Eradication of Helicobacter pylori using one-week triple therapies combining omeprazole with two antimicrobials: the MACH I Study

BACKGROUND

Eradication of Helicobacter pylori provides potential cure in the majority of patients with peptic ulcer disease, and eradication rates of more than 90% have been reported, using omeprazole in combination with two antimicrobials. The choice of antimicrobials, dose regimen and duration of treatment have varied between studies, however, and an optimal treatment still has to be established.

MATERIALS AND METHODS

We conducted an international, randomized, double-blind, placebo-controlled study involving more than 100 patients in each of six treatment groups in 43 hospital gastrointestinal units in Canada, Germany, Ireland, Sweden, and the United Kingdom. Patients (n = 787) with proved duodenal ulcer disease were randomized to treatment twice daily for 1 week with omeprazole, 20 mg (O), plus either placebo (P) or combinations of two of the following antimicrobials: amoxicillin, 1 gm (A), clarithromycin, 250 or 500 mg (C250, C500), or metronidazole, 400 mg (M). Eradication of H. pylori was evaluated by 13C-UBT, performed before and 4 weeks after treatment cessation.

RESULTS

The eradication rates for the all-patients-treated analysis were 96%, OAC500; 95%, OMC250; 90%, OMC500; 84%, OAC250; 79%, OAM; and 1%, OP. OAC500 and OMC250 achieved eradication rates with lower 95% confidence interval limits exceeding 90%. All regimens were well-tolerated, 96% of patients complied with their dose regimen, and 2.3% of the patients discontinued treatment owing to adverse events.

CONCLUSIONS

Omeprazole triple therapies given twice daily for 1 week produce high eradication rates, are well-tolerated, and are associated with high patient compliance. The two most effective therapies were those combining omeprazole, 20 mg, with either amoxicillin, 1 gm, plus clarithromycin, 500 mg, or metronidazole, 400 mg, plus clarithromycin, 250 mg, all given twice daily.

Serial hematologic changes and pregnancy outcome

OBJECTIVE

To reevaluate the concept that poor maternal hematologic changes relate to increased placental protein hormones, increased birth weight, and placenta to birth weight ratio.

METHODS

Sixty-nine normal women were studied prospectively. On several occasions, pre-pregnancy, during pregnancy, and post-delivery, plasma volume was measured together with maternal hematologic indices and placental protein hormone levels. Birth weight and placental weight were measured at delivery.

RESULTS

The decrements in hemoglobin concentration and hematocrit were apparent by 7 weeks' gestation. By 12 weeks, these progressive changes resulted mostly from the increase in plasma volume, and both hemoglobin concentration and hematocrit continued to decrease until near term. Increments in red cell and hemoglobin mass were maximal at 12-28 weeks of pregnancy. Concentrations of the placental hormones hCG and human placental lactogen at 12 weeks showed a lack of correlation with hemoglobin concentration or any other hematologic index. The correlations of birth weight with hemoglobin concentration and hematocrit at 36 weeks were not significant when we controlled for the effect of plasma volume. Neither hemoglobin mass at 36 weeks nor the change in hemoglobin concentration, hematocrit, and mean cell volume from the pre-pregnancy value to that at 36 weeks were significantly related to birth weight, placental weight, or the placenta to birth weight ratio.

CONCLUSION

Low hemoglobin in late pregnancy reflects plasma volume changes, rather than poor maternal nutrition or adaptation, and is not linked to discordant placenta to birth weight ratio.

Long-term outcome after ruptured lateral ankle ligaments. A prospective study of three different treatments in 79 patients with 11-year follow-up

In a prospective study of 79 patients with arthrographically verified acute ruptured lateral ankle ligaments we have evaluated the long-term results of 3 different treatments: operation and walking-cast for 5 weeks, walking-cast alone, and elastic bandage. The follow-up period was 11 (9-13) years. Residual disabilities and late complications, such as instability, pain on activity, and the number of ligament reconstructions and talocrural arthroses were equally low in all 3 groups. We conclude that nonoperative treatment seems adequate.

Accessible hyaluronan receptors identical to ICAM-1 in mouse mast-cell tumours

Immunohistochemical studies of the hyaluronan (HA)-receptor (R), originally found on liver endothelial cells (LEC) and related to the intercellular adhesion molecule 1 (ICAM-1), showed that polyclonal antibodies against HARLEC (HA receptor on LEC) also stain structures in mouse mastocytomas, mainly vessels. To test if intravenously administered HA might target the tumour receptors in vivo, mice carrying an inoculated mastocytoma in one hind leg muscle were injected in the tail vein with 125I-tyrosine (T)-labelled HA and killed 75 min after injection when organs and tissues were checked for radioactivity. When doses exceeding the binding capacity of the liver were injected, a significant increase in radioactivity (up to five-fold) within the tumour tissue was found. The weight adjusted difference between control and tumour tissue was greater for smaller tumours, probably due to necrosis in the larger. HA-staining of tumours from animals receiving 125I-T-HA, showed HA in areas that also stained weakly for ICAM-1 using monoclonal antibodies. ICAM-1 staining was dramatically increased after hyaluronidase treatment of the sections, indicating that the HA is bound to these receptors and thereby blocks antibody recognition.

Absorption of non-haem iron from food during normal pregnancy

OBJECTIVE

To determine whether the increased iron demands of pregnancy could be met by increased absorption from dietary sources.

DESIGN AND SETTING

Longitudinal prospective study in the research unit of a maternity hospital.

SUBJECTS

12 normal pregnant women.

INTERVENTIONS

At 12, 24, and 36 weeks' gestation (within one week) and 16-24 weeks after delivery women ate a breakfast of meat, bread, and orange juice (3.2 mg iron), extrinsically labelled with the stable isotope iron-54 (2.8 mg); the stable isotope iron-57 (200 micrograms) was given intravenously.

MAIN OUTCOME MEASURES

Serum samples were taken for 10 hours after administration of the isotopes; ratios of the isotopes were measured by inductively coupled plasma mass spectrometry, and the absorption of oral iron was calculated.

RESULTS

The geometric mean (95% confidence interval) absorption of iron at 12, 24, and 36 weeks' gestation was 7% (5% to 11%), 36% (28% to 47%), and 66% (57% to 76%) respectively. At 16-24 weeks after delivery the absorption was 11% (6% to 21%). The mean increase in absorption at 36 weeks (compared with that at 12 weeks) was 9.1 times (6.0 to 13.7). One pregnant woman developed iron deficiency anaemia but was otherwise indistinguishable from the others.

CONCLUSIONS

An increase in the absorption of iron from food is a physiological consequence of normal pregnancy, not the result of developing anaemia during pregnancy, and such an increase is large enough to meet the increased requirements of pregnancy provided that the dietary intake is adequate.

Comparison of stable isotopes and radioisotopes in the measurement of iron absorption in healthy women

1. Stable isotope methods are being used to investigate the absorption of dietary iron. In order to be certain that this new methodology is accurate, we have compared results obtained using stable isotopes and inductively coupled plasma mass spectrometry with those determined using a radioisotope and whole body counting. 2. The stable isotope 54Fe (2.8 mg) was given to 10 healthy non-pregnant women. Six women received the isotope in aqueous form, and four took it with a meat meal. The 54Fe served as a carrier for 10 ng of the radioisotope 59Fe. An ampoule (200 micrograms) of the isotope 57Fe or 58Fe was then given intravenously, and in serum samples taken over the next 10 h the ratios of the stable iron isotopes were measured by inductively coupled plasma mass spectrometry and the oral iron absorption was calculated. This was then compared with the results obtained by using a whole body counter to measure (on day 0 and day 14) the gamma-activity emitted by the radioisotope. 3. The mean iron absorption measured by both methods ranged from 8% to 45%. Measurement of the post-absorptive serum enrichment of the stable isotopes provided estimates of absorption from both aqueous and food iron which were similar to that yielded by whole body counting, the mean difference being -1.5% (95% confidence interval -5.2 to 2.1%). Absorption estimated by stable isotopes exhibited the same inverse relationship with the serum ferritin level (body iron stores) to that known to exist with whole body counting.(ABSTRACT TRUNCATED AT 250 WORDS)

Biosynthesis of heparin/heparan sulfate. Identification of a 70-kDa protein catalyzing both the D-glucuronosyl- and the N-acetyl-D-glucosaminyltransferase reactions

The D-glucuronosyl- (GlcA) and N-acetyl-D-glucosaminyl- (GlcNAc) transferase reactions involved in heparin/heparan sulfate biosynthesis were assayed, measuring transfer of radiolabeled GlcA or GlcNAc monosaccharide units from the corresponding UDP-sugars to the appropriate oligosaccharide acceptors. The assays were applied to enzyme purification from bovine serum. The two activities remained inseparable through a series of different chromatographic steps, resulting in approximately -2000-fold purification. Further purification was achieved by chromatofocusing, which showed an isoelectric point of pH approximately -7.0, similar for both activities. SDS-polyacrylamide gel electrophoresis (PAGE) of subfractions from the chromatofocusing procedure revealed an approximately 70-kDa protein in amounts reflecting enzyme activity. SDS-PAGE followed by extraction of gel segments and renaturation of proteins showed that the GlcA- and GlcNAc-transferase activities were both recovered from the same single segment, corresponding to the 70-kDa component. It is proposed that the two glycosyltransferase reactions are catalyzed by the same Golgi enzyme (see also Lidholt, K., Weinke, J. L., Kiser, C. S., Lugemwa, F. N., Bame, K. J., Cheifetz, S., Massagué, J., Lindahl, U., and Esko, J. D. (1992) Proc. Natl. Acad. Sci. U.S.A. 89, 2267-2271).

The intravascular mass of albumin during human pregnancy: a serial study in normal and diabetic women

OBJECTIVE

To quantify the changes in serum albumin during human pregnancy.

DESIGN

Longitudinal prospective study.

SETTING

Before conception and antenatal clinic.

SUBJECTS

Sixty-nine normal women and 23 women with Type 1 diabetes.

INTERVENTIONS

Administration of Evans' blue dye and collection of serum samples.

MAIN OUTCOME MEASURES

Albumin concentration, plasma volume and intravascular mass of albumin.

RESULTS

In normal subjects serum albumin concentration showed a significant decrease of 1.9 (95% CI 1.0 to 2.9) g/l by 7 weeks gestation with a further 8.2 (95% CI 7.5 to 8.9) g/l decrease by 36 weeks gestation, an overall change of 22%. Plasma volume first increased significantly by 190 (95% CI 105 to 275) ml between 7 and 12 weeks, with a further increase of 1003 (95% CI 871 to 1135) ml between 12 and 36 weeks of pregnancy, a change of 53%. The intravascular mass of albumin showed no change between non-pregnant, 7 and 12 week values but there was a significant rise of 19.5 (95% CI 15.1 to 23.9) g between 12 and 28 weeks of gestation, an overall increase of 19%. Diabetic subjects showed similar changes.

CONCLUSIONS

Rather than simply reflecting plasma volume dilution, the changes in serum albumin imply alterations in albumin metabolism during pregnancy.

Absorption of non-haem iron in normal women measured by the incorporation of two stable isotopes into erythrocytes

1. Iron absorption has been quantitatively measured as the incorporation of physiological doses of stable iron isotopes into erythrocytes. Five milligrams of 57Fe (orally) and 250 micrograms of 58Fe (intravenously) were given to five healthy women on 2 consecutive days. Fourteen days later the changes in the 57Fe/56Fe and 58Fe/56Fe ratios in the erythrocytes of each subject were measured using an inductively coupled plasma mass spectrometer. Isotope ratios were also measured in two subjects who were not given any enriched isotope. Concomitant measurements of plasma volume using a dye-dilution technique enabled the estimation of body iron mass and the calculation of iron absorption. 2. The mean coefficients of variation for the 57Fe/56Fe ratio and the 58Fe/56Fe ratio were 0.22% and 0.47%, respectively. This precision allowed enrichments of basal ratios to be reliably detected in all cases. The mean change in the 57Fe/56Fe ratio was 0.00116 (SD 0.00052, P < 0.001) and the mean change in the 58Fe/56Fe ratio was 0.00035 (SD 0.00004, P < 0.001). Control subjects showed no enrichment. 3. The calculated iron absorption ranged from 10% to 34%, and the amount of absorption was related to the iron stores of the subjects. Percentage iron absorption was identical when estimates of the plasma volume (derived from a body mass equation) were used instead of the plasma volume determined by dye-dilution measurements. Incorporation of intravenous iron into erythrocytes was on average 81% (range 68-93%). 4. The method is especially applicable to the study of iron absorption during pregnancy when incorporation into erythrocytes cannot be predicted.

Interphotoreceptor retinoid-binding protein and alpha-tocopherol preserve the isomeric and oxidation state of retinol

Retinol decomposes rapidly into a number of products, including its aldehyde form, retinal, when introduced into buffer in phospholipid vesicles or ethanol. Interphotoreceptor retinoid-binding protein at low concentrations is found to protect retinol from isomerization and oxidation. The addition of alpha-tocopherol to either liposomes or an ethanolic-buffer solution also prevents decomposition. Neither of these agents interferes with the successful regeneration of pigment with 9-cis retinal in rod outer segment preparations or the restoration of sensitivity by retinoids in isolated rod photoreceptors.

Five year audit of peripartum blood glucose control in type 1 diabetic patients

An audit was conducted of the degree of blood glucose control achieved during labour using a simple glucose/insulin infusion regimen. Records were examined of 40 pregnancies in 37 women over a 5-year period. Mean blood glucose was 5.2 +/- 2.2 (SD) mmol-1 7 h before delivery and 4.7 +/- 1.8 mmol-1 1 h before delivery. Four women experienced mild symptomatic hypoglycaemia before delivery and two during the 6 h after delivery. Seven neonates had blood glucose levels of 2.2 mmol-1 or less recorded at any time, but there was no relationship between neonatal hypoglycaemia and maternal hyperglycaemia during labour in the range of achieved maternal blood glucose levels. The mean HbA1 at booking was 8.4 +/- 1.2% (non-diabetic range 5.0-7.5%) and fell to a steady plateau from 12 weeks gestation to delivery averaging 7.5% (2SD above the non-diabetic mean). These data demonstrate the practical applicability of a simple regimen for control of blood glucose during labour in insulin-dependent diabetic women and suggest that less stringent aims of blood glucose control than originally adopted may be appropriate.

Comparison of once-daily intravenous and oral omeprazole on pentagastrin-stimulated acid secretion in duodenal ulcer patients

The effect of 5 days of once-daily dosing with 20 mg p.o. and 40 mg i.v. omeprazole on pentagastrin-stimulated acid secretion was studied in 8 patients with duodenal ulcer. In addition they also received a 10-mg i.v. dose on day 6 during the oral treatment period. The antisecretory effect was measured 6-7 h after dose at a time point when maximal inhibition during the dosing interval is anticipated. The median percent inhibition of peak acid output (PAO) markedly increased from 43% on day 1 to 100% on day 5 during treatment with 20 mg p.o. The first 40-mg i.v. dose produced a median inhibition of 98% of PAO already on day 1. After 5 days of dosing, the inhibition had increased to 100%. On the other hand, a 10-mg i.v. dose could essentially maintain the degree of PAO reduction reached after 5 days of oral treatment. Plasma omeprazole concentrations increased during repeated dosing both with 20 mg p.o. and 40 mg i.v.

Influence of pregnancy on the 75-g OGTT. A prospective multicenter study. The Diabetic Pregnancy Study Group of the European Association for the Study of Diabetes

This study reports the responses to a 75-g oral glucose tolerance test (OGTT) in 1009 pregnant women from throughout Europe. We reached the following conclusions. 1) A pregnant woman tends to have blood glucose concentrations that are elevated for a longer period of time after an oral glucose load. Therefore, approximately 10% of women will reach or exceed 8 mM glucose at 2 h, but it is unlikely that 10% of European women have disordered carbohydrate metabolism. 2) The fasting and 1-h values should be included in any analysis of the response of the patient. By doing this, many fewer women will have responses regarded as abnormal; in this series, it reduced the 79 women with a 2-h value greater than 8 mM to 15 who were considered to have carbohydrate intolerance (2 with diabetes, 13 with impaired glucose tolerance [IGT]). 3) By increasing the 2-h cutoff value to greater than or equal to 9 mM, the number of women regarded as at risk would be reduced by greater than 50% (from 79 to 32 in this series), but 10 of the 13 women with two abnormal values would still have been detected, as would the 2 diabetic women. 4) From the obstetric viewpoint, mothers who screen positive do not have bigger babies, they deliver close to term, and they do not have particular stigmas such as a family history of diabetes or an increased tendency to smoke or to have an adverse obstetric outcome. However, they do tend to be older and heavier.(ABSTRACT TRUNCATED AT 250 WORDS)

Albumin metabolism in fasted subjects during late pregnancy

1. Albumin fractional synthetic rate was determined in five non-pregnant subjects and five normal pregnant subjects in late gestation after an overnight fast by simultaneous prime and intravenous infusion of two precursor amino acids, [15N]glycine and L-[1-13C]leucine, with additional priming of the large but, slowly turning over, urea pool with [15N2]urea. 2. The two tracers yielded similar values of albumin fractional synthetic rate: 6.1 and 6.0%/day in non-pregnant subjects and 7.3 and 7.6%/day in pregnant subjects, for glycine and leucine, respectively. While plasma volume was greater and serum albumin concentration was significantly reduced during pregnancy, the calculated intravascular albumin mass was significantly increased in pregnant subjects. 3. The amount of albumin synthesized in the intravascular compartment was significantly greater at 8.8 and 9.5 g/day in pregnant subjects compared with 6.4 and 6.3 g/day in non-pregnant control subjects (glycine and leucine methods, respectively). Calculated whole-body protein turnover using glycine was not different between the two subject groups, but leucine flux was higher in pregnant subjects. Partitioning of nitrogenous products in urine revealed that pregnant subjects excreted less urea, less ammonia and less creatinine than the non-pregnant control subjects. 4. These findings suggest that whereas the serum albumin concentration decreases during pregnancy secondary to the large increase in plasma volume, there is an increase in albumin synthesis such that total intravascular albumin mass is increased in late pregnancy.

Simultaneous fracture of the ankle and disruption of the superior tibiofibular joint. A case report

We report a case of fracture-dislocation of the ankle occurring together with a disruption of the superior tibiofibular joint. The simultaneous occurrence of these two lesions does not seem to have been reported previously.

Omeprazole in elderly duodenal ulcer patients: relationship between reduction in gastric acid secretion and fasting plasma gastrin

The effect of omeprazole on acid secretion and gastrin levels has been investigated in 10 elderly duodenal ulcer patients in remission. Doses of 5, 10, 20 and 40 mg omeprazole were given once daily for 7 consecutive days and the basal (BAO) and peak (PAO) acid output and fasting plasma gastrin concentration were measured 24 h after the seventh dose. Omeprazole suppressed PAO significantly and dose-dependently after doses of 10, 20 and 40 mg, the suppression being 42%, 75% and 85%, respectively. No patient showed complete inhibition of PAO and at least 20 mg had to be given to obtain a marked inhibitory effect in all patients. Increasing the dose to 40 mg had only a slight additional effect compared to 20 mg. There was a relationship between degree of acid inhibition and the increase in fasting plasma gastrin. PAO had to be suppressed by more than 80% before a moderate increase in fasting plasma gastrin was observed. The optimal once-daily oral dose of omeprazole for inhibition of acid secretion in elderly patients appears to be 20 mg. Omeprazole 20-40 mg may cause a moderate increase in fasting plasma gastrin.

24-hour intragastric acidity and plasma gastrin during long-term treatment with omeprazole or ranitidine in patients with reflux esophagitis

The reduction in intragastric acidity and the subsequent increase in plasma gastrin were compared during long-term treatment with either omeprazole or ranitidine in 19 patients with erosive reflux esophagitis. The patients received 40 mg omeprazole in the morning or 300 mg ranitidine twice daily. After healing, half the dose was given as maintenance treatment for 1 year. Intragastric acidity and plasma gastrin were measured 24 h before entry and monthly with the high dose and after 1, 6, and 12 months with the low dose. Omeprazole reduced intragastric acidity more effectively than ranitidine (p less than 0.001). This difference in efficacy was more pronounced during the daytime. Plasma gastrin increased more after omeprazole than after ranitidine (p less than 0.01), and both drugs showed a normal postprandial response and approached fasting levels before the next dose. During long-term treatment with 20 mg omeprazole in the morning no progressive alterations were observed in 24-h intragastric acidity or plasma gastrin.

Iron absorption during normal human pregnancy: a study using stable isotopes

The absorption of iron has been determined in nine healthy women studied serially during pregnancy and once post delivery. Following the oral administration of 5 mg aqueous 54FeSO4 plus ascorbic acid and the intravenous injection of 200 micrograms 57FeSO4, the isotope ratios of 54Fe: 56Fe and 57Fe: 56Fe in serum were measured by the use of inductively-coupled-plasma mass spectrometry whereby metal ions are vaporized into an argon plasma without previous blood sample preparation. Mean oral Fe absorption was 7.6 (range 1-22)% at 12 weeks gestation, 21.1 (range 9-58)% at 24 weeks, 37.4 (range 18-56)% at 36 weeks and 26.3 (range 8-54)% at 12 weeks post delivery. All the other biochemical and haematological indices were within normal limits for pregnancy. The significant increase (P less than 0.01) in Fe absorption during normal pregnancy suggests that most women would have the potential to meet the Fe demands of pregnancy without the need for supplementation if dietary Fe has similar availability to the aqueous preparation.

Prevention of relapse of reflux esophagitis after endoscopic healing: the efficacy and safety of omeprazole compared with ranitidine

Ninety-eight patients with erosive and/or ulcerative esophagitis unhealed after at least 3 months' treatment with standard doses of cimetidine (greater than or equal to 1200 mg daily) or ranitidine (greater than or equal to 300 mg daily) were primarily included in an acute healing phase study, and 51 were allocated to 40 mg omeprazole once daily and 47 to 300 mg ranitidine twice daily. After 12 weeks of treatment, 46 (90%) patients given omeprazole were healed, compared with 22 (47%) allocated to ranitidine. Healed patients were then given maintenance treatment with either 20 mg omeprazole once daily or 150 mg ranitidine twice daily for 12 months. Plasma gastrin was determined and gastric mucosal biopsy specimens were obtained during the entire study to assess the structure of the exocrine and endocrine cell populations of the oxyntic mucosa. Sixty-seven per cent of the total number of patients randomized to omeprazole were maintained in clinical and endoscopic remission throughout the 12-month study period as compared with only 10% among those given ranitidine (p less than 0.0001). After 4 weeks of omeprazole treatment basal gastrin levels were slightly increased, with a 95% confidence interval for the change of from 8.6 to 16.9 pmol/l. No further increase in basal gastrin levels was observed during the ensuing study months. No significant histopathologic lesion was found in the oxyntic gland mucosa. In conclusion, omeprazole was far superior to ranitidine in preventing recurrence, a goal achieved without adverse events and significant abnormalities in the oxyntic mucosal exocrine or endocrine cells but with a moderate increase in basal gastrin levels.