Eradication rate and adherence with high-dose amoxicillin and proton pump inhibitor as first-line treatment for Helicobacter pylori infection: Experience from University Hospital in Chile

INTRODUCTION

In Chile, more than 70% of adults are infected by Helicobacter pylori. Clarithromycin should not be used in any regimen if there is >15% resistance to this antibiotic, being greater than 26% in our population. In this scenario, the effectiveness of triple therapy (proton pump inhibitor [PPI], clarithromycin, amoxicillin) was only 63.8%.

AIM

To evaluate the eradication rate and safety of dual therapy (esomeprazole and amoxicillin) in high doses, through a prospective, observational, and descriptive study.

METHODS

Patients with a positive urease test obtained in an upper digestive endoscopy were included. Any other previous H. pylori eradication regimen were excluded. All patients were treated with esomeprazole 40 mg three times a day and amoxicillin 750 mg four times a day for 14 days. The eradication rate of the dual therapy was evaluated with the H. pylori stool antigen test (the Pylori-Strip® test used) 6 weeks after completing the eradication treatment and with at least 14 days without PPI, being a negative result, confirmation of the effectiveness of this regimen.

RESULTS

Of 122 patients, 106 had a negative H. pylori antigen in stool; The intention-to-treat and per protocol analysis, the eradication rates were 91.8% [95% CI: 87%-97%] and 94% [95% CI: 90%-98%], respectively. Four patients discontinued treatment due to adverse effects. Smoking and adherence to treatment were associated with eradication rate.

CONCLUSIONS

In this cohort of patients with H. pylori infection, high-dose dual therapy has a high eradication rate and good adherence, raising the possibility that it could be used as first-line therapy in our country. Studies with a larger number of patients should confirm these results.

O-058 Obstetric outcomes of twin gestation after In-Vitro Fertilization and Embryo Transfer (IVT-ET) treatment in patients who underwent hysteroscopic septoplasty for subseptate uterus

Study question

Is there an associated increased risk of preterm birth (PTB) in patients who underwent hysteroscopic septoplasty for subseptate uterus (SSU) with twin gestation through IVF-ET?

Summary answer

This study suggests an increased risk of PTB in patients, who underwent hysteroscopic septoplasty for SSU, and subsequently conceived twins after IVF-ET treatment.

What is known already

In general, the incidence of PTB is higher after IVF-ET treatment. In addition, Müllerian uterine anomalies, such as unicornuate uterus, are considered risk factors for PTB, even with singleton pregnancy. Furthermore, historical data suggest that some patients with uterine anomaly may have cervical incompetence. Twin gestation is associated with PTB in approximately 50% of cases. It is assumed that the obstetric outcome of twin gestation after successful septoplasty should be no different from those with normal uterine cavity. The impact of previous septoplasty for SSU on the obstetric outcomes of twin gestation after IVF-ET treatment has not been adequately studied.

Study design, size, duration

This retrospective cohort study included 377 fertility patients who received treatment between 2006-2019. The study group included 162 patients who underwent hysteroscopic septoplasty for SSU and subsequently conceived dichorionic-diamniotic (DI-DI) twins after IVF-ET treatment (Group 1). The control group included 215 patients who had normal endometrial cavity on hysteroscopy (#109) or Transvaginal 3D ultrasound scan with saline sonohysterogram (#106) and subsequently conceived DI-DI twins after IVF-ET treatment (Group 2).

Participants/materials, setting, methods

This study was conducted at an infertility clinic affiliated with an academic hospital. Demographic, clinical, and obstetric outcome data were collected for both groups and compared using appropriate statistical methods. PTB, severe PTB, extreme PTB, and peri-viable birth were defined as < 37 weeks, <32 weeks, <28 weeks and between 20 weeks-25 weeks 6 days gestation respectively.

Main results and the role of chance

There was no significant difference in mean age, BMI and infertility duration or in the incidence of smoking, primary infertility, tubal factors and unexplained infertility between the two groups. There was significantly lower mean baseline FSH levels (p < 0.01), lower incidence of male infertility (p < 0.001) and higher incidence of ovulatory disorders (p < 0.001) and endometriosis (p < 0.05) in Group 1 compared to Group 2. As expected, there was past history of lower parity rate (p < 0.01) and higher miscarriage rate (p < 0.001) in Group 1 compared to Group 2 prior to septum division. There was significantly higher incidence of PTB (72.8% vs 56.3%, p < 0.01), severe PTB (20.3% vs 8.2%, p < 0.01), extreme PTB (8.3% vs 3.9%, p < 0.05), and peri-viable birth (6.3% vs 1.9%, p < 0.05) in Group 1 compared to Group 2. There was no significant difference in cesarean section rate (82.8% vs 87.5%, p = 0.349) between Group1 and Group 2 respectively. There was significantly lower gestational age at birth in weeks (34.0 + 4.0 vs 35.6 + 3.0, p < 0.001), birth weight of the first newborn (2180.5 + 717.9 vs 2436.4 + 606.6, p < 0.001), and the second newborn (2235.2 + 674.2 vs 2398.0 + 537.9, p < 0.05) in grams in Group 1 compared to Group 2.

Limitations, reasons for caution

Our study has limitations being retrospective in nature. Data on cervical length measurements via ultrasound, if performed, was not available. However, recall bias was prevented by retrieving data from that submitted to the Society of Assisted Reproductive Technology. Additionally, procedural variation was reduced as this was a single-center study.

Wider implications of the findings

Our study suggests that twin gestation after IVF-ET in patients who underwent successful hysteroscopic septoplasty for SSU may increase the likelihood of PTB. Such patients may require increased surveillance with ultrasound cervical length and signs for preterm labor. Future research should focus on measures to reduce PTB in such patients.

Trial registration number

Not Applicable

P-746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Study question

The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus.

Summary answer

The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os.

What is known already

Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os.

Study design, size, duration

This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 -2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment.

Participants/materials, setting, methods

This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups.

Main results and the role of chance

There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P=0.002) and history of RPL (P=0.017) in the study group. There was significant lower incidence of tubal factors infertility (P=0.005) and endometriosis (P=0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P=0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P=0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P=0.000), and delivery by CS (69.6% vs 41.2%; P=0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P=0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively.

Limitations, reasons for caution

A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed.

Wider implications of the findings

Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri.

Trial registration number

Not Applicable

P–746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Study question

The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus.

Summary answer

The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os.

What is known already

Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os.

Study design, size, duration

This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 –2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment.

Participants/materials, setting, methods

This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups.

Main results and the role of chance

There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P = 0.002) and history of RPL (P = 0.017) in the study group. There was significant lower incidence of tubal factors infertility (P = 0.005) and endometriosis (P = 0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P = 0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P = 0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P = 0.000), and delivery by CS (69.6% vs 41.2%; P = 0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P = 0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively.

Limitations, reasons for caution

A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed.

Wider implications of the findings: Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri.

Trial registration number

Not applicable

Lampaya Medicinalis Phil. decreases lipid-induced triglyceride accumulation and proinflammatory markers in human hepatocytes and fat body of Drosophila melanogaster

BACKGROUND

Excess hepatic triglyceride (TG) accumulation (steatosis) commonly observed in obesity, may lead to non-alcoholic fatty liver disease (NAFLD). Altered regulation of intracellular lipid droplets (LD) and TG metabolism, as well as activation of JNK-mediated proinflammatory pathways may trigger liver steatosis-related disorders. Drosophila melanogaster is an animal model used for studying obesity and its associated disorders. In Drosophila, lipids and glycogen are stored in the fat body (FB), which resembles mammalian adipose tissue and liver. Dietary oversupply leads to obesity-related disorders, which are characterized by FB dysfunction. Infusions of Lampaya medicinalis Phil. (Verbenaceae) are used in folk medicine of Chile to counteract inflammatory diseases. Hydroethanolic extract of lampaya (HEL) contains considerable amounts of flavonoids that may explain its anti-inflammatory effect.

METHODS

We studied whether HEL affects palmitic acid (PA, C16:0) and oleic acid (OA; C18:1)-induced TG accumulation and proinflammatory marker content in HepG2 hepatocytes as well as impaired lipid storage and proinflammatory molecule expression in Drosophila melanogaster fed a high-fat diet (HFD).

RESULTS

In HepG2 hepatocytes, exposure to OA/PA elevated TG content, FABP4, ATGL and DGAT2 expression, and the JNK proinflammatory pathway, as well as TNF-α and IL-6 production, while diminished FAS expression. These effects were prevented by HEL co-treatment. In Drosophila larvae fed a HFD, HEL prevented TG accumulation and downregulated proinflammatory JNK pathway activation.

CONCLUSION

HEL effect counteracting OA/PA- and HFD-induced lipid accumulation and proinflammatory marker expression in HepG2 hepatocytes and Drosophila larvae may represent a preventive approach against hepatic steatosis and inflammation, associated to obesity and NAFLD.

Protective effect of the hydroalcoholic extract from Lampaya medicinalis Phil. (Verbenaceae) on palmitic acid- impaired insulin signaling in 3T3-L1 adipocytes

BACKGROUND

Obesity is strongly associated with insulin resistance (IR). IR at the molecular level may be defined as a diminished activation of insulin signaling-related molecules (IRS-1/Akt/AS160) as well as reduced glucose uptake. Subject with obesity have elevated plasma levels of saturated fatty acids, such as palmitic acid (PA), which triggers insulin signaling disruption in vivo and in vitro. Infusions of Lampaya medicinalis Phil. (Verbenaceae) are used in folk medicine of Northern Chile to counteract inflammatory diseases. Hydroethanolic extracts of lampaya (HEL) contain considerable amounts of flavonoids that may explain the biological activity of the plant. The aim of this study was to assess whether HEL exposure protects against PA-disrupted insulin signaling and glucose uptake in adipocytes.

METHODS

Cytotoxicity of a range of HEL concentrations (0.01-10 μg/mL) was evaluated in 3T3-L1 adipocytes. Cells were exposed or not to 0.1 μg/mL of HEL before adding 0.65 mM PA or vehicle and incubated with 100 nM insulin (or vehicle) for 15 min. Phosphorylation of Tyr-IRS-1, Ser-Akt, Thr-AS160 was evaluated by Western blot. Glucose uptake was assessed using the 2-NBDG analogue.

RESULTS

HEL was not cytotoxic at any concentration assessed. PA-induced reduction in insulin-stimulated phosphorylation of IRS-1, Akt and AS160 and glucose uptake were abolished by co-treatment with HEL.

CONCLUSION

These findings give new insights about the effect of HEL ameliorating PA- impaired IRS-1/Akt/AS160 pathway and glucose uptake in adipocytes. More studies should focus on lampaya, since might represent a preventive approach in individuals whose circulating PA levels contribute to IR.

MON-600 Hydroethanolic Extract of Lampaya Medicinalis Phil. (Verbenaceae) Decreases Intracellular Triglycerides and Proinflammatory Marker Expression in Fatty Acid-Exposed HepG2 Hepatocytes

Background: Non-alcoholic fatty liver disease (NAFLD) is the most common hepatic chronic disease worldwide. NAFLD is characterized by an abnormal triglyceride (TG) accumulation (steatosis) in the liver, that may lead to hepatic inflammation (1). DGAT2 is a key enzyme that catalyzes the final step of TG synthesis and whose expression is elevated in NAFLD (2). FABP4 is a transporter of intracellular lipids and its levels are related with inflammation, characterized by a high expression of proinflammatory cytokines such as TNF-α, IL-6 and IL-1β. Palmitic acid (PA, C16:0) and oleic acid (OA; C18:1) are two of the most abundant fatty acids that participate in the formation of TGs in hepatic cells in vivo and in vitro (3). Lampaya medicinalis Phil. (Verbenaceae) is a small bush that grows in the “Puna atacameña” in the North of Chile. The infusion from leaves and aerial parts of the plant has been used by local ethnic groups to treat and cure inflammatory diseases (4). The aim of this study was to assess in vitro the effect of the hydroalcoholic extract of Lampaya medicinalis (HEL) against OA/PA-induced steatosis and proinflammatory marker expression in HepG2 hepatocytes.

Methods: HEL (0.01, 0.1, 1, 10 μg/mL) cytotoxicity potential (48 h) was evaluated by Trypan blue exclusion. Cells were exposed for 48 h to 1 mM OA/PA (2:1) in the presence or not of 0.01 or 10 μg/mL HEL. Intracellular TGs were assessed with Oil Red O staining and quantified with Nile Red reagent by fluorimetry. mRNA expression of DGAT2, TNF-α, IL-6 and IL-1β was evaluated by qRT-PCR. FABP4 content was assessed by Western blot. The levels of TNF-α and IL-6 in the culture media were analysed by ELISA.

Results: HEL was not cytotoxic at any concentration assessed (n=4; p>0.05). The increased content of TG induced by OA/PA was reduced in the presence of HEL (n=7; p<0.05), showing a strong consistency with Oil Red O staining. The increase in the protein content of FABP4 as well as the increment in mRNA expression of DGAT2, TNF-α, IL-6 and IL-1β induced by OA/PA were lower in cells co-exposed to HEL (n=6-9; p<0.05). The incubation with HEL+OA/PA reduced proinflammatory cytokine levels in culture media compared to cells exposed to OA/PA alone (n=6-7; p<0.05).

Conclusion: HEL reduces the OA/PA-induced increase in intracellular TG, DGAT2 and proinflammatory cytokine expression and FABP4 content, as well as the levels of secreted proinflammatory cytokines in HepG2 cells. These findings suggest a protective role for HEL against OA/PA-induced steatosis and inflammation, and therefore that Lampaya medicinalis may represent a promising therapeutic tool for pathologies such as NAFLD.

References: (1) Gluchowski L, et al. Nat Rev Gastroenterol Hepatol. 2017;14(6):343-355. (2) Perry, et al. Nature. 2014;510(7503):84-91. (3) Cunningham P, et al. J Nutr. 2009;139(4):636–639. (4) Morales G, et al. Biol Res. 2014;47:6.

Appropriate medication prescribing in elderly patients: how knowledgeable are primary care physicians? A survey study in Parma, Italy

WHAT IS KNOWN AND OBJECTIVE

Increasing attention is being paid to inappropriate medication prescribing for the elderly. A growing body of studies have detected a prevalence of inappropriate prescribing ranging from 12% to 40% worldwide, including Regione Emilia-Romagna, Italy. To improve quality of prescribing, a multi-phase pilot project in the Local Health Unit (LHU) of Parma, Regione Emilia-Romagna, was established. This phase aimed to assess primary care physicians' knowledge of appropriate prescribing in elderly patients.

METHODS

In total, 155 primary care physicians (51% of the total), convened by the LHU of Parma for an educational session, were asked to complete anonymously a 19-item paper survey. Knowledge of inappropriate medication use in the elderly was assessed using seven clinical vignettes based on the 2002 Beers Criteria. Topics tested included hypertension, osteoarthritis, arrhythmias, insomnia and depression. Data regarding physician's perceived barriers to appropriate prescribing for elderly patients were also collected. To evaluate the relationship between physician knowledge scores and physician characteristics, physicians were classified as having a 'low score' (three or below) or a 'high score' (six or more) with respect to their knowledge of prescribing for the elderly.

RESULTS AND DISCUSSION

All physicians completed the survey. Most physicians (88%) felt confident in their ability to prescribe appropriate medications for the elderly. Thirty-nine physicians (25%) received a 'high score' compared to 26 (17%) who received a 'low score'. 'Lower score' respondents had been in practice for a longer time (P < 0·05) than 'higher score' respondents. Perceived barriers to appropriate prescribing included potential drug interactions (79% of respondents) and the large number of medications a patient is already taking (75%).

WHAT IS NEW AND CONCLUSION

The study results show an unsatisfactory knowledge of appropriate prescribing among primary care physicians in the LHU of Parma, especially among older physicians. Educational strategies tailored to primary care physicians should be establish to enhance knowledge in this area and improve quality of prescribing.

A study of ablation, spatial, and temporal characteristics of laser-induced plasmas generated by multiple collinear pulses

Multi-pulse laser-induced breakdown spectroscopy (LIBS) in the collinear pulse configuration with time-integrating detection was performed on metallic samples in ambient air in an effort to clarify the contributing processes responsible for the signal enhancement observed in comparison with single-pulse excitation. Complementary experiments were also carried out on another LIBS setup using detection by an imaging spectrograph with high time resolution. The effects of laser bursts consisting of up to seven ns-range pulses from Nd-doped solid-state lasers operating at their fundamental wavelength and separated by 8.5-50 micros time gaps was studied. The ablation and emission characteristics of the generated plasmas were investigated using light profilometry, microscopy, plasma imaging, emission distribution mapping, time-resolved line emission monitoring, and plasma temperature calculations. The experimental data suggest that the two contributing processes mainly responsible for the signal enhancement effect are the plume reheating caused by the sequential laser pulses and, more dominantly, the increased material ablation attributed to the lower breakdown threshold for the preheated (molten) sample surface and/or the reduced background gas pressure behind the shockwave of preceding pulses.