Teaching parotid surgery to ENT residents in the era of new technologies: an ex-vivo ovine model

Surgical training has recently assumed a central role in the otolaryngology field, and the necessity to train residents and fellows' skills in a progressive manner has led to an incredible widespread of ex-vivo animal models for several surgical procedures. To report our experience with an ex-vivo ovine model for parotid gland dissection in a training context. A junior resident (PGY-1) and a post-graduate student with no experience in parotid surgery were guided by a skilled surgeon in the parotid gland dissection for each step of the procedure. Three different adult lamb heads were used for this feasibility study. A specific preparation of the model was performed before the training session. Similarity between the ovine model and the human were recorded. The resident and the post-graduate student were able to carry out a complete parotid gland dissection under supervision. The correct identification of surgical landmarks has led to a proper surgical simulation. The facial nerve dissection was adequately performed, and all branches were isolated. Parotid surgery training on an ex-vivo ovine model is useful, easy repeatable, and low cost. The ovine model presented in this study has similarities in size, structure, and tissue consistence to the human parotid, making it an ideal model for residents to simulate parotid surgery.

Non-implantable bone conduction device for hearing loss: a systematic review

There are different treatment options that employ a bone conduction transmission of the sound, for different types of hearing loss, as well as hearing aids, medical intervention via prostheses and surgically implanted medical devices. A middle ear disease causes a decline in the conductive mechanism of hearing. The current possibilities of compensating Conductive Hearing Loss (CHL) solutions include both surgical and no surgical Bone Conduction Devices (BCDs). Due to the invasiveness of the implantable devices and their specific requirements in terms of the temporal bone anatomy, non-implantable BCDs are in some cases preferred in the clinical routine. The goal of this review is to investigate the beneficial effects and safety of non-implantable BC devices, analysing the different type of solutions found so far. A systematic review was performed to identify all the clinical studies evaluating the use of non-invasive BCDs. A qualitative analysis based on data extracted was conducted. From 37 articles, 11 prospective studies and 1 retrospective study were selected for a full analysis, for a total of 173 patients from 4- to 77-years-old. Eight of these studies included adult patients, while the other four are paediatric studies. All the studies analyse non-implantable BCDs commonly used in case of CHL, sensorineural HL and single side deafness. Three of them analyse an adhesive device, six compare the adhesive device with a sound processor mounted on a support fitted on the head, one compare it also with an implant, one analyse the sound processor mounted on different type of support, and one compare different type of sound processor. All the studies showed advantages from the use of non-invasive BCDs, both on adults and children. The non-invasive BCDs analysed in this review show good results both from the audiological and subjective point of view and could be considered a safe and effective solution for patients suffering from conductive hearing loss, sensorineural hearing loss or single-side deafness. More studies are required to confirm these promising results.

The efficacy of Barbed Sutures for Anterior Pharyngoplasty: technical aspects and preliminary results

After the first experiences with the Barbed Sutures (BS) in sleep surgery, we present the Modular Barbed Anterior Pharyngoplasty (M.B.A.Ph.), a functional tenso-structural reconstruction of the soft palate, as a surgical solution for Obstructive Sleep Apnea (OSA) due to antero-posterior collapse at the drug induced sleep endoscopy (DISE) for snoring and mild-moderate OSA. The action of the BS is sustained over time by means of solid and stable tissue scarring. M.B.A.Ph. avoids palatal fibromuscular resection and minimize iatrogenic bleeding (bloodless surgery). The technique is described in detail and some preliminary results are presented.

Minimally invasive surgery under local anaesthesia for chronic rhinosinusitis with nasal polyps: our experience in older adults

OBJECTIVE

This paper aims to report our experience with a minimally invasive surgical procedure for the treatment of chronic rhinosinusitis with nasal polyps, performed in a day-surgery setting under local anaesthesia.

METHODS

A retrospective study of 30 patients with chronic rhinosinusitis with nasal polyps was conducted. Sino-Nasal Outcome Test 22 and modified Lund-Kennedy scores were collected. Intra- and post-operative pain was evaluated using a 10-point visual analogue scale.

RESULTS

The mean Sino-Nasal Outcome Test 22 score decreased from 41.8 ± 15.8 pre-operatively to 13.3 ± 9.5 post-operatively (p < 0.001). Accordingly, the mean endoscopic score decreased from 6.8 ± 1.8 to 0.2 ± 0.7 (p < 0.001). The mean intra-operative pain score was 2.9 ± 3.2, and 29 patients (96.7 per cent) reported no pain in the post-operative period (visual analogue scale score = 0).

CONCLUSION

Our study confirms that minimally invasive surgery represents a safe, repeatable procedure that results in remarkable subjective and objective improvement, without intra- and post-operative pain or discomfort.

In reply to "Commentary to: Endoscopic and clinical benefits of hyaluronic acid in children with chronic adenoiditis and middle ear disease", by Zhengcai Lou

Some considerations will be expressed in consideration of the commentary previously published. In particular, we underline that no other medications were administered to the patients during the study period and any clinical evaluation was postponed in case of acute upper respiratory tract infection in the previous 14 days. We strongly advocate antibiotic treatment during any acute otitis media episode, and we agree that topically administered hyaluronic acid should be considered as a supporting treatment, "complementary to traditional therapies" in children with recurrent disease.

The efficacy of topical hyaluronan in rhinosinusitis: a systematic review

Rhinosinusitis is one of the most common inflammatory conditions of the nasal cavity and paranasal sinuses and is one of the most common causes of absence from work and for visits to the family doctor. The treatment strategy in both acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) is to reduce the severity of the symptoms, minimize the duration of the disease and prevent complications. Topical therapy has become an important tool in otolaryngologists’ armamentarium for rhinosinusitis treatment. Recently, topical hyaluronic acid (HA), the major component of many extracellular matrices that promotes tissue healing, including activation and moderation of the inflammatory responses, cell proliferation, migration and angiogenesis, has been proposed for ARS and CRS adjuvant tool. The aim of the study is to systematically review the published literature regarding all the therapeutic effects of HA on the ARS and CRS. Relevant published studies were found in PubMed, Google Scholar and Ovid, using a combined keyword search or medical subject headings. At the end of our study selection process, 5 relevant publications were included: 2 of them investigated the potential role of HA in reducing symptoms and preventing exacerbations of CRS in adult population, two of them in paediatric patients affected by upper respiratory tract infections and one of them in cystic fibrosis patients with bacterial rhinopharyngitis. Data deriving from the present review of 5 clinical studies showed that the use of topical HA represents a relevant therapeutic advance in rhinosinusitis to minimize symptoms and prevent reacutization with a significant improvement of their quality of life, as it avoids systemic side effects and increases local drug activity. Further studies on larger populations and with new specific nebulization devices for upper airway are needed to confirm these encouraging results.

Topical hyaluronic acid in rhinitis medicamentosa: could our perspective be changed?

This study was designed to prospectively evaluate the role of nebulized hyaluronic acid (HA) administered for 10 days as treatment for patients with rhinitis medicamentosa (RM). RM is a pathological condition of the nasal mucosa induced by prolonged, excessive or improper use of topical decongestants. It is characterized by persistent nasal congestion that can lead the patient to increase the frequency of application and the quantity of the substance being applied, resulting in dependence on topical nasal decongestants. Twenty-five patients were treated with HA nebulized via Spray-sol twice a day for 10-days (T1) (HA Spray-sol treatment group). Subsequently, after 3 days of washout, patients were treated with physiological saline nebulized via Spray-sol twice a day for 10 days. (T2) (saline Spray-sol treatment group). The HA Spray-sol treatment group (tp) significantly improved visual analogue scale (VAS) scores (T0=6.25±1.64 vs T1=3.91±1.30; p less than 0.05), whereas there was no statistically significant difference in the saline Spray-sol treatment group (tp) (p>0.05), results confirmed by the anterior active rhinomanometry (AAR) data (HA Spray-sol tp T0=1.193±0.83 vs T1=0.44±0.25, p less than 0.05; saline Spray-sol tp (p>0.05). An improvement in the Global Rhinitis Score (GRS) was recorded in both groups (T0=15.37±5.16 vs T1=5.54±3.23, p less than 0.05; saline Spray-sol tp T0=15.37±5.16 vs T2=10. 7±5.43; p less than 0.05). Both groups showed a significant reduction in mucosal oedema and nasal secretions. Patients treated with HA Spray-sol reduced or even eliminated (11/25 patients) the use of topical decongestant within 10 days of treatment with HA. The results of this study suggest nebulized topical 9-mg sodium hyaluronate plays a pivotal role in the management of RM.

Systematic review: the efficacy of topical hyaluronic acid on oral ulcers

The management of oral ulcers is a challenge for clinicians. Whilst there is widespread use of topical corticosteroids, antibiotics and antimicrobial, there is only weak evidence for the effectiveness of any of the topical treatments. Hyaluronic Acid (HA) has been recently proposed for topical administration in the treatment of oral ulcers and other painful oral lesions. The aim of the study is to systematically review the published literature regarding all the therapeutic effects of HA on painful oral lesions such as oral ulcers and oral lichen planus. Relevant published studies were found in PubMed, Google Scholar and Ovid using a combined keyword search or medical subject headings. At the end of our study selection process, 4 relevant publications were included: two regarding oral lichen planus, one Behcet’s Disease and Recurrent Aphthous ulcer and one in oral ulcers in general. Both subjective parameters such as healing period, VAS for pain and objective assessments such as number of ulcers, maximal area of ulcer and inflammatory signs, significantly improved after HA treatment. These data allow us to suggest that HA may play a pivotal role in the treatment of oral ulcers.

Prospective multicentre study on barbed reposition pharyngoplasty standing alone or as a part of multilevel surgery for sleep apnoea

OBJECTIVES

The aim of this study was to demonstrate in a prospective multicentre study that Barbed Reposition Pharyngoplasty (BRP) procedure is safe and effective in management of obstructive sleep apnoea/hypopnea syndrome (OSAHS) patients.

DESIGN

Prospective study.

SETTING

Multicentre study.

PARTICIPANTS

Patients suffering from obstructive sleep apnoea.

MAIN OUTCOMES MEASURES

Values of postoperative apnoea-hypopnea index (AHI), oxygen desaturation index (ODI), epworth sleepiness scale (ESS).

RESULTS

111 Barbed Reposition Pharyngoplasty procedures standing alone or as a part of multilevel surgery for OSAHS, performed between January and September 2016, were analysed in 15 different centres. The average hospitalisation period was 2.5 ± 0.5 days. The mean patient age was 46.3 ± 10.5 years. The average body mass index at the time of the procedure was 27.9 ± 3.2, and the majority of the patients were men (83%). The mean preoperative and postoperative apnoea/hypopnea index was 33.4 ± 19.5 and 13.5 ± 10.3, respectively (P < .001). The mean preoperative and postoperative ESS score was 10.2 ± 4.5 and 6.1 ± 3.6, respectively (P < .001). The mean preoperative and postoperative ODI were 29.6 ± 20.7 and 12.7 ± 10.8, respectively (P < .001).

CONCLUSIONS

Patients undergoing BRP standing alone or as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation for success with minimal morbidity.

Chorda tympani nerve, may it have a role in stabilizing middle ear pressure?

The chorda tympani (ChT) is a mixed nerve, branch of the facial nerve, crossing the middle ear and containing the preganglionic parasympathetic axons that innervate the sublingual and submandibular glands. The maintenance of a correct middle ear pressure (MEP) is essential for normal ear functions; its regulation has a sophisticated neural control mainly provided by middle ear receptors (tympanic plexus, TP) and Eustachian tube (ET). The information provided by chemoreceptors and baroreceptors of the TP is transmitted to the nuclei of the solitary tract (NST) and then a neural circuit promotes the activation of ET muscles. We hypothesize that the information provided by the TP may modulate submandibular and sublingual glands activity through a neural pathway involving the NST, the superior salivatory nucleus (SSN) and finally the ChT. According to our hypothesis, sudden perturbations of the MEP may stimulate saliva production with consequent swallowing, opening of the Eustachian tube and endotympanic pressure rebalancing.

[Unilateral frontal sinus aspergillosis: the combined endoscopic and mini-trephination approach]

OBJECTIVE

Aspergillosis is a common fungal infection of the paranasal sinuses. Localization in the frontal sinus is usually secondary to involvement of one of the other sinuses. Isolated frontal sinus aspergillosis is rare and only 5 cases are described in literature.

CLINICAL CASE

We report a case of a patient with a frontal sinus aspergilloma associated with ipsilateral chronic ethmoidal and maxillary sinusitis, successfully treated with a combined endoscopic and mini-trephination approach "Lemoyne technique".

DISCUSSION AND CONCLUSION

The endoscopic approach to the frontal sinus is considered the best way to deal with frontal sinus aspergilloma, but it is sometimes not sufficient to guarantee the complete removal of the fungus ball. In such cases a mini-trephination of the frontal sinus with associated irrigation provides a more accurate visualization and toilette of the sinus.

Evaluation of ear function after cardiopulmonary bypass with otoacoustic emissions: a pilot study

OBJECTIVES

During extracorporeal circulation (ECC) there is a great hemodynamic stress with possible impact on the microcirculation, including cochlear one. Previous studies have evaluated the effect of ECC on inner ear with contrasting results. The aim of this study is to evaluate possible modifications of the outer hair cells (OHC) function after open heart surgery (OHS) under ECC with transient evoked (TEOAEs) and distortion product otoacoustic emissions (DPOAEs).

METHODS

Ten patients (5 F and 5 M), undergoing OHS with ECC, were subjected to an audiological assessment pre- and postoperatively. We compared the pre-operative and post-operative mean auditory thresholds, mean TEOAEs reproducibility and amplitude, and mean DPOAEs amplitude. Student's t-test was used to compare different values.

RESULTS

No significant differences were found between pre- and post-operative audiological assessment both in hearing level and in otoacoustic emissions.

CONCLUSION

OHC function seems to be not affected by hemodynamic stress induced by ECC. Further studies on a larger scale will be necessary to confirm our preliminary data.

Obstructive sleep apnea syndrome: from phenotype to genetic basis

Obstructive sleep apnea syndrome (OSAS) is a complex chronic clinical syndrome, characterized by snoring, periodic apnea, hypoxemia during sleep, and daytime hypersomnolence. It affects 4-5% of the general population. Racial studies and chromosomal mapping, familial studies and twin studies have provided evidence for the possible link between the OSAS and genetic factors and also most of the risk factors involved in the pathogenesis of OSAS are largely genetically determined. A percentage of 35-40% of its variance can be attributed to genetic factors. It is likely that genetic factors associated with craniofacial structure, body fat distribution and neural control of the upper airway muscles interact to produce the OSAS phenotype. Although the role of specific genes that influence the development of OSAS has not yet been identified, current researches, especially in animal model, suggest that several genetic systems may be important. In this chapter, we will first define the OSAS phenotype, the pathogenesis and the risk factors involved in the OSAS that may be inherited, then, we will review the current progress in the genetics of OSAS and suggest a few future perspectives in the development of therapeutic agents for this complex disease entity.

Vestibular-evoked myogenic potentials after superior semicircular canal obliteration

OBJECTIVE

To analyse vestibular evoked myogenic potentials (VEMPs) characteristics in patients with superior semicircular canal dehiscence syndrome (SCDS) after surgical plugging.

MATERIALS AND METHODS

Five surgical plugging of SCD were performed on 4 patients presenting uni- or bilateral SCD. VEMPs were recorded before and after surgery.

RESULTS

Postoperative VEMP testing revealed in all cases a normalization of the response on the operated side.

DISCUSSION

Patients with SCDS typically have VEMPs with pathologically low thresholds and large amplitude potentials. VEMPs represent a screening investigation for SSCD and a valuable tool in the postoperative follow-up to confirm the successful repair of the dehiscence. In bilateral SSCD cases, VEMPs help to localize the worst side which is operated first.

CONCLUSION

VEMPs are essential in both preoperative planning and postoperative monitoring of patients with SCDS.

Otoplasty: special attention in patients wearing hearing aids

OBJECTIVE

Surgical procedure for the correction of prominent ears (lop ears, bat ears) is very common. Nevertheless in some occasions a post operative narrowing of the external meatus and/or an overcorrection of the pinna can arise. In a patient with hearing loss who wears or who is candidate to wear hearing aids this can have severe consequences. This association (prominent ears and hearing loss) can be isolated or found in some congenital syndromes (Noonan, fragile X syndrome).

CASE REPORT

2 cases of otoplasty in patients wearing hearing aids. The Negrevergne otoplasty technique was used in both cases and a simultaneous meatoplasty was performed with the goal of achieving an external ear meatus of a suitable size for a proper use of hearing aids. Also the overcorrection of the pinna was avoided in using this technique allowing the retention of the behind the ear hearing aid.

CONCLUSION

Simultaneous oto-meato-plasty represents a valid solution to avoid post operative inconvenient in patients wearing hearing aids.

Medial displacement of T-tubes: case report

Medial displacement of T-tubes is rare and only 6 cases have been reported in literature. We report a case of a medial displacement of a T-tube in the middle ear behind an intact tympanic membrane with normal mobility. No treatment was undergone as the patient was asymptomatic and no hearing problems were detected. A brief overview of this unusual complication of tympanostomy tubes is presented and the management strategy is discussed.

An overview of hearing impairment in older adults: perspectives for rehabilitation with hearing aids

BACKGROUND

Hearing loss is a common problem in modern society due to the combined effects of noise, aging, disease, and heredity. According to 2005 estimates by the World Health Organization (WHO), 278 million people worldwide have moderate to profound hearing loss in both ears. Incidence increases with age. Approximately 31.4% of people over age 65 have hearing loss and 40% to 50% of people 75 and older have a hearing loss. Only 1 out of 5 people who could benefit from a hearing aids actually wears one.

OBJECTIVE

To review literature for articles that focus on hearing aids.

STATE OF THE ART

Hearing aids have continuously evolved over the past 50 years, in term of styles and technology. Technological advances in hearing aids and HATS (Hearing Assistive Technologies, and Rehabilitation Services) have expanded the range of options available to improve the success of a device use. Today's hearing aids differ significantly from their analog predecessors because the application of digital signal processing has permitted many adaptive and/or automatic features. Included in the benefits of digital hearing aids are improved sound quality, multiple listening programs for different listening environments, advanced noise reduction strategies, acoustic feedback reduction, compatibility with remote control options, and flexibility in manipulation of the frequency, compression, and gain.

CONCLUSIONS

The hearing aids continue to be developed to enhance the characteristics in terms of rehabilitation and acceptability.

A suitable test for identifying high risk adult patients of moderate-severe obstructive sleep apnea syndrome

The aim of this study was the evaluation of the usefulness of a 7-items questionnaire, Rome Questionnaire (RQ), in identifying adult patients at risk of obstructive sleep apnoea syndrome (OSAS). 136 adults (76 M, 60 F) with snoring were enrolled. Each patient underwent to an overnight polysomnography (PSG) study and the patient's bed partner answered the "RQ". RQ survey items mainly addressed the presence and frequency of snoring behaviour, breathing pauses, sore throat, oral breathing and wake time sleepiness. Of the 136 initial patients, 111 (63 M, 48 F; mean age 54.6 +/- 10.84) with a complete PSG examination were included in the study. They were divided according to apnea-hypopnea index (AHI) into two groups: group A with a primary snoring or mild OSAS (AHI < or = 15) and group B with moderate-severe OSAS (AHI > 15). The RQ final score was 25.27 +/- 16.1 for group A and 42.29 +/- 15.2 for group B, with a statistically significant (p < 0.0001) difference. Analyzing the RQ score of group B (moderate-severe OSAS) we surprisingly noticed that most of patients (66%) showed an high RQ score (> 40). No patients with moderate-severe OSAS showed a RQ score < 20 and for every point scored in the questionnaire there is an extra 1.07 (0.7%) risk of belonging to group B. Group B showed a mean body mass index (BMI) of 31.53 (+/- 4.95), significantly (p < 0.001) higher than BMI of group A (26,86 +/- 3.28) and BMI results a good predictive factor (p = 0.013) of mild-severe OSAS. In conclusion, the "RQ", together with BMI, seems to be an useful tool to make a selection of the patients at higher risk of moderate-severe OSAS, who need a prompt PSG evaluation. Our findings will require further validation in larger sample of subjects.

Atypical chronic head and neck pain: don't forget Eagle's syndrome

We report a case of an adult woman with an Eagle's Syndrome (ES) treated with medical therapy. ES is characterized by an aspecific orofacial pain secondary to calcification of the stylohyoid ligament or elongated styoid process. In about 4% of general population an elongated styloid process occurs, while only about 4% of these patients are symptomatic. We report a case of a 49-year-old lady with a 1-year history of oro-pharyngeal foreign body sensation localized at the left tonsillar fossa, associated with a dull intermittent pain. A bony projection was palpable with bimanual transoral exploration. A lateral radiograph and a computed tomography scan of head and neck showed an elongated styloid process of 57 mm on the left side and 48 mm on the right one. The patient refused surgical treatment as first choice. She underwent a non-steroidal anti-inflammatory local treatment, with progressive disappearance of symptoms. After 6 months she had no recurrence of symptoms. In conclusion, a precise differential diagnosis is crucial in order to choose the most adequate treatment, which can be either surgical or non surgical. Medical treatment represents the first choice, followed by surgical styloid process resection, in the case of persistence or ingravescence of the complaint.

Helicobacter pylori diagnosis in patients with liver cirrhosis

BACKGROUND

In cirrhotics, Helicobacter pylori infection is the major cause of peptic lesions, which are an important cause of upper intestinal haemorrhage in these patients. However, some diagnostic methods are not accurate for H. pylori detection in cirrhotics.

AIMS

The study assessed the accuracy of different diagnostic methods for H. pylori detection in cirrhotics with and without gastroduodenal lesions.

METHODS

The study population comprised of 53 cirrhotics. All patients underwent upper endoscopy: three biopsies were taken in the antrum and three in the gastric body. Four biopsies were used for Giemsa staining, while two were used for a rapid urease test. A blood sample was obtained for serology using Western blotting, and a [13C]urea breath test was performed in all patients. Histological assessment was regarded as the gold standard for diagnosis of H. pylori infection.

RESULTS

H. pylori infection was detected at histological assessment in 28 (52.8%) patients. The [13C]urea breath test, rapid urease test, and serology were positive in 27 (51%) patients, 23 (43.4%) patients, and 34 (64.1%) patients, respectively. Sensitivity and specificity were 92.9 and 96% for the [13C]urea breath test, 78.6 and 96% for the rapid urease test, and 78.6 and 52% for serology.

CONCLUSIONS

The [13C]urea breath test is very accurate in cirrhotics, whilst both serology and the rapid urease test give disappointing results.

Gastric cancer prevalence in patients with liver cirrhosis

An increased risk for gastric cancer in patients with liver cirrhosis has recently been reported in epidemiological studies. The present endoscopic study was performed to further evaluate whether people with cirrhosis are at increased risk for gastric cancer development. We reviewed the medical records of all cirrhotic patients referred to our Endoscopic Service for portal hypertension screening and, therefore, cases of latent gastric cancer were observed. For a comparison, the prevalence (age and sex standardized) of latent gastric cancer in the general population was estimated hypothesizing a latency period of 5 years. Overall, 1379 patients with cirrhosis were selected from a total of 15 791 endoscopically examined different patients observed during the period 1982-1997. Histological assessment revealed the presence of gastric cancer in 10 patients (9 males and 1 female). There was a significant 2.6-fold (P<0.01) increase in prevalence of gastric cancer compared with that expected in our cirrhotic patients. In conclusion, our findings confirm that liver cirrhosis would seem to be a risk factor for the development of gastric cancer. Other studies are needed to evaluate the pathogenic mechanisms involved.

High eradication rates of Helicobacter pylori with a new sequential treatment

BACKGROUND

Eradication rates of Helicobacter pylori with standard triple therapy are disappointing, and studies from several countries confirm this poor performance.

AIM

To assess the eradication rate of a new sequential treatment regimen compared with conventional triple therapy for the eradication of H. pylori infection.

METHODS

One thousand and forty-nine dyspeptic patients were studied prospectively. H. pylori-infected patients were randomized to receive 10-day sequential therapy [rabeprazole (40 mg daily) plus amoxicillin (1 g twice daily) for the first 5 days, followed by rabeprazole (20 mg), clarithromycin (500 mg) and tinidazole (500 mg) twice daily for the remaining 5 days] or standard 7-day therapy [corrected] [rabeprazole (20 mg), clarithromycin (500 mg) and amoxicillin (1 g) twice daily]. H. pylori status was assessed by histology, rapid urease test and 13C-urea breath test at baseline and 6 weeks or more after completion of treatment.

RESULTS

Higher eradication rates were found with the sequential regimen compared to the standard regimen (intention-to-treat: 92% vs. 74%, P < 0.0001; per protocol: 95% vs. 77%, P < 0.0001). Higher eradication rates were also seen in patients with peptic ulcer disease and non-ulcer dyspepsia. In both treatments, compliance was similar (> 90%), as was the rate of side-effects, which were mild.

CONCLUSIONS

This 10-day sequential treatment regimen achieves high eradication rates in peptic ulcer disease and non-ulcer dyspepsia.

Quality control of sedation for diagnostic radiological procedures in paediatric patients (waiting for guidelines)

BACKGROUND

The number of children requiring sedation for radiological procedures is increasing. Anaesthesiologists are increasingly involved in giving sedation or general anaesthesia in the rooms of the Radiology Department. This activity is not easy, and can be dangerous. The procedure is often performed on an ambulatory basis, so the child must be alert and discharged rapidly after the procedure.

METHODS

We reviewed the medical charts of 488 patients in order to evaluate the incidence of complications during deep sedation for diagnostic radiological procedures. The patients were sedated with intravenous thiopental or propofol, or with oral chloral hydrate. All the patients were breathing spontaneously and received only supplemental O(2).

RESULTS

We found only a few cases of complications, immediately treated without any recourse to tracheal intubation: respiratory failure with arterial desaturation to 94%, regurgitation, vomiting and persistent cough.

CONCLUSIONS

On the basis of our experience, we believe that deep sedation with endovenous drugs guarantees safety and rapid discharge after the procedure.

Gastric epithelial cell proliferation in patients with liver cirrhosis

An increased risk for gastric cancer in patients with liver cirrhosis has recently been reported. This study was performed in order to determine gastric epithelial cell proliferation in cirrhotic patients and to evaluate the role of congestive gastropathy (CG) and Helicobacter pylori infection in this process. Thirty-six cirrhotic patients and 18 controls were enrolled in the study. All patients underwent endoscopy and three biopsies were performed in the antrum and three in the gastric body. The presence of H. pylori infection was assessed by a rapid urease test and histology. The antral biopsies were used for gastric cell proliferation assessment by an immunohistochemical analysis (Ki-67). There was no significant difference in epithelial cell proliferation between cirrhotics and controls. Gastric proliferation values were higher in patients with H. pylori infection compared with uninfected patients, both in cirrhotic (P = 0.003) and in control groups (P = 0.06). Among the cirrhotic group, we found a progressive increase in gastric cell proliferation values related to the degree of CG, the highest values being observed in cirrhotic patients with severe CG. Moreover, cirrhotics with both severe CG and H. pylori infection had the highest proliferation values when compared with all other subgroups. In conclusion, this study found that: (1) CG significantly affects epithelial cell proliferation in gastric mucosa in cirrhotic patients, (2) H. pylori infection plays a similar role in gastric cell proliferation in both cirrhotic and non-cirrhotic patients, and (3) CG and H. pylori could act synergistically in this process.

Relationship between antral lymphocyte density and basal gastrin levels in patients with Helicobacter pylori infection

BACKGROUND

The mechanism by which Helicobacter pylori causes hypergastrinaemia is not completely understood.

AIM

To evaluate whether antral lymphocyte density could play a role in this alteration.

METHODS

A total of 12 patients with active duodenal ulcer and 10 with non-ulcer dyspepsia were enrolled upon detection of Helicobacter pylori infection at endoscopy Enrolled as controls were 7 matched dyspeptic patients without Helicobacter pylori infection. Biopsy specimens were collected for Helicobacter pylori and histological assessments, and for antral lymphocyte density assessment by a histomorphometric method. A blood sample was obtained from each patient to determine basal gastrin levels. All patients were controlled by a further endoscopy 4 weeks after the end of Helicobacter pylori treatment.

RESULTS

Antral lymphocyte density (5,464 +/- 1,328 and 5,635 +/- 1,186 vs 2,267 +/- 557 lymphocytes/mm2; p<0.001 and p<0.001, respectively) and gastrin levels (66.7 +/- 14.1 and 60.4 +/- 21.7 vs 40.7 +/- 7.8 pg/dl; p=0.004 and p=0.02, respectively) were higher in duodenal ulcer and non-ulcer dyspepsia patients than in controls, while no significant differences emerged between duodenal ulcer and non-ulcer dyspepsia patients. There was a significant direct correlation between antral lymphocyte density and gastrin levels both in duodenal ulcer (r=0.77; p=0.003) and in non-ulcer dyspepsia (r=0.75; p=0.03) patients, while no correlation was found in controls [r=0.12; p=0.8). After treatment, this correlation persisted in 10 eradication failure patients (r=0.68; p=0.027), but disappeared in those successfully cured.

CONCLUSIONS

These data suggest that lymphocyte density in the antral mucosa could play a role in the impaired gastrin production occurring in patients with Helicobacter pylori infection.

Ascorbic acid and intestinal metaplasia in the stomach: a prospective, randomized study

BACKGROUND

Intestinal type metaplasia plays a role in intestinal type gastric carcinoma development. Ascorbic acid demonstrates a protective effect against gastric carcinogenesis, due to its ability to inactivate oxygen free-radicals as well as its nitrite-scavenging effects.

AIM

To assess whether long-term ascorbic acid administration following Helicobacter pylori eradication could affect intestinal metaplasia regression in the stomach.

METHODS

Sixty-five patients were included in the study. The inclusion criterion was the presence of intestinal metaplasia on the gastric mucosa after H. pylori eradication. An upper gastrointestinal endoscopy was performed and 3 biopsy specimens were taken in the antrum, 3 in the gastric body, and 2 in the incisura angularis. Patients were randomized to receive 500 mg of ascorbic acid o.d., after lunch (32 patients) for 6 months or no treatment (33 patients). All patients underwent to endoscopic control at the end of the 6 months.

RESULTS

H. pylori infection recurrence was detected in 6 (9.4%) patients (three from each group), and these patients were excluded from further analysis. We were unable to find evidence of intestinal metaplasia in any biopsied site of the gastric mucosa in 9/29 (31%) patients from the ascorbic acid group and in 1/29 (3.4%) of the patients from the control group (P=0.006). Moreover, a further six (20.7%) patients from the ascorbic acid group presenting chronic inactive pangastritis with widespread intestinal metaplasia at entry, showed less extensive antritis with intestinal metaplasia at control, whilst a similar finding was only seen in one patient from the control group (P=0.051).

CONCLUSION

The administration of ascorbic acid significantly helps to resolve intestinal metaplasia of the gastric mucosa following H. pylori eradication, and its use as a chemoprevention treatment should be considered.

Clinical and histologic predictors of Helicobacter pylori infection recurrence

Factors influencing Helicobacter pylori infection recurrence still have not been fully clarified. The aim of this study was to determine whether, after eradication of H. pylori, any clinical or histologic features could yield information on infection relapse. We enrolled in the study 72 patients successfully treated for H. pylori infection by either dual (n = 49) or triple (n = 23) therapy. H. pylori eradication was defined as a negative bacterial finding by rapid urease test and histologic assessment at least 4 weeks after cessation of therapy. Upon eradication, gastritis grading was performed and patients were asked to return for an endoscopic control 6-8 months later. The recurrence of H. pylori infection was observed in 12 of 72 (16.7%) patients. The infection recurrence rate resulted significantly higher in nonulcer dyspepsia patients (p = 0.01 ) and in women (p = 0.03), whereas infection relapse did not differ between patients treated with dual or triple therapy. There was a strong (p = 0.0001 ) relationship between the persistence of chronic active gastritis after H. pylori eradication and recurrence of infection, whereas gastritis grade and metaplasia were not related to recurrence. In conclusion, this study found that H. pylori infection recurrence after successful dual or triple therapy is fairly high and that gastroduodenal disease, gender, and gastritis activity seem to affect infection relapse.

A new highly effective short-term therapy schedule for Helicobacter pylori eradication

BACKGROUND

Although triple therapy regimens suggested in the Current European guidelines give fairly good results, several studies have reported an unsatisfactory Helicobacter pylori eradication rate (< 80%).

AIM

To evaluate the efficacy of a new short-term treatment sequence on H. pylori eradication.

METHODS

A total of 52 patients with H. pylori infection and either non-ulcer dyspepsia (34 patients) or peptic ulcer (18 patients) were enrolled to receive a 10-day therapy: omeprazole 20 mg b.d. plus amoxycillin 1 g b.d. for the first 5 days, followed by omeprazole 20 mg b.d., clarithromycin 500 mg b.d. and tinidazole 500 mg b.d. for the remaining 5 days. H. pylori infection at entry was assessed by rapid urease test and histology on biopsies from the antrum and the corpus. Bacterial eradication was assessed by endoscopy (peptic ulcer patients) or 13C urea breath test (non-ulcer dyspepsia patients) 4-6 weeks after therapy had ended.

RESULTS

All patients completed the study. H. pylori eradication was achieved in all but one patient, with an eradication rate of 98% (95% CI: 94.3-100) with intention-to-treat analysis. Patient compliance was good (consumption of prescribed drugs > 95%) for all but one patient, who took the triple therapy regimen for 4 days instead of 5 days. No major side-effects were reported but three (6%) patients complained of mild side-effects.

CONCLUSIONS

The use of this 'five plus five' therapy schedule as an initial treatment for H. pylori deserves further investigation.

Helicobacter pylori eradication with dual and low-dose triple therapy in patients with liver cirrhosis

BACKGROUND AND AIMS

Few data exist on the treatment of Helicobacter pylori infection in cirrhotic patients. In this study we assessed the efficacy of standard dual and one-week low-dose triple therapy on Helicobacter pylori eradication in cirrhotics.

PATIENTS AND METHODS

In a prospective study, 83 cirrhotic patients with epigastric pain were randomised to receive either a two-week course of dual therapy, composed of omeprazole 20 mg b.d. plus amoxycillin 1 g b.d. (n = 41) or a one-week course of triple therapy, composed of omeprazole 20 mg b.d., clarithromycin 250 mg b.d., and tetracycline 500 mg b.d (n = 42). Helicobacter pylori infection at entry and eradication 6-8 weeks after the end of therapy were assessed by rapid urease test and histology on biopsies from the antrum and corpus. When eradication did not occur with either dual or triple therapy, patients were given the alternative regimen. Helicobacter pylori eradication in these patients was assessed 6-8 weeks after the end of treatment by a further endoscopy.

RESULTS

Helicobacter pylori eradication was achieved in 87.8% (36 out of 41; 95% confidence interval 77.8-97.8%) of patients after dual therapy and in 85.7% (36 out of 42; 95% confidence interval 75.1-96.3%) of patients treated with triple therapy (p = NS). In patients in whom initial eradication was unsuccessful, re-treatment eradicated Helicobacter pylori in 4 out of 5 patients given the triple regimen and in all 5 patients who received the dual therapy. One patient was lost to follow-up. No major side-effects were reported for either treatment regimen.

CONCLUSIONS

Our data show that both dual and triple therapies are effective in Helicobacter pylori eradication in cirrhotics as well as in eradication failure patients. Therefore, the use of the dual therapy regimen is strongly suggested as an initial treatment for Helicobacter pylori eradication in cirrhotic patients.

Helicobacter pylori infection, plasma ammonia levels, and psychometric testing in cirrhotic patients

OBJECTIVE

The role of Helicobacter pylori (H. pylori) infection as a cause of hepatic encephalopathy is still debated. This study focused on the relationship between H. pylori, plasma ammonia levels, and intellectual function in cirrhotic patients.

METHODS

Forty-seven cirrhotics with latent or mild hepatic encephalopathy were enrolled in the study, upon H. pylori assessment at endoscopy. Plasma ammonia level determinations and psychometric testing were performed at entry in all patients. Patients with H. pylori infection received a 2-wk standard dual therapy and bacterial eradication was assessed at endoscopy 6-8 wk later. On this occasion, plasma ammonia levels and psychometric assessments were repeated. Patients without H. pylori infection at entry were also studied after 6-8 wk for ammonia level assessment and psychometric testing, as a control group. Patients receiving lactulose therapy and those without therapy were grouped separately for statistical analysis.

RESULTS

Among 21 patients without lactulose therapy (group A), basal plasma ammonia levels and psychometric testing scores did not significantly differ between 13 infected and eight uninfected patients. Similarly, among 26 patients undergoing lactulose therapy (group B), basal plasma ammonia concentration and psychometric testing scores did not significantly differ between 13 infected and 13 uninfected patients. Moreover, in group B, both the prevalence of previous overt hepatic encephalopathy episodes and the mean daily dose of lactulose therapy were similar between infected and uninfected patients. In addition, no significant reduction in the plasma ammonia concentrations and in psychometric testing scores emerged in both groups A and B after bacterial eradication.

CONCLUSIONS

This study failed to find a relationship between H. pylori, plasma ammonia levels, and psychometric testing scores in cirrhotic patients with latent or mild hepatic encephalopathy.

Gastric pathology in patients with common variable immunodeficiency

BACKGROUND/AIMS

Common variable immunodeficiency (CVID) is an immunological disorder characterised by defective antibody production. Patients with CVID have a high risk of gastric cancer. It has been suggested that gastric cancer results from an interaction between environmental factors and a genetic predisposition. The role of Helicobacter pylori as an environmental factor in gastric carcinogenesis is of current interest. Moreover, p53 gene mutations have been reported in gastric cancer. This study focuses on the gastric pathology of patients with CVID and correlation with H pylori infection.

METHODS

Thirty four consecutive dyspeptic patients with CVID (mean age 49.6 years, range 14-72; 17 men) were included in the study. An upper gastrointestinal endoscopy was performed and biopsy specimens were taken from the antrum, incisura angularis, and gastric body. Biopsies were used for histological assessment, to identify the presence of H pylori, and to evaluate p53 overexpression.

RESULTS

H pylori infection was detected in 14/34 (41%) patients. Chronic active gastritis involving both antrum and body was observed more frequently in H pylori positive (79%) than H pylori negative (20%) patients (p = 0.001). Similarly, a histological feature of multifocal atrophic gastritis was found more frequently in infected (50%) than uninfected patients (10%) (p = 0.012). In addition, one case of gastric adenocarcinoma and another of notable dysplasia were observed in the H pylori positive group. Overexpression of p53 was found in six (18%) patients, including one with normal gastric mucosa.

CONCLUSIONS

It can be hypothesised that both H pylori and p53 alterations play a role in the gastric carcinogenesis of patients with CVID.

Helicobacter pylori eradication with proton pump inhibitor-based triple therapies and re-treatment with ranitidine bismuth citrate-based triple therapy

BACKGROUND

It has been suggested that short-term triple therapy comprising a proton pump inhibitor, plus clarithromycin and amoxycillin be used as first choice in treating H. pylori infection, while eradication failure patients should be further treated with a quadruple therapy. Nevertheless, conflicting results have been reported using these treatment regimens in different countries.

METHODS

A total of 278 patients with H. pylori infection were randomised to receive one-week triple therapy, comprising clarithromycin 500 mg b.d., amoxycillin 1 g b.d., and either omeprazole 20 mg b.d. (OAC; 90 patients), or pantoprazole 40 mg b.d. (PAC; 95 patients), or lansoprazole 30 mg b.d. (LAC; 93 patients). H. pylori infection at entry, and eradication 4-6 weeks after therapy had ended, were assessed by rapid urease test and histology on biopsies from the antrum and the corpus. When eradication did not occur, patients were given a 2-week treatment comprising ranitidine bismuth citrate 400 mg b.d., tetracycline 500 mg t.d.s. and tinidazole 500 mg b.d. (RBTT). Eradication in these patients was assessed 4-6 weeks after conclusion of treatment by a further endoscopy.

RESULTS

Six patients were lost to the follow-up. At the end of the first course of treatment, the overall H. pylori eradication rate was 78% (95% CI: 73-83) and 79% (95% CI: 75-84) at 'intention-to-treat' (ITT) and 'per protocol' (PP) analysis, respectively, without any statistically significant difference between treatment regimens, although a trend for better results with the omeprazole combination was observed. Moreover, H. pylori eradication was achieved in 82% (95% CI: 75-97) (ITT) and 86% (95% CI: 69-94) (PP) of 38 patients re-treated with RBTT regimen.

CONCLUSIONS

Our data found that this short-term triple therapy is not a satisfactory treatment (< 80% eradication rate) for H. pylori infection. The 2-week triple therapy used as re-treatment in eradication failure patients yielded more promising results.

Measurement variability and diagnostic sensitivity of gastric mucosal inflammatory cell morphometry

OBJECTIVE

To assess the variability and sensitivity of morphometric measures of gastric mucosal lymphocyte and plasma cells to determine a systematic procedure for evaluating the density of these mononuclear inflammatory cells (MNC).

STUDY DESIGN

Gastric biopsies of antrum (n = 3), incisura angularis (n = 2) and corpus (n = 3) from two controls and three patients with Helicobacter pylori-related gastritis (antral, diffuse or multifocal gastritis) were considered. In each biopsy, three fields from each of three sections were selected. In each field, stromal area was obtained by subtracting gland area (GA) from total area, and MNC were counted. Results were expressed as MNC/total mm2 and MNC/stromal mm2. Correlations with GA, coefficients of variation (CV), discriminant power analysis and analysis of variance were performed.

RESULTS

Correlations always existed between GA and MNC/total mm2 and rarely between GA and MNC/stromal mm2. CV of MNC/stromal mm2 were lower (18%) than those of MNC/total mm2 (30%). High sensitivity (95.4%) and specificity (95.8%) were found for MNC/stromal mm2 but not for MNC/total mm2. Differences in MNC/stromal mm2 existed in all subjects (P < .0001). Highly significant differences in MNC/stromal mm2 were also found between normal and inflammatory states, gastric sites and sections.

CONCLUSION

In contrast to MNC/total mm2, MNC/stromal mm2 is an unbiased estimate of MNC density. The following sampling procedure is proposed: two biopsies from each gastric site, two sections from each biopsy and two microscopic fields from each section.

Helicobacter pylori infection in dyspeptic cirrhotic patients

BACKGROUND/AIMS

To date, few studies have focused on the role of Helicobacter pylori (H. pylori) in cirrhotic patients with gastroduodenal disease and reported results are conflicting. The aim of this study was to assess the H. pylori infection rate in dyspeptic cirrhotic patients with or without gastroduodenal lesions at endoscopy.

METHODOLOGY

In a prospective study, 226 consecutive dyspeptic cirrhotic patients were enrolled in the study upon assessment of H. pylori infection. Two-hundred dyspeptic non-cirrhotic patients were also included as controls. The presence of H. pylori was detected by rapid urease test and histology (Giemsa staining) in 3 biopsy specimens from the antrum and 3 from the gastric body.

RESULTS

H. pylori infection was found in 135 (59.7%) cirrhotics and in 121 (60.5%) controls (p = NS). The prevalence of gastric ulcer was higher in cirrhotics than in controls (16% vs. 2.5%, p = 0.0001), while the prevalence of duodenal ulcer was similar (11% vs. 12%, respectively). The H. pylori infection rate was similar between cirrhotics and controls, both with gastric (83% vs. 80%) and with duodenal (88% vs. 96%) ulcers. Moreover, in our study, a H. pylori-related peptic lesion was the cause of previous gastroduodenal bleeding in 6 of 50 (12%) cirrhotic patients.

CONCLUSIONS

Our results indicated that H. pylori infection is implicated in the pathogenesis of peptic ulcer in cirrhotic patients, similar to findings in non-cirrhotic patients.

Gastric pathology in cholecystectomy patients: role of Helicobacter pylori and bile reflux

The data regarding the role of Helicobacter pylori infection in patients with bile reflux are conflicting. Bile reflux is often observed after cholecystectomy. This study focuses on the role of H. pylori in gastric pathology of patients who had undergone cholecystectomy. Eighty-seven consecutive patients were included in the study. An upper gastrointestinal endoscopy was performed, and biopsy specimens were taken in the antrum, incisura angularis, and in the gastric body. The presence of bile reflux in gastric fluid at endoscopic examination was recorded. The overall H. pylori infection rate was 62%, with no difference between patients with (59.7%) and without (64%) endoscopic bile reflux (p = 0.67). The intestinal metaplasia rate in gastric mucosa was significantly higher in patients with both H. pylori and bile reflux than in patients without infection and bile reflux (36.4% vs. 5.6%, p = 0.02). Moreover, the mean number of years after cholecystectomy in patients with intestinal metaplasia was significantly higher than in those without metaplasia (21.1 +/- 7 vs. 11.5 +/- 8 years, p < 0.0001), whereas mean age did not differ significantly between groups (60.3 +/- 12 vs. 55.8 +/- 11 years, p = 0.14). Furthermore, we found four cases of gastric cancer, three with H. pylori infection. The mean number of years after cholecystectomy was significantly higher in patients with gastric cancer than in other patients (21.8 +/- 4 vs. 12.2 +/- 8 years, p = 0.009). This study found that H. pylori infection is frequent in cholecystectomized patients, also in the presence of endoscopic bile reflux. Bile reflux seems to act synergistically with H. pylori infection on gastric pathology.

Helicobacter pylori and plasma ammonia levels in cirrhotics: role of urease inhibition by acetohydroxamic acid

BACKGROUND AND AIMS

The role of Helicobacter pylori as a cause of hyperammonaemia in cirrhotics has still not been fully clarified. This study was aimed at evaluating the effect of acute Helicobacter pylori urease inhibition by oral acetohydroxamic acid administration on blood ammonia levels in cirrhotic patients.

METHODS

Twenty-nine cirrhotics (14 males, 15 females; mean age: 63 years; Child-Pugh class: 14 A, 9 B, and 6 C) undergoing upper gastrointestinal endoscopy were enrolled in the study. The presence of Helicobacter pylori infection was assessed by rapid urease test and histology. A semi-quantitative grading of bacterial density was also performed at histology. All patients received oral acetohydroxamic acid 750 mg, and blood samples for assessment of ammonia levels were taken before and at 15, 30, 60 and 90 minutes after administration.

RESULTS

Helicobacter pylori infection was detected in 20 patients, while 9 patients were uninfected. Acetohydroxamic acid administration led to a significant reduction in blood ammonia levels at 15 and 30 minutes (mean +/- SD, 113 +/- 44 vs 101 +/- 43 and 93 +/- 38 micrograms/dl, respectively; p = 0.002) only in patients with Helicobacter pylori infection. Moreover, the reduction was statistically significant only in Child-Pugh B/C class patients and in those with moderate/marked Helicobacter pylori density in gastric mucosa. Basal ammonia levels did not differ between Helicobacter pylori positive and negative patients, nor in patients with mild and moderate/marked Helicobacter pylori density in gastric mucosa, while Child-Pugh class B/C cirrhotics had higher basal ammonia levels than class A cirrhotics, in both Helicobacter pylori positive and negative groups.

CONCLUSIONS

Our data showed that Helicobacter pylori urease inhibition by acetohydroxamic acid administration significantly reduces blood ammonia levels in patients with more advanced liver cirrhosis and in those with a high bacterial density in gastric mucosa.

Acute coronary disease in essential thrombocythemia and polycythemia vera

OBJECTIVES

The aim of this study is to report our experience on myocardial infarction (MI) in patients with essential thrombocythemia (ET) and polycythemia vera (PV).

DESIGN

Patients with PV and ET consecutively diagnosed and followed in authors' Department between 1 July 1986 and 30 June 1996.

SUBJECTS

Over the past 10 years we have followed 170 patients with ET and 149 with PV, diagnosed according to the Polycythemia Vera Study Group (PVSG) criteria. The patients were divided into 3 groups on the basis of the age at diagnosis (group A < 40, B 41-65, C > 65 years).

INTERVENTIONS

In all patients with PV phlebotomies and/or myelosuppressive therapy were used to keep haematocrit level lower than 45%. Hydroxyurea was given to patients with ET with a positive history for major vascular complications or with an extreme thrombocytosis. Aspirin therapy (ASA) (100 mg per day) was administered in patients with microvascular disturbances or previous thrombosis (in patients with PV also in the presence of atherosclerotic risk factors).

MAIN OUTCOME MEASURES

Frequency of MI in patients with ET and PV with and without ASA therapy.

RESULTS

9.4% of patients with ET and 11.4% of those with PV had MI. 17.6% of patients with PV were younger than 40 years at the moment of MI in contrast to 0% of those with ET. 75% of patients with ET and 70.6% of those with PV with MI had atherosclerotic risk factors such as smoking, hypertension, diabetes, dyslipidaemia. All patients with MI received ASA 100 mg daily after thrombosis and four of the ET group developed a transient ischaemic attack (TIA) afterwards. Four subjects with PV during the follow-up had TIAs and two peripheral arteriopathy in spite of ASA treatment.

CONCLUSIONS

MI is less common in patients with ET younger than 40 years than in older patients. Association of MI and cardiovascular risk factors is frequent in patients with ET and PV. A low dose of ASA could be able to reduce the number of coronary thrombosis without increasing bleeding complications in patients with elevated platelet count and common atherosclerotic risk factors. However, a larger population must be evaluated to confirm our hypothesis.

Analysis of p53 expression in precancerous and malignant gastric mucosa

P53 overexpression, detected by immunohistochemical analysis, has been reported in about 50% of gastric cancers whereas scarce data are available on the p53 oncoprotein in precancerous gastric lesions. This study focused on the p53 expression in gastric cancerous and precancerous lesions. One hundred gastric specimens obtained during endoscopy were analyzed: 14 cases of normal gastric mucosa, 53 of chronic gastritis with intestinal metaplasia and/or dysplasia and 33 gastric tumors. An immunoperoxidase technique and monoclonal anti-p53 antibodies were employed. Eleven out of 31 gastric carcinomas overexpressed p53. No correlation was observed between p53-positivity and histological type and grade of tumors. All precancerous lesions were p53-negative. Our results suggest that p53 overexpression is a relatively late event in gastric carcinogenesis.

Omeprazole plus clarithromycin and either tinidazole or tetracycline for Helicobacter pylori infection: a randomized prospective study

OBJECTIVE

Helicobacter pylori has begun to show resistance to imidazoles and could result in the low efficacy of short-term triple therapy. The aim of this study was to assess whether administration of tetracycline instead of tinidazole in short-term low-dose triple therapy could increase the H. pylori eradication rate.

METHODS

In a prospective study, 113 patients with peptic ulcer (n = 36) or non-ulcer dyspepsia (n = 77) were randomized to receive 1-wk treatment, composed of omeprazole 20 mg b.i.d., clarithromycin 250 mg b.i.d., and either tinidazole 500 mg b.i.d. (n = 57) or tetracycline 500 mg b.i.d. (n = 56), upon detection of H. pylori infection at endoscopy.

RESULTS

H. pylori eradication, defined as a negative bacterial finding in a rapid urease test and upon histologic assessment at least 4 wk after cessation of therapy, was achieved in 86% (49 of 57; 95% confidence interval = 76.9-95) of patients in the first group and in 71.4% (40 of 56; 95% confidence interval = 59.6-83.3) in the second group (p = not significant). Side effects occurred in 28% of patients from the tinidazole-based group and in 12.5% from the tetracycline group (p = not significant). Two patients in the tinidazole group discontinued therapy at 5 and 6 days because of side effects.

CONCLUSIONS

The administration of tetracycline instead of tinidazole in short-term triple therapy yielded disappointing results in H. pylori eradication.

The management of failed dual or triple therapy for Helicobacter pylori eradication

BACKGROUND

After each treatment for Helicobacter pylori infection there is an eradication failure rate ranging from 5 to 50%. Thus, the best therapy schedule and treatment regimen sequence have still to be identified.

METHODS

Patients with H. pylori infection were randomized to receive either a 1-week triple therapy of omeprazole 20 mg b.d., clarithromycin 250 mg b.d. and tetracycline 500 mg b.d. (OCT; 78 patients) or a 2-week dual therapy of omeprazole 20 mg b.d. and amoxycillin 1 g b.d. (OA; 75 patients). H. pylori infection at entry and eradication 4-6 weeks after therapy had ended were assessed by rapid urease test and histology on biopsies from the antrum and the corpus. When eradication did not occur with either the OCT or OA regimens, patients were switched over to the OA or OCT therapy, respectively. Eradication in these patients was assessed 4-6 weeks after conclusion of treatment by a further endoscopy.

RESULTS

H. pylori eradication was achieved in 67.9% (95% CI = 57.6-78.3%) of patients treated with the OCT regimen and in 75.7% (95% CI = 65.9-85.5%) of patients treated with the OA therapy (chi 2 = 1.11; P = 0.29). Moreover, H. pylori eradication was achieved in 39.1% (95% CI = 19.2-59.1%) of patients re-treated with the OA regimen and in 88.9% (95% CI = 74.4-100%) of patients re-treated with the OCT therapy (chi 2 = 8.52; P = 0.003). Thus, the overall success rate 'per protocol' analysis in our study was 81.6% (95% CI = 72.9-90.3%) for the triple and dual therapy sequence and 97.3% (95% CI = 93.6-100%) for dual followed by triple therapy (chi 2 = 8.14; P = 0.004).

CONCLUSIONS

Our data found that H. pylori eradication with OA therapy after OCT therapy failure was poor, while that obtained with OCT after OA therapy was good.