The impact of illness in patients with moderate to severe gastro-esophageal reflux disease

BACKGROUND: Gastro-esophageal reflux disease (GERD) is a common disease. It impairs health related quality of life (HRQL). However, the impact on utility scores and work productivity in patients with moderate to severe GERD is not well known. METHODS: We analyzed data from 217 patients with moderate to severe GERD (mean age 50, SD 13.7) across 17 Canadian centers. Patients completed three utility instruments – the standard gamble (SG), the feeling thermometer (FT), and the Health Utilities Index 3 (HUI 3) – and several HRQL instruments, including Quality of Life in Reflux and Dyspepsia (QOLRAD) and the Medical Outcomes Short Form-36 (SF-36). All patients received a proton pump inhibitor, esomeprazole 40 mg daily, for four to six weeks. RESULTS: The mean scores on a scale from 0 (dead) to 1 (full health) obtained for the FT, SG, and HUI 3 were 0.67 (95% CI, 0.64 to 0.70), 0.76 (95% CI, 0.75 to 0.80), and 0.80 (95% CI, 0.77 to 0.82) respectively. The mean scores on the SF-36 were lower than the previously reported Canadian and US general population mean scores and work productivity was impaired. CONCLUSION: GERD has significant impact on utility scores, HRQL, and work productivity in patients with moderate to severe disease. Furthermore, the FT and HUI 3 provide more valid measurements of HRQL in GERD than the SG. After treatment with esomeprazole, patients showed improved HRQL

Helicobacter pylori Eradication in Non-Ulcer Dyspepsia: Clearing up the Controversy

Veldhuyzen van Zanten et al conducted a double-blind, randomized, multicentre study comparing triple therapy for Helicobacter pylori eradication to placebo for the treatment of nonulcer dyspepsia (NUD) symptoms in adult patients (1). Patients had moderate to severe epigastric pain on entry (rated at least a three on a five-point scale for at least three of the previous 14 days). The main outcome measure was the Mean Dyspepsia Summary Score (MDSS), which represents the mean severity of eight dyspepsia symptoms (epigastric pain, belching, heartburn, upper abdominal bloating, flatulence, sour taste, nausea and halitosis). Of the 1143 patients who were screened for this study in 27 centres across Canada, 157 were randomized. H pylori was eradicated in 82% of the active group compared with 6% in the placebo group. Symptoms improved in both groups over the 12-month study period, but there was no difference between the two groups in MDSS (2.34 in active and 2.30 in placebo groups at baseline, compared with 1.68 and 1.67, respectively, at the last visit). Nor were there differences in any of the individual symptoms, in the proportion of patients who achieved a certain MDSS score or in health care utilization, such as physician visits, need for additional prescriptions or days lost from work. The authors concluded that, compared with placebo, therapy for H pylori produced no sustained improvement of NUD symptoms

Epidemiology of the Antibiotic Resistance of Helicobacter pylori in Canada

BACKGROUND: The rate of Helicobacter pylori resistance to antibiotics determines the cure rate of treatment regimens containing such antibiotics. AIMS: To review the literature to determine the rates of H pylori resistance to metronidazole and clarithromycin in Canada, and whether these rates vary in different regions of Canada

Determinants of Ethnic or Geographical Differences in Infectivity and Transmissibility of Helicobacter pylori

The prevalence of Helicobacter pylori infection is variable in different countries. There are two distinct patterns of H pylori prevalence with respect to age depending on the geographical region studied. The first pattern is widespread infection early in childhood with elevated prevalence rates of close to 80% throughout adulthood, and the second is increasing prevalence with age. This variability in pattern suggests a difference in infectivity or transmissibility of H pylori infection. Potential determinants of these differences are reviewed including environmental, bacterial and host factors. The most important determinant is likely socioeconomic class, which affects living conditions and sanitation, thus altering exposure to the bacterium. Host factors also play a role, perhaps via host receptors for H pylori. Bacterial factors may also contribute, although compelling evidence is lacking

Effectiveness of Second through Sixth Line Salvage Helicobacter pylori Treatment: Bismuth Quadruple Therapy is Almost Always a Reasonable Choice

Aim. There is a paucity of data on the efficacy of empiric H. pylori treatment after multiple treatment failures. The aim of this study is to examine the efficacy of empiric salvage therapy as a second through sixth line treatment. Methods. In this single gastroenterology center prospective study in Montreal, Canada, patients with failed H. pylori treatment were offered empiric salvage therapy based on the patients’ previous antibiotic exposure. Enrollment occurred after 1–5 previous failed attempts and eradication determined at least 4 weeks after completion of treatment. Results. 205 treatments were attempted in 175 patients using 7 different regimens. Eradication was achieved in 154 attempts (PP = 81% (154/191), ITT = 75% (154/205)). Bismuth quadruple therapy (BQT) had higher eradication success (PP = 91% (102/112), ITT = 84% (102/121)) when compared to all PPI triple therapies combined (PP = 66% (49/74), absolute risk reduction (ARR): 25% (95% CI: 13–37), ITT = 62% (49/79), ARR: 22% (95% CI: 10–35), and p<0.001) and when compared to levofloxacin triple therapy (PP = 66% (40/61), ARR: 26% (95% CI: 13–39), ITT = 61% (40/66), and ARR: 24% (95% CI: 10–37)). Eradication was achieved in a high proportion with BQT on attempt two (PP = 94% (67/71), ITT = 91% (67/74)), three (PP = 85% (17/20), ITT = 71% (17/24)), four (PP = 100% (11/11), ITT = 92% (11/12)), and five (PP = 86% (6/7), ITT = 75% (6/8)). Patients with previous combined bismuth and tetracycline exposure had a lower proportion of eradication compared to patients without such an exposure (PP: 60% (6/10) versus 95% (94/99), ARR: 35% (95% CI: 11–64), and p<0.001; ITT: 55% (6/11) versus 90% (94/105), ARR: 35% (95% CI: 10–62), and p<0.01). Conclusions. Salvage therapy with a bismuth quadruple regimen is superior to triple therapies and is effective for second through fifth line empirical treatment (≥85% PP, ≥70% ITT). Successful eradication is significantly lower with BQT if a similar bismuth based regimen was used in the past

A 14-Day Course of Triple Therapy is Superior to a 10-Day Course for the Eradication of Helicobacter pylori: A Canadian Study Conducted in a ‘Real World’ Setting

BACKGROUND: Successful Helicobacter pylori eradication with the traditional seven-day course of proton pump inhibitor (PPI) triple therapy is declining. Prolonging therapy to either 10 or 14 days is associated with better eradications rates

Utility of Serology in Determining Helicobacter pylori Eradication after Therapy

OBJECTIVE: To determine the usefulness of four serological tests in confirming cure of H pylori infection before the previously reported six-month post-treatment delay

A Sampling of Canadian Practice in Managing Nonvariceal Upper Gastrointestinal Bleeding before Recent Guideline Publication: Is there Room for Improvement?

BACKGROUND: There are few recent published consensus guidelines regarding nonvariceal upper gastrointestinal bleeding. In 2003, the Canadian Association of Gastroenterology sponsored a set of 20 recommendations. AIM: To compare current Canadian clinical practice patterns with these most recent guidelines

Does blood urea nitrogen level predict severity and high-risk endoscopic lesions in patients with nonvariceal upper gastrointestinal bleeding?

BACKGROUND: Nonvariceal upper gastrointestinal bleeding (UGIB) is a serious medical condition requiring prompt resuscitation and early endoscopic therapy in those with high-risk endoscopic lesions (HRLs). There are little or no data correlating sole blood urea nitrogen (BUN) level with the severity of nonvariceal UGIB or the presence of HRLs in the adult population