Non-invasive diagnostic tests for Helicobacter pylori infection

BACKGROUND: Helicobacter pylori (H pylori) infection has been implicated in a number of malignancies and non-malignant conditions including peptic ulcers, non-ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin-Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non-invasive tests for diagnosis of H pylori. OBJECTIVES: To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. SEARCH METHODS: We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA: We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as13C or14C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We performed meta-analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. MAIN RESULTS: We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study.Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty-four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test-13C; 21 studies (1810 participants) evaluated urea breath test-14C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test.Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test-13C, urea breath test-14C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test-13C, urea breath test-14C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test-13C, 0.92 (95% CI 0.89 to 0.94) for urea breath test-14C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori infection). In this hypothetical cohort, urea breath test-13C, urea breath test-14C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed).Direct comparisons were based on few head-to-head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test-13C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test-13C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta-analysis of other direct comparisons. AUTHORS' CONCLUSIONS: In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice.We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions

Strategian vaihdos liiketoiminnan elvyttämisen keinona : Nordic Morning Oyj

Digitaalisen teknologian kehitys on vaikuttanut perinteiseen kirjapainoalaan. Vuoden 2008 taantuma pakotti yritykset hakemaan säästöjä ja painokustannukset olivat yksi näistä säästökohteista, minkä takia painotuotteiden kysyntä on laskenut huomattavasti. Työssä pyrittiin tutkimaan graafisen alan murrosta viestintäkonsernia Nordic Morning Oyj käyttäen esimerkkinä. Opinnäytetyö tavoitteena oli selvittää, miten graafisen alan taloustilanteen haasteet ovat vaikuttaneet konserniin, minkälaisia keinoja konsernijohto on löytänyt selviytyäkseen tilanteesta ja miten taloudelliset indikaattorit reagoivat muutoksiin. Vuonna 2008 konserni on vaihtanut strategiansa. Strategia on liiketoiminnan edellytys, koska toisaalta se antaa suuntaa organisaation pitkäaikaiselle menestykselle ja toisaalta se toimii päivittäisen johtamisen työkaluna. Nordic Morning Oyj:n uusi strategia käsittää aseman vahvistamista viestintäalalla, palvelujen monipuolisuuden kehittämistä sekä digitaalisen viestinnän etusijalle asettamista. Tutkimus on etupäässä tilinpäätösanalyysimuotoinen. Tilinpäätös on varsinainen ja pääasiallinen tietojen lähde yrityksen taloudellisesta tilasta ja tuloksesta. Tilinpäätösanalyysin prosessi aloitettiin perustietojen muokkauksella eli oikaisulla. Oikaistu tilinpäätös tutkittiin erilaisilla teknikoilla, kuten prosenttilukumuotoisella tilinpäätösanalyysillä, trendianalyysillä ja tunnuslukuanalyysillä. Tunnuslukujen avulla arvioitiin yrityksen kannattavuutta, vakavaraisuutta ja maksuvalmiutta. Tutkimusanalyysin tuloksista ilmeni, että konsernin liiketoiminta muuntautuu asteittain pääomavaltaisesta ei-pääomavaltaiseen liiketoimintaan. Nordic Morning Oyj:n liiketoiminta ei ollut kovinkaan kannattavaa koko tarkastelujaksona. Mutta konsernin rahan riittävyys (maksuvalmius) oli kohtuullisen hyvällä tasolla. Vakavaraisuuden tunnuslukujen arvot ovat parantuneet vuoden 2013 hyvään tasoon asti. Tutkimustuloksien perusteella todettiin, että strategian vaihdos on tehokas liiketoiminnan uudistamisen keino, jota Nordic Morning Oyj:n johto on hyödyntänyt perusteellisesti. Näin ollen voidaan ennustaa konsernin taloudellisen aseman vahvistumista myös jatkossa.Nordic Morning Plc is one of the leading communication service providers in the Nordic countries. The rapid developments in digital communications technology have had a significant impact on Nordic Morning business in recent years. Digital technologies have started to replace traditional printing technologies, which used to be the Group’s core business. Besides the 2008 recession forced companies to look for means to cut expenses, and the expenses for printing matters were one of these sources of savings. All these caused a considerable drop in the demand for printed products. The purpose of the study was to determine how the graphic industry challenges have affected the Nordic Morning economic situation, and analyze the reaction of the Group’s key economic indicators to the changes. The study was executed as a qualitative research. It was implemented by the methods of percentage financial statements, analysis of trends and ratio analysis. The data for the research were collected from the Group’s financial statements from 2008 to 2013. Also different statistical information was exploited for the industry analysis and the comparison of indicators. The analysis of the financial statements revealed that the proportion of current and non-current assets changed and the capital structure transformed accordingly. Nordic Morning trended to become a less capital-intensive company, which was incorporated into the new strategy of the company. The Group proved rather unprofitable during the reference period, but the liquidity was close to good. The solvency remained at a satisfactory level. The Group made investments in new enterprises and equipment, of which profit was expected later on. The results of this research indicate that a change of strategy is a powerful method of business renewal, and the management of Nordic Morning Plc has taken advantage of it. Thus, it is highly probable that the financial position of the Group will continue to strengthen

ANTIBIOTIC RESISTANCE OF HELICOBACTER PYLORI AMONG CHILDREN AND THERAPY SELECTION

The reason for the low therapy efficiency of many gastrobduodenal diseases is the increasing resistance to the antibiotics helicobacter pylori (Н. pylori), which is conditioned by the mutations of its various genes. The most practical importance is attributed to the 23s RRNA mutations, underlying resistance to claritromicin. According to the international consensus maastrichtb3, the scheme of treatment with the inhibitor of the proton pump, claritromicin and metronidasol is recommended as the 1st line therapy. The present work assesses the resistance of Н. pylori to claritromicin aided by pcrbdiagnostics of the 23s RRNA mutation of rna in the biopsy material of the mucous coat of stomach and standard treatment scheme efficiency if compared with the onebantibiotic scheme – amoxicillin, bismuth and inhibitor of the proton pump. 68 children with Н. pylori bassociated diseases have been examined. The frequency of resistance of Н. pylori to claritromicin made up 28%. The standard 10bday long scheme of treatment was efficient among 14% of the patients, the 7bday long schemes with amoxicillin, bismuth and omeprazole were efficient among 40% of the patients, the 10bday long schemes with amoxicillin, bismuth and omeprazole were efficient among 75% of the patients; with omeprazole replaced by esomeprazole the efficiency was observed among 83% of the patients along with the good treatment tolerance.Key words: helicobacter pylori, antibiotic resistance, eradication