Helicobacter pylori antimicrobial resistance rates in the central region of Portugal

Helicobacter pylori resistance to antimicrobial agents is steadily increasing. It is extremely important to be aware of the local prevalence of antibiotic resistance so as to adjust treatment strategies. During this single-centre, prospective study, we aimed to determine primary and secondary resistance rates of H. pylori to antibiotics as well as host and bacterial factors associated with this problem. Overall, 180 patients (131 female; mean age 43.4±13.5 years; primary resistance 103; secondary resistance 77) with positive (13) C-urea breath test were submitted to upper endoscopy with gastric biopsies. Helicobacter pylori was cultured and antimicrobial susceptibility was determined by Etest and molecular methods. Clinical and microbiological characteristics associated with resistance were evaluated by logistic regression analysis. Among the 180 isolates 50% were resistant to clarithromycin (primary 21.4%; secondary 88.3%), 34.4% to metronidazole (primary 29.1%; secondary 41.6%), 33.9% to levofloxacin (primary 26.2%; secondary 44.2%), 0.6% to tetracycline and 0.6% to amoxicillin. Being female was an independent predictor of resistance to clarithromycin and metronidazole. Previous, failed, eradication treatments were also associated with a decrease in susceptibility to clarithromycin. History of frequent infections, first-degree relatives with gastric carcinoma and low education levels determined increased resistance to levofloxacin. Mutations in the 23S rRNA and gyrA genes were frequently found in isolates with resistance to clarithromycin and levofloxacin, respectively. This study revealed that resistance rates to clarithromycin, metronidazole and levofloxacin are very high and may compromise H. pylori eradication with first-line and second-line empiric triple treatments in Portugal.

Prognostic scores in a gastroenterology intensive care unit

BACKGROUND

Several prognostic systems have been developed and validated in general Intensive Care Units (ICUs). No assessment of these scores was performed in specialized Gastroenterology Intensive Care Units (GICUs).

AIM

To assess the prognostic accuracy of Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II and Sequential Organ Failure Assessment (SOFA) scores systems to predict mortality in a GICU.

METHODS

Retrospective study of 300 consecutively admissions in a GICU. Demographics, indication for admission, APACHE II, SAPS II and SOFA scores and survival at GICU discharge were recorded. Discrimination was evaluated using receiver operations characteristic (ROC) curves and area under a ROC curve (AUC). Calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

Overall GICU mortality was 5.3%. APACHE II, SAPS II and SOFA mean scores of nonsurvivors (21.9, 46.2 and 9.3, respectively) were found to be significantly higher than those of survivors (11.9, 26.7 and 2.2, respectively) (p < 0.001). Discrimination was excellent for all the prognostic systems, with AUC = 0.900, 0.903 and 0.965 for APACHE II, SAPS II and SOFA, respectively. Similarly, APACHE II, SAPS II and SOFA scores achieved good calibration, with p = 0.671, 0.928 and 0.775, respectively. Among the three scores, SOFA showed the best performance, with overall correctness of prediction of 94.0%, while it was 86.2% for APACHE II and 82.7% for SAPS II.

CONCLUSIONS

in GICU, APACHE II, SAPS II and SOFA scores have excellent prognostic accuracy and, among the three scores, SOFA has the greatest overall correctness of prediction.

Fatal mid-gastrointestinal bleeding by cytomegalovirus enteritis in an immunocompetent patient

Cytomegalovirus (CMV) infections are common in immunocompromised patients but rare in immunocompetent individuals. Gastrointestinal disease is frequent in systemic CMV infections but the small bowel is the least common site of involvement. We present the case of a 66 years-old man, with no evidence of immunological deficiency, hospitalized for unspecific symptoms of diarrhea, fever and abdominal pain, which developed massive mid-gastrointestinal bleeding during hospitalization. Enteroscopy revealed congestive, oedematous mucosa with multiple ulcers in the small bowel. Cytomegalic cells with intranuclear inclusions were found on histologic examination, allowing the diagnosis of CMV infection. Ganciclovir in full therapeutic dose was started and surgery was performed as a last resource treatment, but the patient died. This case highlights the rare condition of massive gastrointestinal bleeding due to CMV disease of the small bowel, the major importance of enteroscopy and pathologic evaluation for diagnosis and the poor prognosis of this situation.

"Downhill" varices. A rare cause of esophageal hemorrhage

"Downhill" varices or upper esophageal varices are a rare cause of proximal digestive tract hemorrhage with only 16 cases described in the literature. In our series, hemorrhage due to "downhill" varices represents 0.1% of all acute esophageal variceal bleeding. Their etiology differs from that of the usual "uphill" varices secondary to portal hypertension, and the clinical management should be directed to vascular obstruction if present. We report a case of an 89-year-old male with hemorrhagic "downhill" varices not associated, as usually, with superior vena cava obstruction or compression, but with severe pulmonary hypertension and drug-related hemorrhagic risk factors, whose removal proved sufficient to prevent rebleeding.

Esophageal perforation--associated risk with balloon tamponade after endoscopic therapy. Myth or reality?

BACKGROUND/AIMS

Variceal bleeding is still associated with high mortality and balloon tamponade may be a lifesaving measure when endoscopic therapy is not available or feasible. The risk of esophageal perforation with balloon tamponade after endoscopic therapy is still uncertain. The aims of the study were to investigate balloon tamponade effectiveness and safety after endoscopic therapy.

METHODOLOGY

Retrospective analysis of 100 consecutive episodes of acute variceal bleeding treated with the Sengstaken-Blakemore tube.

RESULTS

Balloon tamponade had an overall effectiveness of 61%. The Child-Pugh score was significantly higher in patients who failed balloon tamponade. In 48 cases balloon tamponade was preceded by failure of endoscopic therapy. Balloon tamponade was more effective if a previous attempt to perform endoscopic therapy happened (75% vs. 48%; p = 0.006). Aspiration was the most frequent complication. No cases of esophageal perforation were registered.

CONCLUSIONS

Currently balloon tamponade is only used as a temporary bridge to other strategies, when other forms of hemostatic therapies do not succeed. Balloon tamponade was more effective in patients with less severe hepatic dysfunction. Previous attempts to perform endoscopic therapy may augment tamponade effectiveness without increasing the risk of esophageal perforation.

Is prophylactic colectomy indicated in patients with MYH-associated polyposis?

OBJECTIVES

The MYH gene has recently been associated with multiple colorectal tumours. It participates in the DNA base-excision-repair, avoiding mutations in other genes, namely the APC and Ki-ras. Recently, biallelic MYH mutations have been described in patients with attenuated polyposis and in 7.5% with classic polyposis and no detectable APC mutation. The aim of this study was to analyse the incidence of germ-line MYH mutations in selected Portuguese families recorded in a hereditary tumour registry and to evaluate the risk of colorectal cancer in this syndrome.

PATIENTS AND METHODS

Nineteen APC mutation negative patients, 13 presenting attenuated polyposis and 6 with classic familial adenomatous polyposis (> 100 adenomas), were screened for germline biallelic MYH mutations.

RESULTS

Biallelic germline mutations in MYH were identified in 9 of the attenuated polyposis and in one of the classic polyposis patients. The mean age at the clinical diagnosis was 50.6 years (from 35 to 69 years); six were men and four women. Five patients belonged to families with affected siblings; three showed evidence for vertical transmission and two had no evidence for familial transmission of the disease. No extra-colonic manifestations were reported. All patients had surgical resections: five total colectomies, four reconstructive proctocolectomies and one left hemicolectomy. Eight patients had associated malignant degeneration: three T3N+, four T3N0 and one T1N+. In the follow-up two patients died due to tumour recurrence.

CONCLUSION

A large frequency of biallelic MYH mutations (69%) was found in APC mutation negative patients belonging to families with attenuated polyposis; the highest percentage was observed in families presenting evidence for horizontal transmission of the disease. The high percentage of degeneration found in these patients suggests that colonoscopy with polypectomies is not sufficient and prophylactic colectomy is recommended. The identification of MYH associated polyposis is important to evaluate the level of risk, particularly for the siblings.

Dieulafoy's lesion: management and long-term outcome

BACKGROUND AND STUDY AIMS

Dieulafoy's lesion is usually considered to be a rare cause of gastrointestinal bleeding and little information is available about the long-term follow-up of this condition. We studied the clinical pattern and long-term outcome in patients with Dieulafoy's lesion who were managed in a gastrointestinal intensive care unit.

PATIENTS AND METHODS

We reviewed the data on the diagnosis, treatment, and outcome of 70 patients admitted to our unit for acute upper gastrointestinal bleeding due to Dieulafoy's lesion. Endoscopic hemostasis was performed in 69 cases. Patients underwent surgery if endoscopic therapy failed. A phone interview was carried out to assess the long-term clinical outcome.

RESULTS

Dieulafoy's lesion accounted for 4 % of cases of upper gastrointestinal bleeding in patients admitted during the period studied. The mean number +/- SD of endoscopies required to establish the diagnosis was 1.4 +/- 0.75. Endoscopic hemostasis was initially successful in 91.3 % of patients, while nearly 16 % of patients required surgery because endoscopic therapy failed. The overall mortality rate was 8.6 %. None of the 52 patients who were followed up by phone reported recurrent bleeding after discharge from hospital, in a mean follow-up period of 69 months.

CONCLUSIONS

Dieulafoy's lesion is a not uncommon cause of severe recurrent gastrointestinal bleeding. Endoscopic therapy is safe and effective in achieving permanent hemostasis. The long-term prognosis for Dieulafoy's lesion is excellent, even when patients are treated using endoscopic methods alone.

Octreotide in acute bleeding esophageal varices: a prospective randomized study

BACKGROUND/AIMS

To assess the value of octreotide in the control of acute bleeding esophageal varices, in a prospective randomized study.

METHODOLOGY

One hundred and ninety-seven patients admitted for variceal bleeding confirmed at endoscopy were recruited and divided into two groups: group I (n = 111) with endoscopic stigmata of recent bleeding; and group II (n = 86) with active bleeding at emergency endoscopy. Patients in group I were randomized to receive a continuous infusion of octreotide (n = 58) or emergency sclerotherapy (n = 53). Patients in group II were assigned to sclerotherapy (n = 42) or to sclerotherapy plus octreotide (n = 44). At the end of the period of study (48 hours), patients were submitted to sclerotherapy or band ligation until variceal obliteration was achieved.

RESULTS

In group I, octreotide was found to be as effective as sclerotherapy regarding hemostasis at 48 hours and on day 7 after the index bleeding episode. Transfusion needs were not significantly different for the two treatment modalities. In group II, the association of octreotide with sclerotherapy was significantly better than sclerotherapy alone either in controlling acute active bleeding (P < 0.001) or in achieving hemostasis at 48 hours (P < 0.01). Transfusion needs were significantly fewer in patients treated with this therapeutic association as compared to sclerotherapy alone.

CONCLUSIONS

These results suggest that octreotide infusion is effective in the treatment of variceal bleeding. In patients with recent bleeding, octreotide infusion is as effective as emergency sclerotherapy. In active variceal bleeding, it is a valuable adjuvant treatment in association with emergency sclerotherapy.

Comparison of ranitidine bismuth citrate plus clarithromycin with omeprazole plus clarithromycin for the eradication of Helicobacter pylori

BACKGROUND

Many dual and triple therapy treatment regimens have been proposed for the eradication of Helicobacter pylori. However, assessing the relative efficacy of these regimens is complicated by differences in study design, and few well-controlled comparative studies have been reported.

METHODS

This multicentre, randomized, double-blind study involved 530 duodenal ulcer patients, of whom 520 had confirmed H. pylori infection. Patients received 14 days b.d. dual therapy of either ranitidine bismuth citrate (RBC) 400 mg or omeprazole 20 mg, both with clarithromycin 500 mg to eradicate H. pylori, followed by a further 14 days of treatment with RBC 400 mg b. d. or omeprazole 20 mg o.d. to facilitate ulcer healing. H. pylori eradication and ulcer healing were assessed at least 26 days after the end of treatment. Adverse events were recorded throughout the study.

RESULTS

H. pylori was eradicated in 90% of patients who received RBC with clarithromycin and in 66% of patients who received omeprazole with clarithromycin (per protocol; P<0.001). intention-to-treat eradication rates were 77% and 60%, respectively (P<0.001). Ulcer healing rates were 97% in the RBC treatment group and 95% in the omeprazole treatment group. Only 3% and 1% of patients in the RBC and omeprazole treatment groups, respectively, were withdrawn due to adverse events.

CONCLUSIONS

RBC with clarithromycin is a simple and highly effective dual therapy regimen for the eradication of H. pylori, and is significantly more effective than omeprazole with clarithromycin. Both treatment regimens are well tolerated and effectively heal duodenal ulcers.

Severe acute liver failure as the initial manifestation of haematological malignancy

Acute liver failure is rarely secondary to lymphoma or leukaemia and it is extremely uncommon as the initial presentation of malignancy. We report a case of a young adult patient with severe acute liver failure referred for liver transplant, in which a Burkitt acute lymphoblastic leukaemia was diagnosed by bone marrow examination. A complete recovery and long remission were obtained with chemotherapy.

[A structural analysis of the entrance exams for specialist interns from 1994 to 1996]

In order to obtain specialist training in Portugal, doctors must pass a multiple-choice examination. The aim of this article is to present a structural and mathematical analysis of the examinations in the last three years. We based our work on the calculation of reliability coefficient of the examinations, and the difficulty and discrimination index of the questions and the examinations as a whole. A detailed analysis of the examinations, including that of each of the three hundred questions, will be published by the Department of Health Manpower in January, 1997.

[The reform of medical education. Some reflections]

The author points out the factors responsible for the changes verified in the last decades in the science and practice of medicine and in medical assistance; emphasizes the modern meaning of Medical Education as an evolutive, integrated and coherent process, and points out the scope of the university along with its development; defines the contemporary pedagogical objectives of undergraduate medical education, and points out the strategies which are considered the most appropriate to achieve them; reports the winds of change which have swept medical education in Portugal, and refers the obstacles that restrain its application to practice. Finally, the author emphasizes that the success of any educational reform requires the conscious and motivated engagement of its fundamental agents--the student and the professor.