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Best LMJ, Takwoingi Y, Siddique S, Selladurai A, Gandhi A, Low B, Yaghoobi M, Gurusamy KS. Non-invasive diagnostic tests for Helicobacter pylori infection. Cochrane Database Syst Rev 2018; 3:CD012080. [PMID: 29543326 PMCID: PMC6513531 DOI: 10.1002/14651858.cd012080.pub2] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Helicobacter pylori (H pylori) infection has been implicated in a number of malignancies and non-malignant conditions including peptic ulcers, non-ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin-Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non-invasive tests for diagnosis of H pylori. OBJECTIVES To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. SEARCH METHODS We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as 13C or 14C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. DATA COLLECTION AND ANALYSIS Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We performed meta-analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. MAIN RESULTS We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study.Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty-four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test-13C; 21 studies (1810 participants) evaluated urea breath test-14C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test.Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test-13C, urea breath test-14C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test-13C, urea breath test-14C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test-13C, 0.92 (95% CI 0.89 to 0.94) for urea breath test-14C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori infection). In this hypothetical cohort, urea breath test-13C, urea breath test-14C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed).Direct comparisons were based on few head-to-head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test-13C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test-13C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta-analysis of other direct comparisons. AUTHORS' CONCLUSIONS In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice.We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions.
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Affiliation(s)
- Lawrence MJ Best
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchEdgbastonBirminghamUKB15 2TT
| | | | | | | | | | - Mohammad Yaghoobi
- McMaster University and McMaster University Health Sciences CentreDivision of Gastroenterology1200 Main Street WestHamiltonONCanada
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Gong Y, Li Q, Yuan Y. Accuracy of testing for anti- Helicobacter pylori IgG in urine for H. pylori infection diagnosis: a systematic review and meta-analysis. BMJ Open 2017; 7:e013248. [PMID: 28455424 PMCID: PMC5719657 DOI: 10.1136/bmjopen-2016-013248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES This meta-analysis aims to systematically measure the potential diagnostic value of anti-Helicobacter pylori IgG in urine for infection diagnosis, using all eligible studies published in English and Chinese languages. DESIGN The random effect model was used to analyse the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative LR (NLR), diagnostic OR (DOR), together with the summary receiver operator characteristic curve. SETTING Literature searches of databases including PubMed, EMBASE, MEDLINE, Web of Science, Chinese National Knowledge Infrastructure and Wanfang databases were performed to retrieve studies evaluating the diagnostic value of urine IgG antibody for H.pylori infection. PRIMARY OUTCOME MEASURE Twenty-three studies with 4963 subjects were included in the current meta-analysis. RESULTS The pooled sensitivity, specificity, PLR, NLR, DOR and area under the curve (AUC) were 0.83 (95% CI 0.82 to 0.85), 0.89 (95% CI 0.88 to 0.90), 8.81 (95% CI 6.37 to 12.2), 0.13 (95% CI 0.09 to 0.2), 73 (95% CI 46.45 to 114.74) and 0.9551, respectively. Subgroup analyses showed that diagnostic accuracy of the urine IgG assay was no different in age, region, study population and assay method. CONCLUSIONS Anti-H. pylori antibody in urine might serve as a good marker in diagnosing H. pylori infection. However, further validation based on a larger sample is still required.
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Affiliation(s)
- Yuehua Gong
- Department of Tumor Etiology and Screening, Cancer Institute and General Surgery, The First Affiliated Hospital of China Medical University and Key Laboratory of Cancer Etiology and Prevention, Liaoning Provincial Education Department, Shenyang, China
| | - Qiuping Li
- Department of Tumor Etiology and Screening, Cancer Institute and General Surgery, The First Affiliated Hospital of China Medical University and Key Laboratory of Cancer Etiology and Prevention, Liaoning Provincial Education Department, Shenyang, China
| | - Yuan Yuan
- Department of Tumor Etiology and Screening, Cancer Institute and General Surgery, The First Affiliated Hospital of China Medical University and Key Laboratory of Cancer Etiology and Prevention, Liaoning Provincial Education Department, Shenyang, China
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Cost-Effectiveness Analysis of Helicobacter pylori Diagnostic Methods in Patients with Atrophic Gastritis. Gastroenterol Res Pract 2017; 2017:2453254. [PMID: 28337217 PMCID: PMC5346403 DOI: 10.1155/2017/2453254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/06/2017] [Accepted: 01/11/2017] [Indexed: 02/07/2023] Open
Abstract
Background. There are several diagnostic methods for Helicobacter pylori (H. pylori) infection. A cost-effective analysis is needed to decide on the optimal diagnostic method. The aim of this study was to determine a cost-effective diagnostic method in patients with atrophic gastritis (AG). Methods. A decision-analysis model including seven diagnostic methods was constructed for patients with AG diagnosed by esophagogastroduodenoscopy. Expected values of cost and effectiveness were calculated for each test. Results. If the prevalence of H. pylori in the patients with AG is 85% and CAM-resistant H. pylori is 30%, histology, stool H. pylori antigen (SHPAg), bacterial culture (BC), and urine H. pylori antibody (UHPAb) were dominated by serum H. pylori IgG antibody (SHPAb), rapid urease test (RUT), and urea breath test (UBT). Among three undominated methods, the incremental cost-effective ratios (ICER) of RUT versus SHPAb and UBT versus RUT were $214 and $1914, respectively. If the prevalence of CAM-sensitive H. pylori was less than 55%, BC was not dominated, but its H. pylori eradication success rate was 0.86. Conclusions. RUT was the most cost-effective at the current prevalence of CAM-resistant H. pylori. BC could not be selected due to its poor effectiveness even if CAM-resistant H. pylori was more than 45%.
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Ibrahim EAS, Moustafa MAM, Monis W. Comparison between phenol red chromo-endoscopy and a stool rapid immunoassay for the diagnosis of Helicobacter pylori in patients with gastritis. J Microsc Ultrastruct 2015; 3:175-180. [PMID: 30023197 PMCID: PMC6014272 DOI: 10.1016/j.jmau.2015.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/24/2015] [Accepted: 05/22/2015] [Indexed: 02/08/2023] Open
Abstract
Helicobacter pylori infection is a widespread problem all over the world. Non-invasive techniques are demanded for rapid diagnosis and treatment follow up. The aim of this study was to compare the diagnostic value of phenol red chromo-endoscopy and stool (Rapid Strip HpSA) for H. pylori detection with reference to histopathology as the gold standard. A total of 80 adult patients with dyspepsia were enrolled on this study. Patients underwent phenol red chromo-endoscopy. Multiple Gastric biopsies were taken and examined for H. pylori detection. Stool sample was collected from every patient for Rapid Strip HpSA test. The study included 38 males (47.5%) and 42 females (52.5%) with their ages ranged between 19 and 56 years. According to histopathology, 71 patients (88.8%) were H. pylori positive and 9 (11.2%) were negative, most of biopsies showed inflammation with variable degree of activity, which showed significant statistical correlation with the density of H. pylori (P < 0.05). Phenol red chromo-endoscopy had 90.1% sensitivity, 88.9% specificity, 98.5% positive predictive value (PPV), 53.3% negative predictive value (NPV) and 90% accuracy. Rapid Strip HpSA had a sensitivity 93%, 77.8% Specificity, 97.1% PPV, 58% NPV and 91.3% accuracy. In conclusion; Phenol red chromo endoscopy was more specific and less sensitive than the rapid stool Rapid Strip HpSA® test regarding the detection of H. pylori infection with reference to histopathology as a gold standard, yet both showed high diagnostic accuracy; thus they can be used as reliable diagnostic tools for H. pylori infection in cases contraindicated for gastric biopsy.
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Affiliation(s)
| | | | - Walaa Monis
- Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Yamamoto T, Ishii T, Sanaka M, Kuyama Y. Diagnosis ofHelicobacter pyloriinfection using RAPIRUN®H. pyloriantibody detection kit. Expert Rev Mol Diagn 2014; 8:565-9. [DOI: 10.1586/14737159.8.5.565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lee YC, Tseng PH, Liou JM, Chen MJ, Chen CC, Tu CH, Chiang TH, Chiu HM, Lai CF, Ho JC, Wu MS. Performance of a one-step fecal sample-based test for diagnosis of Helicobacter pylori infection in primary care and mass screening settings. J Formos Med Assoc 2012; 113:899-907. [PMID: 25530066 DOI: 10.1016/j.jfma.2012.05.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 04/21/2012] [Accepted: 05/21/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND/PURPOSE An alternative screening test is needed to efficiently eradicate Helicobacter pylori from a population with prevalent upper gastrointestinal lesions. We evaluated the performance of a new one-step fecal test for H. pylori for diagnosis of H. pylori infection in Taiwan. METHODS We developed a fecal test to detect H. pylori based on the immunochronomatographic assay and a mixture of monoclonal antibodies. We first recruited symptomatic patients from the primary care setting to evaluate fecal test performance using a reference standard consisting of (13)C urea breath test, rapid urease test, and histology. We also compared the performance of the fecal test with that of others. Next, we recruited asymptomatic participants from the mass screening setting to evaluate population attendance for the fecal test and compared its performance with that of (13)C urea breath test. RESULTS In the primary care setting, 117 patients were recruited; H. pylori infection was confirmed in 58 (49.6%). Fecal test sensitivity, specificity, positive and negative predictive values, and accuracy were 88.0% [95% confidence interval (CI): 79.6-96.4%], 100%, 100%, 89.4% (95% CI, 82.0-96.8%), and 94% (95% CI, 89.7-98.3%), respectively. Fecal test specificity and positive predictive value were significantly higher than those of the serological test, whereas the sensitivity and negative predictive value were lower than those of the (13)C urea breath test (p < 0.05). In the mass screening setting, 2720 of 3520 invited individuals participated (77.3%; 95% CI, 76-78.7%); 649 (23.9%) showed positive results. Concordance rate and kappa statistic between the fecal test and (13)C urea breath test were 91.7% (563/614; 95% CI, 89.9-94.1%) and 0.78 (95% CI, 0.73-0.84), respectively. CONCLUSION Given the acceptable sensitivity, excellent specificity, and high participation rate to screening, the one-step H. pylori stool antigen test is feasible for wide application in the community.
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Affiliation(s)
- Yi-Chia Lee
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Division of Biostatistics, Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ping-Huei Tseng
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jyh-Ming Liou
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Mei-Jyh Chen
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Integrated Diagnostic & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chuan Chen
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chia-Hung Tu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tsung-Hsien Chiang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Integrated Diagnostic & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Fang Lai
- Research and Development, Firstep Bioresearch Incorporation, Tainan, Taiwan
| | - Jhon-Chun Ho
- Research and Development, Firstep Bioresearch Incorporation, Tainan, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Primary Care Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Evaluation of rapid urine test for the detection of Helicobacter pylori infection in the Vietnamese population. Dig Dis Sci 2010; 55:89-93. [PMID: 19241167 DOI: 10.1007/s10620-009-0720-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Accepted: 01/12/2009] [Indexed: 12/16/2022]
Abstract
PURPOSE This study attempted to assess the value of the RAPIRUN test for the diagnosis of Helicobacter pylori infection in the Vietnamese population. METHODS We recruited 148 Vietnamese patients undergoing upper gastrointestinal endoscopy during which five gastric biopsies were taken; blood and urine samples were collected from each patient. Helicobacter pylori infection status was determined by a combination of three different methods, including culture, immunohistochemistry, and serum ELISA. RAPIRUN tests were performed using urine samples. RESULTS The sensitivity, specificity, and accuracy of the RAPIRUN test in these Vietnamese patients were 79.5, 90.7, and 84.5%, respectively. CONCLUSIONS The RAPIRUN test is useful for the diagnosis of H. pylori infection in the Vietnamese population, showing high specificity, acceptable sensitivity, non-invasiveness, convenience, and rapidity.
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Trajman A, Luiz RR. McNemar chi2 test revisited: comparing sensitivity and specificity of diagnostic examinations. Scandinavian Journal of Clinical and Laboratory Investigation 2008; 68:77-80. [PMID: 18224558 DOI: 10.1080/00365510701666031] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
When evaluating a novel diagnostic examination for clinical use, it should be compared with a reference standard, defined as the best available examination, which may include clinical and laboratory criteria. The novel examination and reference standard's results are usually presented in the form of a 2 x 2 table, which allows calculation of sensitivity, specificity and accuracy. It has been recommended that the measures of statistical uncertainty should be reported, such as the 95% confidence interval, when evaluating the accuracy of diagnostic examinations. Comparing the difference in sensitivity or specificity of a novel examination with the reference standard is important when evaluating its usefulness. The McNemar chi(2) test, used to compare discordance of two dichotomous responses, can be applied for this purpose. However, applying the McNemar test to a 2 x 2 table for comparing the accuracy of examinations is not recommended, since this test is sensitive to the proportion of positive versus negative subjects. Moreover, if the novel examination has higher sensitivity than the one considered as the reference standard, constructing a classic 2 x 2 table would result in low specificity of the novel examination. Thus, in order to compare sensitivities and specificities between examinations, this table is inappropriate and an independent reference standard is necessary. In this article, we propose the use of the McNemar chi(2) test to compare sensitivities between examinations using a 2 x 2 table exclusively among diseased patients, defined by a set of criteria and follow-up of patients. Likewise, specificities can be compared applying the McNemar test among healthy individuals.
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Affiliation(s)
- A Trajman
- Gama Filho University, School of Medicine, Rio de Janeiro, Brazil.
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Yilmaz O. Progress in developing accurate tests for the diagnosis of Helicobacter pylori infection. EXPERT OPINION ON MEDICAL DIAGNOSTICS 2007; 1:531-540. [PMID: 23496359 DOI: 10.1517/17530059.1.4.531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Helicobacter pylori is a chronic infectious agent as defined the major pathogen causing gastritis, gastric and duodenal ulcer, gastric carcinoma and mucosa-associated lymphoid tissue lymphoma, however little is known about its role in functional dyspepsia. H. pylori is the only microorganism known to inhabit the human stomach and the gastric mucosal cells. Chronic H. pylori infection of the stomach is increasingly recognized as a major risk factor for the development of gastroduodenal disease. H. pylori can be detected by non-invasive and invasive methods, the latter requiring endoscopy.
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Affiliation(s)
- Ozlem Yilmaz
- Dokuz Eylül University, Faculty of Medicine, Department of Microbiology and Clinical Microbiology, 35340, Inciralti, ˙Izmir, Turkey +90 232 412 45 06 ; +90 232 259 05 41 ;
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Abstract
Although there are attempts to perform Helicobacter pylori diagnosis directly in vivo using magnification endoscopy, most articles on diagnosis this year concerned non-invasive tests and molecular methods. For urea breath tests, there are attempts to have a quicker and cheaper test and to evaluate its role in cases of premalignant lesions. For stool antigens tests, evaluation of kits using monoclonal antibodies was carried out. Molecular tests have been applied for typing and detection of resistant mutants.
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Affiliation(s)
- Meltem Yalinay Cirak
- Department of Microbiology and Clinical Microbiology, Gazi University Faculty of Medicine, Besevler, Ankara, Turkey
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