Effectiveness and Safety of the Switch from Remicade® to CT-P13 in Patients with Inflammatory Bowel Disease

BACKGROUND AND AIMS

To evaluate the clinical outcomes in patients with IBD after switching from Remicade® to CT-P13 in comparison with patients who maintain Remicade®.

METHODS

Patients under Remicade® who were in clinical remission with standard dosage at study entry were included. The 'switch cohort' [SC] comprised patients who made the switch from Remicade® to CT-P13, and the 'non-switch' cohort [NC] patients remained under Remicade®.

RESULTS

A total of 476 patients were included: 199 [42%] in the SC and 277 [58%] in the NC. The median follow-up was 18 months in the SC and 23 months in the NC [p < 0.01]. Twenty-four out of 277 patients relapsed in the NC; the incidence of relapse was 5% per patient-year. The cumulative incidence of relapse was 2% at 6 months and 10% at 24 months in this group. Thirty-eight out of 199 patients relapsed in the SC; the incidence rate of relapse was 14% per patient-year. The cumulative incidence of relapse was 5% at 6 months and 28% at 24 months. In the multivariate analysis, the switch to CT-P13 was associated with a higher risk of relapse (HR = 3.5, 95% confidence interval [CI] = 2-6). Thirteen percent of patients had adverse events in the NC, compared with 6% in the SC [p < 0.05].

CONCLUSIONS

Switching from Remicade® to CT-P13 might be associated with a higher risk of clinical relapse, although this fact was not supported in our study by an increase in objective markers of inflammation. The nocebo effect might have influenced this result. Switching from Remicade® to CT-P13 was safe.

Effect of Chondroitin Sulphate on Pro-Inflammatory Mediators and Disease Activity in Patients with Inflammatory Bowel Disease

BACKGROUND/AIMS

To evaluate the incidence rate of relapse in patients with inflammatory bowel disease (IBD) undergoing chondroitin sulphate (CS) treatment and its effect on the concentrations of several pro-inflammatory proteins.

METHODS

Prospective, observational, 12-month follow-up study in patients with IBD in remission, starting CS (Condrosan®, Bioiberica S.A.) treatment for osteoarthritis (OA). Crohn's Disease Activity Index and modified Truelove-Witts severity index were calculated for Crohn's disease and ulcerative colitis (UC) respectively. Levels of vascular endothelial growth factor (VEGFA), -C, fibroblast growth factor 2, hepatocyte growth factor, angiopoietin (Ang)-1, Ang-2, transforming growth factor beta, tumour necrosis factor alpha, interleukin (IL)-1β, IL-6, IL-12, IL-17, IL-23, intracellular adhesion molecule-1, vascular adhesion molecule-1, matrix metalloproteinase-3 and PGE2 were quantified by ELISA. OA joint pain was evaluated using a visual analogue scale.

RESULTS

A total of 37 patients (19 UC and 18 Crohn's disease) were included. The mean values for OA joint pain decreased after 12 months from 5.9 ± 2.8 to 3.0 ± 2.3 (p < 0.05). Only 1 patient (with UC) flared during follow-up. The incidence rate of relapse was 3.4% per patient-year of follow-up. Mean serum VEGFA levels increased between baseline (492 pg/ml) and 12-month treatment (799 pg/ml; p < 0.05).

CONCLUSION

The incidence of IBD relapse in patients under CS treatment was lower than that generally reported. This treatment might modulate VEGFA. CS decreases OA-related pain in patients with IBD.

Neuroimaging in the Evaluation of Patients with Non-Acute Headache

Available studies offer only limited guidance on neuroimaging of non-acute headache patients. The aim of this study was to estimate the frequency of significant intracranial lesions in patients with headache and to determine the clinical variables helpful in identifying patients with intracranial lesions. All patients aged ≥l 15 years attending the Neurology Clinic with non-acute headache were included in the study and followed prospectively. Every patient was investigated by neuroimaging studies, either computed tomography or magnetic resonance imaging. Neuroimaging results were classified as ‘significant abnormalities’, ‘nonsignificant abnormalities’ or ‘normal’. Significant abnormalities included neoplastic disease, hydrocephalus, vascular malformations, Chiari malformation, large arachnoid cysts, intracranial haemorrhage, and acute cerebral infarcts. Consecutive patients ( n = 1876; 1243 women and 633 men) were included. Their mean age was 38 years (range 15-95 years). Neuroimaging studies detected significant lesions in 22 patients [1.2%, 95% confidence interval (CI) 0.7, 1.8]. The rate of significant intracranial abnormalities in patients with headache and normal neurological examination was 0.9% (95% CI 0.5, 1.4). The only clinical variable associated with a higher probability of intracranial abnormalities was neurological examination. The proportion of patients with headache and intracranial lesions is relatively small, but neither neurological examination nor the features in the clinical history permit us to rule out such abnormalities.

Helicobacter pylori second-line rescue therapy with levofloxacin- and bismuth-containing quadruple therapy, after failure of standard triple or non-bismuth quadruple treatments

BACKGROUND

The most commonly used second-line Helicobacter pylori eradication regimens are bismuth-containing quadruple therapy and levofloxacin-containing triple therapy, both offering suboptimal results. Combining bismuth and levofloxacin may enhance the efficacy of rescue eradication regimens.

AIMS

To evaluate the efficacy and tolerability of a second-line quadruple regimen containing levofloxacin and bismuth in patients whose previous H. pylori eradication treatment failed.

METHODS

This was a prospective multicenter study including patients in whom a standard triple therapy (PPI-clarithromycin-amoxicillin) or a non-bismuth quadruple therapy (PPI-clarithromycin-amoxicillin-metronidazole, either sequential or concomitant) had failed. Esomeprazole (40 mg b.d.), amoxicillin (1 g b.d.), levofloxacin (500 mg o.d.) and bismuth (240 mg b.d.) was prescribed for 14 days. Eradication was confirmed by (13) C-urea breath test. Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by questionnaires.

RESULTS

200 patients were included consecutively (mean age 47 years, 67% women, 13% ulcer). Previous failed therapy included: standard clarithromycin triple therapy (131 patients), sequential (32) and concomitant (37). A total of 96% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 91.1% (95%CI = 87-95%) and 90% (95%CI = 86-94%). Cure rates were similar regardless of previous (failed) treatment or country of origin. Adverse effects were reported in 46% of patients, most commonly nausea (17%) and diarrhoea (16%); 3% were intense but none was serious.

CONCLUSIONS

Fourteen-day bismuth- and levofloxacin-containing quadruple therapy is an effective (≥90% cure rate), simple and safe second-line strategy in patients whose previous standard triple or non-bismuth quadruple (sequential or concomitant) therapies have failed.

Optimised empiric triple and concomitant therapy for Helicobacter pylori eradication in clinical practice: the OPTRICON study

BACKGROUND

Empiric triple therapy for Helicobacter pylori should be abandoned when clarithromycin resistance rate is >15-20%. Optimisation of triple therapy (high-dose acid suppression and 14-day duration) can increase eradication rates by 10%.

AIM

To compare the efficacy and safety of optimised triple (OPT-TRI) and nonbismuth quadruple concomitant (OPT-CON) therapies.

METHODS

Prospective multicentre study in 16 Spanish centres using triple therapy in clinical practice. In a 3-month two-phase fashion, the first 402 patients received an OPT-TRI therapy [esomeprazole (40 mg b.d.), amoxicillin (1 g b.d) and clarithromycin (500 mg b.d) for 14 days] and the last 375 patients an OPT-CON treatment [OPT-TRI therapy plus metronidazole (500 mg b.d)].

RESULTS

Seven-hundred seventy-seven consecutive patients were included (402 OPT-TRI, 375 OPT-CON). The OPT-CON therapy achieved significantly higher eradication rates in the per-protocol [82.3% (95% CI = 78-86%) vs. 93.8% (91-96%), P < 0.001] and intention-to-treat analysis [81.3% (78-86%) vs. 90.4% (87-93%), P < 0.001]. Adverse events (97% mild/moderate) were significantly more common with OPT-CON therapy (39% vs. 47%, P = 0.016), but full compliance with therapy was similar between groups (94% vs. 92%, P = 0.4). OPT-CON therapy was the only significant predictor of successful eradication (odds ratio, 2.24; 95% CI: 1.48-3.51, P < 0.001). The rate of participating centres achieving cure rates ≥ 90% favoured OPT-CON therapy (OPT-TRI 25% vs. OPT-CON 62%).

CONCLUSIONS

Empiric OPT-CON therapy achieved significantly higher cure rates (>90%) compared to OPT-TRI therapy. Addition of metronidazole to OPT-TRI therapy increased eradication rates by 10%, resulting in more mild adverse effects, but without impairing compliance with therapy.

Third-line rescue therapy with bismuth-containing quadruple regimen after failure of two treatments (with clarithromycin and levofloxacin) for H. pylori infection

BACKGROUND

Helicobacter pylori eradication therapy with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin fails in >20 % of cases. A rescue therapy with PPI-amoxicillin-levofloxacin still fails in >20 % of patients.

AIM

To evaluate the efficacy and tolerability of a bismuth-containing quadruple regimen in patients with two consecutive eradication failures.

METHODS

Prospective multicenter study of patients in whom 1st treatment with PPI-clarithromycin-amoxicillin and 2nd with PPI-amoxicillin-levofloxacin had failed. A 3rd eradication regimen with a 7- to 14-day PPI (standard dose b.i.d.), bismuth subcitrate (120 mg q.i.d. or 240 mg b.i.d.), tetracycline (from 250 mg t.i.d. to 500 mg q.i.d.) and metronidazole (from 250 mg t.i.d. to 500 mg q.i.d.). Eradication was confirmed by (13)C-urea-breath-test 4-8 weeks after therapy. Compliance was determined through questioning and recovery of empty medication envelopes. Adverse effects were evaluated by means of a questionnaire.

RESULTS

Two hundred patients (mean age 50 years, 55 % females, 20 % peptic ulcer/80 % uninvestigated-functional dyspepsia) were initially included, and two were lost to follow-up. In all, 97 % of patients complied with the protocol. Per-protocol and intention-to-treat eradication rates were 67 % (95 % CI 60-74 %) and 65 % (58-72 %). Adverse effects were reported in 22 % of patients, the most common being nausea (12 %), abdominal pain (11 %), metallic taste (8.5 %), and diarrhea (8 %), none of them severe.

CONCLUSION

A bismuth-containing quadruple regimen is an acceptable third-line strategy and a safe alternative after two previous H. pylori eradication failures with standard clarithromycin- and levofloxacin-containing triple therapies.

Health care costs of complex perianal fistula in Crohn's disease

AIM

To evaluate the use of health care resources and the associated costs of complex perianal Crohn's disease (CD) from the National Health System perspective.

METHODS

We conducted a multicenter, retrospective, observational study in which gastroenterologists from 11 hospitals in the Community of Madrid took part. Data was collected on the direct healthcare resources (pharmacological treatments, surgical procedures, laboratory/diagnostic tests, visits to specialists and emergency departments, and hospitalizations) consumed by 97 adult patients with complex perianal CD which was active at some point between January 1, 2005, and case history review.

RESULTS

We recorded 527 treatments: 73.1% pharmacological (32.3% antibiotic, 20.5% immunomodulator, 20.3% biological) and 26.9% surgical. Mean annual global cost was €8,289/patient, 75.3% (€6,242) of which was accounted for by pharmacological treatments (€13.44 antibiotics; €1,136 immunomodulators; €5,093 biological agents), 12.4% (€1,027) by hospitalizations and surgery, 7.7% (€640) by medical visits, 4.2% (€350) by laboratory/diagnostic tests, and 0.4% (€30) by emergency department visits.

CONCLUSIONS

Pharmacological therapies, and in particular biological agents, are the main cost driver in complex perianal CD; costs due to surgery and hospitalizations are much lower.

Safety of thiopurines and anti-TNF-α drugs during pregnancy in patients with inflammatory bowel disease

OBJECTIVES

The safety of thiopurines and anti-tumor necrosis factor-α (TNF-α) drugs during pregnancy remains controversial, as the experience with these drugs in this situation is limited. Our aim is to assess the safety of thiopurines and anti-TNF-α drugs for the treatment of inflammatory bowel disease (IBD) during pregnancy.

METHODS

Retrospective, multicenter study in IBD patients. Pregnancies were classified according to the therapeutic regimens during pregnancy or during the 3 months before the conception: non-exposed group, pregnancies exposed to thiopurines alone (group A), and pregnancies exposed to anti-TNF-α drugs (group B). An unfavorable Global Pregnancy Outcome (GPO) was considered if pregnancy developed with obstetric complications in the mother and in the newborn.

RESULTS

A total of 187 pregnancies in the group A, 66 pregnancies in the group B, and 318 pregnancies in the non-exposed group were included. The rate of unfavorable GPO was different among the three groups (31.8% in non-exposed group, 21.9% in group A, and 34.8% in group B), being lower in pregnancies under thiopurines than among non-exposed (P = 0.01). The rate of pregnancy complications was similar among the three groups (27.7% in non-exposed, 20.9% in group A, and 30.3% in group B). The rate of neonatal complications was different among the three groups (23.3% in non-exposed group, 13.9% in group A, and 21.2% in group B), being lower in pregnancies under thiopurines than among non-exposed (P = 0.01). In the multivariate analysis, the treatment with thiopurines (odds ratio = 0.6; 95% confidence interval = 0.4-0.9, P = 0.02) was the only predictor of favorable GPO, whereas maternal age >35 years at conception was the only predictor of unfavorable GPO. The treatment with anti-TNF-α drugs was not associated with an unfavorable GPO.

CONCLUSION

The treatment with thiopurines and anti-TNF-α drugs does not seem to increase the risk of complications during pregnancy and does seem to be safe for the newborn.

Evaluation of liver fibrosis by transient elastography (Fibroscan®) in patients with inflammatory bowel disease treated with methotrexate: a multicentric trial

BACKGROUND

Methotrexate is an effective treatment for inflammatory bowel disease (IBD). However, long-term treatments have been associated with the development of liver fibrosis. FibroScan® is a noninvasive, safe, and effective technique to evaluate liver fibrosis.

AIM

To evaluate the presence of significant liver fibrosis by transient elastography (FibroScan®) in IBD patients treated with methotrexate.

METHODS

Cross-sectional study including IBD patients treated with methotrexate from different hospitals. Clinical and analytical data, duration of treatment, and cumulative dose of methotrexate were obtained. Liver stiffness was assessed by FibroScan®. The cutoff value for significant liver fibrosis (according to METAVIR) was F ≥ 2: 7.1 kPa. Results. In the study, 46 patients were included, 30 women (65%), with a mean age of 43 ± 10 years. 31 patients had Crohn's disease (67.4%), 13 ulcerative colitis (28.3%), and 2 indeterminate colitis (4.3%). The mean cumulative dose of methotrexate was 1242 ± 1349 mg, with a mean treatment duration of 21 ± 24 months. The mean value of liver stiffness was 4.7 ± 6.9 kPa. There were 35 patients (76.1%) with F01, 8 patients (17.4%) with F = 2, and 3 patients with F ≥ 3 (6.5%). There were no differences in liver stiffness depending on sex, age, type of IBD, or cumulative dose of methotrexate.

CONCLUSIONS

(1) Development of advanced liver fibrosis in IBD patients treated with methotrexate is exceptional. (2) There were no differences in liver stiffness depending on the type of IBD or the cumulative dose of methotrexate. (3) FibroScan® may be potentially useful for evaluation and follow-up of liver fibrosis in methotrexate-treated patients.

Intensification of infliximab therapy in Crohn's disease: efficacy and safety

INTRODUCTION

The response of Crohn's disease (CD) to infliximab is initially good, although a loss of efficacy is observed over time. Dose escalation has been recommended in such cases.

AIMS

To study the response to an intensified infliximab regimen in patients with CD; and to evaluate the adverse effects associated with intensification of therapy and identify predictors of loss of response.

METHODS

We performed a retrospective multicenter survey of all patients with CD who had been treated with at least the 3 induction doses of standard infliximab therapy, and for whom treatment had to be intensified due to loss of response. We analyzed the efficacy of the intensified regimen.

RESULTS

Thirty-three patients were included. After the first intensification dose, 79% of patients had a clinical response (33.5% complete response, 45.5% partial response). In the long term, 83%, 69%, 47%, and 29% of patients who had an initial response to the intensification maintained the response at 6, 12, 18, and 36 months, respectively. The loss of efficacy after escalation was 43% per patient-year of follow-up. One patient had an infusion reaction after 36 doses. One patient developed a herpes zoster infection.

CONCLUSIONS

A high proportion of patients whose dose of infliximab is increased due to loss of efficacy respond initially. However, nearly half lose the response after one year. The safety profile of an intensified infliximab regimen is good.

Surgical repair and biological therapy for fecal incontinence in Crohn's disease involving both sphincter defects and complex fistulas

BACKGROUND AND AIMS

Surgeons have traditionally tried to avoid any complex surgical procedures in Crohn's patients with complex perianal diseases because of the fear of complications, worsening the patient's condition and risking an eventual proctectomy. The introduction of biological therapy has changed the management of Crohn's disease. This study assesses the long-term success of addressing defects in anal sphincter and complex fistula when patients receive anti-TNF-α antibodies.

METHODS

Ten consecutive patients were prospectively scheduled for induction therapy with 5mg/kg Infliximab at week 0, 2 and 6 and maintenance every 8 weeks associated with azathioprine. Elective surgery was performed conducting a simultaneous approach to the sphincter defect and fistula tracts. Outcomes were long-term continence, complications which were assessed by a Wexner's score along with a complementary questionnaire. Statistical analysis was performed using general linear model of repeated measures.

RESULTS

Three patients had complications related to surgery: two abscesses and low intersphincteric fistula and one case of rectal stenosis causing fecal urgency. There was no suture dehiscence. Wexner's score improved at 12 months (10.0±2.4 vs. 18.0±2.6; p=0.003) and over time (48 month 9.5±2.8; p=0.001). These scores were significantly worse when patients had urgency before treatment (12.8±1.2 vs. 9.5±2.8; p=0.03) but not when the urgency appeared later. No patient remained incontinent to solid stools. Three patients had occasional incontinence to liquid stools associated to disease reactivation.

CONCLUSION

Surgical repair and immunomodulator therapy with infliximab could be an option in incontinent patients with Crohn's disease involving both a sphincter defect and severe or refractory fistulas.

Thiopurine methyl-transferase activity and azathioprine metabolite concentrations do not predict clinical outcome in thiopurine-treated inflammatory bowel disease patients

BACKGROUND

Low thiopurine-methyl-transferase (TPMT) activity and high 6-thioguanine-nucleotide (6TGN) concentrations have been linked to therapeutic success in inflammatory bowel disease patients treated with thiopurines; however, this has not been implemented in clinical practice.

AIM

To identify a therapeutic threshold value for TPMT or 6TGN concentrations, and their capability to predict treatment safety and efficacy.

METHODS

Prospective multicentre study including steroid-resistant/dependent patients starting thiopurines. The TPMT activity was determined at inclusion (>5 U/mL required). Azathioprine metabolites [6TGN, 6-methyl-mercaptopurine ribonucleotides (6MMP), and 6TGN/6MMP and 6TGN/TPMT ratios] were periodically monitored during steroid tapering and after withdrawal for 6 months or until a new flare occurred.

RESULTS

A total of 113 patients were analysed (62% clinical response). Areas under the receiver operating characteristic (ROC) curve (AUC) relating clinical response and metabolite levels at 2, 4 and 6 months after steroid withdrawal were less than 0.7. The AUCs relating final response and initial TPMT activity or metabolite concentrations at 2, 4, 8 and 16 weeks after starting thiopurines were less than 0.7. No cut-off point with worthwhile sensitivity/specificity was found. Eight (7%) patients developed thiopurine-related toxicity that could not be linked to TPMT activity or 6TGN levels.

CONCLUSIONS

Our results do not support determination of TPMT activity or 6TGN concentrations to predict treatment outcome, and no useful serum metabolites threshold value to adjust the drug's dose was identified.

A zoonotic ringworm outbreak caused by a dysgonic strain of Microsporum canis from stray cats

BACKGROUND

Cats are frequent carriers of Microsporum canis and veterinary students are at high risk of exposure and acquisition of the organism a la infección.

OBJECTIVES

An outbreak of zoonotic ringworm carried by a litter of stray cats is described. Four veterinary students, four dogs, and six cats living in five separate locations were affected. All had direct or indirect contact with the infected kitten litter. We tried to identify the causal dermatophyte.

METHODS

Conventional and mycological culture methods were used.

RESULTS

Microscopic features of scrapings and hairs treated with 20% KOH strongly suggested a M. canis etiology, and a diagnosis of ringworm was empirically supported by successful treatment of humans and animals. Nevertheless, cultures failed to show the expected morphology.

CONCLUSIONS

Culture features of our strain are compared with those described by other authors for dysgonic M. canis strains. Epidemiological features are also discussed.

Mercaptopurine rescue after azathioprine-induced liver injury in inflammatory bowel disease

BACKGROUND

Azathioprine (AZA) liver toxicity arises in approximately 3% of inflammatory bowel disease patients and may result in treatment discontinuation.

AIM

To describe the tolerance to mercaptopurine (MP) in patients with previous AZA-related liver injury.

METHODS

Retrospective description of 31 patients (14 Crohn's, 17 ulcerative colitis), in which AZA therapy was interrupted because of liver injury, with MP started as alternative therapy.

RESULTS

Mean AZA dose was 2.2 +/- 0.4 mg x kg/day. Median (interquartile range) of AZA exposure when liver injury was detected was 2 months (1-5.2). The type of AZA-related injury was cytolitic in 32%, cholestatic in 39% and mixed in 29%. After a median of 2.5 months (0.7-5.2), the therapy was switched to MP at a mean dose of 1.3 +/- 0.2 mg x kg/day. Median of follow-up of MP therapy was 32 months (8-54). In 87.1% of patients (95%CI: 70-96%), MP was tolerated without further liver injury; of these, 77.4% tolerated full MP doses and 9.7% tolerated lower doses. In a further cohort of 12.9% of patients, (95%CI: 3-29%), liver injury reappeared (two cholestasis, two mixed), 1-3 months after the onset of MP exposure.

CONCLUSION

The administration of MP is a good alternative in patients with AZA-related liver injury, before thiopurines are definitely discarded.

Understanding care of people with dementia in Spain: cohabitation arrangements, rotation and rejection to long term care institution

BACKGROUND

Most people with dementia in Spain live at home with their families. Current changes in the family structure are transforming the care of people with dementia through new cohabitation arrangenments and rotation practices.

OBJECTIVE

To describe the cohabitation arrangements of families of people with dementia in Spain and to understand the caregivers' characteristics related to rotation and the rejection of long term care institutions.

METHODS

A cross sectional study -NEDICES study- was conducted using both quantitative and qualitative methodologies.150 caregivers of people with dementia from two communities from Madrid, Spain, were surveyed using a questionnaire designed to describe cohabitation arrangements and care. Qualitative methods included: 13 caregivers participating in focus groups, and 3 caregivers in Semi Structured Interviews aimed to understand rotation practices and rejection to long term care institution.

RESULTS

Characteristics related with rotation were: sex of persons with dementia, widowhood, socio-economic status, caregiver relationship and burden of the caregiver. The qualitative study showed that the use of the rotation was related to normative behaviors and with obligation feelings, along with a change in the role of women in the current Spanish family. The use of long term care institutions was related to geographical distance of the family.

CONCLUSIONS

The results of this study suggest that rotation has appeared in Spain as a new mechanism of care for people with dementia, and its related to the rejection of long term care institutions.

Acute pancreatitis in inflammatory bowel disease, with special reference to azathioprine-induced pancreatitis

BACKGROUND

Pancreatitis is a potentially severe condition. Patients with inflammatory bowel disease (IBD) seem to be at increased risk for acute pancreatitis.

AIM

To describe the incidence, main causes and possible predictive factors of acute pancreatitis in inflammatory bowel disease.

METHODS

Information was retrospectively extracted from the clinical records of patients followed in the IBD Units of nine hospitals in Madrid (n = 5073).

RESULTS

A total of 82 acute pancreatitis episodes were diagnosed (cumulative incidence, 1.6%); 98% of them were mild. Recurrent acute pancreatitis developed in 13% of patients. Most cases of acute pancreatitis (63.4%) were attributed to drug exposure [azathioprine/mercaptopurine (AZA/MP) n = 46, mesalazine (mesalamine) n = 6]; 20.7% were idiopathic, and 12.2% were biliary. Incidence of acute pancreatitis in patients treated with AZA/MP was 3.1%. In patients with acute pancreatitis, female gender (OR 3.4 95% CI: 1.3-9.3; P = 0.012) and Crohn's disease (CD) (OR 5.8 95% CI: 1.6-20.6; P = 0.007) were risk factors for AZA/MP-associated acute pancreatitis, the latter also when analysed only in patients treated with AZA/MP (n = 1477) (OR 5.2 95% CI: 1.8-14; P = 0.002).

CONCLUSIONS

The incidence of acute pancreatitis in our IBD patients (1.6%) is similar to that previously described. Drugs, mainly AZA/MP, are the leading cause. AZA-induced acute pancreatitis is always mild. Patients with CD are at a higher risk for AZA/MP-associated acute pancreatitis. The frequency of idiopathic acute pancreatitis is higher than expected, suggesting that part of these cases could be extraintestinal manifestations of IBD.

Impaired apoptosis in lymphoblasts from Alzheimer's disease patients: cross-talk of Ca2+/calmodulin and ERK1/2 signaling pathways

We have analyzed the intracellular signals that allow lymphoblasts from Alzheimer's disease (AD) patients to escape from serum deprivation-induced apoptosis. The following observations suggested that modulation of ERK1/2 activity by Ca(2+)/calmodulin (CaM) is involved in preventing apoptosis: (i) ERK1/2 activity seems to support lethality in control cells, as PD98059, the inhibitor of the activating MEK prevented cell death; (ii) control cells show a persistent and higher stimulation of ERK1/2 than that of AD cells in the absence of serum; (iii) CaM antagonists have no effects on control cells, but sensitize AD cells to death induced by serum withdrawal and increased ERK1/2 phosphorylation, and (iv) no apoptotic effects of CaM antagonists were observed in AD cells treated with PD98059. These results suggest the existence of an activation threshold of the ERK1/2 pathway setting by Ca(2+)/CaM-dependent mechanisms, which appears to be the critical factor controlling cell survival or death decision under trophic factor withdrawal.

Progressive nonfluent aphasia associated with a new mutation V363I in tau gene

Reported here is a new missense mutation V363I in exon 12 of the microtubule-associated protein tau (MAPT) gene associated with progressive nonfluent aphasia, with onset at the age of 69 years in a woman. Although near mute, she maintained complex activities and had no discernible deficits outside of language until the age of 75 years, when progressive gait and swallowing disturbances appeared. There was a history of late-onset aphasia and apraxia in her father. All of her children were asymptomatic adults, but psycholinguistic abnormalities were detected in those bearing the mutation, consisting of difficulties in comprehension, both reading (symbol discrimination and comprehension of oral spelling) and oral (matching sentences to pictures and comprehension of locative relationships). A mutation-bearing sibling showed no abnormalities at 70 years old, consistent with the limited penetrance expected in late-onset disease. The mutation, corresponding to a highly conserved residue in the fourth tubulin-binding repeat, was not present in 194 normal individuals with the same genetic background.

[Prevalence of vascular risk factors among Spanish populations aged 70 years and over, as reported in door-to-door studies on neurological diseases]

INTRODUCTION

The aim of this study was to re-analyze door-to-door studies on neurological diseases among the elderly, in which vascular risk factors (VRF) were studied, describing methodological characteristics and prevalence of VRF.

METHODS

The surveys were identified in two phases. They were aimed at ascertaining prevalence of stroke, dementias or Parkinsonisms and, at the time of individual screening, had collected data on at least three of the following VRF: arterial hypertension (AHT), smoking habit, diabetes mellitus and hypercholesterolemia. A questionnaire was drawn up to collect the data reported in each study, and a database was constructed. VRF prevalences were quantified and analyzed using logistic regression.

RESULTS

The total of the re-analyzed population was 12,510 persons aged 70 years and over, residents in seven geographic areas during the period 1994-2002. Information available on VRF was essentially self-reported. The prevalence of self-reported AHT was 25.7 % in men and 44.2 % in women, and that of measured AHT was 61 % and 71.9 %, respectively. Populations with arterial pressure obtained by direct measurement registered 138 higher risks (OR: 1.74; 95 % CI: 1.51-2.01, and OR: 1.48; 95% CI: 1.33-1.64). Reported prevalence of diabetes, hypercholesterolemia and smoking habit were 14.3 %, 23.3% and 8.5 %, respectively.

CONCLUSIONS

There was a high prevalence of VRF among the Spanish elderly population. However, its relationship with dementia, Parkinsonisms and cerebrovascular disease could not be studied due to the poor quality of the VRF data. The differences between measured and self-reported arterial pressure suggest the existence of undetected AHT and wide scope for prevention.

Megalin mediates the transport of leptin across the blood-CSF barrier

Leptin, a peptide hormone secreted by adipose tissue, exhibits a large range of central and peripheral actions. It has been proposed that the participation of leptin in diseases such as obesity is due to, at least in part, its impaired transport across the blood-brain barrier (BBB). Since, the mechanisms by which brain takes up leptin remain unclear, we set out to study how leptin may cross the BBB. We have used different immunoassays and lentiviral vectors to analyze the role of megalin in the transport of leptin in rodents and humans. We demonstrate that circulating leptin is transported into the brain by binding to megalin at the choroid plexus epithelium. Indeed, the downregulation of megalin expression in physiological and pathological situations such as aging and Alzheimer's disease was correlated with poor entry of leptin into the brain. Moreover, amyloid beta (Abeta) deposits of choroid plexus could be disturbing megalin function. The present data indicate that leptin represents a novel megalin ligand of importance in the levels and therapeutic actions of leptin into the brain.

Causes of ischemic stroke in young adults, and evolution of the etiological diagnosis over the long term

BACKGROUND

Causes of ischemic stroke in young adults (15-45 years) are diverse, but undetermined etiology is common in a majority of studies.

AIMS

The present series study aims to evaluate causes and changes in the etiological diagnosis of ischemic stroke in young adult patients admitted to a tertiary medical center over a period of 27 years.

METHODS

We retrospectively reviewed the records of patients with a first-ever stroke in the age range of 15-45 years who were admitted to the '12 de Octubre' University Hospital between 1974 and 2002.

RESULTS

272 young adults with ischemic stroke were identified. The etiological diagnoses were: undetermined in 36% of patients, large-artery atherosclerosis in 21%, cardioembolism in 17%, non-atherosclerotic vasculopathy in 17%, and other specific etiologies in 9%. While in the first study period (1974-1988) 45% of patients were diagnosed with uncertain etiology, in the last period (1989-2002) only 26% were diagnosed with cryptogenic stroke (45% with two or more potential etiologies identified; 45% with no identified cause despite complete evaluation, and 10% with incomplete evaluation).

CONCLUSIONS

The etiological diagnosis of stroke in young adults has changed over time as a result of improvements in diagnostic workup. While cryptogenic stroke was the most frequent diagnosis in the past, today specific causes (non-atherosclerotic vasculopathy, large-artery atherosclerosis, cardioembolism and hematological disorder) are identified in the majority of patients.

Review article: how to control and improve adherence to therapy in inflammatory bowel disease

Any chronic disease is a risk situation for non-adherence to treatment. This results in suboptimal medication, and poor disease control. Adherence and compliance are directly related to therapeutic success, which is further complicated in inflammatory bowel disease patients. There is a wide array of circumstances that increase the likelihood of non-compliance in a given patient: difficult-to-follow treatment schedules (multiple doses and multiple drugs), insufficient patient information, longer evolution of the disease and inactive disease. Depression, male gender, active employment and living alone are also associated with poorer adherence to therapy. Monitoring drug intake is possible in many circumstances, directly or indirectly (urinary salicylate levels; erythrocyte metabolites and increased mean corpuscular volume and bilirubin in patients under azathioprine; blood levels of ciclosporin or tacrolimus). However, such measures are probably better utilized for dose adjustment and not for the identification of non-compliant patients. High-risk patients are a target group in which pre-emptive intervention could ensure better compliance. If the question of non-adherence arises, for instance, as a possible cause of therapy failure, the patient should be carefully approached. This should take into consideration factors that may be corrected and, most importantly, should aim at building a better patient-doctor relationship.

[Clinical validity of two scales of instrumental activities in Alzheimer's disease]

INTRODUCTION

Activities of daily living (ADL) are a major domain in the clinical assessment of Alzheimer's disease (AD) patients. However, ADL scales have not been sufficiently validated in Spain.

METHODS

Patients attending a neurology outpatient clinic were classified according to the global deterioration scale (GDS). Afterwards, an independent evaluator administers two scales of instrumental activities of daily living (IADL): Lawton and Brody's scale of IADL (SIADL) and Pfeffer's functional activities questionnaire (FAQ). The SIADL was scored in the original way (dichotomic) (SIADLd) and in an alternative way (ordinal) (SIADLo). Internal consistency (Cronbach alpha coefficient), test-retest reliability (intraclass correlation coefficient), diagnostic validity (sensitivity, specificity, number of patients correctly classified) and influence of different variables (regression analysis) were analyzed for the SIADLd, the SIADLo and the FAQ.

RESULTS

Ninety-eight patients were recruited. Internal consistency, reliability and diagnostic validity were good or excellent for the three scales. The SIADLo showed better diagnostic and scale features than the SIADLd, but the FAQ surpassed both in all the studied variables. No scale was able to make a proper distinction between patients with subjective complaints (GDS 2) and patients without complaints (GDS 1). Sex and age influenced the SIADL score, but not the FAQ score. The FAQ reached a sensitivity of 0.95 and a specificity of 0.88 in the screening of dementia.

CONCLUSIONS

The SIADL and the FAQ are useful, valid and reliable tools for the clinical assessment of AD patients. Ordinal scoring is more advantageous than dichotomic scoring in the SIADL, but the FAQ is preferable.

Adherence to treatment in inflammatory bowel disease

AIM

Adherence to therapy is important to ensure success. We wanted to explore this feature in patients with inflammatory bowel disease.

PATIENTS AND METHODS

We explored adherence to treatment and its modifiers in 40 patients with inflammatory bowel disease using a battery of tests.

RESULTS

A 67% of patients (95% CI: 51-81%) acknowledged a certain degree of involuntary nonadherence, and 35% (95% CI: 20-51%) of voluntary nonadherence. Overall, 72% (95% CI: 56-85%) of patients had some form of nonadherence. An objective correlation of these self-reported data was assessed by the determination of urine salicylate levels in the subset of patients treated with mesalazine or its derivatives (15 cases). Two of them (13%) had no detectable urinary drug levels, indicating complete nonadherence. Voluntary nonadherence was higher in patients with lower scores in the intestinal (p = 0.02) and social areas (p = 0.015) of IBDQ-32, as well as in those with less active Crohn s disease (p < 0.005), patients with high depression scores and high patient-physician discordance (p = 0.01), patients with long-standing disease (p = 0.057), patients who considered themselves not to be well informed about the treatment they were getting (p = 0.04) or who trusted their attending physicians less (p = 0.03).

CONCLUSIONS

Intentional nonadherence to therapy is prevalent among patients with inflammatory bowel disease. A correction of factors associated to poor adherence could lead to higher therapeutic success.

Long-term prognosis of ischemic stroke in young adults. Study of 272 cases

BACKGROUND

There have been few studies of the long-term prognosis of young adults with ischemic stroke. The present study aimed to evaluate the long-term clinical outcome in a large series of young adults with ischemic stroke admitted to a tertiary medical center over the last 27 years, and to identify possible predictors for mortality, stroke recurrence and poor functional recovery.

METHODS

We retrospectively reviewed 272 young adults (15-45 years) with a first-ever ischemic stroke admitted to the Neurology Department of University Hospital "12 de Octubre" between 1974 and 2001. Follow-up assessments were performed by review of medical records and telephone interviews.

RESULTS

Nine patients (3%) died as the result of their initial stroke and follow-up information about the status of 23 (8%) patients was not available. The remaining 240 patients (89%) were followed. Two hundred and ten of them (88%) were alive with a mean follow-up of 12.3 years and 30 (12%) died during follow-up. The average annual mortality rate was 1.4%, being notably higher during the first (4.9%) than in the subsequent years (0.9%) after the initial stroke. Ninety per cent of the followed patients were independent and 53% returned to work, although adjustments were necessary for 23% of them. The annual stroke recurrence rate during the first year was 3.6% dropping to 1.7% in subsequent years. Age over 35 years, male gender, the presence of cardiovascular risk factors and large-artery atherosclerosis in the carotid territory were predictors of negative long-term outcome after the initial stroke.

CONCLUSIONS

The long-term prognosis for the ischemic stroke in the young is better than in the elderly, but the risk of mortality in young adults with ischemic stroke is much higher than in the general population of the same age. A bad prognosis is associated with an atherosclerotic risk profile, with a higher mortality and recurrent stroke rates and poorer functional recovery. The main functional limitation in the young survivors of their initial ischemic stroke occurs in work activity, since most patients are independent but almost half of them do not return to work.

Selective memory impairment on an adapted Mini-Mental State Examination increases risk of future dementia

OBJECTIVE

To determine whether selective memory impairment (SMI) on an adapted Mini-Mental State Examination (aMMSE) test increases risk of future dementia in a population-based survey of central Spain.

BACKGROUND

SMI is a strong predictor of dementia in the elderly. However, most approaches have used extensive memory batteries, which are not always suitable for screening purposes.

METHODS

The basal cohort consisted of 2982 poorly educated individuals aged 65 or over. Dementia, stroke and parkinsonism cases were previously excluded. At entry, participants received a structured interview including an aMMSE. Two groups were created according to basal cognitive performance, namely: (1) aMMSE > 23 and no word remembered on the aMMSE delayed-recall task (SMI group); and (2) aMMSE > 23 and at least one word remembered on the delayed-recall task (control group). In a three-year follow-up wave, conversion rate to dementia was calculated and logistic regression was performed.

RESULTS

Of a total of 2507 subjects who completed the two evaluations, 280 qualified for SMI at entry. In the SMI group, 25 subjects (8.9%) developed dementia vs 26 subjects (1.2%) in the control group. Taking the two groups together, and once demographic and medical variables had been controlled, a low delayed-recall score increased dementia conversion rate (OR 0.47, 95% CI 0.34-0.64). Alzheimer's disease was the main cause of dementia (79.8%).

CONCLUSIONS

Memory impairment is a risk factor for future dementia in the neurologically-healthy elderly. This can be observed in a subgroup of subjects with SMI defined on the aMMSE delayed-recall subscore. Some other measurements should be added to the SMI construct to improve its predictive validity.

[Anticoagulant treatment in hemorrhagic brains infarts due to large sinus venous thrombosis]

Cerebral venous and sinus thrombosis is an infrequent condition which presents with a wide spectrum of signs and a variable mode of onset. Sinus thrombosis may cause isolated intracranial hypertension but also may cause cerebral venous infarcts, which are frequently hemorrhagic. Treatment with antithrombotic agents is controversial because there is only one randomised controlled trial with unfractionated heparin. We report a 46- years-old man complaining of progressive headache, paraparesis and dysphasia. After admission, his neurological status worsened and he developed tetraparesis, depressed level of consciousness and seizures. A cranial computarized tomography (CT) scan showed multiple hyperdensities suggestive of hemorrhagic infarcts. Magnetic resonance imaging (MRI) study confirmed extensive cerebral venous thrombosis. Unfractionated heparin was administered for two weeks followed by acenocumarol. Within a few days his neurological status improved, and five weeks after admission the patient only hadd slight neurological deficit. After 11 years of follow-up, he has had a complete recovery. The G20210A mutation in the prothrombin gene was detected as a likely risk factor for venous thrombosis. Therapeutical and diagnosis aspects are discussed. We review the previous literature on the topic.

Pyoderma gangrenosum associated with ulcerative colitis: response to infliximab

Pyoderma gangrenosum is an extraintestinal manifestation of inflammatory bowel disease that can be therapeutically troublesome. We comment on the case of a patient with clinically inactive ulcerative colitis who progressively developed necrotic lesions on both tibial aspects of his legs, which corresponded both clinically and histologically to pyoderma gangrenosum. Treatment with steroids and azathioprine could not control this complication. A single dose of infliximab 5 mg/kg was given, achieving an impressive response of the skin lesions followed by complete healing 3 months later. Infliximab can be useful in the management of refractory extraintestinal manifestations of inflammatory bowel disease.

Efficacy and safety of thiopurinic immunomodulators (azathioprine and mercaptopurine) in steroid-dependent ulcerative colitis

BACKGROUND

The efficacy of azathioprine in the management of steroid-dependent ulcerative colitis is taken for granted. However, study populations frequently include together steroid-dependent and refractory patients.

AIM

To assess the efficacy and safety of thiopurinic immunomodulators in strictly defined steroid-dependent ulcerative colitis.

METHODS

Survey of 34 patients with steroid-dependent ulcerative colitis, treated with azathioprine according to protocol. Therapeutical success: glucocorticoid withdrawal within 12 months, without steroid requirements during another year.

RESULTS

Mean age was 39.1 +/- 17 years. Pancolitis and extensive colitis accounted for 50% of cases. Therapeutic success of immunomodulator treatment reached 70.6%, intention to treat analysis (confidence interval 95%: 52-84%) and 72.7%, as per protocol (confidence interval 95%: 54-86%). Mean time to steroid withdrawal was 4.6 months. In therapy successes, mean corpuscular volume and total serum bilirubin increased with treatment time (P = 0.0001). Fifteen adverse effects were observed in 13 patients (38%). Azathioprine was withdrawn in seven cases (20.6%); in four of them (with liver toxicity), treatment with mercaptopurine was indicated.

CONCLUSIONS

Therapy with thiopurinic immunomodulators (azathioprine) represents the first option in the management of steroid-dependent ulcerative colitis. Its efficacy (70%) and its acceptable safety support this view. Increasing mean corpuscular volume and serum bilirubin values may be a surrogate marker of a beneficial effect.

Infliximab induces clinical, endoscopic and histological responses in refractory ulcerative colitis

BACKGROUND

infliximab is a monoclonal antiTNF-ct antibody that has repeatedly shown to be effective in the management of Crohn's disease. However, data are scarce about its efficacy in ulcerative colitis.

AIM

to describe the joint experience of three Spanish hospitals in the use of infliximab in patients with active refractory ulcerative colitis.

PATIENTS AND METHODS

we present seven cases of ulcerative colitis (6 with chronic active disease despite immunosuppressive therapy, and one with acute steroid-refractory ulcerative colitis) treated with infliximab 5 mg/kg of body weight. Clinical response was evaluated by means of the Clinical Activity Index at 2, 4 and 8 weeks after initial infusion. Biochemical (erythrocyte sedimentation rate and C-reactive protein), endoscopic, and histological changes were also assessed.

RESULTS

mean age of patients was 45.8 +/- 17 years (range 23-77); 4 were female. No adverse effects were recorded. Inflammatory activity diminished significantly in 6 of 7 patients (85.7%; CI 95%: 42-99%) both from a clinical (p = 0.01) and biochemical (p <0.05) point of view. Five out of six patients (83.3%; 36-99%) with corticosteroid-dependent disease could be successfully weaned off these drugs. Five patients were endoscopicly controlled both before and after therapy, and a positive endoscopic and histological response could be recorded in all of them.

CONCLUSION

infliximab may be an effective and safe therapy for some patients with ulcerative colitis refractory to other forms of therapy, although controlled studies are needed to assess its role in the general management of this disease.

[Neurological emergencies in a university hospital]

INTRODUCTION

We analyze the demand and to describe the neurological assistance in a university hospital.

MATERIAL AND METHODS

We have performed a retrospective and descriptive study of patients attended in the emergency services by neurologists from June 2000 to May 2001. The inventory and analysis has been carried out across a database in which we codify the reports of the patients diagnosed by means of CIE-9. We have been selected one month where we have collected all calls that neurologist have received, not only those of which reports was realized and codified.

RESULT

The total number of neurological patients attended in a year was 1,864 representing 2.85% of all emergencies. The most frequent diagnostic were: cerebrovascular stroke (24.57%), epilepsy (13.06%) and headache (6.07%). Few seasonal variation was noted. There was no difference for sex. In the month's study there were 426 patients, which represented 7.78% of all medical urgencies. The most frequent calls came from internal medicine (65.02%).

CONCLUSION

Neurological emergencies constitute a large percentage of third level hospital's emergencies which justify a neurologist in the medical emergencies team.

Healing of Helicobacter pylori gastric ulcers: only eradication matters

INTRODUCTION

some authors suggest that Helicobacter pylori eradication favors gastric ulcer healing.

OBJECTIVE

to study which factors influence ulcer healing in patients suffering from gastric ulcer with H. pylori infection.

SUBJECTS AND METHODS

a prospective study of 230 patients with gastric ulcer associated to H. pylori infection. Chronic ingestion of non-steroidal anti-inflammatory drugs was considered as an exclusion. In an initial endoscopy, malignancy was histologically excluded and two biopsies each of antrum and body were obtained. Also, ELISA IgG serology and a 13C-urea breath test were performed. Eradication therapy with omeprazole (20 mg twice a day), clarithromycin (500 mg twice a day) and amoxicillin (1 g twice a day) was administered for seven days, followed by omeprazole 20 mg once a day for five more weeks. Endoscopy was repeated after 6 weeks of treatment and breath test was repeated 2 month after completing therapy.

RESULTS

overall gastric ulcer healing was achieved in 80.8% (95% CI: 75-85%) of cases by intention-to-treat, and in 82.6% (77-87%) per protocol. Ulcer healing was achieved in 94.3% (90-97%) of patients with eradication success, but only in 40.8% (28-54%) of patients with eradication failure (p<0.0001). In the multivariate analysis, H. pylori eradication was the only variable that correlated with ulcer healing (odds ratio 24; 95% CI: 10-56; p<0.0001) (x2 model: 64.4; p<0.0001). Additional variables (age, sex, sporadic ingestion of NSAIDs, smoking, previous ulcer disease, ulcer size and location) were not related to healing.

CONCLUSION

H. pylori eradication favors ulcer healing in patients with gastric ulcer, which is an argument in favor of the etiological role of the microorganism in this disease. Other factors did not influence ulcer healing.

[CADASIL: a case with clinical, radiological, histological and genetic diagnoses]

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a rare inherited cerebrovascular disease. The onset of clinical symptoms occurs with migraine with aura, transient ischemic attacks, recurrent subcortical ischemic infarcts, neuropsychiatric changes reaching subcortical dementia. Brain magnetic resonance images show multiple deep cerebral infarcts in white matter and basal ganglia and diffuse leukoencephalopathy. Neuropathologic hallmark consists of deposition of small electron dense granular patches related to the basement membrane of vascular smooth muscle cells with degeneration of smooth muscle cells and media and luminal obliteration. Recently, the genetic characteristics of this disorder have been reported. Missense mutations in notch3 gene localized in chromosome 19 are involved in its pathogenesis. Only three families from Spain have been reported. Here we describe a patient with typical clinical symptoms, neuroimaging and pathology of CADASIL. C406T (Arg110Cys) mutation in notch3 gene was found. We comment on the clinical symptoms of different members of the patient's family.

Efficacy and tolerability of entacapone in patients with Parkinson's disease treated with levodopa plus a dopamine agonist and experiencing wearing-off motor fluctuations. A randomized, double-blind, multicentre study

The efficacy and tolerability of entacapone was investigated in a randomized, double-blind, placebo-controlled, 3-month study of 162 patients with Parkinson's disease (PD) treated with levodopa and a dopamine agonist and experiencing wearing-off motor fluctuations. Patients were randomized in a 3 : 2 ratio to entacapone 200 mg or placebo, administered with each dose of levodopa. Efficacy was judged on the improvement of "on" and "off" time while awake (Patient Diary and UPDRS part IV Item 39), Investigators' Global Assessment, the SF-36 Health Survey, and changes in levodopa dosages. Patients were monitored for adverse events, laboratory safety and vital signs throughout the study. Improvements in "on" time as assessed using patient diary data showed a trend in favour of entacapone, however these did not reach statistical significance. "Off" time while awake (UPDRS part IV Item 39) showed an improvement of at least one category in 36% of entacapone-treated patients, compared with 22% in the control group (p = 0.0038). The proportion of patients showing an improvement at the Investigators' Global Assessment was significantly higher (p = 0.0006) in the entacapone-treated group of patients. Also, the proportion of patients with a reduction in their daily levodopa dose was significantly higher (p = 0.02) in the entacapone group (28%) compared with placebo (13%). As expected, the most frequent adverse events were dopamine-mediated (dyskinesia: entacapone 31% versus placebo 13%), and harmless urinary discoloration. The modest increase in dyskinesias could be readily managed by levodopa down-adjustment, and, at study end there was no significant difference for the UPDRS "overall dyskinesia score" between entacapone and placebo. In conclusion, although the primary efficacy variable did not reach statistical significance, the present results demonstrate that entacapone provides additional antiparkinsonian benefits to levodopa therapy and is well tolerated in levodopa-treated PD patients experiencing wearing-off motor fluctuations despite adjunct dopamine agonist therapy.

Seven-day proton pump inhibitor, amoxicillin and clarithromycin triple therapy. factors that influence Helicobacter pylori eradications success

AIM

To evaluate which factors influence eradication success with standard triple therapy for Helicobacter pylori.

PATIENTS AND METHODS

A prospective study was made of 891 patients infected by H. pylori and diagnosed with duodenal ulcer (n=422), gastric ulcer (n=221), or functional dyspepsia (n=248). Initially, an endoscopy with biopsies of antrum and body (haematoxylin-eosin stain), and a 13C-urea breath test were performed. All patients were treated for seven days with either omeprazole 20 mg twice daily in 442 patients (OCA) or pantoprazole 40 mg twice daily in 449 patients (PCA), associated to clarithromycin (500 mg twice a day) and amoxicillin (1 g twice a day). Two months after completing therapy urea breath test was repeated to confirm eradication.

RESULTS

Mean age +/- SD was 51.6 +/- 15 years, 61% were male. Overall eradication rate was 73.7% (95% CI 69-77%) and 80.8% (77-84%) with OCA and PCA therapy, respectively, showing significant difference between treatment regimens (chi 2 =6.3; p= 0.01). As refers to underlying diseases, H. pylori eradication was achieved in 77.4% (74-80%) of peptic ulcers and 77% (71-82%) of functional dyspepsia (p=n.s.). With our two treatment regimens (OCA/PCA) eradication success was 74/81% in peptic ulcer (p=0.03), and 72/80% in functional dyspepsia (p=0.1). In the multivariate analysis, type of therapy was the only variable that correlated with eradication success (odds ratio 1.5; 95% CI: 1.1-2.1) (chi2 model: 6,4; p=0.01).

CONCLUSIONS

Standard triple therapy containing a proton pump inhibitor, clarithromycin and amoxicillin for seven days achieves in our community a moderate eradication success; this result could improve by using pantoprazole instead of omeprazole. This therapy is equally effective in patients with peptic ulcer and functional dyspepsia.

Myoglobinuria and COX deficiency in a patient taking cerivastatin and gemfibrozil

The authors describe a patient who presented with myoglobinuria after starting cerivastatin-gemfibrozil therapy. Muscle histochemistry revealed ragged-red fibers and cytochrome c oxidase negative (COX) fibers, and biochemistry showed a defect of COX activity. Immunoblot analysis showed a 60% reduction of COX I and COX II polypeptides. Cerivastatin myotoxicity might be related to a depletion of essential metabolites needed to anchor COX subunit I to mitochondrial membrane.

Acute pancreatitis in childhood

AIM

to evaluate etiological agents involved in acute pancreatitis in children, as well as clinical, laboratory and radiological findings and the illness clinical course.

PATIENTS AND METHODS

we reviewed the cases of acute pancreatitis diagnosed over the last 15 years. The criteria used for cases to be included were acute abdominal pain, elevated serum amylase levels and/or ultrasound abnormalities in the pancreatic area in conscious patients, and the last two criteria in unconscious patients.

RESULTS

thirty-one children were included (average age 7.9 years, range 2-15; 55% males). Infection and gallstones were the most common causes (19 and 16 %, respectively). In all, 9.7% of cases were drug-related (valproic acid, L-asparaginase, azathioprine combined with high doses of methylprednisolone); 6.5% were traumatic in origin and another 6.5% was due to systemic diseases. In 35.5 % no cause was found (idiopathic). The most frequent symptoms were abdominal pain (90%) and emesis (38%). Amylase serum levels were elevated in all patients. Abdominal ultrasound scans were abnormal in 64%, with an increase in the pancreatic area in 48% and hypoechogenicity in 51%. Seven cases required surgical treatment (22%). Seven children had acute pancreatitis, and three of them died as a result of shock unrelated to pancreatitis. Relapse of disease occurred in 19% of patients.

CONCLUSIONS

acute pancreatitis should always be considered in children with abdominal pain. There are a wide variety of etiological factors and in a high percentage of patients no underlying cause is found. Prognosis is variable owing to the heterogeneity of the clinical course of this illness in children.

Efficacy of quadruple therapy with pantoprazole, bismuth, tetracycline and metronidazole as rescue treatment for Helicobacter pylori infection

AIM

To study the efficacy of a 7-day quadruple regimen combining pantoprazole, bismuth, tetracycline and metronidazole as rescue treatment for Helicobacter pylori infection after failure of standard triple therapy.

METHODS

A prospective study was made of 140 patients infected with H. pylori and diagnosed with peptic ulcer or non-ulcer dyspepsia in whom triple therapy with proton pump inhibitor, clarithromycin and amoxicillin had failed. The patients were treated with quadruple therapy including pantoprazole, 40 mg twice daily, colloidal bismuth subcitrate, 120 mg four times daily, tetracycline, 500 mg four times daily, and metronidazole, 500 mg three times daily, for 7 days. Two months after completion of therapy, a 13C-urea breath test was performed to confirm eradication.

RESULTS

With quadruple therapy, the H. pylori eradication rates were 82% (95% confidence interval (CI), 75-88%) by 'intention-to-treat' and 85% (95% CI, 79-91%) by 'per protocol'. No major side-effects were observed. No differences in eradication success were observed in relation to underlying disease (peptic ulcer: 85% (95% CI, 76-91%) vs. non-ulcer dyspepsia: 83% (95% CI, 68-93%)) or smoking habits (smokers: 86% (95% CI, 75-93%) vs. non-smokers: 83% (95% CI, 71-91%)).

CONCLUSION

Quadruple therapy with pantoprazole, bismuth, tetracycline and metronidazole for 7 days is an effective H. pylori eradication treatment for patients in whom standard triple therapy has failed.

[Evolution and treatment response in microscopic colitis]

AIM

To study the clinical characteristics, treatment response and evolution in patients with microscopic colitis.

MATERIAL AND METHODS

We performed a retrospective analysis of 24 patients (15 with collagenous colitis and 9 with lymphocytic colitis). Clinical and diagnostic features, treatment response and evolution according to the presence of maintenance therapy were evaluated.

RESULTS

The mean age of the patients was 59.7 years and most were male. Nine patients took non-steroidal anti-inflammatory drugs (NSAID). No significant association was found with other drugs. Four patients presented associated rheumatological disease. Most patients presented insidious-onset diarrhea without pathological products, which was frequently associated with other symptoms (abdominal pain, bloating, weight loss, asthenia, tenesmus, and incontinence). Seven patients showed a slight increase in globular sedimentation rate. Fat in stools and radiological investigations (transit and opaque enema) were normal in patients who underwent these tests. Endoscopy revealed non-specific alterations in 42% of the patients while results were normal in the remaining patients. One patient showed clinical improvement on withdrawal of NSAIDs and 4 patients improved spontaneously. Clinical response was achieved in 7 of 13 patients treated with antimotility drugs, in 8 of 9 patients treated with salicylates, in 3 treated with oral corticoids, in 1 treated with cholestyramine and in 1 treated with topical budesonide. Nineteen patients required no maintenance therapy, 4 were administered salicylates and 1 was administered cholestyramine. After a mean follow-up of 42 months, evolution was chronic and intermittent in 14 patients and chronic and continuous in 1; 9 patients presented a single episode. No significant differences were found between patients administered maintenance therapy and those who were not or between collagenous colitis and lymphocytic colitis in the parameters analyzed.

CONCLUSIONS

Microscopic colitis constitutes a group of diseases characterized by chronic diarrhea, few systemic effects and minimal radiological and/or endoscopic alterations. Evolution is characterized by recurrent episodes, with good response to treatment with cholestyramine, salicylates or corticoids when required.

Problems and issues with door-to-door, two-phase surveys: an illustration from central Spain

In 1994-1995, a screening and examination survey was conducted to ascertain the prevalence of dementia, Parkinson's disease and stroke in two urban communities and one rural community of central Spain. We use this survey to illustrate many nonclinical aspects of conducting two-phase prevalence surveys. Special emphasis is given to two common weaknesses in such surveys: screening nonparticipation and screening validation.

[Basal concentrations of gastrin and pepsinogen I and II in gastric ulcer: influence of Helicobacter pylori infection and usefulness in the control of the eradication]

AIM

To study the influence of Helicobacter pylori eradication on basal gastrin and pepsinogen I and II levels in patients with gastric ulcer over a 1-year follow-up period, and to assess the usefulness of these values in confirming H. pylori eradication after treatment.

METHODS

Fifty-six patients with gastric ulcer and H. pylori infection were prospectively studied. At the beginning of the study, endoscopy with biopsies for histologic examination and urease testing was carried out, as were 13C-urea breath test and blood samples for determination of gastrin and pepsinogen I and II values by radioimmunoassay and serology. Histologic study, 13C-urea breath test and laboratory determinations were repeated at months 1, 6 and 12 after completion of eradication treatment.

RESULTS

H. pylori infection was eradicated in 82.1% of patients. In patients with successful H. pylori eradication, the initial mean gastrin value was 75.5 +/- 39.1 pg/ml, while at 1 month after treatment this value decreased to 49.2 +/- 21 pg/ml (p < 0.0001). No further reductions were noted. Initial pepsinogen I and II values were 104 +/- 58 and 15.8 +/- 10 ng/ml, respectively, whereas at month 1 after treatment these values were 77 +/- 42 and 7.3 +/- 4 ng/ml, respectively (p < 0.0001) and were 72 +/- 41 and 6.7 +/- 3 ng/ml respectively at month 6 (p < 0.01); no further variations were observed thereafter. The area under the ROC curve which reveals eradication through reductions in hormonal values was 0.70 for gastrin, 0.78 for pepsinogen I, 0.93 for pepsinogen II and 0.92 for the pepsinogen I/II ratio. At months 6 and 12 after treatment completion, differences in mean gastrin and pepsinogen I and II values between the patients with normal histologic findings and those with chronic gastritis were significant (p < 0.05).

CONCLUSIONS

a) H. pylori eradication is associated with an early fall in basal gastrin values and a progressive decrease in basal pepsinogen I and II values. b) In patients with gastric ulcer, determination of the decrease in basal pepsinogen II levels is a useful and early non-invasive method for confirming eradication. c) Determination of gastrin and pepsinogen I and II values may be useful for assessing improvement in gastritis 6 months after treatment completion.

Concordance between noninvasive tests in detecting Helicobacter pylori and potential use of serology for monitoring eradication in gastric ulcer

Our aim was to determine concordance between 13C-urea breath test and serology in detecting Helicobacter pylori and to study their potential use for monitoring eradication in patients with gastric ulcer. We prospectively studied 73 gastric ulcer patients. On endoscopy, biopsies were taken for hematoxylineosin staining and rapid urease testing. Blood samples were drawn for immunoglobulin G antibody determination by enzyme-linked immunosorbent assay (ELISA). A 13C-urea breath test was performed as well. Histology, serology, and urea breath tests were all repeated 1, 6, and 12 months after therapy completion in 56 infected patients. A proportion of positive agreement between serology and breath test results as high as 0.95 was found. McNemar statistic was 3 (p = 0.08), whereas kappa statistic was 0.83 (p < 0.0001). At month 6, significant differences in patients successfully treated relative to baseline serologic values were observed (chi2 = 11.7; p < 0.001). The area under the receiver operating characteristic (ROC) curve for diagnostic efficiency was 0.76, sensitivity was 74%, and specificity was 90% (for H. pylori eradication) when the fall of at least one category in serologic levels was considered as cut-off point. No further decreases in serologic levels were noted over the next 6 months, and 48.8% of patients remained seropositive 1 year after completion of successful treatment. A high concordance between serology and 13C-urea breath test results is observed when the two procedures are used for H. pylori infection diagnosis in patients with gastric ulcer. Also, serology can be successfully used for monitoring H. pylori eradication 6 months after therapy completion.