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Tazinkeng N, Monteiro JF, Mbianyor BE, Nowbuth AA, Ntonifor M, Evenge C, Nkhoma A, Moss SF, Asombang AW. Knowledge and approach towards Helicobacter pylori diagnosis and management among primary care physicians in Cameroon: a cross-sectional study. Trans R Soc Trop Med Hyg 2024; 118:313-320. [PMID: 38172074 DOI: 10.1093/trstmh/trad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/26/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Low- and middle-income countries have a high prevalence of Helicobacter pylori infection (HPI). In Cameroon, the majority of HPIs are diagnosed and treated by primary care physicians (PCPs). We sought to assess the knowledge and practices of PCPs in the diagnosis and management of HPI in Cameroon. METHODS A hospital-based cross-sectional study was carried out in four randomly selected regions of Cameroon from November 2021 to June 2022. In each of the selected regions, PCPs were recruited by non-probability convenience sampling and interviewed using a pre-structured questionnaire. Chi-squared, Fisher's exact and Student's t-tests were performed for descriptive analyses. Multivariable logistic regression was used to examine associations between knowledge and practice, with the model adjusted by age of the PCP, geographic region, number of patients and years in practice. Analysis was performed in SAS version 9.4 (SAS Institute, Cary, NC, USA). RESULTS A total of 382 PCPs were included in the analysis. The majority (60.0%) were males between the ages of 20-29 y (64.1%). Most PCPs (80.9%) reported that HPI is the cause of gastroesophageal reflux disease and 41.8% reported that HPI is the main cause of dyspeptic symptoms. The dominant diagnostic tests used for HPI were serology (52.8%) and stool antigen (30.9%). The most frequently used first-line therapies were amoxicillin (AMX), clarithromycin (CLA), metronidazole (MNZ) and proton pump inhibitor (PPI) concomitant therapy (32.2%), AMX-CLA-PPI triple therapy (18.6%) and AMX-MNZ-PPI triple therapy (13.1%). Half of the practitioners (48.6%) treat HPI empirically, without positive H. pylori testing. About half of the PCPs (48%) do not request laboratory confirmation of H. pylori eradication following treatment. CONCLUSIONS There is inadequate knowledge and significant differences in the clinical approach towards HPI among PCPs in Cameroon. We recommend more teaching programs and continuous medical education on HPI.
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Affiliation(s)
- Nkengeh Tazinkeng
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Department of Research, Pan-African Organization for Health, Education and Research, Lusaka, Zambia
- Department of Population Health Research, Health Education and Research Organization, Buea, Cameroon
| | | | - Bill-Erich Mbianyor
- Department of Population Health Research, Health Education and Research Organization, Buea, Cameroon
| | - Avis Anya Nowbuth
- Department of Research, Pan-African Organization for Health, Education and Research, Lusaka, Zambia
| | - Monela Ntonifor
- Department of Population Health Research, Health Education and Research Organization, Buea, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Claudia Evenge
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Alick Nkhoma
- Royal Stoke Hospital, NHS Trust, Stoke-on-Trent, UK
| | - Steven F Moss
- Warren Alpert Medical School of Brown University, Rhode Island, USA
| | - Akwi W Asombang
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Department of Research, Pan-African Organization for Health, Education and Research, Lusaka, Zambia
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Abstract
Helicobacter pylori is the most common chronic bacterial infection worldwide and the most significant risk factor for gastric cancer, which remains a leading cause of cancer-related death globally. H pylori and gastric cancer continue to disproportionately impact racial and ethnic minority and immigrant groups in the United States. The approach to H pylori case-finding thus far has relied on opportunistic testing based on symptoms or high-risk indicators, such as racial or ethnic background and family history. However, this approach misses a substantial proportion of individuals infected with H pylori who remain at risk for gastric cancer because most infections remain clinically silent. Moreover, individuals with chronic H pylori infection are at risk for gastric preneoplastic lesions, which are also asymptomatic and only reliably diagnosed using endoscopy and biopsy. Thus, to make a significant impact in gastric cancer prevention, a systematic approach is needed to better identify individuals at highest risk of both H pylori infection and its complications, including gastric preneoplasia and cancer. The approach to H pylori eradication must also be optimized given sharply decreasing rates of successful eradication with commonly used therapies and increasing antimicrobial resistance. With growing acceptance that H pylori should be managed as an infectious disease and the increasing availability of susceptibility testing, we now have the momentum to abandon empirical therapies demonstrated to have inadequate eradication rates. Molecular-based susceptibility profiling facilitates selection of a personalized eradication regimen without necessitating an invasive procedure. An improved approach to H pylori eradication coupled with population-level programs for screening and treatment could be an effective and efficient strategy to prevent gastric cancer, especially in minority and potentially marginalized populations that bear the heaviest burden of H pylori infection and its complications.
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Affiliation(s)
- Steven F Moss
- Brown University, Providence, Rhode Island; Providence VA Medical Center, Providence, Rhode Island
| | - Shailja C Shah
- University of California at San Diego, San Diego, California; VA San Diego Healthcare System, San Diego, California
| | - Mimi C Tan
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
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Sugano K, Moss SF, Kuipers EJ. Gastric Intestinal Metaplasia: Real Culprit or Innocent Bystander as a Precancerous Condition for Gastric Cancer? Gastroenterology 2023; 165:1352-1366.e1. [PMID: 37652306 DOI: 10.1053/j.gastro.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/02/2023]
Abstract
Gastric intestinal metaplasia (GIM), which denotes conversion of gastric mucosa into an intestinal phenotype, can occur in all regions of the stomach, including cardiac, fundic, and pyloric mucosa. Since the earliest description of GIM, its association with gastric cancer of the differentiated (intestinal) type has been a well-recognized concern. Many epidemiologic studies have confirmed GIM to be significantly associated with subsequent gastric cancer development. Helicobacter pylori, the principal etiologic factor for gastric cancer, plays the most important role in predisposing to GIM. Although the role of GIM in the stepwise progression model of gastric carcinogenesis (the so-called "Correa cascade") has come into question recently, we review the scientific evidence that strongly supports this long-standing model and propose a new progression model that builds on the Correa cascade. Eradication of H pylori is the most important method for preventing gastric cancer globally, but the effect of eradication on established GIM, is limited, if any. Endoscopic surveillance for GIM may, therefore, be necessary, especially when there is extensive corpus GIM. Recent advances in image-enhanced endoscopy with integrated artificial intelligence have facilitated the identification of GIM and neoplastic lesions, which will impact preventive strategies in the near future.
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Affiliation(s)
| | - Steven F Moss
- Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ernst J Kuipers
- Erasmus Medical Center, Rotterdam and Minister, Ministry of Health, Welfare, and Sport, Hague, The Netherlands
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Riaz MS, Moss SF, Shapiro JM, Cerezo C, Herzlinger M. Diagnostic and Treatment Practices for Helicobacter Pylori Infection in an Academic Pediatric Hospital. R I Med J (2013) 2023; 106:35-39. [PMID: 37368832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND In 2016, ESPGHAN/NASPGHAN issued revised guidelines for the management of Helicobacter pylori (H. pylori) infection in children and adolescents. Recommendations include performing antibiotic susceptibility testing to tailor therapy. The aim of our study was to evaluate the H. pylori treatment landscape in pediatric patients at our institution. METHODS We performed a retrospective study of patients diagnosed with H. pylori infection at a single academic children's hospital from 2015 to 2021. The frequency of each treatment regimen and their respective eradication rates were calculated. We compared trends in antibiotic prescriptions and eradication rates before and after 2016. RESULTS One hundred and ninety-six patients were included. Triple therapy with amoxicillin, clarithromycin, and a proton pump inhibiter (PPI) was the most often prescribed regimen (46.5%), followed by amoxicillin, metronidazole, and PPI (33%). Eradication rates were 70% for amoxicillin, clarithromycin, and PPI and 64% for amoxicillin, metronidazole, and PPI. CONCLUSION Our results show eradication rates for both regimens were comparable but suboptimal, highlighting the need to incorporate resistance testing into broader practice.
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Affiliation(s)
- Muhammad Safwan Riaz
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The University of Oklahoma Health Sciences Center, The Children's Hospital at OU Medicine, Oklahoma City, Oklahoma
| | - Steven F Moss
- Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Jason M Shapiro
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases at Hasbro Children's Hospital, Providence, Rhode Island; Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Carolina Cerezo
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases at Hasbro Children's Hospital, Providence, Rhode Island; Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Michael Herzlinger
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases at Hasbro Children's Hospital, Providence, Rhode Island; Brown University Warren Alpert Medical School, Providence, Rhode Island
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Moss SF, Chey WD, Daniele P, Pelletier C, Jacob R, Tremblay G, Hubscher E, Leifke E, Malfertheiner P. Brief communication: global temporal trends in the efficacy of clarithromycin-based regimens for the treatment of Helicobacter pylori infection. Therap Adv Gastroenterol 2023; 16:17562848231167284. [PMID: 37388121 PMCID: PMC10302680 DOI: 10.1177/17562848231167284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/15/2023] [Indexed: 07/01/2023] Open
Abstract
Background Helicobacter pylori eradication rates achieved with clarithromycin-based triple therapies are declining due to antibiotic resistance, but data regarding temporal changes in efficacy with these eradication therapies are scarce. Objective To evaluate the efficacy of clarithromycin-based triple eradication regimens over time. Design A comprehensive literature review and time-trend analysis. Data sources and methods Bibliographies of recently published systematic literature reviews were searched and supplemented with a targeted literature review conducted using Medline and Embase databases and ProQuest from conception to May 2021. Studies reporting H. pylori eradication rates of clarithromycin-based triple therapies were included and temporal trends were estimated using a random-effects model. Results Eradication rates for triple therapies containing proton pump inhibitors (PPIs), clarithromycin, and amoxicillin showed a significant decline over the past 23 years (p = 0.0315). However, this decline was not significant when eradication rates achieved with vonoprazan-based triple therapy were included (p = 0.3910). Conclusion Vonoprazan-based triple therapy partially mitigated the decline in eradication rates seen with PPI-based triple therapy, likely due to more powerful acid suppression of vonoprazan.
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Affiliation(s)
- Steven F Moss
- Division of Gastroenterology, Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
| | | | | | - Rinu Jacob
- Phathom Pharmaceuticals, Florham Park, NJ, USA
| | | | | | | | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany
- LMU Medizinische Klinik und Poliklinik II, Muenchen, Germany
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Moss SF, Dang LP, Chua D, Sobrado J, Zhou Y, Graham DY. Comparable Results of Helicobacter pylori Antibiotic Resistance Testing of Stools vs Gastric Biopsies Using Next-Generation Sequencing. Gastroenterology 2022; 162:2095-2097.e2. [PMID: 35196541 DOI: 10.1053/j.gastro.2022.02.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 12/20/2022]
Affiliation(s)
- Steven F Moss
- Department of Medicine, Division of Gastroenterology, Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Long P Dang
- Department of Medicine, Division of Gastroenterology, Fountain Valley Hospital, Fountain Valley, California
| | | | | | - Yi Zhou
- American Molecular Laboratories, Vernon Hills, Illinois
| | - David Y Graham
- Department of Medicine, Division of Gastroenterology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas
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Ho JJC, Argueta EA, Moss SF. Helicobacter pylori Treatment Regimens: A US Perspective. Gastroenterol Hepatol (N Y) 2022; 18:313-319. [PMID: 36398140 PMCID: PMC9666828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Helicobacter pylori infects nearly one-third of the US population. H pylori is a significant cause of gastroduodenal disease, including peptic ulcers and cancers. However, rising antibiotic resistance has complicated management of H pylori. This article provides a practical review of management strategies, including first-line empiric therapies and how to treat patients when prior therapies fail. Bismuthbased quadruple therapy remains the standard initial empiric regimen, although a rifabutin-based triple regimen is another approach for empiric therapy in the United States. Clarithromycin and levofloxacin therapies should be avoided except when treating a strain of known susceptibility. When therapies fail, resistance should be tested with molecular or culture-based methods. Knowing local resistance patterns and/or using practice-based eradication rates is important for devising logic-based clinical choices. Ultimately, shared decision-making, patient counseling, and careful attention to drug type and dosage are essential for refractory cases.
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Affiliation(s)
- Jonathan J. C. Ho
- Department of Internal Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Erick A. Argueta
- Division of Gastroenterology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Steven F. Moss
- Division of Gastroenterology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
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Affiliation(s)
- Erick A Argueta
- Department of Medicine, Division of Gastroenterology, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Steven F Moss
- Department of Medicine, Division of Gastroenterology, Alpert Medical School of Brown University, Providence, Rhode Island.
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Tse CS, Hinds S, Nguyen H, Xiong N, Moss SF, Bhagra A. A 12-Year North American Longitudinal Study of Gender Equity and Equality in Gastroenterology. Gastroenterology 2022; 162:63-67. [PMID: 34743915 DOI: 10.1053/j.gastro.2021.10.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/14/2021] [Accepted: 10/22/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Chung Sang Tse
- Division of Gastroenterology, University of California, San Diego, San Diego, California
| | - Shaliesha Hinds
- Division of Gastrointestinal and Liver Diseases, Keck Hospital of University of Southern California, Los Angeles, California
| | - Hang Nguyen
- Yale School of Medicine, New Haven, Connecticut
| | - Nancy Xiong
- Community and Public Health Promotion, Rhode Island College, Providence, Rhode Island
| | - Steven F Moss
- Gastroenterology Fellowship Program, Brown University, Providence, Rhode Island
| | - Anjali Bhagra
- Division of General Internal Medicine, Office of Equity, Inclusion and Diversity, Mayo Clinic, Rochester, Minnesota
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Abstract
PURPOSE OF REVIEW Gastric cancer remains one of the most common causes of death globally. Increasing evidence suggests that many gastric cancer cases can be prevented by eradicating its most important etiological agent, Helicobacter pylori. Using the search terms 'H. pylori' and 'gastric cancer' we reviewed the scientific literature regarding the association between H. pylori and gastric cancer published from 1 January 2020 to 30 May 2021. We review the most important articles relevant to the clinical issues regarding H. pylori eradication for gastric cancer prevention. RECENT FINDINGS In randomized trials, eradication of H. pylori is associated with an approximately 50% reduction in sporadic gastric cancer. A similar benefit was observed when screening first-degree relatives of gastric cancer cases, after resection of early gastric cancer to prevent metachronous neoplasia, and in population-based screen and treatment programs in areas of high H. pylori and gastric cancer prevalence. Even in relatively low gastric cancer countries such as the United States, gastric cancer may potentially be avoided by screening for H. pylori, especially among minority groups who are at greatest risk. SUMMARY Gastric cancer is preventable, at least in part, by H. pylori eradication. Ongoing screening trials will help determine whether population-based H. pylori screening programs are feasible and cost-effective. Their results are likely to differ according to H. pylori and gastric cancer prevalence rates.
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Affiliation(s)
- Erick A Argueta
- Division of Gastroenterology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Elfanagely Y, Atsawarungruangkit A, Scharfen J, Pavlech L, Moss SF. Association Between Obstructive Sleep Apnea and Barrett's Esophagus: A Systematic Review and Meta-Analysis. Dig Dis Sci 2021; 66:3689-3697. [PMID: 33236316 DOI: 10.1007/s10620-020-06709-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/03/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) has gastrointestinal implications as it is associated with gastroesophageal reflux disease. Less certain is an independent association between OSA and Barrett's esophagus. We performed a systematic review and meta-analysis to evaluate the association between OSA and Barrett's esophagus. METHODS A systematic search of Ovid MEDLINE, Embase, Web of Science, CINAHL, and the Cochrane Central Register of Controlled Trials was performed. Inclusion criteria were observational studies (retrospective and case-control) assessing the association between OSA and Barrett's esophagus in adult subjects. Data from the included studies were extracted and used to calculate the pooled odds ratio of OSA with 95% confidence interval (CI) between patients with Barrett's esophagus and those without, using a random-effects model. RESULTS Altogether six studies involving 2333 subjects met the inclusion criteria and were included in this meta-analysis. The pooled analysis found a significantly increased risk of OSA, high risk of OSA, and patient-reported OSA symptoms among patients with Barrett's esophagus versus those without Barrett's esophagus, with a pooled odds ratio (OR) of 2.19 (95% CI 1.53-3.15). A subgroup analysis for cases of definite OSA (formally diagnosed via polysomnography) and Barrett's esophagus (n = 2 studies) also demonstrated significant association (OR 2.59, 95% CI 1.39-4.84). CONCLUSION A significantly increased risk of OSA among patients with Barrett's esophagus was demonstrated in this meta-analysis. Further investigation is warranted to determine the pathophysiology and clinical implications of this association.
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Affiliation(s)
- Yousef Elfanagely
- Department of Internal Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Jane Brown Ground, Suite 0100, Providence, RI, USA.
| | | | - James Scharfen
- Department of Internal Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Jane Brown Ground, Suite 0100, Providence, RI, USA
| | - Laura Pavlech
- Brown University Library, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Steven F Moss
- Division of Gastroenterology, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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Abstract
Helicobacter pylori infection remains one of the most prevalent infections worldwide, causing significant morbidity and mortality from gastric malignancies and peptic ulcers. This article provides a summary of the microbiology and pathogenesis of this bacterium, emphasizing the complex and protean effects of H pylori on gastric epithelial cells, including stem and progenitor populations, and evasion of host immune defenses. Increasing antibiotic resistance has made management more challenging. This article discusses the appropriate diagnostic modality for different clinical scenarios, and the evolving treatment of H pylori infections, including the use of antibiotic susceptibility testing to aid regimen selection.
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Affiliation(s)
- Jaehoon Cho
- Division of Gastroenterology, Brown University, 593 Eddy Street, POB 240, Providence, RI 02903, USA
| | - Akriti Prashar
- Department of Gastroenterology, Hepatology and Nutrition, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Cell Biology Program, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M5G0A4, Canada
| | - Nicola L Jones
- Department of Gastroenterology, Hepatology and Nutrition, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Cell Biology Program, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M5G0A4, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Steven F Moss
- Division of Gastroenterology, Brown University, 593 Eddy Street, POB 240, Providence, RI 02903, USA.
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Elfanagely Y, Atsawarungruangkit A, Moss SF. Understanding GI Twitter and Its Major Contributors. Gastroenterology 2021; 160:1917-1921. [PMID: 33548237 DOI: 10.1053/j.gastro.2021.01.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 01/25/2023]
Affiliation(s)
| | - Amporn Atsawarungruangkit
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Steven F Moss
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Argueta EA, Alsamman MA, Moss SF, D’Agata EM. Impact of Antimicrobial Resistance Rates on Eradication of Helicobacter pylori in a US Population. Gastroenterology 2021; 160:2181-2183.e1. [PMID: 33577874 PMCID: PMC9115583 DOI: 10.1053/j.gastro.2021.02.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/23/2020] [Accepted: 02/04/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Erick A. Argueta
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University
| | | | - Steven F. Moss
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University
| | - Erika M.C. D’Agata
- Division of Infectious Diseases, Rhode Island Hospital, Warren Alpert Medical School of Brown University
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Shah SC, Iyer PG, Moss SF. AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review. Gastroenterology 2021; 160:1831-1841. [PMID: 33524402 PMCID: PMC8281326 DOI: 10.1053/j.gastro.2020.11.059] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 02/08/2023]
Abstract
The purpose of this CPU Expert Review is to provide clinicians with guidance on the management of Helicobacter pylori after an initial attempt at eradication therapy fails, including best practice advice on specific regimen selection, and consideration of patient and systems factors that contribute to treatment efficacy. This Expert Review is not a formal systematic review, but is based upon a review of the literature to provide practical advice. No formal rating of the strength or quality of the evidence was carried out. Accordingly, a combination of available evidence and consensus-based expert opinion were used to develop these best practice advice statements.
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Affiliation(s)
- Shailja C. Shah
- Division of Gastroenterology, Veterans Affairs Tennessee Valley Health System, Nashville, TN,Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Steven F. Moss
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, RI
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Atsawarungruangkit A, Yuan J, Kodama T, Cheng MT, Mansouri M, Han B, Kongkamnerd J, Riegg F, Menon A, Moss SF. Evolving global and national criteria for identifying a suspected case of COVID-19. J Int Med Res 2020; 48:300060520938943. [PMID: 32865095 PMCID: PMC7469754 DOI: 10.1177/0300060520938943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background The outbreak of coronavirus disease 2019 (COVID-19) began in December 2019 and continues to spread worldwide. Rapid and accurate identification of suspected cases is critical in slowing spread of the virus that causes the disease. We aimed to highlight discrepancies in the various criteria used by international agencies and highly impacted individual countries around the world. Methods We reviewed the criteria for identifying a suspected case of COVID-19 used by two international public health agencies and 10 countries across Asia, Europe, and North America. The criteria included information on the clinical causes of illness and epidemiological risk factors. Non-English language guidelines were translated into English by a co-author who is fluent in that particular language. Results Although most criteria are modifications of World Health Organization recommendations, the specific clinical features and epidemiological risks for triggering evaluation of patients with suspected COVID-19 differed widely among countries. The rationale for these differences may be related to each country’s resources, politics, experience with previous outbreaks or pandemics, health insurance system, COVID-19 outbreak severity, and other undetermined factors. Conclusion We found no consensus regarding the best diagnostic criteria for identifying a suspected case of COVID-19.
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Affiliation(s)
- Amporn Atsawarungruangkit
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
- Amporn Atsawarungruangkit, Rhode Island Hospital, 593 Eddy Street, POB 240, Providence, Rhode Island 02903, United States.
| | - Jin Yuan
- Boston University School of Medicine, Boston, Massachusetts, United States
| | | | | | | | - Boram Han
- East Boston Neighborhood Health Center, Boston, Massachusetts, United States
- Boston Medical Center, Boston, Massachusetts, United States
| | | | - Fabian Riegg
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
- University of Tübingen, Tübingen, Germany
| | - Anupama Menon
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Steven F. Moss
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
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Rebello D, Bakhit M, McCarty TR, Machan JT, Nagar A, Moss SF. Heparin bridge is associated with more post-polypectomy bleeding and emergency department visits among anticoagulated patients. Ann Gastroenterol 2020; 33:73-79. [PMID: 31892801 PMCID: PMC6928471 DOI: 10.20524/aog.2019.0430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/07/2019] [Indexed: 01/23/2023] Open
Abstract
Background: Among patients undergoing colonoscopy, anticoagulants are usually stopped and are sometimes substituted by a heparin bridge (hep-bridge). We aimed to assess adverse events associated with hep-bridge compared to temporary cessation of anticoagulants (no-bridge). Methods: This was a single-center, retrospective cohort study that included anticoagulated patients undergoing colonoscopy between 2013 and 2016 at a Veterans Affairs Medical Center. In the no-bridge cohort, warfarin was stopped for 5 days and novel anticoagulants for 2 days pre-procedure. In the hep-bridge cohort, anticoagulants were stopped and were substituted by subcutaneous enoxaparin. The primary outcome was post-polypectomy bleeding. Secondary outcomes included cardiovascular events, all-cause adverse events and emergency department or unscheduled ambulatory office visits within 30 days. The predictive values of the HAS-BLED and CHADS2 scores were evaluated. Results: A total of 662 patients were included, of whom 551 underwent polypectomy (mean age 68.6 years; 97.6% male). Four hundred seventy colonoscopies were performed with no-bridge and 192 with hep-bridge. Post-polypectomy bleeding occurred in 6.0% of procedures: 5.7% in the no-bridge cohort compared to 13.0% of hep-bridge procedures (P=0.0038). Cardiovascular or thrombotic events occurred after 2.6% of the no-bridge and 5.2% of the hep-bridge procedures (P=0.1176). Emergency department or unscheduled office visits within 30 days were reported after 18.7% of the no-bridge procedures and 29.7% of the hep-bridge procedures (P<0.0001). Neither CHADS2 nor HASBLED scores predicted bleeding. Conclusion: The use of hep-bridge was associated with a greater incidence of post-polypectomy bleeding and more emergency department and unscheduled office visits compared with cessation of all anticoagulants.
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Affiliation(s)
- Dionne Rebello
- Department of Internal Medicine, Brown University, Providence, RI (Dionne Rebello)
| | - Mena Bakhit
- Division of Gastroenterology, Brown University, Providence, RI (Mena Bakhit, Steven F. Moss)
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA (Thomas R. McCarty).,Harvard Medical School, Boston, MA (Thomas R. McCarty)
| | - Jason T Machan
- Biostatistics and Research, RI Hospital, Providence, RI (Jason T. Machan)
| | - Anil Nagar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT (Anil Nagar).,West Haven Veteran Affairs Medical Center, West Haven, CT (Anil Nagar)
| | - Steven F Moss
- Division of Gastroenterology, Brown University, Providence, RI (Mena Bakhit, Steven F. Moss).,Providence Veteran Affairs Medical Center, Providence, RI (Steven F. Moss), USA
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Alsamman MA, Vecchio EC, Shawwa K, Acosta-Gonzales G, Resnick MB, Moss SF. Retrospective Analysis Confirms Tetracycline Quadruple as Best Helicobacter pylori Regimen in the USA. Dig Dis Sci 2019; 64:2893-2898. [PMID: 31187323 DOI: 10.1007/s10620-019-05694-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Declining Helicobacter pylori (H. pylori) eradication rates have prompted a switch in first-line therapy from standard triple (PPI, clarithromycin, and amoxicillin) to bismuth-based quadruple therapy. A caveat of the ACG 2017 H. pylori treatment guidelines was a paucity of recent US eradication data. AIM To determine Rhode Island H. pylori eradication data, in the largest US study from the last two decades. METHODS Electronic records were queried for patients with H. pylori infection diagnosed by pathology, urea breath test, or stool antigen from 2015 to 2017. Demographics, diagnostic test, treatment regimen, and test of cure were extracted. Eradication rates were calculated, and treatment regimens were compared. RESULTS A total of 1710 patients were identified (64% female): 825 (46%) diagnosed by breath test, 755 (42%) by biopsy, and 191 (12%) by stool antigen. Full data were obtained on 1101 patients. Seven regimens were used: quadruple (64%), triple (25%), doxycycline quadruple (5%), and miscellaneous (6%). Quadruple was superior to triple: (85% vs. 75%, P = 0.002), quadruple 14 days versus triple 14 days (87% vs. 79%, P = 0.0052), quadruple 10 days versus triple 10 days (77% vs. 67%, P = 0.33). Increased therapy length improved eradication (quadruple 14 days vs. 10 days, 87% vs. 77%, P = 0.002; triple 14 days versus 10 days 79% vs. 67%, P = 0.13). Finally, substituting doxycycline for tetracycline yielded lower eradication (85% vs. 67%, P = 0.006). CONCLUSION Quadruple therapy is superior to triple therapy within the Rhode Island population. Fourteen-day therapy achieves superior eradication compared to 10-day therapy, and doxycycline is inferior to tetracycline for quadruple therapy. Our findings support adherence to ACG and international guidelines advising 14-day quadruple therapy.
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Affiliation(s)
- Mohd Amer Alsamman
- Division of Hospital Medicine, The Miriam Hospital, The Warren Alpert Medical School of Brown University, 164 Summit Avenue, Providence, RI, USA
| | - Eric C Vecchio
- Internal Medicine, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Khaled Shawwa
- Division of Nephrology and Hypertension, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Gabriel Acosta-Gonzales
- Department of Pathology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Murray B Resnick
- Department of Pathology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Steven F Moss
- Division of Gastroenterology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA.
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19
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Affiliation(s)
| | - Steven F Moss
- Warren Alpert Medical School of Brown University, Providence, RI
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20
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Affiliation(s)
- Erick A Argueta
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Steven F Moss
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
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Fallone CA, Moss SF, Malfertheiner P. Reconciliation of Recent Helicobacter pylori Treatment Guidelines in a Time of Increasing Resistance to Antibiotics. Gastroenterology 2019; 157:44-53. [PMID: 30998990 DOI: 10.1053/j.gastro.2019.04.011] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/25/2019] [Accepted: 04/03/2019] [Indexed: 12/13/2022]
Abstract
Increasing resistance to antibiotics worldwide has adverse effects on the effectiveness of standard therapies to eradicate Helicobacter pylori infection. We reviewed guidelines developed by expert groups in Europe, Canada, and the United States for the treatment of H pylori infection. We compared the recommendations of these guidelines, reconciled them, and addressed the increasing resistance of H pylori to antibiotic therapy regimens. The guidelines recommend bismuth quadruple therapy for first-line treatment, replacing clarithromycin-based triple therapy. There is consensus for concomitant 4-drug therapy as an alternative, especially when bismuth is not available. When therapy is unsuccessful, it is likely due to resistance to clarithromycin, levofloxacin, and/or metronidazole; these drugs, if used previously, should be avoided in subsequent eradication attempts. Second-line therapies should be bismuth quadruple therapy or levofloxacin triple therapy, depending on suspected resistance, reserving rifabutin-based triple and high-dose dual amoxicillin proton pump inhibitor therapy for subsequent treatment attempts. The increasing resistance of H pylori to antibiotic therapy necessitates local availability of susceptibility tests for individuals, and establishment of regional and national monitoring programs to develop evidence-based locally relevant eradication strategies. Further studies into the development of more easily accessible methods of resistance testing, such as biomarker analysis of stool samples, are required. Options under investigation include substituting vonoprazan for proton pump inhibitors, adding probiotics, and vaccine development. Narrow-spectrum antibiotics and new therapeutic targets could be identified based on genomic, proteomic, and metabolomic analyses of H pylori.
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Affiliation(s)
- Carlo A Fallone
- Department of Medicine, Division of Gastroenterology, McGill University Health Center, Montreal, Québec, Canada.
| | - Steven F Moss
- Department of Medicine, Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany; Ludwig Maximilian University Clinic, Medical Clinic II, München, Germany
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Richter V, Gonzalez JO, Hazan S, Gottlieb G, Friedenberg K, Gatof D, Ganeshappa R, Delgado JS, Abramowitz D, Hardi R, Coates A, Haq M, Mehta N, Jones BA, Moss SF, Shirin H. The validity of breath collection bags method in detecting Helicobacter pylori using the novel BreathID ® Hp Lab System: a multicenter clinical study in 257 subjects. Ther Adv Gastrointest Endosc 2019; 12:2631774519843401. [PMID: 31192315 PMCID: PMC6543788 DOI: 10.1177/2631774519843401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 03/14/2019] [Indexed: 02/05/2023] Open
Abstract
Background and Aim: The BreathID®Hp urea breath test provides several advantages over other 13C breath analyzers for the detection of Helicobacter pylori. We evaluated the sensitivity and specificity of a new BreathID®Hp Lab System (Exalenz Bioscience Ltd, Israel), a 13C-urea breath test system using breath sampling bags that facilitates multiple testing in a multicenter international clinical study. Methods: A total of 257 subjects with evaluable results for urea breath test, rapid urease test, and histology were enrolled into two study groups: 189 naïve subjects were included in the pre-therapy group, and 68 subjects comprised the post-eradication therapy group. Analytical studies were conducted to evaluate the stability, reproducibility, and repeatability of the 13C-urea breath test results using a delta over baseline cut-off value of 5. Results: Among the pre-therapy subjects evaluated with the composite results from the rapid urease test and histology/immunohistochemistry, 176 results matched those of the urea breath test, resulting in an overall agreement of 98.3% with a sensitivity of 100% and specificity of 97.9%. In the post-eradication therapy cohort, the overall agreement between the urea breath test and the biopsy diagnosis was 98.5%; the sensitivity of the urea breath test in this cohort was 92.3% and the specificity was 100%. There was uniformly high overall reproducibility (99.48%) of the test results over different batches of breath sample bags, when analyzed on different days and under different storage conditions, showing stability of the breath samples in the breath collection bags Conclusion: The BreathID®Hp Lab System is a highly accurate and dependable method for the diagnosis of H. pylori infection.
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Affiliation(s)
- Vered Richter
- Institute of Gastroenterology, Liver Diseases and Nutrition, Assaf Harofeh Medical Center, Tel-Aviv University, Zerifin, Israel
| | | | | | | | | | - David Gatof
- Innovative Clinical Research, Lafayette, CO, USA
| | - Ravi Ganeshappa
- Digestive Disease Center of South Texas, P.L.L.C, San Antonio, TX, USA
| | | | - Dov Abramowitz
- Institute of Gastroenterology, Liver Diseases and Nutrition, Assaf Harofeh Medical Center, Tel-Aviv University, Zerifin, Israel
| | - Robert Hardi
- Chevy Chase Clinical Research, Chevy Chase, MD, USA
| | - Allan Coates
- West Michigan Clinical Research Center, Wyoming, MI, USA
| | | | - Nilesh Mehta
- Digestive Disease Care PC, New Hyde Park, NY, USA
| | | | | | - Haim Shirin
- Institute of Gastroenterology, Liver Diseases and Nutrition, Assaf Harofeh Medical Center, Tel-Aviv University, Zerifin, Israel
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23
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Affiliation(s)
- Songhua Zhang
- Division of Gastroenterology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Steven F Moss
- Division of Gastroenterology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
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El-Serag HB, Kao JY, Kanwal F, Gilger M, LoVecchio F, Moss SF, Crowe S, Elfant A, Haas T, Hapke RJ, Graham DY. Houston Consensus Conference on Testing for Helicobacter pylori Infection in the United States. Clin Gastroenterol Hepatol 2018; 16:992-1002.e6. [PMID: 29559361 PMCID: PMC6913173 DOI: 10.1016/j.cgh.2018.03.013] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/02/2018] [Accepted: 03/09/2018] [Indexed: 02/07/2023]
Abstract
Despite guidelines for detection and treatment of Helicobacter pylori infection, recommendations to test patients before and after therapy are commonly not followed in the United States. At the Houston Consensus Conference, 11 experts on management of adult and pediatric patients with H pylori, from different geographic regions of the United States, met to discuss key factors in diagnosis of H pylori infection, including identification of appropriate patients for testing, effects of antibiotic susceptibility on testing and treatment, appropriate methods for confirmation of infection and eradication, and relevant health system considerations. The experts divided into groups that used a modified Delphi panel approach to assess appropriate patients for testing, testing for antibiotic susceptibility and treatment, and test methods and confirmation of eradication. The quality of evidence and strength of recommendations were evaluated using the GRADE system. The results of the individual workshops were presented for a final consensus vote by all panel members. After the Expert Consensus Development meeting, the conclusions were validated by a separate panel of gastroenterologists, who assessed their level of agreement with each of the 29 statements developed at the Expert Consensus Development. The final recommendations are provided, on the basis of the best available evidence, and provide consensus statements with supporting literature to implement testing for H pylori infection at health care systems across the United States.
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Affiliation(s)
- Hashem B. El-Serag
- Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - John Y. Kao
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, Michigan
| | - Fasiha Kanwal
- Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas,Center for Innovation in Quality, Effectiveness, and Safety, Houston, Texas
| | - Mark Gilger
- Baylor College of Medicine, Children’s Hospital of San Antonio, San Antonio, Texas,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Frank LoVecchio
- Department of Medicine, University of Arizona, Tucson, Arizona
| | | | - Sheila Crowe
- Department of Medicine, University of California, San Diego, La Jolla, California
| | - Adam Elfant
- Cooper Medical School, Rowan University, Camden, New Jersey
| | - Thomas Haas
- Department of Pathology, Mercy Health System, Janesville, Wisconsin
| | - Ronald J. Hapke
- Northwest Gastroenterology Clinic, Department of Gastroenterology, Legacy Emanuel Medical Center, Portland, Oregon
| | - David Y. Graham
- Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas
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25
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Affiliation(s)
- O Siddique
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - S F Moss
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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26
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Siddique O, Ovalle A, Siddique AS, Moss SF. Helicobacter pylori Infection: An Update for the Internist in the Age of Increasing Global Antibiotic Resistance. Am J Med 2018; 131:473-479. [PMID: 29353050 DOI: 10.1016/j.amjmed.2017.12.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 02/07/2023]
Abstract
Helicobacter pylori infects approximately half the world's population and is especially prevalent in the developing world. H. pylori is an important cause of global ill health due to its known etiological role in peptic ulcer disease, dyspepsia, gastric cancer, lymphoma, and more recently, recognized in iron deficiency anemia and idiopathic thrombocytopenic purpura. Increased antibiotic usage worldwide has led to antibiotic resistance among many bacteria, including H. pylori, resulting in falling success rates of first-line anti-H. pylori therapies. Eradication failures are principally due to resistance to clarithromycin, levofloxacin, and metronidazole. Several new treatment options or modifications of established regimens are now recommended by updated practice guidelines for primary or secondary therapy. Because these updated recommendations were published in the gastroenterological literature, internists and primary care physicians, who commonly manage H. pylori, may be unaware of these advances. In this review, we outline the changing epidemiology of H. pylori, advise on diagnostic test selection for patients not undergoing endoscopy, and highlight current management options in this era of growing antibacterial resistance.
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Affiliation(s)
- Osama Siddique
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Anais Ovalle
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI
| | | | - Steven F Moss
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI; Division of Gastroenterology and Hepatology, Alpert Medical School of Brown University, Providence, RI.
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27
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Pellicano R, Zagari RM, Zhang S, Saracco GM, Moss SF. Pharmacological considerations and step-by-step proposal for the treatment of Helicobacter pylori infection in the year 2018. MINERVA GASTROENTERO 2018; 64:310-321. [PMID: 29600697 DOI: 10.23736/s1121-421x.18.02492-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the past 30 years, multidrug regimens consisting of a proton pump inhibitor (PPI) and two or three antibiotics have been used in treating Helicobacter pylori (H. pylori) infection. In clinical practice, the optimal regimen to cure H. pylori infection should be decided regionally. Considering the first treatment, the Maastricht V/Florence Consensus Report and the American College of Gastroenterology Clinical Management Guideline highlight that in countries with low clarithromycin resistance rates (<15%), an empiric clarithromycin-based regimen can be used. In countries with high clarithromycin resistance rates or, in the American Guideline, with a previous exposure to clarithromycin, a bismuth-containing quadruple therapy (with metronidazole and tetracycline) is the first choice. In case of persistent infection, after a previous clarithromycin-containing regimen, this drug should be avoided in second line therapy. Options after initial eradication failure include tailored therapy (choosing antibiotic combinations based on antibiotic susceptibility testing), empiric bismuth-containing quadruple therapy or triple levofloxacin-based therapy. Encouraging data are reported, both for the first-line and for rescue treatments, with the use of a formulation of bismuth subcitrate potassium, metronidazole, and tetracycline contained in a single capsule, together with a PPI. Rifabutin- and furazolidone-based regimens should also be considered in rescue regimens. Vonoprazan, a new type of potassium-competitive acid blocker that produces more potent acid inhibition than PPIs, provides improved H. pylori eradication rates in combination with antibiotics. In this review, the authors provide an overview on the current knowledge on the treatment of H. pylori infection, with focus on therapeutic challenges in this field.
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Affiliation(s)
| | - Rocco M Zagari
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Songhua Zhang
- Department of Medicine and Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Giorgio M Saracco
- Unit of Gastroenterology, Molinette-SGAS Hospital, Turin, Italy.,Department of Medical Sciences, University of Turin, Turin, Italy
| | - Steven F Moss
- Department of Medicine and Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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28
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Zhang S, Kim W, Pham TT, Rogers AB, Houghton JM, Moss SF. Native and bone marrow-derived cell mosaicism in gastric carcinoma in H. pylori-infected p27-deficient mice. Oncotarget 2018; 7:69136-69148. [PMID: 27655701 PMCID: PMC5342465 DOI: 10.18632/oncotarget.12049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 09/02/2016] [Indexed: 01/25/2023] Open
Abstract
Objective Chronic Helicobacter pylori (H. pylori) infection promotes non-cardia gastric cancer. Some mouse models suggest that bone marrow derived cells (BMDC) contribute to Helicobacter-associated gastric carcinogenesis. We determined whether this increased susceptibility to Helicobacter-induced gastric carcinogenesis of p27-deficient mice is dependent upon their p27-null BMDC or their p27-null gastric epithelial cells. Design Female mice (recipients) were irradiated and transplanted with BMDC from male donors. Wild type (WT) mice in group 1 (control) received BMDC from male GFP-transgenic mice. Female WT and p27 KO mice were engrafted with male p27KO mice BMDC (Group 2) or GFP-transgenic WT BMDC (Group 3). Recipients were infected with H. pylori SS1 for one year. Results Mice lacking p27 in either the BM pool or gastric epithelium developed significantly more advanced gastric pathology, including high-grade dysplasia. Co-staining of donor BMDC in dysplastic gastric glands was confirmed by immunofluorescence. Gastric expression of IL-1 beta protein was reduced in groups 2 and 3 (p < 0.05 vs control) whereas expression of IFN-γ and chemokines MIP-1 beta, MIG, IP-10 and RANTES in group 2 were significantly higher than group 3. Conclusions Both bone marrow-derived and gastric epithelial cells contribute to the increased gastric cancer susceptibility of p27-deficient H. pylori-infected mice.
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Affiliation(s)
- Songhua Zhang
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Woojin Kim
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Tu T Pham
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Arlin B Rogers
- Department of Biomedical Sciences, Tufts Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, USA
| | - Jean Marie Houghton
- Department of Medicine and Cancer Biology, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Steven F Moss
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Simons M, Scott-Sheldon LAJ, Risech-Neyman Y, Moss SF, Ludvigsson JF, Green PHR. Celiac Disease and Increased Risk of Pneumococcal Infection: A Systematic Review and Meta-Analysis. Am J Med 2018; 131:83-89. [PMID: 28801224 DOI: 10.1016/j.amjmed.2017.07.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/03/2017] [Accepted: 07/03/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Celiac disease has been associated with hyposplenism, and multiple case reports link celiac disease and pneumococcal infections; however, increased risk of pneumococcal infection in celiac disease has not been confirmed. The purpose of this study was to conduct a systematic review to determine the risk of pneumococcal infections in celiac disease. METHODS Relevant studies were identified using electronic bibliographic searches of PubMed, OVID, Medline, and EMBASE (1980 to February 2017) and reviewing abstracts from major conferences in gastroenterology. Using number of events in celiac patients and referent patients, we calculated a summary relative risk of pneumococcal infections. All analyses were conducted in Comprehensive Meta-Analysis software using random-effects assumptions. RESULTS Of a total of 156 articles, 3, representing 3 large databases (the Swedish National Inpatient Register; the Oxford Record Linkage Study; and the English National Hospital Episode Statistics) were included. Each compared patients with celiac disease and confirmed pneumococcal infection to a specific reference group: inpatients and/or the general population. Overall, the odds of pneumococcal infection were higher among hospitalized celiac patients compared with controls (odds ratio 1.66; 95% confidence interval 1.43-1.92). There was no evidence of heterogeneity (Q[1] = 1.17, P = .56, I2 = 0%). CONCLUSIONS Celiac disease is associated with an increased risk of pneumococcal infection. Preventive pneumococcal vaccination should be considered for those with celiac disease, with special attention to those aged 15-64 years who have not received the scheduled pneumococcal vaccination series as a child.
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Affiliation(s)
- Malorie Simons
- Division of Internal Medicine, Alpert Medical School of Brown University and Rhode Island Hospital, Providence.
| | - Lori A J Scott-Sheldon
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI; Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
| | - Yesenia Risech-Neyman
- Division of Gastroenterology, Alpert Medical School of Brown University and Rhode Island Hospital, Providence
| | - Steven F Moss
- Division of Gastroenterology, Alpert Medical School of Brown University and Rhode Island Hospital, Providence
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, United Kingdom; Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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Alzahrani S, Nelson J, Moss SF, Paulus JK, Knowler WC, Pittas AG. H. pylori seroprevalence and risk of diabetes: An ancillary case-control study nested in the diabetes prevention program. J Diabetes Complications 2017; 31:1515-1520. [PMID: 28739267 PMCID: PMC5603174 DOI: 10.1016/j.jdiacomp.2017.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine the association between H. pylori infection and risk of incident diabetes in adults at high risk for diabetes who participated in the Diabetes Prevention Program (DPP) study. METHODS In a nested case-control study conducted among 421 adults with newly diagnosed diabetes and 421 matched controls, we examined the association between serological status of H. pylori at baseline and risk of incident diabetes over a mean follow-up period of 2.6years. Using data from the baseline visit of the DPP, we also examined the cross-sectional association between presence of H. pylori antibodies and insulin sensitivity, insulin secretion and the disposition index-like measure after a 75-g oral glucose tolerance test (OGTT). RESULTS At baseline, H. pylori antibodies were present in 40% of participants who developed diabetes and 39% of controls. After adjusting for matching factors, there was no association between exposure to H. pylori and incident diabetes (odds ratio [OR] of 1.04 (95% CI, 0.77 to 1.40). In cross-sectional analyses, H. pylori status was not significantly associated with insulin sensitivity and disposition index-like measure from OGTT. CONCLUSIONS In adults at high risk for diabetes, H. pylori seropositivity was not associated with risk of developing diabetes.
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Affiliation(s)
- Saud Alzahrani
- Division of Endocrinology, Diabetes and Metabolism, Tufts Medical Center, Boston, MA; Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Steven F Moss
- Division of Gastroenterology, Brown University, Providence, RI
| | - Jessica K Paulus
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - William C Knowler
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ
| | - Anastassios G Pittas
- Division of Endocrinology, Diabetes and Metabolism, Tufts Medical Center, Boston, MA; Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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Broide E, Richter V, Mendlovic S, Shalem T, Eindor-Abarbanel A, Moss SF, Shirin H. Lymphoid follicles in children with Helicobacter pylori-negative gastritis. Clin Exp Gastroenterol 2017; 10:195-201. [PMID: 28860835 PMCID: PMC5560569 DOI: 10.2147/ceg.s133421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose The prevalence of Helicobacter pylori gastritis has been declining, whereas H. pylori-negative gastritis has become more common. We evaluated chronic gastritis in children with regard to H. pylori status and celiac disease (CD). Patients and methods Demographic, clinical, endoscopic, and histologic features of children who underwent elective esophagogastroduodenoscopy were reviewed retrospectively. Gastric biopsies from the antrum and corpus of the stomach were graded using the Updated Sydney System. H. pylori presence was defined by hematoxylin and eosin, Giemsa, or immunohistochemical staining and urease testing. Results A total of 184 children (61.9% female) met the study criteria with a mean age of 10 years. A total of 122 (66.3%) patients had chronic gastritis; 74 (60.7%) were H. pylori-negative. Children with H. pylori-negative gastritis were younger (p=0.003), were less likely to present with abdominal pain (p=0.02), and were mostly of non-Arabic origin (p=0.011). Nodular gastritis was found to be less prevalent in H. pylori-negative gastritis (6.8%) compared with H. pylori-positive gastritis (35.4%, p<0.001). The grade of mononuclear infiltrates and neutrophil density was more severe in the H. pylori-positive group (p<0.001). Pan-gastritis and lymphoid follicles were associated most commonly with H. pylori. Although less typical, lymphoid follicles were demonstrated in 51.3% of H. pylori-negative patients. The presence or absence of CD was not associated with histologic findings in H. pylori-negative gastritis. Conclusion Our findings suggest that lymphoid follicles are a feature of H. pylori-negative gastritis in children independent of their CD status.
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Affiliation(s)
- Efrat Broide
- Pediatric Gastroenterology Service, Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Assaf Harofeh Medical Center, Tzrifin, Israel.,Gastroenterology Service, Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Assaf Harofeh Medical Center, Tzrifin, Israel.,Sackler School of Medicine, Tel Aviv University
| | - Vered Richter
- Gastroenterology Service, Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Assaf Harofeh Medical Center, Tzrifin, Israel
| | - Sonia Mendlovic
- Pathology Institute, Assaf Harofeh Medical Center, Tzrifin, Israel
| | - Tzippora Shalem
- Pediatric Gastroenterology Service, Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Assaf Harofeh Medical Center, Tzrifin, Israel.,Department of Pediatrics, Assaf Harofeh Medical Center, Tzrifin, Israel
| | | | - Steven F Moss
- Division of Gastroenterology, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Haim Shirin
- Gastroenterology Service, Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Assaf Harofeh Medical Center, Tzrifin, Israel.,Sackler School of Medicine, Tel Aviv University
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Chey WD, Leontiadis GI, Howden CW, Moss SF. Response to Georgopoulos et al. Am J Gastroenterol 2017; 112:1169-1170. [PMID: 28725080 DOI: 10.1038/ajg.2017.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | | | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Steven F Moss
- Division of Gastroenterology, Brown University, Providence, Rhode Island, USA
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Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212-239. [PMID: 28071659 DOI: 10.1038/ajg.2016.563] [Citation(s) in RCA: 866] [Impact Index Per Article: 123.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/07/2016] [Indexed: 02/07/2023]
Abstract
Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. While choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process. For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole. When first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used. If a patient received a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options. If a patient received first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. Details regarding the drugs, doses and durations of the recommended and suggested first-line and salvage regimens can be found in the guideline.
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Affiliation(s)
- William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | | | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Steven F Moss
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Abstract
Gastric cancer has long been recognized to be accompanied and preceded by chronic gastritis, lasting decades. Arguably, the most important development in our understanding of gastric cancer pathogenesis over the past 50 years has been the realization that, for most cases of gastric cancer, Helicobacter pylori is the cause of the underlying gastritis. Gastritis can promote gastric carcinogenesis, typically via the Correa cascade of atrophic gastritis, intestinal metaplasia, and dysplasia. Nested case-control studies have shown that H pylori infection increases the risk of gastric cancer significantly, both of the intestinal and diffuse subtypes, and that H pylori is responsible for approximately 90% of the world's burden of noncardia gastric cancer. Based largely on randomized studies in high gastric cancer prevalence regions in East Asia, it appears that primary and tertiary intervention to eradicate H pylori can halve the risk of gastric cancer. Some public health authorities now are starting screening and treatment programs to reduce the burden of gastric cancer in these high-risk areas. However, there is currently much less enthusiasm for initiating similar attempts in the United States. This is partially because gastric cancer is a relatively less frequent cause of cancer in the United States, and in addition there are concerns about theoretical downsides of H pylori eradication, principally because of the consistent inverse relationship noted between H pylori and esophageal adenocarcinoma. Nevertheless, establishing a link between chronic H pylori infection and gastric cancer has led to novel insights into cancer biology, the gastrointestinal microbiome, and on individual and population-based gastric cancer prevention strategies.
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Affiliation(s)
- Steven F. Moss
- Correspondence Address correspondence to: Steven F. Moss, MD, Gastroenterology Division, Rhode Island Hospital, 593 Eddy Street, APC 414, Providence, Rhode Island 02903. fax: (401) 444-2939.Gastroenterology Division, Rhode Island Hospital593 Eddy Street, APC 414ProvidenceRhode Island 02903
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Oberg K, Modlin IM, De Herder W, Pavel M, Klimstra D, Frilling A, Metz DC, Heaney A, Kwekkeboom D, Strosberg J, Meyer T, Moss SF, Washington K, Wolin E, Liu E, Goldenring J. Consensus on biomarkers for neuroendocrine tumour disease. Lancet Oncol 2015; 16:e435-e446. [PMID: 26370353 PMCID: PMC5023063 DOI: 10.1016/s1470-2045(15)00186-2] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/24/2015] [Accepted: 03/26/2015] [Indexed: 02/06/2023]
Abstract
Management of neuroendocrine neoplasia represents a clinical challenge because of its late presentation, lack of treatment options, and limitations in present imaging modalities and biomarkers to guide management. Monoanalyte biomarkers have poor sensitivity, specificity, and predictive ability. A National Cancer Institute summit, held in 2007, on neuroendocrine tumours noted biomarker limitations to be a crucial unmet need in the management of neuroendocrine tumours. A multinational consensus meeting of multidisciplinary experts in neuroendocrine tumours assessed the use of current biomarkers and defined the perquisites for novel biomarkers via the Delphi method. Consensus (at >75%) was achieved for 88 (82%) of 107 assessment questions. The panel concluded that circulating multianalyte biomarkers provide the highest sensitivity and specificity necessary for minimum disease detection and that this type of biomarker had sufficient information to predict treatment effectiveness and prognosis. The panel also concluded that no monoanalyte biomarker of neuroendocrine tumours has yet fulfilled these criteria and there is insufficient information to support the clinical use of miRNA or circulating tumour cells as useful prognostic markers for this disease. The panel considered that trials measuring multianalytes (eg, neuroendocrine gene transcripts) should also identify how such information can optimise the management of patients with neuroendocrine tumours.
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Affiliation(s)
- Kjell Oberg
- Department of Medical Sciences, Endocrine Oncology, Uppsala University, Uppsala, Sweden
| | | | - Wouter De Herder
- Section of Endocrinology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
| | | | - David Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - David C Metz
- Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Anthony Heaney
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Dik Kwekkeboom
- Department of Nuclear Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
| | | | - Timothy Meyer
- University College London Cancer Institute, London, UK
| | - Steven F Moss
- Brown University, Liver Research Center, Providence, RI, USA
| | - Kay Washington
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward Wolin
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Eric Liu
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James Goldenring
- Department of Cell and Developmental Biology, Vanderbilt University Medical Center, Nashville, TN, USA
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Affiliation(s)
- Raymond T Lee
- Department of Internal Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI, 02903, USA,
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Zhang S, Lee DS, Morrissey R, Aponte-Pieras JR, Rogers AB, Moss SF. Early or late antibiotic intervention prevents Helicobacter pylori-induced gastric cancer in a mouse model. Cancer Lett 2015; 359:345-51. [PMID: 25853150 DOI: 10.1016/j.canlet.2015.01.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
H. pylori infection causes gastritis, peptic ulcers and gastric cancer. Eradicating H. pylori prevents ulcers, but to what extent this prevents cancer remains unknown, especially if given after intestinal metaplasia has developed. H. pylori infected wild-type (WT) mice do not develop cancer, but mice lacking the tumor suppressor p27 do so, thus providing an experimental model of H. pylori-induced cancer. We infected p27-deficient mice with H. pylori strain SS1 at 6-8 weeks of age. Persistently H. pylori-infected WT C57BL/6 mice served as controls. Mice in the eradication arms received antimicrobial therapy (omeprazole, metronidazole and clarithromycin) either "early" (at 15 weeks post infection, WPI) or "late" at 45 WPI. At 70 WPI, mice were euthanized for H. pylori determination, histopathology and cytokine/chemokine expression. Persistently infected mice developed premalignant lesions including high-grade dysplasia, whereas those given antibiotics did not. Histologic activity scores in the eradication groups were similar to each other, and were significantly decreased compared with controls for inflammation, epithelial defects, hyperplasia, metaplasia, atrophy and dysplasia. IP-10 and MIG levels in groups that received antibiotics were significantly lower than controls. There were no significant differences in expression of IFN-γ, TNF-α, IL-1β, RANTES, MCP-1, MIP-1α or MIP-1β among the three groups. Thus, H. pylori eradication given either early or late after infection significantly attenuated gastric inflammation, gastric atrophy, hyperplasia, and dysplasia in the p27-deficient mice model of H. pylori-induced gastric cancer, irrespective of the timing of antibiotic administration. This was associated with reduced expression of IP-10 and MIG.
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Nisimova L, Wen S, Cross-Knorr S, Rogers AB, Moss SF, Chatterjee D. Role of Raf kinase inhibitor protein in Helicobacter pylori-mediated signaling in gastric cancer. Crit Rev Oncog 2015; 19:469-81. [PMID: 25597356 DOI: 10.1615/critrevoncog.2014012044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Helicobacter pylori is a helical bacterium that colonizes the stomach in over half of the world's population. Infection with this bacterium has been linked to peptic ulcer disease and gastric cancer. The bacterium has been shown to affect regulatory pathways in its host cells through specific virulence factors that control gene expression. Infection with H. pylori increases levels of phosphorylation of Raf kinase inhibitor protein (pRKIP) in gastric adenocarcinoma (AGS) cells in vitro and in vivo. We investigated the role of H. pylori in the phosphorylation of RKIP as a possible mechanism to downregulate pro-survival signals in gastric adenocarcinoma. pRKIP induces RKIP transcriptional activity, which serves to induce apoptosis of damaged cells to prevent further tumorigenesis. Infection of wild type and RKIP knockout mice with H. pylori for 2 months further confirmed roles of RKIP and pRKIP in the prevention of gastric cancer progression. Loss of RKIP in AGS cells results in increased expression of the Cag A virulence factor after H. pylori infection and RKIP overexpression inhibits H. pylori-mediated STAT3 phosphorylation and STAT3 and NF-κB transcriptional activity. We examined the role of mTOR (mammalian target of rapamycin) after H. pylori infection on the phosphorylation of RKIP. Cells treated with rapamycin, an inhibitor of mTOR, displayed less expression of pRKIP after H. pylori infection. Microarray antibody analysis was conducted on wild-type and RKIP-knockdown AGS cells and showed that in the absence of RKIP, there was increased expression of pro-tumorigenic proteins such as EGFR, Raf-1, and MAPKs. Although further work is needed to confirm the interaction of RKIP and mTOR in AGS cells as a result of H. pylori infection, we hypothesize that H. pylori-mediated induction of pro-survival signaling in gastric epithelial cells induces a feedback response through the activation of RKIP. The phosphorylated, or active, form of RKIP is important in protecting gastric epithelial cells from tumorigenesis after H. pylori infection.
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Affiliation(s)
- Liana Nisimova
- Department of Medicine, Rhode Island Hospital and The Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sicheng Wen
- Department of Medicine, Rhode Island Hospital and The Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sam Cross-Knorr
- Department of Medicine, Rhode Island Hospital and The Alpert Medical School of Brown University, Providence, Rhode Island
| | - Arlin B Rogers
- Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts
| | - Steven F Moss
- Department of Medicine, Rhode Island Hospital and The Alpert Medical School of Brown University, Providence, Rhode Island
| | - Devasis Chatterjee
- Department of Medicine, Rhode Island Hospital and The Alpert Medical School of Brown University, Providence, Rhode Island
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39
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Abstract
Over recent decades, the incidence of cancers of the gastroesophageal junction, including gastric cardia tumors, has increased markedly. This is a trend that has been well documented, especially in studies from the USA and northern Europe that have also demonstrated a concomitant rise in the ratio of cardia to distal gastric cancers. The rise in the prevalence of gastric cardia adenocarcinoma has been paralleled by the worldwide obesity epidemic, with almost all epidemiological studies reporting increased body mass index and obesity increase the risk of cardia cancer development. However, the strength of this association is less marked than the link between obesity and esophageal adenocarcinoma, and the mechanisms remain poorly understood. Other possible confounders of the relationship between obesity and cardia cancer include the decline in Helicobacter pylori infection and the widespread use of proton pump inhibitors, although these have rarely been controlled for in case-control and cohort studies investigating associations between obesity and cardia cancer. We review these epidemiological trends and discuss proposed mechanisms for the association, drawing attention to controversies over the difficulty of defining cardia cancer. The relative paucity of high-quality epidemiological studies from other regions of the world should prompt further investigation of this issue, especially in populations undergoing rapid socioeconomic change.
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Affiliation(s)
- Sidney Olefson
- Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
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40
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Moise L, McMurry JA, Pappo J, Lee DS, Moss SF, Martin WD, De Groot AS. Identification of genome-derived vaccine candidates conserved between human and mouse-adapted strains ofH. pylori. Human Vaccines 2014; 4:219-23. [DOI: 10.4161/hv.4.3.5394] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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41
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Zhang S, Lee DS, Morrissey R, Aponte-Pieras JR, Rogers AB, Moss SF. Early or late antibiotic intervention prevents Helicobacter pylori-induced gastric cancer in a mouse model. Cancer Lett 2014; 355:106-12. [PMID: 25218349 DOI: 10.1016/j.canlet.2014.09.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 09/01/2014] [Accepted: 09/04/2014] [Indexed: 02/08/2023]
Abstract
H. pylori infection causes gastritis, peptic ulcers and gastric cancer. Eradicating H. pylori prevents ulcers, but to what extent this prevents cancer remains unknown, especially if given after intestinal metaplasia has developed. H. pylori infected wild-type (WT) mice do not develop cancer, but mice lacking the tumor suppressor p27 do so, thus providing an experimental model of H. pylori-induced cancer. We infected p27-deficient mice with H. pylori strain SS1 at 6-8 weeks of age. Persistently H. pylori-infected WT C57BL/6 mice served as controls. Mice in the eradication arms received antimicrobial therapy (omeprazole, metronidazole and clarithromycin) either "early" (at 15 weeks post infection, WPI) or "late" at 45 WPI. At 70 WPI, mice were euthanized for H. pylori determination, histopathology and cytokine/chemokine expression. Persistently infected mice developed premalignant lesions including high-grade dysplasia, whereas those given antibiotics did not. Histologic activity scores in the eradication groups were similar to each other, and were significantly decreased compared with controls for inflammation, epithelial defects, hyperplasia, metaplasia, atrophy and dysplasia. IP-10 and MIG levels in groups that received antibiotics were significantly lower than controls. There were no significant differences in expression of IFN-γ, TNF-α, IL-1β, RANTES, MCP-1, MIP-1α or MIP-1β among the three groups. Thus, H. pylori eradication given either early or late after infection significantly attenuated gastric inflammation, gastric atrophy, hyperplasia, and dysplasia in the p27-deficient mice model of H. pylori-induced gastric cancer, irrespective of the timing of antibiotic administration. This was associated with reduced expression of IP-10 and MIG.
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Affiliation(s)
- Songhua Zhang
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Dong Soo Lee
- Department of Gastroenterology, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Rhiannon Morrissey
- Department of Biology and Biomedical Sciences, Salve Regina University, Newport, RI 02840, USA
| | - Jose R Aponte-Pieras
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Arlin B Rogers
- Department of Biomedical Sciences, Tufts Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA 01536, USA
| | - Steven F Moss
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.
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Affiliation(s)
- Steven F Moss
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Dalal RS, Moss SF. At the bedside: Helicobacter pylori, dysregulated host responses, DNA damage, and gastric cancer. J Leukoc Biol 2014; 96:213-24. [PMID: 24823809 PMCID: PMC4101088 DOI: 10.1189/jlb.4bt0214-100r] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 04/14/2014] [Accepted: 04/17/2014] [Indexed: 12/15/2022] Open
Abstract
Clinical trials performed in populations at high GC risk have demonstrated that eradication of Helicobacter pylori from the stomach with a course of combination antimicrobials helps prevent gastric carcinogenesis when they are administered before precancerous lesions have yet developed. In this review, we consider the insights into H. pylori-associated gastric carcinogenesis that have been gained from these and many other clinical studies in the field to highlight priority areas for basic research and clinical investigation. Among these are defining the magnitude of the risk reduction that may be achieved in clinical practice and at a population level by H. pylori eradication and investigating when, during the slow multistep progression to GC, intervention will be of the most benefit. Additional strategies to prevent GC induced by H. pylori, including chemoprevention, dietary modification, and close endoscopic surveillance, may also have value in augmenting the risk reduction. Why only a small subpopulation of those infected by H. pylori go on to develop GC may be partially explained by genetic susceptibility related to SNPs in several genes regulating the intensity of the gastric inflammatory response to H. pylori. Investigation of the basic mechanisms underlying the promotion of GC by H. pylori and the associated inflammatory response will likely continue to improve clinical strategies for the prevention of one of the most common causes of cancer death globally. See related review, At the Bench: H. pylori, dysregulated host responses, DNA damage, and gastric cancer.
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Affiliation(s)
- Rahul S Dalal
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Steven F Moss
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Zhang S, Desrosiers J, Aponte-Pieras JR, DaSilva K, Fast LD, Terry F, Martin WD, De Groot AS, Moise L, Moss SF. Human immune responses to H. pylori HLA Class II epitopes identified by immunoinformatic methods. PLoS One 2014; 9:e94974. [PMID: 24740005 PMCID: PMC3989244 DOI: 10.1371/journal.pone.0094974] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 03/21/2014] [Indexed: 12/30/2022] Open
Abstract
H. pylori persists in the human stomach over decades and promotes several adverse clinical sequelae including gastritis, peptic ulcers and gastric cancer that are linked to the induction and subsequent evasion of chronic gastric inflammation. Emerging evidence indicates that H. pylori infection may also protect against asthma and some other immune-mediated conditions through regulatory T cell effects outside the stomach. To characterize the complexity of the CD4+ T cell response generated during H. pylori infection, computational methods were previously used to generate a panel of 90 predicted epitopes conserved among H. pylori genomes that broadly cover HLA Class II diversity for maximum population coverage. Here, these sequences were tested individually for their ability to induce in vitro responses in peripheral blood mononuclear cells by interferon-γ ELISpot assay. The average number of spot-forming cells/million PBMCs was significantly elevated in H. pylori-infected subjects over uninfected persons. Ten of the 90 peptides stimulated IFN-γ secretion in the H. pylori-infected group only, whereas two out of the 90 peptides elicited a detectable IFN-γ response in the H. pylori-uninfected subjects but no response in the H. pylori-infected group. Cytokine ELISA measurements performed using in vitro PBMC culture supernatants demonstrated significantly higher levels of TNF-α, IL-2, IL-4, IL-6, IL-10, and TGF-β1 in the H. pylori-infected subjects, whereas IL-17A expression was not related to the subjects H. pylori-infection status. Our results indicate that the human T cell responses to these 90 peptides are generally increased in actively H. pylori-infected, compared with H. pylori-naïve, subjects. This information will improve understanding of the complex immune response to H. pylori, aiding rational epitope-driven vaccine design as well as helping identify other H. pylori epitopes with potentially immunoregulatory effects.
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Affiliation(s)
- Songhua Zhang
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Joseph Desrosiers
- Institute for Immunology and Informatics, University of Rhode Island, Providence, Rhode Island, United States of America
| | - Jose R. Aponte-Pieras
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Kristen DaSilva
- Institute for Immunology and Informatics, University of Rhode Island, Providence, Rhode Island, United States of America
| | - Loren D. Fast
- Institute for Immunology and Informatics, University of Rhode Island, Providence, Rhode Island, United States of America
- Division of Hematology and Oncology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Frances Terry
- EpiVax, Inc., Providence, Rhode Island, United States of America
| | | | - Anne S. De Groot
- Institute for Immunology and Informatics, University of Rhode Island, Providence, Rhode Island, United States of America
- EpiVax, Inc., Providence, Rhode Island, United States of America
| | - Leonard Moise
- Institute for Immunology and Informatics, University of Rhode Island, Providence, Rhode Island, United States of America
- EpiVax, Inc., Providence, Rhode Island, United States of America
| | - Steven F. Moss
- Division of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
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Abstract
Over the last decades, it has become evident that chronic infection by Helicobacter pylori is achieved by colonizing an almost exclusive niche and hiding from many of the host's cellular immune defense mechanisms. Although recent years have seen progress in our understanding of the innate and adaptive immune response against H. pylori, it is still uncertain how to promote the development of immunity with the final goal of a successful vaccine. Research published in the last year revealed an intriguing mutual regulation of innate response mechanisms of mucosal epithelial cells by the host and H. pylori, respectively. A further focus was put on the interaction between H. pylori and dendritic cells, with some emphasis on the inflammasome and the resulting T-cell responses. Moreover, the function of microRNAs in macrophages and gastric MALT lymphoma development has been studied in more detail. Several novel antigens and adjuvants have been tested as vaccination strategies, primarily in mice. In this review, we present a concise summary of advances in the area of inflammation, immunity, and vaccines during the last twelve months.
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Affiliation(s)
- Manuel Koch
- Department of Molecular Biology, Max Planck Institute for Infection Biology, Berlin, Germany
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Moise L, Moss SF, De Groot AS. Moving Helicobacter pylori vaccine development forward with bioinformatics and immunomics. Expert Rev Vaccines 2013; 11:1031-3. [PMID: 23151160 DOI: 10.1586/erv.12.80] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Cao W, Tian W, Hong J, Li D, Tavares R, Noble L, Moss SF, Resnick MB. Expression of bile acid receptor TGR5 in gastric adenocarcinoma. Am J Physiol Gastrointest Liver Physiol 2013; 304:G322-7. [PMID: 23238937 PMCID: PMC3566614 DOI: 10.1152/ajpgi.00263.2012] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 12/12/2012] [Indexed: 02/08/2023]
Abstract
Bile reflux is a risk factor in the development of intestinal metaplasia in the stomach and is believed to function as an initiator of gastric carcinogenesis. However, whether the G protein-coupled bile acid receptor TGR5 is expressed in this tumor is not known. In this study, we determined the expression of TGR5 in gastric adenocarcinoma and examined the role of TGR5 in cell proliferation. Strong TGR5 staining was present in 12% of cases of intestinal metaplasia but in no cases of normal gastric epithelium (P < 0.01). Moderate to strong TGR5 membranous and cytoplasmic staining was present in 52% of the intestinal but in only 25% of the diffuse subtype of adenocarcinomas (P < 0.001). Kaplan-Meier univariate survival analysis revealed that moderate to strong TGR5 staining was associated with decreased patient survival (P < 0.05). Treatment with taurodeoxycholic acid (TDCA, a bile acid) significantly increased thymidine incorporation in the AGS gastric adenocarcinoma cell line, suggesting that bile acids may increase cell proliferation. This increase was significantly decreased by knockdown of TGR5 with TGR5 small-interfering RNA (siRNA). In addition, overexpression of TGR5 significantly enhanced TDCA-induced increases in thymidine incorporation. TGR5 is coupled with G(q)α and Gα(i-3) proteins. TDCA-induced increase in thymidine incorporation was significantly decreased by knockdown of G(q)α and Gα(i-3) with their siRNAs. We conclude that TGR5 is overexpressed in most gastric intestinal-type adenocarcinomas, and moderate to strong TGR5 staining is associated with decreased patient survival in all gastric adenocarcinomas. Bile acids increase cell proliferation via activation of TGR5 receptors and G(q)α and Gα(i-3) proteins.
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Affiliation(s)
- Weibiao Cao
- Department of Pathology, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.
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Byun SW, Chang YJ, Chung IS, Moss SF, Kim SS. Helicobacter pylori decreases p27 expression through the delta opioid receptor-mediated inhibition of histone acetylation within the p27 promoter. Cancer Lett 2012; 326:96-104. [PMID: 22867947 DOI: 10.1016/j.canlet.2012.07.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 07/22/2012] [Accepted: 07/27/2012] [Indexed: 12/13/2022]
Abstract
Chronic Helicobacter pylori infection is associated with the decreased expression of the gastric tumour suppressor protein p27. Because transcription of the gene p27 may be regulated epigenetically through histone acetylation, which is mediated by G-protein coupled delta opioid receptor (DOR) stimulation, we examined whether H. pylori regulates the DOR/histone acetylation/p27 promoter pathway. The levels of acetylated histone and p300, a gene-specific histone acetyltransferase within the p27 promoter, were measured using ChIP assays. The expression of phospho-DOR was evaluated by Western blot and immunohistochemical analyses. Growth curves were constructed, and cell proliferation was assessed after BrdU incorporation. Low p27 expression in acutely H. pylori-infected AGS gastric epithelial cells and in chronically H. pylori-infected AGS-derived HS3C cells was associated with approximate 20% and 40% decreases in p27 mRNA expression, respectively, when compared to p27 mRNA levels in uninfected AGS parental cells. The low p27 mRNA levels following H. pylori infection were associated with a 15-60% reduction in p27 promoter histone H4 acetylation. The recruitment of p300 to the p27 promoter was also markedly decreased by H. pylori infection. The expression of phospho-DOR was decreased by H. pylori infection in cell lines in vitro and in H. pylori-infected human gastric mucosa in vivo. The level of cellular p27 inversely correlated with cell proliferation in HS3C cells. These results demonstrate that H. pylori decreases p27 expression by modulating the DOR and thereby inhibiting histone acetylation of the p27 promoter. These findings link low gastric p27 expression levels with increased instances of gastric carcinogenesis associated with H. pylori infection.
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Affiliation(s)
- Sang Won Byun
- Department of Internal Medicine, Uijongbu St. Mary's Hospital, The Catholic University of Korea, Uijongbu 480-717, South Korea
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Ruiz VE, Sachdev M, Zhang S, Wen S, Moss SF. Isolating, immunophenotyping and ex vivo stimulation of CD4+ and CD8+ gastric lymphocytes during murine Helicobacter pylori infection. J Immunol Methods 2012; 384:157-63. [PMID: 22814402 DOI: 10.1016/j.jim.2012.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 06/07/2012] [Accepted: 07/06/2012] [Indexed: 12/30/2022]
Abstract
Helicobacter pylori infection is associated with severe chronic inflammation, yet the host immune response is rarely able to clear the bacterium. Thymus derived lymphocyte populations such as T helper 1, T helper 17, and T regulatory cells are known to play important roles in the chronicity of H. pylori infection as well as contributing to ongoing gastric pathology. It is yet to be established how these immune cell populations interact in the gastric environment during H. pylori infection. Mouse models of infection offer an opportunity to investigate these interactions in detail. Flow cytometric analysis provides excellent lymphocyte characterization due to its high specificity, sensitivity and potential to perform multiple simultaneous measurements. However, this requires a viable enriched single cell suspension after adequate tissue dissociation, which poses a challenge due to the heterogeneity of gastric tissue. We have evaluated several isolation techniques and have optimized a protocol to isolate and enrich lymphocytes from the H. pylori-infected murine stomach. EDTA/DTT followed by Collagenase IV digestion successfully dissociates an average of 1 × 10⁷ cells per mouse. Further enrichment using Lympholyte M gradient yields on average 4 × 106 CD45+ lymphocytes per stomach. Following isolation we compared lymphocyte stimulation by CD3/CD28, phorbol 12-myristate 13-acetate (PMA) and ionomycin or H. pylori lysate and determined that CD3/CD28 effectively induces stimulation of IFNγ and IL 17A, but impairs Foxp3 expression. Using an optimized protocol we observed a 2-fold increase of CD8+ IFNγ-expressing lymphocytes localized specifically to the gastric compartment during H. pylori infection. The mechanisms of H. pylori immunopathogenesis are still considered enigmatic, therefore this optimized protocol can help delineate further novel immune cell targets that mediate H. pylori-induced pathology and identify the correlates of immunity for vaccine development.
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Affiliation(s)
- Victoria E Ruiz
- Department of Medicine, Division of Gastroenterology, Rhode Island Hospital and Brown University, Providence, RI 02903, USA.
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