Excellent outcome in patients with primary biliary cholangitis in Northwest Italy followed up for up to 30 years

OBJECTIVE

Primary biliary cholangitis (PBC) is a rare chronic autoimmune cholangiopathy, characterized by a variable course and response to treatment. We aimed to describe long-term outcomes of PBC patients referred to three academic centres in Northwest Italy.

METHODS

This is an ambispective cohort study of PBC patients (retrospective component: diagnosis before 1 January 2019; prospective component: thereafter), including 302 patients: 101 (33%) followed up in Novara, 86 (28%) in Turin, 115 (38%) in Genoa. Clinical features at diagnosis, biochemical response to therapy and survival were analyzed.

RESULTS

Among the 302 patients (88% women, median age 55 years, median follow-up 75 months), alkaline phosphatase (ALP) levels significantly decreased during treatment with ursodeoxycholic acid (UDCA, P < 0.0001) and obeticholic acid (P < 0.0001). At multivariate analysis, ALP at diagnosis was predictive of 1-year biochemical response to UDCA [odds ratio 3.57, 95% confidence interval (CI) 1.4-9, P < 0.001]. Estimated median survival free of liver transplantation and hepatic complications was 30 years (95% CI 19-41). Bilirubin level at diagnosis was the only independent risk factor for the combined outcome of death, transplantation or hepatic decompensation (hazard ratio, 1.65, 95% CI 1.66-2.56, P = 0.02). Patients presenting with total bilirubin at diagnosis ≥0.6 times the upper normal limit (ULN) had a significantly lower 10-year survival compared to those with bilirubin <0.6 times ULN (63% vs. 97%, P < 0.0001).

CONCLUSION

In PBC, both short-term response to UDCA and long-term survival can be predicted by simple conventional biomarkers of disease severity, obtained at diagnosis.

Predictors of serious adverse events and non-response in cirrhotic patients with primary biliary cholangitis treated with obeticholic acid

BACKGROUND & AIMS

Obeticholic acid (OCA) has recently been restricted in patients with primary biliary cholangitis (PBC) with "advanced cirrhosis" because of its narrow therapeutic index. We aimed to better define the predicting factors of hepatic serious adverse events (SAEs) and non-response in cirrhotic patients undergoing OCA therapy.

METHODS

Safety and efficacy of treatment were evaluated in a cohort of consecutive PBC cirrhotic patients started with OCA. OCA response was evaluated according to the Poise criteria. Risk factors for hepatic SAEs and non-response were reported as risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

One hundred PBC cirrhotics were included, 97 Child-Pugh class A and 3 class B. Thirty-one had oesophageal varices and 5 had a history of ascites. Thirty-three per cent and 32% of patients achieved a biochemical response at 6 and 12 months respectively. Male sex (adjusted-RR 1.75, 95%CI 1.42-2.12), INR (1.37, 1.00-1.87), Child-Pugh score (1.79, 1.28-2.50), MELD (1.17, 1.04-1.30) and bilirubin (1.83, 1.11-3.01) were independently associated with non-response to OCA. Twenty-two patients discontinued OCA within 12 months: 10 for pruritus, 9 for hepatic SAEs (5 for jaundice and/or ascitic decompensation; 4 for upper digestive bleeding). INR (adjusted-RR 1.91, 95%CI 1.10-3.36), lower albumin levels (0.18, 0.06-0.51), Child-Pugh score (2.43, 1.50-4.04), history of ascites (3.5, 1.85-6.5) and bilirubin (1.30, 1.05-1.56), were associated with hepatic SAEs. A total bilirubin≥1.4 mg/dl at baseline was the most accurate biochemical predictor of hepatic SAEs under OCA.

CONCLUSIONS

An accurate baseline assessment is crucial to select cirrhotic patients who can benefit from OCA. Although OCA is effective in one third of cirrhotics, bilirubin level ≥1.4 mg/dl should discourage from its use.

Rifabutin-Based Rescue Therapy for Helicobacter pylori Eradication: A Long-Term Prospective Study in a Large Cohort of Difficult-to-Treat Patients

The most commonly used regimens fail to eradicate Helicobacter pylori (H. pylori) infection in 5–10% of patients. Those not cured with treatments based on amoxicillin, clarithromycin, nitroimidazoles, fluoroquinolones, bismuth or tetracycline have no other conventional options thereafter. In this prospective long-term monocentric study, patients who failed to eradicate H. pylori following treatment with all conventional antibiotics were included. All subjects were treated with rifabutin 150 mg, amoxicillin 1 g and a standard dose of proton pump inhibitor, twice daily for 14 days. A negative ¹³C-urea breath test was used four weeks after treatment completion as an index of H. pylori eradication. Three hundred and two patients were included. Fifty-four percent (164/302) had peptic ulcer disease while 45.7% (138/302) had gastritis or functional dyspepsia. Per-protocol eradication and intention-to-treat eradication were achieved in 72.7% and 71.5%, respectively. A univariate analysis showed that gender, ethnic background, smoking habits and familial history of gastric diseases were not predictive factors of response, while with multiple logistic regression analysis, the ethnic background (Italian) predicted a poor response in the second period of the study (2010–2017). In conclusion, this study on a large cohort of very difficult-to-treat patients showed that rifabutin-based rescue therapy is an acceptable and safe strategy after multiple eradication failures with conventional antibiotics.

Gastroenterology today: between certainties and news

This special article reports on two crucial issues discussed during a meeting. The first was the updated management of Helicobacter pylori (H. pylori) infection. This was approached taking into account the recent European Guidelines, with a focus on novelties in treatment. In particular, considering the increasing H. pylori antibiotic resistance to clarithromycin, in countries with a high clarithromycin resistance rate, the bismuth-containing quadruple therapies should be preferred. The new formulation, with bismuth, metronidazole, and tetracycline contained in a single capsule (three-in-one), has shown exciting results both in naive and in non-responder patients. Levofloxacin- and rifabutin-containing triple therapies should be proposed to patients who experienced H. pylori treatment failures. Another key message on H. pylori management was that, after one or more failures, standard antimicrobial susceptibility testing should be considered before prescribing a further treatment. The second issue concerned the novelties on dysbiosis of intestinal microbiota and its clinical consequences. Among the latter, the focus was on both constipation-predominant irritable bowel syndrome (IBS-C) and microscopic colitis. Since the number of microorganisms inhabiting the gastrointestinal (GI) tract is estimated to be about 10 times higher than that of human cells, it is not surprising to foresee the clinical consequences of dysbiosis. However, to date the role of dysbiosis in IBS-C and in microscopic colitis is poorly known and major efforts are needed to understand if manipulating microbiota could improve the treatment of these and other diseases both within and outside the GI tract. At a meeting held in Turin, Italy, on May 27, 2017 two crucial issues of modern gastroenterology were discussed: the updated management of Helicobacter pylori (H. pylori) infection and the novelties regarding the dysbiosis of intestinal microbiota and its clinical consequences. Among the latter, a focus was made on both constipation-predominant irritable bowel syndrome (IBS-C) and microscopic colitis. In this special article we report the most recent salient advances discussed during this meeting.

Prevention of paracentesis-induced circulatory dysfunction in cirrhosis: standard vs half albumin doses. A prospective, randomized, unblinded pilot study

BACKGROUND

Paracentesis-induced circulatory dysfunction is a well-known complication of large volume paracentesis. Albumin infusion (8g of albumin/L of ascites removed) is effective in preventing it, but high costs and scant availability limit its use.

AIM

To compare standard vs half albumin doses.

METHODS

Seventy cirrhotic patients treated with large volume paracentesis were randomized to receive intravenous albumin as prevention of paracentesis-induced circulatory dysfunction: group 1 (35 patients) received 4g/L of ascites removed, group 2 (35 patients) received 8g/L of ascites removed.

RESULTS

The incidence of paracentesis-induced circulatory dysfunction (14% vs 20% in group 1 and group 2, respectively; p=ns), hyponatremia (9% vs 6%, p=ns) and renal impairment (0% in both groups) on the 6th day from paracentesis was similar between the two groups. After 6 months of follow-up, rates of survival and of recurrence of ascites requiring large volume paracentesis were not different between the two groups.

CONCLUSIONS

This unblinded, randomized, pilot study suggests that treatment with half doses of albumin is effective in the prevention of paracentesis-induced circulatory dysfunction and its related clinical complications in cirrhotic patients with tense ascites treated by large volume paracentesis. If confirmed, these results could support a significant costs reduction in the management of ascites in cirrhotic patients.

Helicobacter pylori eradication: metronidazole or tinidazole? Data from Turin, Italy

AIM

Triple therapy consisting of a proton pump inhibitor (PPI) and two antibiotics is used as first choice in treating Helicobacter pylori (H. pylori) infection. Since in the North Italian population, metronidazole resistance is less than 40%, this antibiotic would be preferable as first approach. The aim of this randomized study was to assess the efficacy of a metronidazole-based versus a tinidazole-based treatment, in naïve patients with H. pylori infection.

METHODS

Diagnosis and eradication of H. pylori infection were assessed by 13C-urea breath test, and by histology when an endoscopic examination was necessary. A total of 171 patients was treated: 91 (47 males, mean age 50+/-3 years) with metronidazole 250 mg q.i.d., amoxicilline 1 gr b.i.d. and PPI standard dose (MAO), and 80 (36 males, mean age 52+/-3.8 years) with tinidazole 500 mg b.i.d., amoxicilline 1 gr b.i.d. and PPI standard dose (TAO) regimen for 7, 10 or 14 days.

RESULTS

Three patients suspended MAO treatment due to side effects. H. pylori eradication was obtained as follow indicated. After 7 days, in 23/30 (76.6%) patients in MAO versus 20/27 (74.0%) in TAO regimen. After 10 days, in 20/26 (76.9%) patients in MAO versus 20/26 (76.9%) in TAO regimen. After 14 days, in 25/32 subjects (78.1%) in MAO versus 21/27 (77.7%) in TAO treatment. The differences among durations or between metronidazole-versus tinidazole-based triple therapy were not statistically different.

CONCLUSION

Treatment with metronidazole is as effective as that with tinidazole in terms of efficacy. Moreover, duration did not influence efficacy of treatment.

Noradrenalin vs terlipressin in patients with hepatorenal syndrome: a prospective, randomized, unblinded, pilot study

BACKGROUND/AIMS

Treatment of hepatorenal syndrome (HRS) is based on vasoconstrictors. Terlipressin is the one with the soundest evidence. Noradrenalin has been suggested as an effective alternative. The current study was aimed at assessing the efficacy and safety of noradrenalin vs terlipressin in patients with HRS.

METHODS

Twenty-two consecutive cirrhotic patients with HRS (9 with HRS type 1; 13 with HRS type 2) were included. Patients were randomly assigned to be treated with noradrenalin (0.1-0.7 microg/kg/min) and albumin (10 patients) or with terlipressin (1-2 mg/4h) and albumin (12 patients). Treatment was administered until HRS reversal or for a maximum of two weeks. Patients were followed-up until liver transplantation or death.

RESULTS

Reversal of HRS was observed in 7 of the 10 patients (70%) treated with noradrenalin and in 10 of the 12 patients (83%) treated with terlipressin, p=ns. Treatment led in both groups to a significant improvement in renal and circulatory function. No patient developed signs of myocardial ischemia.

CONCLUSIONS

Data from this unblinded, pilot study suggest that noradrenalin is as effective and safe as terlipressin in patients with HRS. These results would support the use of noradrenalin, a cheap and widely available drug, in the management of these patients.

[Helicobacter pylori and headache: a minireview]

The interest that surrounds the bacterium Helicobacter pylori (H. pylori) is due not only to its causal role in several gastroduodenal diseases, but also to its supposed involvement in the pathogenesis of extragastric manifestations. This review provides a literature update on the hypothetic correlation between H. pylori and headache. The authors examine three aspects of this potential association: epidemiology, intervention trials and pathogenesis. Regarding the first, apart in some subgroups, no difference in prevalence exists between patients and controls. Considering the intervention studies, it is documented that, at 6 and 12 months, bacterial eradication is associated to disappearance of symptoms in 23% and 28% of cases, and to a significant decrease of intensity, frequency and duration of acute attacks in the remaining patients. As to the pathogenetic aspect, if H. pylori has a role, it does not act through oxidative stress. In conclusion, the involvement of H. pylori infection in the pathogenesis of headache is unclear. Further investigations should focalize on particular subgroups of patients and, encouraged from data produced by intervention studies, evaluate the long-term benefit of eradication.

[Gastroenterology outpatient clinic of the Molinette Hospital (Turin, Italy): the 2003-2006 report]

AIM

Given the demographic shifts and needs of cost rationalization, it is of high priority to organize health care on the basis of ambulatory outpatients models. The aim of this study was to examine activity at the gastro-hepatology outpatients clinic of the Molinette Hospital. In this facility, the management is based on a work team organization that follows cohorts of patients with specific pathologies.

METHODS

All services, consultations and urea breath test (UBT) for the diagnosis of Helicobacter pylori infection, carried out from January 2003 to December 2006, were extrapolated from the computerized system. Consultations were divided into first examination and controls. Furthermore, the destination of the patients after each consultation was considered.

RESULTS

During the year 2003, 8 842 consultations and 4 071 UBT were carried out, in the year 2004, 11 342 consultations and 2 409 UBT, in the year 2005, 12 474 consultations and 2 510 UBT, in the year 2006, 12 249 consultations and 2 357 UBT. No further specialistic management was required for 25% of patients, while 2% had been hospitalized in the bed unit, 3% in the short hospitalization unit or the day-hospital. The remaining 70% were included in work teams or monitored thereafter. The comparison with consultations from 1994 shows an increase due to both first examination (+300%) and controls (+83%).

CONCLUSIONS

The burden of the requests from the population and primary care structures addressed to the outpatients clinic of gastro-hepatology is relevant. The activity of this facility leads to a low rate of hospitalization as well as of cost reduction.

[Prototype of a system for electric conduction at contact with laparoscopic tools]

The authors present their prototype of a system for electric conduction at contact with laparoscopic tools, devised, designed and produced by them at the Politecnico di Torino, Department of Mechanical Engineering. The system consists of a two sided plate, one side is a non conducting adhesive surface to stick to the surgical glove and the other side is a subtle flexible shell of a conductor. The Authors used the instrument with surgical tools with a metallic handle, during three cholecystectomies. Nowadays all standard laparoscopic tools have the chance and the need to be electrified. Now the way commonly used to electrify a laparoscopic tool is using a wire plugged to a fixed conducting point of the instrument. This prototype has been devised and produced to avoid some discomforts met during the numerous manoeuvres of connecting and disconnecting the wire at the time of a surgical intervention. This device permits the direct transfer (by contact) of electric energy from the wire to surgical tools. The advantage is to be more rapid in changing surgical tools obtaining, immediately an electrified instrument in your hand.

A double Meckel's diverticulum as obscure gastrointestinal bleeding cause. Report of a case

Meckel's diverticulum is the most common developmental anomaly of the gastrointestinal tract, affecting 1-4% of the general population. It is usually an incidental finding during laparotomy for other causes; occasional complications are bleeding, obstruction, diverticulitis and perforation. Up to 60% of Meckel's diverticula harbor heterotopic mucosa (mostly gastric or pancreatic), neoplastic degeneration occurs in 1-5% of cases. We report herein a case of obscure gastrointestinal bleeding in a 25-years-old man, due to a double Meckel's diverticulum, both located into jejunum and ileum, harboring ectopic gastric mucosa, diagnosed by a small bowel double contrast enema and managed laparoscopically with a tangential resection. To the best of our knowledge this is an unfrequent case of such a variant of Meckel's diverticulum with ectopic gastric mucosa diagnosed by double contrast enema.

How accurate is the culture of Helicobacter pylori in a clinical setting? An appraisal

AIM

The trend towards increasing prevalence of Helicobacter pylori (H. pylori) antibiotic resistance may jeopardize the efficacy of most regimens. Culture of the bacterium, the useful method able to address therapy, is influenced by various factors. Thus, validation of the procedure is fundamental. Most studies have been carried out in microbiological settings, while only few have been conducted in clinical frames. We evaluated the accuracy of culture for detection of H. pylori in a clinical dedicated laboratory.

METHODS

Forty-six patients (28 females, 18 males, mean age 56+/-4.7 years) were included. Thirty experienced failure to H. pylori eradication after at least 3 courses of treatment. The control group included 16 subjects suffering from gastroesophageal reflux disease and negativity for H. pylori infection. Diagnostic strategy was based on histology, culture testing, serology and 13C-urea breath test. A patient was considered infected if 2 tests were positive. A commercial culture medium in microaerophilic atmosphere was utilized.

RESULTS

Out of 30 positive specimens, culture correctly identified 29. In 1 case, no growth of micro-organisms occurred. In the control group, bacterial culture accurately identified all negative samples. One of them indicated growth but neither aspect nor confirmation tests identified H. pylori. Sensitivity was 96.7%, specificity 100%, and accuracy 97.8%. Positive and negative predictive values were 100% and 94.1%, respectively.

CONCLUSIONS

Culture of H. pylori is a feasible method and provides a good level of diagnostic accuracy even in a clinical setting by following international guidelines combined with training of specialized personnel.

[Non-invasive diagnosis of Helicobacter pylori infection in the 2006 clinical practice]

At present, 2 approaches are used to detect Helicobacter pylori (H. pylori): invasive, if based on biopsies taken during endoscopy, and non-invasive, if they do not rely on endoscopic approach. A 3rd option is offered by the string test, that employs an invasive non-endoscopic strategy. The present review attempts to update on the diagnostic non-invasive approaches to patients in the clinical setting. Non-invasive tests include urea breath test (UBT), antigen stool assay, serology, and ''doctor's tests''. The choice of the methods depends on the situation, for example, the clinical circumstances, the diagnostic accuracy, the costs of the testing strategy, and the availability of the tests in the respective area. According to European guidelines, UBT and antigen stool assay are recommended in patients without alarm symptoms or under 45 years of age, at low risk of malignancy in the test and treat strategy. Confirmation of H. pylori eradication following treatment should be tested by UBT; the stool antigen assay is the alternative if the former is not available.

Role of Helicobacter pylori infection in peptic ulcer haemorrhage

AIM

In spite of the diffusion of endoscopic treatment, mortality rate due to peptic ulcer haemorrhage (PUH) remains high. Helicobacter pylori (H. pylori) infection and nonsteroidal anti-inflammatory drugs (NSAIDs) are the 2 main aetiological factors, but their interactive role is controversial. The aim of this study was to determine both the prevalence of H. pylori infection and NSAIDs consumption in PUH and their prognostic importance.

METHODS

In a prospective study, 41 consecutive patients (33 males, 8 females) admitted for PUH were recruited. H. pylori status was investigated both by measuring specific antibodies in serum and by histological detection on gastric biopsies obtained after one month from bleeding. In case of doubt, either a 13C urea breath test, or a stool antigen test were associated. All patients were treated with medical therapy associated to endoscopic treatment in most severe cases.

RESULTS

Sixteen patients were infected from H. pylori (group A), 12 had a history of NSAIDs consumption (group B), and 13 had both risk factors (group C). The median duration of hospitalisation was 7 days for each group and correlated with age (P<0.04). Severity of PUH (high risk of rebleeding) was higher in group A (13/16; 81%) and group C (9/13; 69%), with respect to group B (6/12; 50%). This difference was not significant.

CONCLUSIONS

H. pylori infection has a predominant role in causing PUH as well as in the prognosis and clinical course of this condition. Hence, it is important to determine H. pylori status in every patient with PUH.

Digestive endoscopy is not a major risk factor for transmitting hepatitis C virus

BACKGROUND

The potential role of digestive endoscopy as a mode for transmission of hepatitis C virus (HCV) is controversial.

OBJECTIVE

To evaluate the role of digestive endoscopy in transmitting HCV by comparing the incidence of HCV infection in a cohort of patients undergoing endoscopy and in a cohort of blood donors.

DESIGN

Prospective cohort study.

SETTING

3 endoscopic units and 2 blood banks in northwestern Italy.

PATIENTS

The potentially exposed cohort consisted of 9188 outpatients consecutively recruited from 3 endoscopic units. Of 9008 patients negative for antibody to HCV (anti-HCV), 8260 (92%) were retested for anti-HCV 6 months after endoscopy. The unexposed cohort consisted of 51,230 healthy, anti-HCV-negative persons who donated blood at 2 blood banks in the same area and during the same time period; 38,280 of them (75%) were tested again for anti-HCV 6 to 48 months after the first blood donation (95,317 person-years of observation).

MEASUREMENTS

Differences in the anti-HCV seroconversion rate between the exposed cohort (patients undergoing endoscopy) and the unexposed cohort (blood donors). Seroconversion was evaluated by a third-generation enzyme immunoassay for anti-HCV; persons positive for anti-HCV were tested for HCV RNA by polymerase chain reaction.

RESULTS

All 8260 persons undergoing endoscopy remained negative for anti-HCV 6 months after the procedure (risk per 1000 persons, 0 [95% CI, 0 to 0.465]); in particular, none of the 912 patients who underwent endoscopy with the same instrument previously used on HCV carriers showed anti-HCV seroconversion (risk per 1000 persons, 0 [CI, 0 to 4.195]). Four blood donors became positive for anti-HCV and HCV RNA (mean follow-up, 2.49 years; 0.042 case per 1000 person-years [CI, 0.011 to 0.107 case per 1000 person-years]); each had undergone minor surgery before the second test.

LIMITATIONS

In the endoscopy cohort, 8.3% of patients were lost to follow-up.

CONCLUSIONS

These findings support the hypothesis that properly performed digestive endoscopy is not a major risk factor for the transmission of HCV.

Decreasing eradicaton rate of Helicobacter pylori infection with metronidazole-based triple therapy. A randomised study

BACKGROUND

Helicobacter pylori (H. pylori) infection plays an important role in the pathogenesis of duodenal ulcer (DU) disease. Low DU recurrences and reinfection rates were universally described, when treatment was effective. It has been suggested that short-term triple therapy, comprising a proton pump inhibitor plus two antibiotics (clarithromycin, amoxicillin or a nitroimidazole), should be used as first choice in treating H. pylori infection. Nevertheless, conflicting results have been reported on using these treatment regimens in different countries, due to the resistance of H. pylori against one or more antibiotics. Our aim was to compare the efficacy, for H. pylori eradication, of 1-week triple therapy versus 10 and 14-day triple schedules, in patients with a history of recurrent DU.

METHODS

A total of 159 patients (85 males, mean age 59.2+/-3.2 years) was randomly treated with a triple therapy including a standard dose of omeprazole twice daily, amoxicillin 1 g twice daily and metronidazole 500 mg twice daily. Fifty-three patients received 1-week triple therapy (Group I), 53 subjects were treated with 10-day triple therapy (Group II) and 53 others with 14-day triple therapy (Group III). H. pylori infection at entry and eradication, at least 4 weeks after therapy had ended, was assessed by 13C urea breath test and histology on biopsies from the antrum and the corpus.

RESULTS

Of the 159 subjects randomised into the study, 6 (3 in group II and 3 in group III) were excluded from the per protocol (PP) analysis because of discontinuations. At the end of the course of treatment, the overall H. pylori eradication rate in the intention-to-treat analysis, was 73.5% (39/53) in group I, 71.6% (38/53) in group II and 73.5% (39/53) in group III, without any statistically significant difference. Moreover, the PP analysis also showed no statistical differences, with an eradication rate of 73.5% (39/53) in group I, 76% (38/50) in group II and 78% (39/50) in group III. The reported frequency of side-effects was evenly distributed between the groups, but 6 patients (3.7%) stopped because of adverse events only in groups II and III.

CONCLUSIONS

The present study shows that there is no significant difference between the three regimens although the 14-day triple therapy shows a slightly higher H. pylori eradication rate. There is a strong need, in our region, to put forward surveillance programmes to monitor the prevalence of local resistant strains and to guide treatment on the basis of resistance patterns.

High-grade B-cell lymphoma arising in mucosa-associated lymphoid tissue of the duodenum

Duodenal mucosa-associated lymphoid tissue lymphoma is a rare neoplasm. We report a case of a 70-year-old man with non-Hodgkin's lymphoma located in the descending duodenum that was not associated with Helicobacter pylori infection of the stomach. A surgical resection due to obstruction of the bowel lumen above the ligament of Treitz was performed. No invasion into the adjacent structure was confirmed at surgery. The pathological examination showed an infiltration of the duodenal mucosa and submucosa with B lymphocytes. Monoclonal proliferation of the lymphoid tissue was demonstrated by polymerase chain reaction. The histological appearance and the demonstration of monoclonality fulfilled the criteria for malignant high-grade B-cell lymphoma arising from mucosa-associated lymphoid tissue.

[Gastroenterologists in ambulatory care. The experience in Turin in the year 2000]

BACKGROUND

Digestive diseases (GI) have a major impact on public health in Italy. Hospital stay for digestive pathologies parallels that due to cardiovascular causes. Total mortality for GI causes is also very high. The management of GI pathologies is therefore a major task for the National Health System. To the experienced gastroenterologist it is clear that a large number of hospitalisation is linked to a lack of careful outpatient follow-up of diseases such as cirrhosis, ulcerative colitis and peptic ulcer.

METHODS

One year of activity of our Gastro-entero-Hepatology outpatient service is examined. The management of the majority of GI diseases is organized in working teams of physicians and surgeons following cohorts of patients suffering of a specific disease.

RESULTS

During the year 2000 not only a statistically significant higher number of patients has been examined (p<0.05), in comparison with 1994, but also the hospitalisation rate was lowered resulting in a very significative cost-containment.

CONCLUSIONS

The specialization of outpatient activities into working teams offers advantages in terms of more appropriate medical care and cost reduction, partly due to a less frequent hospitalisation. The obvious counterpart was an increase of request of such form of follow-up from patients, resulting in longer delay to the access.

Seroprevalence of Helicobacter pylori infection among blood donors in Torino, Italy

BACKGROUND

Helicobacter pylori (H. pylori) infection is one of the most common infections world-wide. A cohort effect model has been proposed to clarify the differences in the prevalence among the different age-class with a rate of infection higher in old individuals than in younger ones. The source of bacterial acquisition as well as the mode of transmission (oral-oral or fecal-oral) are still unknown and studies have confirmed the role of socio-economic factors and characteristics of childhood living conditions for the acquisition of H. pylori. In this study we analysed the age and gender-specific prevalence of H. pylori infection in a population of apparently healthy subjects, i.e. blood donors attending the blood bank of our hospital.

METHODS

From April 1995 to July 1995, 619 consecutive volunteer blood donors (523 males, 96 females, mean age 47+/-5.3 years, range 18-65 years), attending the Molinette Hospital's Blood Bank (Torino), were recruited. H. pylori seroprevalence was assessed by presence of antibodies (IgG) against the bacterium in serum, by means of a commercial enzyme linked immunosorbent assay (ELISA, Helori-test Eurospital).

RESULTS

The overall H. pylori seroprevalence in the population was 47%: 265/523 males (51%) were seropositive versus 26/96 females (27%) (p<0.0001, OR 2.77 [confidence interval 95% 1.674.61]). When subdivided into sex and decade of age-groups the difference was significative in three subgroups: among male subjects between 20-29 years, male subjects between 40-49 years and male subjects between 50-59 years. The seroprevalence was also significatively higher in older than younger both in males than females.

CONCLUSIONS

This study confirms the cohort effect and for a future survey an equilibrated number of persons belonging to the different groups will be planned.

Detection in an enzyme immunoassay of an immune response to a recombinant fragment of the 128 kilodalton protein (CagA) of Helicobacter pylori

The possibility of using a recombinant fragment of the CagA (128 kDa protein) for the diagnosis of Helicobacter pylori infection was evaluated. Following cloning of the gene coding for the CagA, a recombinant fragment of it was expressed in Escherichia coli, purified and used in Western blot and an EIA to screen sera from 82 patients with gastroduodenal disease who underwent endoscopic examination. In Western blot, good correlation was found between the serological data obtained with the recombinant antigen and those obtained using non-purified extracts of Helicobacter pylori. The EIA using the antigen showed a sensitivity of 96.2% and a specificity of 96.6% compared with Western blot. These data indicate that the recombinant protein is a reliable antigen for detection of infections with Helicobacter pylori strains that are associated with disease. The EIA assay described may be used in follow-up of the progression of the illness and the results of therapy.

Chronic infection in woodchucks infected by a cloned hepatitis delta virus

Two woodchucks (Marmota monax) intrahepatically inoculated with hepatitis delta virus (HDV) complementary DNA clones pSVL-D3 and pSVL-Ag showed virological and pathological signs of acute and chronic HDV infection. HDV-RNA and hepatitis delta antigen (HDAg) were detected in serum by slot-blot hybridization and by western blot five weeks after inoculation. Liver biopsy specimens collected at 8th week post inoculum were positive for HDV-RNA. Anti-HDV antibodies were detected at the 11th and 9th weeks, respectively. Histological finding of hepatocarcinoma and persistence of circulating HDV-RNA and anti-HDV were observed up to the 10th month. Both woodchucks produced "small" and "large" HDAg antigen, although the inoculated cloned DNA bears the coding capability solely for the small antigen. A transient decrease of woodchuck hepatitis virus DNA (WHV-DNA) level was observed during the peak of HDV infection. Successive inoculation of acute-phase serum in three woodchucks resulted in a successful infection in one of the animals.