RESUMEN
BACKGROUND: Epidemiological differences suggest that treatments for H. pylori eradication should be locally validated. AIM: To perform a cost benefit study of different treatment options for H. pylori infection. PATIENTS AND METHODS: One hundred and sixty-seven patients with active duodenal ulcer and H. pylori infection who completed a 2-week treatment with one of the following regimens were included: famotidine plus amoxycillin plus metronidazole (FAM), omeprazole plus amoxycillin plus tinidazole (OAT) or lansoprazole plus clarithromycin plus amoxycillin in 3 (LAC1) or 2 (LAC2) daily doses. We compared efficacy, adverse effects and cost. RESULTS: Eradication rate was 74.6, 72.9, 96.4 y 91.7% for FAM, OAT, LAC1 and LAC2 respectively (p < 0.05). Direct cost ranged from US$ 50 for FAM to US$ 220 for LAC1. A decision analysis was carried out in a model including direct and indirect costs and considering retreatment with antibiotics after the first treatment failure and one-year treatment with H2-blockers in case of a second failure. FAM was selected as the most cost-effective option, with an estimated cost of about US$ 300 +/- 148 per patient. However, cost associated to LAC2 was very similar (US$ 320 +/- 58) and the lower standard deviation suggests less variation. Sensitivity analyses, considering reasonable fluctuation in parameters such as eradication rate, cost and follow-up period suggest that a regimen containing a proton pump inhibitor, clarithromycin and amoxycillin may be the most cost-effective treatment. CONCLUSIONS: These results should be confirmed in other settings, specially in ordinary clinical practice, far from clinical research.
Asunto(s)
Antibacterianos/uso terapéutico , Antiulcerosos/uso terapéutico , Úlcera Duodenal/tratamiento farmacológico , Infecciones por Helicobacter/tratamiento farmacológico , Helicobacter pylori/efectos de los fármacos , Adulto , Análisis Costo-Beneficio , Quimioterapia Combinada , Úlcera Duodenal/microbiología , Femenino , Humanos , Masculino , Bombas de Protones/uso terapéutico , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of this study was to evaluate the effect of Helicobacter pylori (H. pylori) eradication on the natural history of duodenal ulcer disease and the reinfection rate after treatment in a developing country. METHODS: A total of 111 H. pylori-infected patients with duodenal ulcer were treated with either omeprazole or famotidine plus two antibiotics for 2 wk. Those failed to respond to treatment were retreated with bismuth-based triple therapy. RESULTS: The radication rate was 76% (95% CI: 67-83%). Eventually, H. pylori was eradicated in 96 of the 111 patients (86%), who were followed-up clinically and endoscopically for a mean of 37.2 months. The cumulative reinfection rate after eradication (Kaplan-Meier) was 8%+/-3% in yr 1, 11%+/-4% in yr 2, and 13%+/-4% in yr 3. Nine of the 12 reinfections occurred during yr 1. Recurrence of duodenal ulcer was detected in five patients (5.2%), all of them during yr 1 of follow-up. Histologically, gastritis scores (according to the Sydney system) improved significantly after eradication. CONCLUSIONS: In a high prevalence setting, H. pylori eradication and early reinfection rates after treatment are similar to rates observed in a low prevalence environment, whereas the late reinfection rate seems to be higher. However, up to 3 yr after treatment, most treated patients are free of H. pylori infection and/or ulcer activity. Even longer follow-up studies are necessary to determine whether specific retreatment policies are necessary to maintain long term eradication in developing countries.
Asunto(s)
Países en Desarrollo , Úlcera Duodenal/microbiología , Infecciones por Helicobacter/tratamiento farmacológico , Helicobacter pylori , Adolescente , Adulto , Anciano , Amoxicilina/administración & dosificación , Antiulcerosos/uso terapéutico , Chile , Quimioterapia Combinada/administración & dosificación , Úlcera Duodenal/diagnóstico , Úlcera Duodenal/tratamiento farmacológico , Famotidina/uso terapéutico , Femenino , Estudios de Seguimiento , Gastritis/diagnóstico , Gastritis/microbiología , Infecciones por Helicobacter/complicaciones , Infecciones por Helicobacter/diagnóstico , Humanos , Masculino , Metronidazol/administración & dosificación , Persona de Mediana Edad , Omeprazol/uso terapéutico , Recurrencia , Tinidazol/administración & dosificaciónRESUMEN
We have previously cloned 10 Helicobacter pylori antigen genes from a Chilean strain including: cytotoxin VacA, a truncated region of CagA (called A17), a species-specific protein (Ag26), urease subunits (UreA, UreB), a flagellin, (FlaB), heat shock proteins (HspA and HspB), an adhesin (HpaA) and a lipoprotein (Lpp20). Immunogenicity of these antigens was tested by immunoblot with sera of Chilean infected patients, revealing that HpaA, A17, HspB and VacA were more frequently recognized (86%, 82%, 68% and 68%, respectively). According to the clinical condition, it was determined that Lpp20 was preferentially recognized by sera from non-ulcer dyspepsia patients (80%), A17 and VacA by patients with duodenal ulcer (92% and 83% respectively), and HspB by patients with duodenal ulcer (83%) and gastric cancer (90%). An ELISA was developed with a purified mixture of A17 and VacA antigens to test the different groups of patients. It was found that sera from duodenal ulcer patients showed higher values than those from non-ulcer dyspepsia patients, but this difference was not significant (p<0.2). Moreover, sera from gastric cancer patients showed values lower than those from non-ulcer dyspepsia patients (p<0.019). These results indicate that, in the Chilean population, antibodies raised against VacA and A 7 are not markers either for duodenal ulcer or for gastric cancer.
Asunto(s)
Anticuerpos Antibacterianos/sangre , Antígenos Bacterianos , Úlcera Duodenal/inmunología , Dispepsia/inmunología , Helicobacter pylori/inmunología , Neoplasias Gástricas/inmunología , Adulto , Antígenos Bacterianos/genética , Proteínas Bacterianas/genética , Proteínas Bacterianas/inmunología , Biomarcadores , Estudios de Casos y Controles , Chile , Úlcera Duodenal/complicaciones , Dispepsia/complicaciones , Ensayo de Inmunoadsorción Enzimática , Escherichia coli/genética , Genes Bacterianos , Proteínas de Choque Térmico/genética , Proteínas de Choque Térmico/inmunología , Infecciones por Helicobacter/complicaciones , Infecciones por Helicobacter/inmunología , Helicobacter pylori/genética , Humanos , Proteínas Recombinantes/genética , Proteínas Recombinantes/inmunología , Neoplasias Gástricas/complicacionesRESUMEN
BACKGROUND: 99mTc red blood cell scintigraphy is a non invasive diagnostic method for low flow gastrointestinal bleeding. AIM: To assess the diagnostic yield of this method in patients admitted with gastrointestinal bleeding in whom upper gastrointestinal endoscopy was negative. PATIENTS AND METHODS: The clinical records of 59 patients, aged 6 to 90 years old (35 male), with active gastrointestinal bleeding subjected to a 99mTc red blood cell scintigraphy were reviewed. All had non diagnostic upper gastrointestinal endoscopic studies, and in 20 a selective arteriography was performed. RESULTS: In 40 patients the scintigraphy was positive for gastrointestinal bleeding, and in 57% of these the exam was positive during the first hour. Fifteen of the 19 patients with a negative scintigraphy did not have an active clinical bleeding at the moment of the examination. In 24 patients, a final etiological diagnosis was reached. In 93% of these patients scintigraphy correctly identified the bleeding site. In one patient with a negative scintigraphy, angiography disclosed a pseudo aneurysm of the splenic artery that was not bleeding actively. CONCLUSIONS: In these patients with negative upper gastrointestinal endoscopy 99mTc red blood cell scintigraphy had a 91% sensitivity for the diagnosis of active gastrointestinal bleeding.
Asunto(s)
Enfermedades del Colon/diagnóstico por imagen , Hemorragia Gastrointestinal/diagnóstico por imagen , Radiofármacos , Pertecnetato de Sodio Tc 99m , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Eritrocitos/diagnóstico por imagen , Femenino , Humanos , Intestino Delgado/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Cintigrafía , Estudios RetrospectivosRESUMEN
BACKGROUND: Patients with acute pancreatitis (AP) and a normal gallbladder by standard echographic evaluation may have "occult" gallbladder disease or microlithiasis with recurrent episodes of AP. AIM: To conduct a prospective evaluation of patients with the diagnosis of non-biliary AP in order to detect "occult" gallbladder disease and to compare its clinical presentation with that of biliary AP. PATIENTS AND METHODS: Patients admitted with the diagnosis of AP to a clinical hospital were included in the study. According to an abdominal ultrasound study, patients were classified as having or not cholelithiasis. A duodenal biliary drainage was performed in 15 patients with AP and without gallbladder stones. RESULTS: Patients without cholelithiasis had recurrent AP more often than patients with biliary AP (53 and 3.3% respectively). Excessive alcohol ingestion did not rule out the possibility of biliary etiology. In 6 patients, the analysis of duodenal bile showed cholesterol crystals, and cholecystectomy confirmed the existence of gallbladder disease in 5. All of them remained asymptomatic during a follow-up period of four years. One patient refused surgery, with subsequent development of gallstones and recurrent episodes of AP. In other 4 patients, gallbladder disease was confirmed by percutaneous gallbladder puncture or during cholecystectomy. No recurrence of AP were observed during the follow-up CONCLUSIONS: Microlithiasis or "occult" gallbladder disease accounts for at least 67% of the original "non-biliary" AP. Duodenal bile analysis is a useful and necessary technique for the evaluation of patients with "non-biliary" acute pancreatitis. Careful clinical and echographic follow-up of this subgroup of patients with AP is mandatory.
Asunto(s)
Colelitiasis/complicaciones , Pancreatitis/complicaciones , Enfermedad Aguda , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis/sangre , Estudios Prospectivos , Factores de Riesgo , Cálculos de la Vejiga Urinaria/complicacionesRESUMEN
BACKGROUND: Intrasphincteric injection of botulinum toxin (BoTx) has demonstrated to be effective in the short-term treatment of achalasia. AIM: To assess the efficacy, safety and long-term outcome of BoTx injection into the lower esophageal sphincter (LES) of patients with achalasia. PATIENTS AND METHODS: Eight patients received 80 units of BoTx. Assessment of response was based on changes in the symptom scores (0-9) and esophageal manometric studies. RESULTS: Six out of 8 patients (75%) had sustained clinical improvement after therapy. This effect was maintained for a mean time of 17.8 months. The symptom score decreased from a mean of 6.7 to 0.5 (p < 0.01) and after treatment, LES pressure decreased from 63 to 25.5 mm Hg (p = 0.07). There were no serious adverse effects. Five of the six responders have relapsed. Two of these patients received a second BoTx injection with satisfactory results, two went to surgery and one refused other type of therapy and died of pneumonia. CONCLUSIONS: Intrasphincteric BoTx injection is a simple, safe and effective method of treatment in patients with achalasia, with a duration of response averaging 1.5 years. Its use may be suggested in some patients with high surgical risk and those who refuse a more invasive therapy. It is also useful in malnourished patients to attain an adequate nutritional status before surgery.
Asunto(s)
Antidiscinéticos/administración & dosificación , Toxinas Botulínicas/administración & dosificación , Acalasia del Esófago/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Unión Esofagogástrica , Femenino , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
A NIH Consensus Conference recommended Helicobacter pylori eradication to all ulcer patients, based mainly on information coming from countries with a low prevalence of infection in general population. The epidemiological situation is different in developing countries, where a pandemic of H. pylori goes unchecked, and most people become infected at young age. It is possible that response to eradication therapies and reinfection rate were to be included among the differences between developed and developing countries, raising doubts about the worldwide applicability of NIH recommendations. Limited published evidence and our experience suggest that eradication therapies have a lower efficacy and reinfection rate is significantly higher in developing compared to developed countries. In spite of this, the risk of ulcer recurrence after H. pylori eradication is substantially reduced compared to antisecretory therapy. Model analysis to evaluate the cost-effectiveness of H. pylori eradication, using figures that probably include the clinical and costs situation of developing countries, suggests that also from an economic perspective H. pylori eradication should be the standard treatment for peptic ulcer disease in developing countries. Local studies must determine the best eradication therapy for a particular geographical location, and longer follow-up of eradicated patients is needed to determine the true reinfection rate.
Asunto(s)
Antibacterianos/uso terapéutico , Infecciones por Helicobacter/tratamiento farmacológico , Helicobacter pylori , Úlcera Péptica/tratamiento farmacológico , Análisis Costo-Beneficio , Países Desarrollados , Países en Desarrollo , Úlcera Duodenal/tratamiento farmacológico , Úlcera Duodenal/economía , Infecciones por Helicobacter/economía , Infecciones por Helicobacter/epidemiología , Humanos , Úlcera Péptica/economía , RecurrenciaRESUMEN
We have shown that patients with previous acute pancreatitis (AP) may have an abnormal catabolism of chylomicron remnants (CMR). Because apoprotein E (Apo E) genetic polymorphism has an important influence on CMR clearance, we compared frequency distribution of Apo E phenotypes in 52 patients with AP, 109 patients with gallstones, and 110 control subjects. Apo E phenotypes were detected by isoelectric focusing and immunoblotting. After adjusting for differences in age and gender, fasting triglyceride level was comparable between the study groups. The frequency distribution of Apo E phenotypes was not different between the three study groups and it was in Hardy-Weinberg equilibrium. The gene frequency for Apo E2 was 0.212, 0.273, and 0.243 in AP, gallstone, and control group, respectively. For Apo E3 it was 0.701, 0.627, and 0.674, and for Apo E4 0.090, 0.100, and 0.083 in the same groups, respectively. Differences were not statistically significant (chi 2). In conclusion, the abnormal catabolism of CMR in patients with AP is not attributable to Apo E polymorphism. An alternative explanation may be sought in the activity of the recently identified hepatocytic Apo E receptor [LDL-related receptor protein (LRP)].
Asunto(s)
Apolipoproteínas E/genética , Pancreatitis/genética , Polimorfismo Genético , Enfermedad Aguda , Adulto , Alelos , HDL-Colesterol/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis/sangre , alfa-Macroglobulinas/metabolismoRESUMEN
Vegetation plays a primal role in arid ecosystems, since it creates microclimate conditions that moderate the characteristics of the region whereby the rational use of vegetal resources is fundamental. Felling, clearing and overgrazing lead to decrease in organic contribution and stimulate soil compaction, causing an alteration of microbial activity, with losses in nutrient turnover. The global biological activity is a soil parameter easy to obtain and indicates the presence and diversity of soil life as well as substrate availability and is useful in order to characterize soil potential fertility. This work was carried out in Natural Forest Reserve Chancaní, Province of Córdoba (Argentina), which is representative of Argentine Dry Chaco. Dominant tree species are: Prosopis flexuosa and Aspidosperma quebracho blanco. The global biological activity (GBA) was measured along one year, under trees, under shrubs and in interspaces. Soil samples were taken monthly from plots with four management systems: 1) forest, ii) selective clearing (only dominant species remain), iii) bush (clearing invaded by Larrea sp) and iv) grazing (cleared area, neither trees nor shrubs). GBA was evaluated using the CO2 release method, after ten days of incubation. It is concluded that in the plots with grasses and under the trees GBA was higher than with other treatments. The lesser GBA was detected in bushes and interspaces. All differences were more prominent during extreme temperature months. No significant difference between both species of dominant trees was observed.
Asunto(s)
Plantas , Suelo/análisis , Crianza de Animales Domésticos , Argentina , Ecología , Agricultura Forestal , Estaciones del Año , ÁrbolesRESUMEN
Vegetation plays a primal role in arid ecosystems, since it creates microclimate conditions that moderate the characteristics of the region whereby the rational use of vegetal resources is fundamental. Felling, clearing and overgrazing lead to decrease in organic contribution and stimulate soil compaction, causing an alteration of microbial activity, with losses in nutrient turnover. The global biological activity is a soil parameter easy to obtain and indicates the presence and diversity of soil life as well as substrate availability and is useful in order to characterize soil potential fertility. This work was carried out in Natural Forest Reserve Chancaní, Province of Córdoba (Argentina), which is representative of Argentine Dry Chaco. Dominant tree species are: Prosopis flexuosa and Aspidosperma quebracho blanco. The global biological activity (GBA) was measured along one year, under trees, under shrubs and in interspaces. Soil samples were taken monthly from plots with four management systems: 1) forest, ii) selective clearing (only dominant species remain), iii) bush (clearing invaded by Larrea sp) and iv) grazing (cleared area, neither trees nor shrubs). GBA was evaluated using the CO2 release method, after ten days of incubation. It is concluded that in the plots with grasses and under the trees GBA was higher than with other treatments. The lesser GBA was detected in bushes and interspaces. All differences were more prominent during extreme temperature months. No significant difference between both species of dominant trees was observed.
RESUMEN
Vegetation plays a primal role in arid ecosystems, since it creates microclimate conditions that moderate the characteristics of the region whereby the rational use of vegetal resources is fundamental. Felling, clearing and overgrazing lead to decrease in organic contribution and stimulate soil compaction, causing an alteration of microbial activity, with losses in nutrient turnover. The global biological activity is a soil parameter easy to obtain and indicates the presence and diversity of soil life as well as substrate availability and is useful in order to characterize soil potential fertility. This work was carried out in Natural Forest Reserve Chancaní, Province of Córdoba (Argentina), which is representative of Argentine Dry Chaco. Dominant tree species are: Prosopis flexuosa and Aspidosperma quebracho blanco. The global biological activity (GBA) was measured along one year, under trees, under shrubs and in interspaces. Soil samples were taken monthly from plots with four management systems: 1) forest, ii) selective clearing (only dominant species remain), iii) bush (clearing invaded by Larrea sp) and iv) grazing (cleared area, neither trees nor shrubs). GBA was evaluated using the CO2 release method, after ten days of incubation. It is concluded that in the plots with grasses and under the trees GBA was higher than with other treatments. The lesser GBA was detected in bushes and interspaces. All differences were more prominent during extreme temperature months. No significant difference between both species of dominant trees was observed.
RESUMEN
A recent study reports that patients with previous acute pancreatitis commonly have an abnormal clearance of serum triglycerides after an oral fat load. This observation supports the hypothesis that patients with previous acute pancreatitis and normal fasting serum triglyceride levels may have a preexistent abnormality in the metabolism of chylomicrons. To test this hypothesis, the catabolism of chylomicrons and their remnants was studied in a series of 7 patients who had sustained an attack of pancreatitis (2, gallstone related; 2, alcohol ingestion; 1, hydatid cyst; and 3, no associated pathological condition) at least 18 mo earlier. All the patients had previously had abnormal oral-fat tolerance test results. These patients were compared with a series of 6 healthy volunteers. Chylomicrons were endogenously labeled with an oral dose of retinyl palmitate, and their plasma elimination half-life was calculated. The retinyl palmitate absorption rate constants were similar in control and pancreatitis patients. The chylomicron t1/2 were 2.3 +/- 0.8 (SD) h and 3.9 +/- 1.8 h in the control and pancreatitis groups, respectively (p = 0.07). The chylomicron remnant t1/2 was 2.7 +/- 1.1 h in the control group and 5.2 +/- 2.4 h in the pancreatitis group (p less than 0.05). This study supports the hypothesis that subjects with previous acute pancreatitis may have an abnormality in the catabolism of chylomicron particles. This abnormality may represent a preexistent genetic condition expressed in either the apoprotein composition of chylomicrons or in the hepatic apolipoprotein E-receptor activity.
Asunto(s)
Quilomicrones/sangre , Pancreatitis/sangre , Enfermedad Aguda , Adulto , Colesterol/sangre , Cromatografía Líquida de Alta Presión , Quilomicrones/metabolismo , Diterpenos , Humanos , Lipoproteínas VLDL/sangre , Masculino , Tasa de Depuración Metabólica , Persona de Mediana Edad , Pancreatitis/metabolismo , Ésteres de Retinilo , Factores de Tiempo , Triglicéridos/sangre , Vitamina A/administración & dosificación , Vitamina A/análogos & derivados , Vitamina A/sangreRESUMEN
The etiology and pathogenesis of acute pancreatitis are unknown in the majority of patients. However, it is well known that there are several relevant clinical conditions associated to acute pancreatitis such as, gallstone disease, alcoholism and hypertriglyceridemia. The possible pathogenic relationships between acute pancreatitis and hypertriglyceridemia are discussed in this article. It has recently been shown that a significant proportion of patients with a history of acute pancreatitis have an abnormal clearance of exogenous triglycerides, indicating the presence of a preexistent metabolic abnormality in this population. This observation supports the hypothesis of a possible genetic heterogeneity related to either an abnormal apoprotein profile of chylomicrons, or hepatic receptor mechanism of chylomicron remnants uptake in the liver. If this hypothesis proves to be correct, then a genetic marker may be available to identify the subjects at high risk for acute pancreatitis.