The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridioides difficile infection and other potential indications: second edition of joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) guidelines

The first British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS)-endorsed faecal microbiota transplant (FMT) guidelines were published in 2018. Over the past 5 years, there has been considerable growth in the evidence base (including publication of outcomes from large national FMT registries), necessitating an updated critical review of the literature and a second edition of the BSG/HIS FMT guidelines. These have been produced in accordance with National Institute for Health and Care Excellence-accredited methodology, thus have particular relevance for UK-based clinicians, but are intended to be of pertinence internationally. This second edition of the guidelines have been divided into recommendations, good practice points and recommendations against certain practices. With respect to FMT for Clostridioides difficile infection (CDI), key focus areas centred around timing of administration, increasing clinical experience of encapsulated FMT preparations and optimising donor screening. The latter topic is of particular relevance given the COVID-19 pandemic, and cases of patient morbidity and mortality resulting from FMT-related pathogen transmission. The guidelines also considered emergent literature on the use of FMT in non-CDI settings (including both gastrointestinal and non-gastrointestinal indications), reviewing relevant randomised controlled trials. Recommendations are provided regarding special areas (including compassionate FMT use), and considerations regarding the evolving landscape of FMT and microbiome therapeutics.

Conversion of unresponsiveness to immune checkpoint inhibition by fecal microbiota transplantation in patients with metastatic melanoma: study protocol for a randomized phase Ib/IIa trial

BACKGROUND

The gut microbiome plays an important role in immune modulation. Specifically, presence or absence of certain gut bacterial taxa has been associated with better antitumor immune responses. Furthermore, in trials using fecal microbiota transplantation (FMT) to treat melanoma patients unresponsive to immune checkpoint inhibitors (ICI), complete responses (CR), partial responses (PR), and durable stable disease (SD) have been observed. However, the underlying mechanism determining which patients will or will not respond and what the optimal FMT composition is, has not been fully elucidated, and a discrepancy in microbial taxa associated with clinical response has been observed between studies. Furthermore, it is unknown whether a change in the microbiome itself, irrespective of its origin, or FMT from ICI responding donors, is required for reversion of ICI-unresponsiveness. To address this, we will transfer microbiota of either ICI responder or nonresponder metastatic melanoma patients via FMT.

METHODS

In this randomized, double-blinded phase Ib/IIa trial, 24 anti-PD1-refractory patients with advanced stage cutaneous melanoma will receive an FMT from either an ICI responding or nonresponding donor, while continuing anti-PD-1 treatment. Donors will be selected from patients with metastatic melanoma treated with anti-PD-1 therapy. Two patients with a good response (≥ 30% decrease according to RECIST 1.1 within the past 24 months) and two patients with progression (≥ 20% increase according to RECIST 1.1 within the past 3 months) will be selected as ICI responding or nonresponding donors, respectively. The primary endpoint is clinical benefit (SD, PR or CR) at 12 weeks, confirmed on a CT scan at 16 weeks. The secondary endpoint is safety, defined as the occurrence of grade ≥ 3 toxicity. Exploratory endpoints are progression-free survival and changes in the gut microbiome, metabolome, and immune cells.

DISCUSSION

Transplanting fecal microbiota to restore the patients' perturbed microbiome has proven successful in several indications. However, less is known about the potential role of FMT to improve antitumor immune response. In this trial, we aim to investigate whether administration of FMT can reverse resistance to anti-PD-1 treatment in patients with advanced stage melanoma, and whether the ICI-responsiveness of the feces donor is associated with its effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05251389 (registered 22-Feb-2022). Protocol V4.0 (08-02-2022).

Clinical Application and Potential of Fecal Microbiota Transplantation

Fecal microbiota transplantation (FMT) is a well-established treatment for recurrent Clostridioides difficile infection. FMT has become a more readily available and useful new treatment option as a result of stool banks. The current state of knowledge indicates that dysbiosis of the gut microbiota is implicated in several disorders in addition to C. difficile infection. Randomized controlled studies have shown FMT to be somewhat effective in treating ulcerative colitis, irritable bowel syndrome, and hepatic encephalopathy. In addition, FMT has been beneficial in treating several other conditions, such as the eradication of multidrug-resistant organisms and graft-versus-host disease. We expect that FMT will soon be implemented as a treatment strategy for several new indications, although further studies are needed.

Clinical Application and Potential of Fecal Microbiota Transplantation

Fecal microbiota transplantation (FMT) is a well-established treatment for recurrent Clostridioides difficile infection. FMT has become a more readily available and useful new treatment option as a result of stool banks. The current state of knowledge indicates that dysbiosis of the gut microbiota is implicated in several disorders in addition to C. difficile infection. Randomized controlled studies have shown FMT to be somewhat effective in treating ulcerative colitis, irritable bowel syndrome, and hepatic encephalopathy. In addition, FMT has been beneficial in treating several other conditions, such as the eradication of multidrug-resistant organisms and graft-versus-host disease. We expect that FMT will soon be implemented as a treatment strategy for several new indications, although further studies are needed.

How to: Establish and run a stool bank

BACKGROUND

Since 2013, several stool banks have been developed following publications reporting on clinical success of 'faecal microbiota transplantation' (FMT) for recurrent Clostridium difficile infections (CDI). However, protocols for donor screening, faecal suspension preparation, and transfer of the faecal suspension differ between countries and institutions. Moreover, no European consensus exists regarding the legislative aspects of the faecal suspension product. Internationally standardized recommendations about the above mentioned aspects have not yet been established.

OBJECTIVE

In 2015, the Netherlands Donor Feces Bank (NDFB) was founded with the primary aim of providing a standardized product for the treatment of patients with recurrent CDI in the Netherlands. Standard operation procedures for donor recruitment, donor selection, donor screening, and production, storage, and distribution of frozen faecal suspensions for FMT were formulated.

RESULTS AND DISCUSSION

Our experience summarized in this review addresses current donor recruitment and screening, preparation of the faecal suspension, transfer of the faecal microbiota suspension, and the experiences and follow-up of the patients treated with donor faeces from the NDFB.

[Faecal microbiota transplantation: indications in perspective]

- As yet, with cure rates around 85%, recurrent Clostridium difficile infection is the only definite indication for faecal microbiota transplantation.- Faecal microbiota transplantation induces clinical remission and endoscopic improvements in 24-30% of patients with ulcerative colitis, compared to 5% (water) to 20% (autologous faeces) in placebo-treated patients. Current research focuses on the identification of 'super donors', and subgroups of patients in which faecal microbiota transplantation is effective.- In patients with metabolic syndrome, faecal microbiota transplantation may increase insulin sensitivity. Weight, body mass index, and energy metabolism are not affected by faecal microbiota transplantation in humans.- In addition to the aforementioned indications, faecal microbiota transplantation is an emerging treatment modality for patients with Crohn's disease, irritable bowel syndrome, graft-versus-host-disease, and carriage of multidrug-resistant micro-organisms. Randomized controlled trials, comparing faecal microbiota transplantation with placebo treatment, are required to determine the effectiveness of faecal microbiota transplantation in these patient groups.

[Fecal microbiota transplantation, a novel therapy for recurrent Clostridium difficile infection]

Clostridium difficile infection is caused by a disturbance of the gut microbiota, often resulting from the use of antibiotics. Among a sub group of patients with this disorder, treatment with antibiotics is not effective. They develop a chronic, recurrent infection. Such patients can be treated with a fecal microbiota transplantation (FMT), or fecal transplantation. The crucial steps for safe application of fecal transplantation are central donor selection and screening. To optimise safety and to guarantee the availability of donor feces for fecal transplantation, the Nederlandse Donor Feces Bank (Dutch Donor Feces Bank) was established. At this facility, ready-to-use, screened donor feces can be ordered for patients with (recurrent) Clostridium difficile infections, who can then be treated at their own hospital.

A nation-wide population-based study of inguinal hernia repair incidence and age-stratified recurrence in an Asian population

PURPOSE

It has been estimated in the UK that 27 % of men and 3 % of women will undergo an inguinal hernia repair (IHR) during their lifetimes. However, no epidemiologic study investigating IHR has been performed to date in an Asian population. The present study explored the incidence and recurrence of IHR in an Asian population using a nation-wide population-based dataset in Taiwan.

METHODS

Based on the National Health Insurance Database, we identified 5806 patients who underwent an IHR between 2000 and 2010 and followed them until they had a recurrence, died during hospitalization, left the program, or the study ended. We calculated the age-stratified recurrence rates and used Cox proportional hazards to explore the influence of demographic and clinical factors on recurrence. We also plotted IHR occurrence over the study period.

RESULTS

Among the 5806 sampled subjects who had an IHR, 565 (9.73 %) had an IHR recurrence yielding an overall incidence of 18.23 per 1000 person-years. The hazard ratios for recurrence increased with age, and were greater among men and blue collar workers. The incidence of IHR decreased from 168.21 to 92.10 per 100,000 person-years over the study period. Surgical complication rates ranged between 0.16 and 2.57 %.

CONCLUSIONS

On account of the increased risk of recurrence with age, young hernia patients may not want to delay surgery. This study detected a decreasing trend in initial IHR rates, confirming similar trends reported in Western countries. However, the incidence of initial IHR is lower in Taiwan than it is in the West.

Association between osteoporosis and psoriasis: results from the Longitudinal Health Insurance Database in Taiwan

This population-based analysis explored the association between osteoporosis and a previous diagnosis of psoriasis. We found that the adjusted odds ratio (OR) of having been previously diagnosed with psoriasis for subjects with osteoporosis was 1.65 (95 % confidence interval [CI], 1.42-1.94) when compared to controls.

INTRODUCTION

Although previous studies have investigated this association between psoriasis and osteoporosis, significant controversy remains regarding its presence. Therefore, this study set out to explore the association between osteoporosis and a previous diagnosis of psoriasis through a population-based case-control study in Taiwan.

METHODS

We identified 17,507 cases with a diagnosis of osteoporosis and randomly extracted 52,521 controls without a history of osteoporosis. We used conditional logistic regression analyses to calculate the OR for having been previously diagnosed with psoriasis.

RESULTS

Subjects with osteoporosis had a significantly higher prevalence of previously diagnosed psoriasis (1.50 % vs. 0.87 %, p < 0.001) compared to controls. Conditional logistic regression analysis revealed that the OR of having been previously diagnosed with psoriasis for subjects with osteoporosis was 1.65 (95 % CI, 1.42-1.94) when compared to controls after adjusting for monthly income, hypertension, diabetes, coronary heart disease, hyperlipidemia, rheumatoid arthritis, stroke, renal disease, Parkinson's disease, hyperthyroidism, chronic hepatopathy, Cushing's syndrome, malabsorption, tobacco use disorder, obesity, alcohol abuse/alcohol dependence syndrome, the use of SSRIs, and the use of systemic glucocorticoids. Furthermore, osteoporosis was significantly associated with a previous diagnosis of psoriasis in both sexes; the adjusted OR of prior psoriasis for cases when compared to controls was 1.52 (95 % CI, 1.16-1.99) and 1.73 (95 % CI, 1.44-2.13) for males and females, respectively. We also found that the adjusted OR of prior severe psoriasis for cases was 1.96 (95 % CI, 1.37-2.81) that of controls.

CONCLUSIONS

This investigation succeeded in detecting an association between osteoporosis and prior psoriasis among both men and women.

Association between osteoporosis and urinary calculus: evidence from a population-based study

SUMMARY

This population-based case-control analysis investigated the association between osteoporosis and prior urinary calculus (UC) in Taiwan. We succeeded in detecting an association between osteoporosis and prior UC (adjusted odds ratio = 1.66). This association was consistent and significant regardless of stone location.

INTRODUCTION

UC has been demonstrated to be a risk factor for osteoporotic fractures, but no studies to date have directly investigated the association between UC and osteoporosis. This case-control analysis aimed to investigate the association of osteoporosis with prior UC using a population-based dataset in Taiwan.

METHODS

We first identified 39,840 cases ≥40 years who received their first-time diagnosis of osteoporosis between 2002 and 2009 and then randomly selected 79,680 controls. We used conditional logistic regression analyses to compute the odds ratio (OR) and the corresponding 95 % confidence interval (CI) for having been previously diagnosed with UC between cases and controls.

RESULTS

The OR of having been previously diagnosed with UC for patients with osteoporosis was 1.66 (95 % CI = 1.59-1.73) when compared to controls after adjusting for geographic location, urbanization level, type I diabetes mellitus, coronary heart disease, hyperlipidemia, rheumatoid arthritis, stroke, renal disease, Parkinson's disease, hyperthyroidism, chronic hepatopathy, Cushing's syndrome, malabsorption, gastrectomy, obesity, and alcohol abuse/alcohol dependence syndrome. The results consistently showed that osteoporosis was significantly associated with a previous diagnosis of UC regardless of stone location; the adjusted ORs of prior kidney calculus, ureter calculus, bladder calculus, and unspecified calculus when compared to controls were 1.71 (95 % CI = 1.61-1.81), 1.60 (95 % CI = 1.47-1.74), 1.59 (95 % CI = 1.23-2.04), and 1.69 (95 % CI = 1.59-1.80), respectively.

CONCLUSIONS

This study succeeded in detecting an association between osteoporosis and prior UC. In addition, our findings were consistent and significant regardless of stone location.

Bisphosphonates reduced the risk of acute myocardial infarction: a 2-year follow-up study

This population-based matched cohort analysis explored the effects of bisphosphonate treatment on acute myocardial infarction (AMI). We found that patients who received bisphosphonate therapy had a lower risk of AMI during a 2-year follow-up period (hazard ratio (HR) = 0.35). Our data support that bisphosphonates may provide protective effects against cardiovascular events.

INTRODUCTION

Although bisphosphonates have been suggested to have anti-atherosclerotic effects in animal models, evidence in human subjects is still conflicting. Therefore, this study aimed to explore the effects of bisphosphonate treatment on AMI using a population-based cohort study.

METHODS

We identified 1,548 patients who received bisphosphonate therapy for osteoporotic fractures and randomly extracted 4,644 subjects with vertebral or hip fractures as a comparison cohort. Each patient was individually tracked for 2 years to identify those who subsequently suffered an AMI. Stratified Cox proportional hazards regressions were performed to assess the effect of bisphosphonate treatment on the risk of AMI.

RESULTS

Six (0.4 %) of the patients who received bisphosphonate therapy and 49 (1.1 %) of the comparison subjects suffered an AMI during the 2-year follow-up period. The incidence rate of AMI was 1.94 (95 % CI = 0.79-4.03) per 1,000 person-years in patients who received bisphosphonate therapy and 5.28 (95 % CI = 3.95-6.92) per 1,000 person-years in comparison patients. Regression analysis revealed that patients who received bisphosphonate therapy had a lower hazard of AMI during the 2-year follow-up period than comparison patients (HR = 0.37, 95 % CI = 0.16-0.85, p = 0.020). After censoring cases that died from non-AMI causes and adjusting for both demographic and risk factors, the HR of AMI for patients who received bisphosphonate therapy was 0.35 (95 % CI = 0.14-0.84, p = 0.020) than that of comparison patients.

CONCLUSIONS

Patients who received bisphosphonate therapy had a lower risk of AMI during the 2-year follow-up period. Our data support that bisphosphonates may provide protective effects against cardiovascular events.

Risk of infections subsequent to pyogenic liver abscess: a nationwide population-based study

This nationwide study aimed to provide risk estimates for a panel of infections subsequent to pyogenic liver abscesses (PLA) in Taiwan. In this study, we selected 12 050 patients diagnosed with PLA as our study cohort and 60 250 non-PLA patients as our comparison cohort. We individually tracked each subject for a 1-year period beginning with their index date to identify those who were subsequently diagnosed with any of the following infections: pneumonia, endophthalmitis, septic pulmonary embolism, pulmonary abscess, pleural empyema, meningitis, abscess of prostate, renal and perinephric abscess, epidural spinal abscess, osteomyelitis, necrotizing fasciitis, splenic abscess, psoas abscess and infectious endocarditis. We found that during the 1-year follow-up period, the subjects with PLA had a consistently higher incidence of all types of infections than comparison subjects. In particular, compared with subjects without PLA, the adjusted hazard ratios (HR) of pulmonary abscess, pleural empyema, renal and perinephric abscess, epidural spinal abscess and splenic abscess were 26.71, 18.56, 43.21, 51.32 and 126.51, respectively. We further analysed the HR of extra-hepatic Klebsiella pneumoniae infections among patients with PLA caused by K. pneumoniae. We found that the HR was higher for 12 of the 15 analysed extra-hepatic infections after restricting the analysis to only infections with K. pneumoniae aetiologies.

A population-based 2-year follow-up study on the relationship between bisphosphonates and the risk of stroke

This study aimed to explore the effect of bisphosphonate treatment on stroke using a large population cohort study. We found that the patients who received bisphosphonate therapy were less likely to suffer a stroke than comparison patients (hazard ratio (HR) = 0.79; 95% confidence interval (CI) = 0.66-0.99; p = 0.005) during a 2-year follow-up period.

INTRODUCTION

Animal models have suggested that bisphosphonates have a beneficial effect on the cardiovascular system. However, data on this topic in human subjects are still lacking. This study aimed to explore the protective effect of bisphosphonate treatment on stroke using a large population cohort study.

METHODS

We identified 2,148 patients who received bisphosphonate therapy for osteoporotic fractures. We randomly extracted 6,444 subjects with vertebral or hip fractures as a comparison group matched with the study group on age, sex, and year of index date. Each patient was individually tracked for 2 years to identify those who suffered a stroke. Stratified Cox proportional hazards regressions were performed to assess the effect of bisphosphonate treatment on the risk of stroke.

RESULTS

We found that 184 (8.6%) patients who received bisphosphonate therapy and 696 (10.8%) comparison patients suffered a stroke during the follow-up period. After adjusting for demographic variables and medical co-morbidities, stratified Cox proportional hazards regressions stratified by propensity score revealed that patients who received bisphosphonate therapy were less likely to suffer a stroke than comparison patients (HR = 0.79; 95% CI = 0.66-0.99). The adjusted HR for subarachnoid/intra-cerebral hemorrhage for patients who received bisphosphonate therapy was only 0.53 times (95% CI = 0.33-0.92) that of comparison patients, and the hazard of having an ischemic stroke during the 2-year follow-up period was 0.81 times that of comparison patients (95% CI = 0.65-0.96).

CONCLUSION

Patients who received bisphosphonate therapy were associated with a lower risk of stroke during a 2-year follow-up period.

The effects of chronic periodontitis and its treatment on the subsequent risk of psoriasis

BACKGROUND

Although psoriasis and chronic periodontitis (CP) may share an underlying immune dysregulation as part of their pathologies, to date only one small-scale cross-sectional pilot study has investigated the potential association between CP and psoriasis.

OBJECTIVES

This study aimed to investigate the subsequent risk for psoriasis following a diagnosis of CP by utilizing a cohort study design and population-based dataset in Taiwan.

METHODS

In total, 115 365 patients with CP were included in the study cohort and 115 365 patients without CP were included in the comparison cohort. We individually tracked each patient for a 5-year period to identify those who had subsequently received a diagnosis of psoriasis. A Cox proportional hazards regression was performed to compute the 5-year risk of subsequent psoriasis following a diagnosis of CP.

RESULTS

We found that the incidence rate of psoriasis during the 5-year follow-up period was 1·88 [95% confidence interval (CI) 1·77-1·99] per 1000 person-years in patients with CP and 1·22 (95% CI 1·14-1·32) per 1000 person-years in comparison patients. After censoring those who died during the follow-up period, and adjusting for monthly income and geographical region, compared with comparison patients, the hazard ratio (HR) of psoriasis for patients with CP was 1·52 (95% CI 1·38-1·70). Furthermore, the study subjects who had undergone a gingivectomy or periodontal flap operation had only a slightly higher adjusted risk of psoriasis than comparison patients (HR 1·26).

CONCLUSIONS

This study detected an increased risk for psoriasis among patients with CP. Treatment for CP attenuated, but did not nullify, the risk for subsequent psoriasis.

Haemorrhoids are associated with erectile dysfunction: a population-based study

Haemorrhoids are associated with regional vascular abnormalities and rectal pain, which are hypothesized to increase the risk of erectile dysfunction (ED); however, few studies have investigated the association between ED and haemorrhoids. This case-control study aimed to estimate the association between haemorrhoids and ED by using a population-based data in Taiwan. We identified 6,310 patients with ED as cases and randomly selected 31,550 controls. Conditional logistic regression was performed to compute the odds ratio (OR) for having been previously diagnosed with haemorrhoids between cases and controls. The results show that haemorrhoids were found to be present among 1,572 (24.9%) cases and 4,491 (14.20%) controls. The OR for prior haemorrhoids among cases was 1.90 (95% CI = 1.78-2.03) when compared with controls after adjusting for monthly income, geographical location, hypertension, diabetes, coronary heart disease, hyperlipidemia, obesity and alcohol abuse/alcohol dependence syndrome. Younger cases demonstrated a higher risk for prior haemorrhoids when compared with controls. In particular, the adjusted OR among cases <30 years old was 3.71 (95% CI = 2.74-5.02) when compared with controls. We concluded that there was an association between ED and a prior diagnosis of haemorrhoids.

Medical comorbidity associated with psoriasis in adults: a population-based study

BACKGROUND

Most publications to date on comorbidities associated with psoriasis have focused on cardiovascular and metabolic diseases. Few comprehensive investigations of medical comorbidities in a cohort of patients with psoriasis appear in the literature.

OBJECTIVES

To examine the prevalence of comorbidities in adult patients with psoriasis, including a comparison of comorbid prevalence vs. that in controls without psoriasis, in a nationally representative dataset in Taiwan.

METHODS

There were 1685 adult patients with psoriasis in the study group and 5055 randomly selected subjects in the comparison group. We used conditional logistic regression analyses to examine the risk of 29 comorbidities for these two groups after adjusting for monthly income, geographical region of residence and the level of urbanization of each patient's community of residence.

RESULTS

After adjusting for several potential confounders, patients with psoriasis had higher odds of comorbid congestive heart failure [odds ratio (OR) 1·63], ischaemic heart disease (OR 1·51), renal failure (OR 1·45), uncomplicated diabetes (OR 1·37), liver diseases (OR 1·34), hepatitis B or C (OR 1·34), complicated diabetes (OR 1·32), hyperlipidaemia (OR 1·28), hypertension (OR 1·24) and peptic ulcer (OR 1·22) than did patients without psoriasis. However, patients with mild psoriasis had higher odds of comorbidity only with uncomplicated diabetes (OR 1·55), asthma (OR 1·30), liver diseases (OR 1·30) and peptic ulcer (OR 1·26) than patients without psoriasis.

CONCLUSIONS

We conclude that psoriasis is associated with a variety of medical comorbidities including cardiovascular diseases, metabolic diseases, renal failure, liver diseases, viral hepatitis B or C, asthma and peptic ulcers.

Increased colorectal cancer risk in first-degree relatives of patients with hyperplastic polyposis syndrome

INTRODUCTION

Hyperplastic polyposis syndrome (HPS) is characterised by the presence of multiple colorectal hyperplastic polyps and is associated with an increased colorectal cancer (CRC) risk. For first-degree relatives of HPS patients (FDRs) this has not been adequately quantified. Reliable evidence concerning the magnitude of a possible excess risk is necessary to determine whether preventive measures, like screening colonoscopies, in FDRs are justified.

AIMS AND METHODS

We analysed the incidence rate of CRC in FDRs and compared this with the general population through person-year analysis after adjustment for demographic characteristics. Population-based incidence data from the Eindhoven Cancer Registry during the period 1970-2006 were used to compare observed numbers of CRC cases in FDRs with expected numbers based on the incidence in the general population.

RESULTS

A total of 347 FDRs (41% male) from 57 pedigrees were included, contributing 11 053 person-years of follow-up. During the study period, a total of 27 CRC cases occurred among FDRs compared to five expected CRC cases (p<0.001). The RR of CRC in FDRs compared to the general population was 5.4 (95% CI 3.7 to 7.8). Four FDRs satisfied the criteria for HPS. Based on the estimated HPS prevalence of 1:3000 in the general population the projected RR of HPS in FDRs was 39 (95% CI 13 to 121).

CONCLUSIONS

FDRs of HPS patients have an increased risk for both CRC and HPS compared to the general population. Hence, as long as no genetic substrate has been identified, screening colonoscopies for FDRs seem justified but this needs to be prospectively evaluated.

Struggling with recurrent Clostridium difficile infections: is donor faeces the solution?

Patients with recurrent Clostridium difficile infections (CDI) in hospitals and the community constitute an increasing treatment problem. While most patients with a first infection respond to either metronidazole or oral vancomycin, therapy in recurrent C. difficile infections tends to fail repeatedly. Lack of alternative treatment options can be a tremendous burden, both to patients and their treating physicians. Most guidelines recommend prolonged oral vancomycin pulse and or tapering schedules, but evidence-based treatment strategies are lacking. The role of immunoglobulins, whey prepared from vaccinated cows, probiotics or other antibiotics is unclear. Since 1958 several case series and case reports describe a treatment strategy where faecal infusions are successfully given for the treatment of recurrent CDI. Restoring intestinal flora has been historically thought of as the mechanism responsible for cure in these patients. In the literature, more than 150 patients have received faeces from a healthy donor, either infused through an enema, or through a nasoduodenal or nasogastric tube. We summarise the literature regarding treatment with donor faeces for recurrent CDI, and introduce the FECAL trial, currently open for inclusion.

[Treatment of recurrent Clostridium difficile-associated diarrhoea with a suspension of donor faeces]

OBJECTIVE

To study the effect of treating recurrent Clostridium difficile-associated diarrhoea (CDAD) with a suspension of donor faeces.

DESIGN

Uncontrolled interventional study.

METHOD

Patients that, despite adequate antibiotic therapy, had developed at least 2 recurrences ofCDAD, including at least one recurrence that had been treated with a vancomycin tapering regimen, were included in the study. Relatives or volunteers served as faeces donor. All donors were previously examined for the presence of HIV, hepatitis B- and C-virus, and acute infection with cytomegalovirus or Epstein-Barr virus. The donor faeces were examined for the presence of C. difficile, Yersinia, Campylobacter, Shigella, Salmonella, and parasites. Before the infusion of donor faeces, the patients were treated for 4 days with vancomycin 500 mg q.i.d., followed by colon lavage. The suspension of 150 g of donor faeces dissolved in 300-400 ml of NaCl was infused into the jejunum via a duodenal catheter or into the caecum via colonoscopy.

RESULTS

7 CDAD patients were included and treated, including 2 with the hypervirulent C. difficile-strain PCR ribotype 027, toxinotype III. In 5 patients, the defaecation frequency returned to normal almost immediately after treatment and the cultures and toxin tests for C. difficile were repeatedly negative. In the remaining 2 patients, the treatment was successful after a repeated infusion of faeces from a different donor.

CONCLUSION

Treatment with donor faeces seems promising for patients who develop repeated recurrences despite adequate therapy and could be valuable in the future during (local) epidemics of the PCR ribotype 027 strain. A randomised nationwide study (FECAL trial) has been started in order to determine the efficacy of this treatment.

Genetic defects underlying Peutz-Jeghers syndrome (PJS) and exclusion of the polarity-associated MARK/Par1 gene family as potential PJS candidates

LKB1/STK11 germline inactivations are identified in the majority (66-94%) of Peutz-Jeghers syndrome (PJS) patients. Therefore, defects in other genes or so far unidentified ways of LKB1 inactivation may cause PJS. The genes encoding the MARK proteins, homologues of the Par1 polarity protein that associates with Par4/Lkb1, were analyzed in this study because of their link to LKB1 and cell polarity. The genetic defect underlying PJS was determined through analysis of both LKB1 and all four MARK genes. LKB1 point mutations and small deletions were identified in 18 of 23 PJS families using direct sequencing and multiplex ligation-dependent probe amplification analysis identified exon deletions in 3 of 23 families. In total, 91% of the studied families showed LKB1 inactivation. Furthermore, a MARK1, MARK2, MARK3 and MARK4 mutation analysis and an MARK4 quantitative multiplex polymerase chain reaction analysis to identify exon deletions on another eight PJS families without identified LKB1 germline mutation did not identify mutations in the MARK genes. LKB1 defects are the major cause of PJS and genes of the MARK family do not represent alternative PJS genes. Other mechanisms of inactivation of LKB1 may cause PJS in the remaining families.

Oral and maxillofacial manifestations of familial adenomatous polyposis

Patients with familial adenomatous polyposis (FAP) develop multiple premalignant colorectal adenomas. Untreated, one or more of these polyps will progress to colorectal carcinoma in middle-aged adults. Extra-intestinal manifestations of FAP are frequently observed and this combination has been called Gardner's syndrome. Oral and maxillofacial symptoms of FAP include an increased risk of jaw osteomas, odontomas and supernumerary or unerupted teeth. Early diagnosis of FAP is crucial and may be life saving. As oral signs usually precede gastrointestinal symptoms, the dentist may play an important role in the diagnosis of FAP.

STK11 status and intussusception risk in Peutz-Jeghers syndrome

BACKGROUND

Peutz-Jeghers syndrome (PJS) is caused by germline STK11 mutations and characterised by gastrointestinal polyposis. Although small bowel intussusception is a recognised complication of PJS, risk varies between patients.

OBJECTIVE

To analyse the time to onset of intussusception in a large series of PJS probands.

METHODS

STK11 mutation status was evaluated in 225 PJS probands and medical histories of the patients reviewed.

RESULTS

135 (60%) of the probands possessed a germline STK11 mutation; 109 (48%) probands had a history of intussusception at a median age of 15.0 years but with wide variability (range 3.7 to 45.4 years). Median time to onset of intussusception was not significantly different between those with identified mutations and those with no mutation detected, at 14.7 years and 16.4 years, respectively (log-rank test of difference, chi(2) = 0.58, with 1df; p = 0.45). Similarly no differences were observed between patient groups on the basis of the type or site of STK11 mutation.

CONCLUSIONS

The risk of intussusception in PJS is not influenced by STK11 mutation status.

STRAD in Peutz-Jeghers syndrome and sporadic cancers

BACKGROUND/AIMS

LKB1 is a tumour suppressor gene that is associated with Peutz-Jeghers syndrome (PJS), a rare autosomal dominant cancer predisposition syndrome. However, germline mutations in the LKB1 gene are found in only about 60% of patients with PJS, suggesting the existence of a second PJS gene. The STRAD gene, encoding an LKB1 interacting protein that activates LKB1, which subsequently leads to polarisation of cells, is an interesting candidate for a second PJS gene and a potential tumour suppressor gene in sporadic carcinomas.

METHODS

The involvement of STRAD in 42 PJS associated tumours (sporadic lung, colon, gastric, and ovarian adenocarcinomas) was studied using loss of heterozygosity (LOH) analysis of eight microsatellite markers on chromosome 17, including TP53, BRCA1, and STRAD markers.

RESULTS

Loss of the marker near the STRAD locus was seen in 13 of 29 informative cases, including all gastric adenocarcinomas. Specific LOH of the STRAD marker was found in four of 29 informative cases. For these patients all exons and exon-intron boundaries of the STRAD gene were sequenced, but no somatic mutations were identified. Furthermore, no germline STRAD mutations were found in 10 patients with PJS and family members without LKB1 germline mutation.

CONCLUSIONS

Despite the frequent occurrence of LOH in the STRAD region, these results indicate that inactivation of the STRAD gene is not essential in the sporadic adenocarcinomas studied, although it is possible that STRAD may be inactivated in different ways. In addition, no evidence was found for the hypothesis that STRAD is a second PJS susceptibility gene.

[Oral and maxillofacial manifestations of familial adenomatosis polyposis. Gardner's syndrome]

Patients suffering from familial adenomatosis polyposis develop multiple pre-malignant gastrointestinal polyps and are at high risk of developing colon cancer. In addition extra-intestinal manifestations are observed frequently. The combination of extra-intestinal manifestations and familial adenomatosis polyposis is named Gardner's syndrome. An early diagnosis of this disease is important because it could mean a better prognosis for the patient. This review describes the oral and maxillofacial symptoms of FAP, and its potential implications for dental treatment.

[Cutaneous myiasis caused by a double infestation with larvae of Dermatobia hominis and Cochliomyia hominivorax]

In a 51-year-old man who had visited Surinam, cutaneous myiasis was diagnosed, caused by simultaneous infestation with the larvae of two different species of flies: Dermatobia hominis and Cochliomyia hominivorax. On his right lower arm the man had two solitary, furuncle-like lesions with a central breathing hole. Two days after these holes had been occluded with vaseline, two white larvae of D. hominis emerged. On both ankles the man had large, undermined ulcers containing hundreds of creeping larvae about 2 cm in length with a salmon-like colour: C. hominivorax. The larvae were removed from the ulcers by hand and by rinsing with physiological saline, after which the wounds healed rapidly. Myiasis is seen in the Netherlands mostly in people returning from a holiday in myiasis-endemic areas.

Sulindac targets nuclear beta-catenin accumulation and Wnt signalling in adenomas of patients with familial adenomatous polyposis and in human colorectal cancer cell lines

Nonsteroidal anti-inflammatory drugs (NSAIDs) have chemopreventive potential against colorectal carcinomas (CRCs). Inhibition of cyclooxygenase (COX)-2 underlies part of this effect, although COX-2-independent mechanisms may also exist. Nonsteroidal anti-inflammatory drugs appear to inhibit the initial stages of the adenoma-carcinoma sequence, suggesting a link to the APC/beta-catenin/TCF pathway (Wnt-signalling pathway). Therefore, the effect of the NSAID sulindac on nuclear (nonphosphorylated) beta-catenin and beta-catenin/TCF-mediated transcription was investigated. Nuclear beta-catenin expression was assessed in pretreatment colorectal adenomas and in adenomas after treatment with sulindac from five patients with familial adenomatous polyposis (FAP). Also, the effect of sulindac sulphide on beta-catenin/TCF-mediated transcription was studied. Adenomas of FAP patients collected after treatment with sulindac for up to 6 months showed less nuclear beta-catenin expression compared to pretreatment adenomas of the same patients. Sulindac sulphide abrogated beta-catenin/TCF-mediated transcription in the CRC cell lines DLD1 and SW480, and decreased the levels of nonphosphorylated beta-catenin. As a result, the protein levels of the positively regulated TCF targets Met and cyclin D1 were downregulated after sulindac treatment. This study provides in vivo and in vitro evidence that nuclear beta-catenin localisation and beta-catenin/TCF-regulated transcription of target genes can be inhibited by sulindac. The inhibition of Wnt-signalling provides an explanation for the COX-2-independent mechanism of chemoprevention by NSAIDs.

Role of neuronal nicotinic receptors in the effects of nicotine and ethanol on contextual fear conditioning

Nicotine can enhance contextual learning while ethanol impairs some forms of learning. Nicotine can overcome some of the impairing effects of ethanol when the two drugs are co-administered. The specific brain nicotinic acetylcholine receptors (nAChRs) that mediate nicotine's effects on contextual learning and whether any of ethanol's actions are mediated by nAChRs are unknown. The potential roles of nAChRs in contextual and cued fear conditioning as well as the effects of nicotine, ethanol, or co-administration of nicotine and ethanol were examined in wild type and homozygous null mutant mice from alpha7, beta2, beta3, and beta4 mouse lines at 24 h after training. Nicotine was given prior to training and testing, whereas ethanol was given only before training. Nicotine enhanced contextual learning in both alpha7 wild types and mutants when mice were trained at 0.17 mA, but not 0.35 mA. Mutants lacking the alpha7 subunit were less sensitive to the memory impairing effects of ethanol trained at 0.35 mA. beta2 Null mutants receiving saline showed a small, but significant, impairment in contextual learning compared with wild type littermates when the shock stimulus was 0.35 mA. Beta2 Null mutant mice also did not respond to the cognitive enhancing effects of nicotine alone, or after ethanol administration. beta3 and beta4 null mutants did not differ from wild types either after saline or any of drug treatments. These results show that beta2-containing nAChRs, but not beta3- or beta4-containing receptors, mediate the enhancing effects of nicotine on contextual learning and confirm previous studies implicating beta2 in other forms of learning. A new role for alpha7 nAChRs in regulating sensitivity to the cognitive disrupting effects of ethanol is proposed.

Molecular analysis of sulindac-resistant adenomas in familial adenomatous polyposis

PURPOSE

Sulindac causes the reduction of adenomas in familial adenomatous polyposis (FAP) patients, but complete regression is unusual, and breakthrough of colorectal carcinoma during sulindac treatment has been described. The molecular features related to sulindac resistance are unknown. Therefore, we investigated molecular alterations in adenomas from FAP patients with complete adenoma regression on sulindac (responsive patients) and from FAP patients with sulindac-resistant adenomas (resistant patients).

DESIGN

Fourteen baseline adenomas (removed before sulindac treatment) from six responsive patients were studied. Also, 9 baseline adenomas and 34 resistant adenomas (removed during sulindac treatment) from three resistant patients were analyzed. Using immunohistochemistry, we evaluated the expression of beta-catenin, cyclooxygenase-2 (Cox-2), p53, Bcl-2, and Bax. K-ras codon 12 mutations, loss of heterozygosity at 5q (APC locus), and microsatellite instability were studied with PCR-based techniques.

RESULTS

There were no significant differences between baseline adenomas from sulindac-responsive and -resistant patients (P > 0.05). There was less loss of membranous beta-catenin staining and less nuclear beta-catenin accumulation in resistant adenomas compared with baseline adenomas from the same (sulindac-resistant) patients (P < 0.01) or baseline adenomas from responsive patients (P < 0.01). Epithelial Cox-2 expression was less, though not significant, in resistant adenomas compared with baseline adenomas from resistant patients, but was significantly less in baseline adenomas from responsive patients (P < 0.01). K-ras mutations were found in 8 of 34 resistant adenomas (24%) and in none of the baseline adenomas (P < 0.05). Stromal Cox-2 expression, staining of p53 and Bcl-2, and loss of heterozygosity at 5q were comparable in both groups. Loss of Bax staining and microsatellite instability were not found in any adenoma.

CONCLUSIONS

Sulindac-resistant adenomas display less alteration in beta-catenin staining and less epithelial Cox-2 expression when compared with adenomas removed before sulindac treatment. K-ras mutations may contribute to sulindac-resistance. Continued research is needed to investigate molecular alterations related to sulindac resistance.

Molecular genetic alterations in hamartomatous polyps and carcinomas of patients with Peutz-Jeghers syndrome

AIM

To investigate whether mutations in the STK11/LKB1 gene and genes implicated in the colorectal adenoma-carcinoma sequence are involved in Peutz-Jeghers syndrome (PJS) related tumorigenesis.

METHODS

Thirty nine polyps and five carcinomas from 17 patients (from 13 families) with PJS were analysed for loss of heterozygosity (LOH) at 19p13.3 (STK11/LKB1 gene locus), 5q21 (APC gene locus), 18q21-22 (Smad4 and Smad2 gene locus), and 17p13 (p53 gene locus), and evaluated for immunohistochemical staining of p53. In addition, mutational analysis of K-ras codon 12, APC, and p53 and immunohistochemistry for Smad4 expression were performed on all carcinomas.

RESULTS

LOH at 19p was seen in 15 of the 39 polyps and in all carcinomas (n = 5). Interestingly, six of the seven polyps from patients with cancer had LOH, compared with nine of the 31 polyps from the remaining patients (p = 0.01). In one polyp from a patient without a germline STK11/LKB1 mutation, no LOH at 19p or at three alternative PJS candidate loci (19q, 6p, and 6q) was found. No LOH at 5q was observed. However, mutational analysis revealed an APC mutation in four of the five carcinomas. LOH at 17p was not seen in polyps or carcinomas; immunohistochemistry showed expression of p53 in one carcinoma and focal expression in three polyps. At subsequent sequence analysis, no p53 mutation was found. One carcinoma had an activating K-ras codon 12 mutation and another carcinoma showed 18q LOH; however, no loss of Smad4 expression was seen.

CONCLUSIONS

These results provide further evidence that STK11/LKB1 acts as a tumour suppressor gene, and may be involved in the early stages of PJS tumorigenesis. Further research is needed to see whether LOH in PJS polyps could be used as a biomarker to predict cancer. Differences in molecular genetic alterations noted between the adenoma-carcinoma sequence and PJS related tumours suggest the presence of a distinct pathway of carcinogenesis.

Microsatellite instability and expression of hMLH-1 and hMSH-2 in sebaceous gland carcinomas as markers for Muir-Torre syndrome

Sebaceous gland carcinomas (SGCs) are rare malignant skin tumors occurring sporadically or as a phenotypic feature of the Muir-Torre syndrome (MTS). A subset of patients with MTS have a variant of the hereditary nonpolyposis colorectal cancer syndrome caused by mutations in mismatch repair (MMR) genes, which lead to microsatellite instability (MSI). We evaluated the value of MSI and loss of expression of the MMR genes, hMLH-1 and hMSH-2, as a marker to identify and distinguish MTS from sporadic SGC. Using a nationwide pathology report database system, we identified patients with the MTS phenotype. SGCs from 10 MTS patients and the colorectal carcinomas from 3 additional MTS patients were collected. In addition, SGCs from eight patients without a history of visceral neoplasm were collected. MSI was detected in 9 of 13 MTS-associated tumors (69%) versus 0 of 8 sporadic SGCs (P = 0.002). Except for the age of onset of colorectal carcinoma [58 years in the MSI-positive group versus 69.8 years in the MSI-negative group (P = 0.17)], no differences were seen between the MSI-negative and the MSI-positive MTS patients. Loss of expression of hMLH-1 (n = 4) or hMSH-2 (n = 4) was found in MSI-positive patients only. MSI and loss of expression of MMR genes can be used as markers for MTS in patients with SGC. Consequently, MSI and loss of MMR gene expression in a patient presenting with SGC as the initial malignancy have important consequences for the patient and family. There are at least two variants of MTS with different molecular genetic mechanisms because 31% of the patients with the MTS phenotype had no MSI.

Rectal epithelial apoptosis in familial adenomatous polyposis patients treated with sulindac

BACKGROUND

Sulindac regresses colorectal adenomas in patients with familial adenomatous polyposis (FAP), although the mechanism of polyp regression is unclear.

AIMS

To determine whether differences occur in alteration of rectal epithelial apoptotic index and expression of apoptosis related proteins in FAP patients treated with sulindac compared with placebo.

PATIENTS

Twenty one FAP patients; 12 had not undergone colectomy.

METHODS

Patients with FAP were treated with sulindac 150 mg orally twice a day for three months (n=10) or placebo (n=11). Colorectal polyp number was determined and biopsies of the normal rectal mucosa were performed before and after three months of treatment. Response to treatment and alteration of the apoptotic ratio (index in base of crypt divided by index in surface epithelium) were evaluated. Bcl-2, bax, p21/WAF-1, and p53 proteins were assessed semiquantitatively by immunohistochemistry.

RESULTS

Significant decreases in polyp number and in the apoptotic ratio were seen in patients treated with sulindac compared with controls. The mean percentage change in polyp number from baseline was -46% in the sulindac group and +13% in the placebo group (p=0.005). Mean percentage change in the apoptotic ratio was -8% and +25% in the sulindac and placebo treated patients, respectively (p=0.004). No differences in expression or compartmentalisation of apoptosis related proteins were noted between treatment groups.

CONCLUSIONS

Sulindac regression of colorectal adenomas is accompanied by alteration of the rectal epithelial apoptotic ratio with relative increase in apoptosis in surface cells compared with the deeper crypt. The utility of the apoptotic ratio as an intermediate biomarker for colorectal tumorigenesis deserves further study.

Prevention of ulcer recurrence after eradication of Helicobacter pylori: a prospective long-term follow-up study

BACKGROUND & AIMS

Short-term follow-up studies show lower relapse rates of duodenal and gastric ulcers after successful Helicobacter pylori eradication. The aim of this study was to determine the long-term outcome of ulcer disease after successful H. pylori eradication.

METHODS

We prospectively studied the long-term effect of H. pylori eradication on ulcer recurrence rates in patients after endoscopically proven healing of duodenal or gastric ulcers between 1984 and 1995. Patients using nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, or maintenance antisecretory therapy were excluded. H. pylori infection was assessed by culture and histopathology of gastric biopsy specimens. After endoscopically proven ulcer healing and successful H. pylori eradication, 186 patients with ulcers underwent elective endoscopy every 3 months during the first year of follow-up and were advised to contact us at symptom recurrence. Thereafter, 96 patients were available for elective half-yearly endoscopies. The 89 patients who did not choose to undergo the repeated endoscopies were asked about symptom recurrence and to undergo elective endoscopy in 1995.

RESULTS

Successful H. pylori eradication was achieved in 141 patients with duodenal ulcers and 45 patients with gastric ulcers. None of the 141 H. pylori-eradicated patients with duodenal ulcers had an ulcer relapse after follow-up of 367 patient-years. Ulcer relapses were also absent in the 45 H. pylori-eradicated patients with gastric ulcers after 113 patient-years of follow-up.

CONCLUSIONS

Excluding patients taking aspirin or NSAIDs, recurrence of duodenal or gastric ulcers is completely prevented after successful H. pylori eradication for up to 9.8 years.

Helicobacter pylori reinfection is virtually absent after successful eradication

This study examined whether reinfection or recrudescence accounts for the reappearance of Helicobacter pylori infection after apparent successful eradication. In a prospective study, 173 patients cured from H. pylori infection underwent follow-up endoscopies, with biopsies for culture and histopathology, every 3 months during the first year after treatment. Subsequently, elective half-yearly endoscopies were performed in 124 patients; the remaining 49 underwent follow-up endoscopy only in 1995. At reappearing infection, DNA profiles of pretreatment and recurrent strains were compared. After 3.5 years (range, 1.0-9.2), H. pylori infection recurred in 9 patients (5.2%). Reappearing infections were classified as endoscopically transmitted reinfection (n = 2), unclassified because of loss of pretreatment isolate (n = 1), or recrudescence (identical DNA patterns before and after treatment; n = 6). The reappearance rate of infection, discarding endoscopic transmission, was 1.2% (7/601 H. pylori-negative patient-years). There was virtually no reinfection with H. pylori after eradication in this adult Western population. These data do not rule out acquisition of H. pylori.

Effect of Helicobacter pylori eradication on gastritis in relation to cagA: a prospective 1-year follow-up study

BACKGROUND & AIMS

Whether Helicobacter pylori eradication resolves intestinal metaplasia and atrophy and whether infection with cagA+ H. pylori is related to a specific clinical outcome are not known. The aim of this study was to investigate the role of H. pylori eradication on the course of intestinal metaplasia (IM) and atrophy in relation to cagA.

METHODS

In a large prospective study, the cagA status of H. pylori isolated from consecutive dyspeptic patients was related to clinical outcome before and 1 year after successful eradication of H. pylori. At pretreatment and 4-6 weeks and on average 1 year after eradication therapy, the degree of gastritis and the status of H. pylori were assessed by culture and histopathology.

RESULTS

Specimens of cagA+ H. pylori were recovered from 122 of 155 (79%) patients infected with H. pylori. Pretreatment degrees of gastritis activity, superficial epithelial damage, IM, and atrophy were significantly greater in patients infected with cagA+ H. pylori (P < 0.001). After successful eradication of H. pylori, a significant improvement of activity of gastritis and superficial epithelial damage occurred (P < 0.001), but the degree of IM and atrophy did not change, irrespective of the cagA status.

CONCLUSIONS

The usefulness of H. pylori eradication to revert precancerous lesions such as IM and atrophy after 1-year follow-up is questionable.

Treatment of Helicobacter pylori infection with low or high dose omeprazole combined with amoxycillin and the effect of early retreatment

BACKGROUND

Cure rates of H. pylori infection, using dual therapy with omeprazole and amoxycillin, vary considerably and the efficacy of retreatment with this regimen in the case of initial failure is controversial. Therefore, we conducted a large prospective double-blind randomized trial, studying the efficacy of low vs. high dose omeprazole in dual therapy and of early retreatment with the same regimens.

METHODS

One hundred and sixty-eight consecutive H. pylori-positive patients, suffering from either peptic ulcer disease or functional dyspepsia, were enrolled. Group I (n = 84) received omeprazole 20 mg b.d. plus amoxycillin 750 mg t.d.s., for 2 weeks. Group II (n = 84) received omeprazole 40 mg t.d.s. plus amoxicillin 750 mg t.d.s., for 2 weeks.

RESULTS

The H. pylori eradication rate was 60.2% in group I and 64.3% in group II (P = 0.59). Cure of H. pylori infection was significantly better in patients with peptic ulcer disease, compared to non-ulcer dyspeptics (P = 0.016). Retreatment, given in 54 patients, was successful in 21.4% patients in group I and in 28% patients in group II (P = 0.58).

CONCLUSIONS

High dose of omeprazole has no advantage compared to low dose in terms of eradication efficacy. Early retreatment with the same regimen offers limited improvement in cure rate. Presence of peptic ulcer disease influences cure rates significantly.

Treatment of Helicobacter pylori infection: a review of the world literature

BACKGROUND

None of the currently used anti-Helicobacter pylori drug regimens cures the infection 100%, and cure results still vary considerably. The present article reviews the effectiveness of currently used antimicrobial regimens, aimed to cure H. pylori infection.

METHODS

Data collection started from the beginning of the anti-H. pylori-therapy era until May 1995. No attempt at formal metanalysis has been made, because many studies have been published only in abstract form. Attempts were made to exclude duplicates of studies by comparison to previously reported ones; the authors of suspected duplicates were contacted. After amalgamation of the number of included patients and the number of successfully treated patients, the mean values of eradication rates and the 95% confidence intervals were calculated.

RESULTS

A total of 237 treatment arms were analyzed. Bismuth triple therapy continues to reach high eradication rates worldwide (78-89%). Side effects leading to diminished patient compliance and the marked decline of eradication efficacy in cases of metronidazole resistance are considered to be the major drawbacks of this therapy. Proton pump inhibitor (PPI) dual therapy is better tolerated with fewer side effects than is bismuth triple therapy. The mean eradication rates vary from 55 to 75%, and the extremes lie between 24 and 93%. PPI triple therapies have been shown to be very effective against H. pylori (eradication rates, 80-89%). Quadruple therapy leads to a mean eradication rate of 96%.

CONCLUSION

Based on efficacy, PPI triple or bismuth triple therapy are recommended as first-line treatment for H. pylori infection. Quadruple therapy could serve as second-line treatment for eradication of initial failures and in case of metronidazole resistance.

Predicting radionuclide bone scan findings in patients with newly diagnosed, untreated prostate cancer: prostate specific antigen is superior to all other clinical parameters

Presently, the standard staging evaluation of prostate cancer includes digital rectal examination, measurement of serum tumor markers and a radionuclide bone scan. To evaluate the ability of local clinical stage, tumor grade, serum acid phosphatase, serum prostatic acid phosphatase (PAP) and serum prostate specific antigen (PSA) to predict bone scan findings, a retrospective review of 521 randomly chosen patients (mean age 70 years, range 44 to 92 years) with newly diagnosed, untreated prostate cancer was performed. Local clinical stage, tumor grade, acid phosphatase, PAP and PSA all correlated positively with bone scan findings (p less than 0.0001). Using receiver operating characteristic curves, however, PSA had the best over-all correlation with bone scan results. The median serum PSA concentration in patients with a positive bone scan was 158.0 ng./ml., whereas men with a negative bone scan had a median serum PSA level of 11.3 ng./ml. (p less than 0.0001). Using multivariate logistic regression analysis, local clinical stage, tumor grade, acid phosphatase and PAP were evaluated in combination with PSA to assess whether these parameters increased the ability of PSA alone to predict bone scan findings. None of these clinical parameters, irrespective of the combination used, contributed appreciably to the predictive power of PSA alone. A probability plot with 95% confidence intervals was constructed that allows the practicing urologist to estimate on an individual basis the probability of a positive bone scan for any given serum PSA value. The most significant finding of this study, however, was the negative predictive value of a low serum PSA concentration for bone scan findings. In 306 men with a serum PSA level of 20 ng./ml. or less only 1 (PSA 18.2 ng./ml.) had a positive bone scan (negative predictive value 99.7%). This finding would suggest that a staging radionuclide bone scan in a previously untreated prostate cancer patient with a low serum PSA concentration may not be necessary.

A rational approach to the mandibular parasymphyseal fracture

Facial scarring is avoided when a transoral degloving approach is used for treatment of parasymphyseal fractures. Complete visualization of the fracture line before and after the reduction is an added advantage of this safe, rapid, and technically easy approach. In patients with both parasymphyseal and condylar fractures, Risdon wires can also be used.

The use of intraoral dexamethasone after extraction of mandibular third molars

All oral surgeions have encountered problems associated with edema, trismus, and pain after intraoral procedures. In third-molar surgery, pain and trismus are often directly proportional to edema. Therefore, in the patient with minimal edema, pain and trismus should be proportionally reduced. Parenteral use of the corticosteroid dexamethasone, given as a transoral injection at the time of operation, appears to be effective in the prevention of postoperative edema.