintenance treatment or symptomatic relapse.

RESULTS

Of 231 initially treated patients, 223 were healed (no erosive esophagitis) and entered the maintenance study. The estimated proportions of patients in remission after 6 months of maintenance treatment with 20 mg of omeprazole once per day (n = 102) and 150 mg of ranitidine twice per day (n = 103) were 89.2% and 75.7%, respectively. The single daily dose of omeprazole worked significantly better than the doses of ranitidine (p < 0.001). The omeprazole group, in comparison to the ranitidine group, had a significantly higher number of patients without symptoms (37.8% vs 54.7%) and a lesser percentage of moderate symptoms (9.45% vs 19.8%).

CONCLUSIONS

Maintenance treatment with omeprazole (20 mg once daily) is superior to ranitidine (150 mg twice daily) in keeping patients with mild to moderate erosive reflux esophagitis in remission over a 6-month period.

EEG coherence in Alzheimer's disease

EEG coherence can be used to evaluate the functionality of cortical connections and to get information about the synchronization of the regional cortical activity. We studied EEG coherence in patients affected by clinically probable Alzheimer's disease (AD) in order to quantify the modifications in the cortico-cortical or cortico-subcortical connections. The EEGs were recorded in 10 AD patients (with mild or moderate degrees of dementia) and in 10 normal age-matched subjects, at rest and eye-closed, from 16 electrodes with linked-ears reference. Spectral parameters and coherence were calculated by a multichannel autoregressive model using 50 artifact-free epochs, 1 s duration each. Alpha coherence was significantly decreased in 6 patients, the decrease being more accentuated in the area near the electrode taken into account; a significant delta coherence increase was found in a few patients between frontal and posterior regions. The AD group showed a significant decrease of alpha band coherence, in particular in temporo-parieto-occipital areas, more evident in patients with a more severe cognitive impairment. These abnormalities could reflect two different pathophysiological changes: the alpha coherence decrease could be related to alterations in cortico-cortical connections, whereas the delta coherence increase could be related to the lack of influence of subcortical cholinergic structures on cortical electrical activity.

Cytotoxin-associated gene A-positive Helicobacter pylori infection in the elderly. Association with gastric atrophy and intestinal metaplasia

To evaluate if the infection with strains of cytotoxin-associated gene A (CagA)-positive Helicobacter pylori is associated with either peptic ulcer and gastric atrophy or intestinal metaplasia in the elderly, we studied 71 H. pylori-positive patients older than 62 years old (34 men, 37 women; mean age, 77.5 years; range, 62-89 years) affected with gastric ulcer (GU) (n = 10), duodenal ulcer (DU) n = 22), or chronic gastritis (CG) (n = 39). H. pylori infection was documented by means of gastric histology, rapid urease test, and polymerase chain reaction (PCR) assay performed on gastric biopsies using two sets of primers: one for the ureC gene specific for H. pylori, and the second specific for the CagA gene. H. pylori-CagA positivity was significantly more common in patients with GU (9 of 10, 90%) than with DU (11 of 22, 50%; p < 0.05) or CG (17 of 39, 43.5%; p = 0.01). Gastric atrophy and intestinal metaplasia were significantly more common in CagA-positive patients than in CagA-negative patients (gastric atrophy: 40.54% vs 11.76, p = 0.007; intestinal metaplasia: 40.54% vs 14.70%, p = 0.01). No difference in prevalence of gastric atrophy and intestinal metaplasia was found in patients divided according to pathology (GU, DU, or CG). Logistic regression demonstrated that gastric atrophy and intestinal metaplasia were independent factors significantly associated with CagA-positivity (gastric atrophy: odds ratio = 4.53, 95% confidence interval 1.25-16.4; intestinal metaplasia: odds ratio = 3.44, 95% confidence interval 1.01-11.7). Our findings help to confirm the hypothesis that an infection with CagA-positive H. pylori strains may be catalytic in inducing gastric changes which can evolve into malignancies.

Dual therapy with high or low doses of omeprazole does not achieve an acceptable rate of Helicobacter pylori eradication in duodenal ulcer patients. A multicentre randomized long-term detailed study

BACKGROUND

It has been reported that dual therapy with high doses of omeprazole and amoxycillin proves efficient for Helicobacter pylori eradication.

AIM

To compare the efficacy, safety and tolerability of eradicating regimens with omeprazole/amoxycillin.

METHODS

In this randomized multicentre study, 267 duodenal ulcer patients were treated for 2 weeks with omeprazole 40 bid (Group A) or 20 mg bid (Group B), respectively, and with amoxycillin 0.5 g. qid followed by 4 weeks of 20 mg omeprazole om. Helicobacter pylori status was assessed by both histology and urease test in the antrum and the corpus. The patients were then followed-up for 9 months.

RESULTS

Helicobacter pylori infection was cured in 62.9% of group A (95% CI: 53.8-71.4) and in 44.8% of group B (95% CI: 35.6-54.3; p = 0.007). Healing was achieved in 91.9% of patients in group A (95% CI:85.7-96.1), and in 87.9% of patients in group B (95% CI:80.6-93.2). The estimated probability of being in ulcer remission for cured patients was 0.95 (95% CI: 0.90-0.99) and for the not cured was 0.41 (95% CI: 0.24-0.59; p = 0.0001). However, between the two treatment groups no significant differences in symptom relief or ulcer recurrence were observed. Both regimens were well tolerated with minor side-effects occurring likewise within the two groups. At two months in cured patients antral histology revealed a total (group A + B) prevalence of 13.7% of active chronic gastritis.

CONCLUSIONS

This long-term, large-size study clearly indicates that dual therapy does not represent a truly effective eradication therapy and this regime cannot be recommended.

The effect of Helicobacter pylori infection on NSAID-related gastroduodenal damage in the elderly

OBJECTIVE

To evaluate the effect of Helicobacter pylori infection on the prevalence and severity of non-steroidal anti-inflammatory drug (NSAID)-related upper gastrointestinal lesions in the elderly.

PATIENTS AND METHODS

One hundred and twenty-eight symptomatic NSAID users (47 males, 81 females; mean age 79.5 years, range 67-95 years) were evaluated by endoscopy. NSAID use was evaluated at the time of endoscopy by interview and general practitioners' clinical records. Patients were separated by the following use patterns: (1) Occasional Users: patients who had taken NSAIDs sporadically, on an as-needed basis in the 7-day period before endoscopy; (2) Acute Users: patients who had taken NSAIDs regularly during the last month; and (3) Chronic Users: patients who had taken NSAIDs regularly for more than 1 month. H. pylori infection was diagnosed by gastric histology (modified Giemsa stain) and the rapid urease test. Statistical analysis was performed by means of the chi 2 test with standardized deviates.

RESULTS

Of the 128 subjects, 107 (83.6%) presented with gastroduodenal damage: 3 patients (2.3%) had erosive oesophagitis; 38 patients (29.7%) had gastric ulcer (GU); 43 patients (33.6%) had duodenal ulcer (DU); 3 patients (2.3%) had both GU and DU and 20 patients (15.6%) had erosive gastritis. Seventy-four of the 128 patients (57.8%) were found to be H. pylori positive. In comparison to H. pylori-negative subjects, those who were H. pylori-positive had a significantly higher percentage of GU and DU (74.3% vs. 53.7%, P = 0.02) and a lower percentage of non-gastroduodenal lesions (10.8% vs. 24.0%, P = 0.05). No significant trend in H. pylori positivity was found in the 50/128 (39.06%) patients who presented with bleeding lesions (H. pylori positive 36.5%, H. pylori negative 42.6%, not significant). At endoscopy 78% of occasional NSAID users, 93.8% of acute users and 88.7% of chronic users presented with upper gastrointestinal lesions (not significant). No significant differences in NSAID use patterns were observed between H. pylori-positive and H. pylori-negative subjects.

CONCLUSION

H. pylori infection in the elderly is associated with an increase in the NSAID-related GU and DU, but not with a higher prevalence of upper gastrointestinal bleeding.

Helicobacter pylori eradication in the healing and recurrence of benign gastric ulcer: a two-year, double-blind, placebo controlled study

BACKGROUND

Helicobacter pylori infection is associated with idiopathic gastric ulcer in about 90% of the cases, but only a few controlled studies aimed at evaluating gastric ulcer healing and the natural history after Helicobacter pylori-eradication have been carried out.

OBJECTIVE

The aim of the present study was to evaluate the efficacy of omeprazole coupled with amoxicillin in the eradication of Helicobacter pylori and healing and prevention of gastric ulcer recurrence.

PATIENTS

Fifty-nine patients with active gastric ulcer were randomized under double-blind conditions to receive either omeprazole 20 mg twice daily for four weeks plus amoxicillin 3 g daily during the first and second week (29 patients, Group A) or omeprazole .20 mg twice daily for 4 weeks plus placebo for two weeks (30 patients, Group B).

METHODS

Endoscopic studies were carried out at the end of the 4 weeks treatment (or after 8 weeks in non-healed patients) as well as 2, 6 and 12 months later. A total of 3 biopsies in the antrum, 3 in the gastric body and at least seven at the edge of the crater were taken at each endoscopic control for exclusion, of malignancy, histological detection of Helicobacter pylori and for evaluation of gastric histology according to the Sydney system.

RESULTS

With intention to treat analysis, the percentage of healing after 4 and 8 weeks was 86% and 100% in Group A patients and 86% and 93% in Group B, respectively. Two patients dropped out in Group B for non medical reasons. The percentage of eradication was 63% in Group A and 7% in Group B. During a 12-month follow-up gastric ulcer relapsed in 20/32 (63%) of the persistently Helicobacter pylori positive patients. Only two out 20 (10%) Helicobacter pylori cured patients showed a gastric ulcer relapse and Helicobacter pylori reinfection. Twenty out of 30 patients, still healed after 12 months, underwent endoscopic control after two years. A gastric ulcer relapse was observed in three out of nine (33%) patients with persisting infection after treatment. No gastric lesions, but one case of erosive oesophagitis were observed in the 11 Helicobacter pylori-eradicated patients.

CONCLUSIONS

In our experience, Helicobacter pylori eradication does not favour gastric ulcer healing but does positively influence the subsequent natural history.

Omeprazole for severe reflux esophagitis in children

BACKGROUND

Severe esophagitis is a rare complication of gastroesophageal reflux in children. In adults, omeprazole therapy of severe erosive esophagitis has become the gold standard short-term treatment of the disease. In children, data on its use are limited, and problems about the dosage are unresolved. The aim of this study was to evaluate the efficacy of a simplified, body-weight-based daily dosage of omeprazole in children with severe esophagitis.

METHODS

Ten children (median age 75.6 months; range 25-109 months) with severe esophagitis were prospectively investigated. All patients were evaluated by endoscopy, histology, and 24-h pH-metry study before and after 3 months of omeprazole. The starting dose of omeprazole was 20 mg as a single daily dose in children weighing less than 30 kg, and 40 mg daily for those weighing over 30 kg.

RESULTS

A significant improvement in all the children was demonstrated after 3 months of treatment by clinical, endoscopic, and pH-metry assessment. However, histologic study failed to show significant improvement of both inflammatory and hyperplastic findings. Relapse occurred in six of 10 patients after discontinuation of therapy.

CONCLUSIONS

Omeprazole is effective in the short-term treatment of severe oesophagitis in children. The daily dose of the drug could be easily based on the body weight. The persistence of histologic features of esophagitis in spite of clinical and endoscopic healing could be an indicator of poor outcome.

Role of Helicobacter pylori infection on upper gastrointestinal bleeding in the elderly: a case-control study

Nonsteroidal antiinflammatory drug (NSAID) use is known to be associated with a high incidence of upper gastrointestinal tract bleeding in the elderly. The increased prevalence of Helicobacter pylori (HP) infection, which also occurs with age, suggests that an interaction between NSAID use and HP infection may explain the higher incidence of ulcer complications in the elderly. The aim of the present study was to determine if a relationship exists between HP infection and NSAID use in elderly patients with upper gastrointestinal bleeding. This was a case-control study on 146 elderly patients (73/group). The bleeding group consisted of 37 males and 36 females (mean age 80.4 years, range 70-96) with symptoms (hematemesis, melena, anemia with loss of more than 3 g hemoglobin), and endoscopic stigmata of bleeding. The control group consisted of 73 age- and sex-matched patients with the same endoscopic diagnosis but with no endoscopic stigmata of bleeding. NSAID use was evaluated by interview at the time of endoscopy, and HP infection was confirmed in all cases by histology and the rapid urease test. Statistical analyses were performed using the chi-square test and logistic regression. In both groups, 46.57% of patients were affected with gastric ulcer, 36.98% with duodenal ulcer, and 16.43% with erosive gastritis. The bleeding group had a significantly higher percentage of NSAID users (53.42% vs 19.17%, P < 0.0001) and a lower percentage of HP-positive patients (47.94% vs 72.60%, P = 0.004). The NSAID use pattern was as follows: occasional users (sporadic, as needed during the previous week): 53.8% of bleeding cases and 50% of controls; acute users (continuous therapy for less than one month): 17.9% of bleeding cases and 28.5% of controls; and chronic users (continuous therapy for more than one month): 28.2% of bleeding cases and 21.4% of controls. The logistic regression demonstrated that NSAID use was significantly related to an increase risk of bleeding both in gastric (odds ratio: 4.98, 95% CI: 1.83-13.6) and duodenal ulcer patients (odds ratio: 10.2, 95% CI: 2.25-46.7) while HP-positivity presented a significant inverse relationship with bleeding only in subjects with gastric lesions (odds ratio: 0.20, 95% CI: 0.07-0.55). NSAID use and HP infection were also shown to be independent, unrelated factors, with the overall risk of bleeding in HP-positive NSAID users identified to be significantly less than in HP-negative NSAID users. In conclusion, in elderly patients: (1) NSAID use increases the risk of upper gastrointestinal bleeding while HP infection was associated with a low risk for gastric bleeding; and (2) the two factors are independent variables, therefore the HP-positive NSAID user has a lower risk than the HP-negative NSAID user.

Efficacy of intravenous propafenone in termination of atrial flutter by overdrive transesophageal pacing previously ineffective

Fifty patients with symptomatic type I atrial flutter in whom termination of the arrhythmia with transesophageal stimulation was unsuccessful were randomized to undergo a repeat procedure after intravenous propafenone (n = 25) or placebo (n = 25). Immediate sinus rhythm recovery rate was 36% in the propafenone group and 4% in the placebo group (p = 0.005), indicating that intravenous propafenone increases the rate of successful transesophageal stimulation and can be used when a first attempt at conversion is ineffective.

Headache in a population-based elderly cohort. An ancillary study to the Italian Longitudinal Study of Aging (ILSA)

The aims of this ancillary study to the Italian Longitudinal Study of Aging were: (1) to provide reliable prevalence data on headache in an elderly population, (2) to classify the subtypes of headache according to International Headache Society criteria, and (3) to identify possible risk factors and associated pathologies in the elderly. A total of 312 subjects were examined, 148 women and 164 men, with a mean age of 73 years (SD 5.5). For 236 subjects (75.7%), 141 men (85.9%) and 95 women (64.2%), headache had never been a problem; 57 subjects (18.3%), 21 men (12.8%) and 36 women (24.3%), reported troublesome headache only in the past. Nineteen subjects (6%), 6 men (3.6%) and 13 women (8.8%), reported current headache: in this group tension-type headache was the most prevalent, accounting for 2.6%; secondary headaches ranked second, accounting for 2.2%; and only 1% had current migraine. Our data indicate female sex and younger age as risk factors for headache, and associate migraine and secondary headaches with hypertension, tension-type headaches and secondary headaches with diabetes, and tension-type headaches with myocardial ischemia.

A PET follow-up study of recovery after stroke in acute aphasics

The neural correlates of recovery from aphasia are largely unknown. Several different sources of evidence, from clinical studies to neurophysiological investigations, have suggested a contribution of the contralateral, undamaged hemisphere in recovery from aphasia. Eight patients with unilateral left hemispheric stroke were submitted to a standard language examination and to a [18F]FDG PET study in the recent phase after stroke (within 2 weeks) and 6 months later. All patients had a substantial recovery of specific aspects of language functions at the follow-up. Analysis of regional glucose metabolism showed hypometabolism in structurally unaffected regions both in the left and in the right hemisphere (diaschisis), in the acute stage. Glucose metabolism increased significantly on both sides in all patients at the second PET study. Regional analysis showed significant positive correlations between changes in metabolic values in several cortical and subcortical regions in the right hemisphere and changes in language performance at follow-up. The present findings show that an extensive, bihemispheric depression of metabolism is found in the acute stage after stroke in aphasic patients. Language recovery in the first months after aphasia onset is associated with regression of functional depression (diaschisis) in structurally unaffected regions, in particular in the right hemisphere.

Cure of Helicobacter pylori infection in the elderly: effects of eradication on gastritis and serological markers

BACKGROUND

Specific data on anti-H. pylori treatments in elderly people are very scarce. The aim of the study was to evaluate in the elderly the efficacy of different anti-H. pylori therapies and the behaviour of serum anti-H. pylori antibodies, pepsinogen A and C, and PGA/PGC ratio induced by the anti-H. pylori treatment.

METHODS

One hundred and twenty-one dyspeptic patients aged > 60 years (mean age, 73 years; range, 61-89 years) with H. pylori-positive gastric ulcers (17 patients), duodenal ulcers (33 patients) or chronic gastritis (71 patients) were treated with one of the following anti-H. pylori treatments: (A) omeprazole 20 mg/day plus azithromycin 500 mg/day for 3 days; (B) omeprazole 20 mg/day plus azithromycin 500 mg/day for 3 days plus metronidazole 250 mg q.d.s. for 7 days; (C) omeprazole 40 mg/day plus azithromycin 500 mg/day for 3 days plus metronidazole 250 q.d.s. for 7 days; (D) omeprazole 20 mg/day plus clarithromycin 250 b.d. for 7 days; (E) omeprazole 20 mg/day plus clarithromycin 250 b.d. for 7 days plus metronidazole 250 q.d.s. for 7 days; and (F) omeprazole 40 mg/day plus clarithromycin 250 mg b.d. for 7 days plus metronidazole 250 mg q.d.s. for 7 days. At the baseline and 2 months after therapy, endoscopy and serum anti-H. pylori antibodies, pepsinogen A and C, and PGA/PGC ratio were measured.

RESULTS

Ten patients (8.2%) dropped out of the study. Six patients (4.9%) reported side-effects. The eradication rates of the six regimens, expressed using intention-to-treat and per protocol analysis, were, respectively: (A) 39% and 44%; (B) 50% and 56%; (C) 65% and 77%; (D) 47% and 50%; (E) 85% and 90%; and (F) 83% and 87%. The triple therapy for regimens E and F was significantly more effective than dual therapies (regimens A and D; intention-to-treat = P < 0.007, per protocol = P < 0.001) or the triple therapy for regimens B and C (intention-to-treat = P < 0.009, per protocol = P < 0.03). Patients cured of H. pylori infection showed a significant decrease in the activity of gastritis (P < 0.0001), a significant drop in IgG anti-H. pylori (P = 0.0004) and pepsinogen C (P < 0.0001), and an increase in PGA/PGC ratio (P < 0.001), while patients remaining H. pylori-positive showed no changes in the serum parameters.

CONCLUSIONS

In the elderly, triple therapy with omeprazole+metronidazole+clarithromycin for 1 week is well tolerated and highly effective; anti-H. pylori antibody and PGC serum levels decrease soon after anti-H. pylori therapy only in patients cured of H. pylori infection.

Partial regression of Barrett's esophagus by long-term therapy with high-dose omeprazole

BACKGROUND

Barrett's esophagus is mainly regarded as an acquired condition related to increased gastroesophageal reflux. Thus it is conceivable that abolition of acid reflux would lead to its regression. The aim of this study was to assess whether long-term treatment with high-dose omeprazole (60 mg/day) produces a consistent control of gastric acid production and normalizes the esophageal acid exposure, thus reducing the length of Barrett's epithelium.

METHODS

Fourteen patients (8 men and 6 women, mean age 52 years) with histologic diagnosis of columnar epithelium longer than 3 cm in the distal part of the esophagus were enrolled and began receiving 60 mg of omeprazole in a single daily morning dose. Before therapy and after 6 and 12 months of therapy, all patients had endoscopy with four-quadrant biopsies at 2 cm intervals. A 24-hour esophagogastric pH recording was performed at entry and after 10 days, 6 months, and 12 months of treatment in all patients.

RESULTS

The initial length of Barrett's epithelium (4.5 +/- 1.9 cm) was significantly reduced after 6 months (3.1 +/- 1.1; p < 0.01) and 12 months (2.1 +/- 1.6; p < 0.005) of treatment. Values were significantly lower at 12 than at 6 months (p < 0.03). The 24-hour mean gastric pH after 10 days (5.89 +/- 0.58), 6 months (5.71 +/- 0.55), and 12 months (5.54 +/- 0.76) of therapy was always higher (p < 0.001) than the basal level (1.9 +/- 0.49). No significant difference in gastric pH was seen over the treatment period. The 24-hour mean percent of time in which pH in the esophagus was below 4.0 decreased significantly (p < 0.001) from a basal rate of 29.4% to 3.5%, 3.0%, and 4.9% in the various time intervals of therapy. There was a normalization of esophageal acid exposure in all patients but two.

CONCLUSIONS

It can be concluded that the antisecretory effect of 60 mg/day of omeprazole is consistent and is kept constant throughout the entire 1-year treatment period. The consequent normalization of esophageal acid exposure in almost all patients in our series led to a partial, but significant, regression in the length of Barrett's epithelium.

The clinical usefulness of serum pepsinogens, specific IgG anti-HP antibodies and gastrin for monitoring Helicobacter pylori treatment in older people

OBJECTIVE

To evaluate the clinical usefulness of Pepsinogen A (PGA) and C (PGC), PGA/PGC ratio, gastrin, and specific IgG anti-HP antibodies (anti-HP Ab) in monitoring the effect of cure for Helicobacter pylori (HP) infection in older people.

DESIGN

We studied the changes in serum parameters (PGA, PGC, PGA/PGC ratio, gastrin and anti-HP Ab) in older patients before and 2 months after stopping therapy for the cure of HP infection.

PATIENTS

Eighty-eight older patients (M = 43, F = 45, mean age = 73.3, range = 60-89) with chronic gastritis (42), gastric ulcer (14) or duodenal ulcer (32) were found HP-positive by histology of gastric antral and body biopsies and the rapid urease test.

INTERVENTIONS

Two different associations of antibiotics and antiulcer drugs (omeprazole, metronidazole, azithromycin, or clarithromycin) for 2-4 weeks.

MEASUREMENTS

At the beginning of the study and 2 months after treatment withdrawal, the subjects were studied by upper G.I. endoscopy with at least two antral and two body gastric biopsies (Giemsa stain and rapid urease test for HP); serum PGA (RIA method, microgram/mL), PGC (RIA method, microgram/mL), PGA/PGC ratio, gastrin (RIA method, picogr/mL), and anti-HP Ab (ELISA method, Biolife, MU/mL) were also determined. Statistical analysis was based on either the Wilcoxon test, for paired data, the chi-square test, the Kruskal Wallis test, or the Mann-Whitney test for unpaired data. The choice of the best cut-off value in the different parameters was performed by receiver operating characteristics curves (ROC) and by Youden index. The correlation between HP density in the gastric mucosa and gastritis activity was verified by Spearman rank correlation test.

RESULTS

After therapy, 56/88 patients proved HP-negative (HP-eradicated: M = 30, F = 26, mean age = 73.0, range = 60-87 years), whereas 32/88 were not cured (HP-persistent: M = 13, F = 19, mean age = 73.0, range = 60-89 years). After therapy, in HP-eradicated cases, a statistically significant change was found in anti-HP Ab (75.23 +/- 8.94 vs 47.32 +/- 5.26, P < .001), PGC (21.58 +/- 1.97 vs 14.34 +/- 1.75, P < .001), and PGA/PGC ratio (8.46 +/- 0.68 vs 11.54 +/- 0.89, P < .001), but not in PGA and gastrin. On the other hand, in HP-persistent cases, anti-HP Ab, PGA, PGC, PGA/ PGC ratio and gastrin did not change after therapy. The sensitivity and specificity were, respectively, 0.62 and 0.56 for anti-HP Ab and 0.75 and 0.56 for the PGA/PGC ratio, which demonstrated the best diagnostic accuracy (68%).

CONCLUSIONS

The eradication of HP from the stomach of older patients induces a rapid and significant decrease in serum levels of IgG anti-HP antibodies and PGC, with an increase in PGA/PGC ratio but not in gastrin. Unchanged serum levels of IgG anti-HP antibodies, PGC, and PGA/PGC ratio 2 months after completing HP eradication therapy are indicative of ongoing HP infection. The PGA/PGC ratio showed the best diagnostic accuracy among serum measures tested.

Endogenously labeled thyroid hormones (131I-T3/T4) in sera of patients with differentiated thyroid carcinoma

Patients with differentiated thyroid carcinoma (DTC), who have undergone thyroidectomy and radioablation with iodine (131I), are usually monitored with ultrasonography (US) of the neck, 131I whole body scan (WBS), and determination of thyroglobulin (Tg) concentrations in serum. A chromatographic method (CHROM), designed for detection of in vivo labeled thyroid hormones (131I-T3/T4) that circulate in the body after administration of 131I for a WBS, may be used in monitoring of these patients. This study included 35 patients with DTC. Ultrasonography, WBS, Tg, and CHROM method were performed for each of them. One patient was followed-up 6 times, 11 were monitored twice, and the remaining group of 23 patients was examined only once (51 diagnostic tests). We found CHROM results to be in disagreement with the WBS and/or Tg findings in three patients out of 35 at the time of the first visit. In one of them WBS was negative, while Tg and CHROM findings were positive. In this patient the local metastases were proven by US with fine needle biopsy (FNB). In another patient (without signs of thyroid tissue remnant, determined by WBS, Tg, and US) only CHROM was positive. Finally, in the third patient, a thyroid remnant was proven positive on WBS and US (negative CHROM and Tg). We registered an additional peak (peak 4) in chromatograms of 12 out of 35 patients. This component could be tentatively characterized as 3,3'-diiodo-L-thyronine (131I-3,3'-T2). Although this preliminary study included a small number of patients, we show that the CHROM method can be useful as an additional test in monitoring of patients with DTC, especially those with discordant WBS and Tg results.