Helicobacter pylori: when is treatment now indicated?

Abstract
The prevalence of Helicobacter pylori in Western societies has rapidly declined, as reflected by the consistent decline in peptic ulcer disease. Nevertheless, there remains a cohort of the elderly population with a high prevalence of H. pylori infection. While the benefits of H. pylori eradication for H. pylori -associated duodenal ulcer disease is beyond dispute, a number of contentious areas remains. The aim of the present paper is to review the benefits of H. pylori eradication in clinical situations that may confront the non-gastroenterologist. (Intern Med J 2002; 32: 465−469)     

How to manage musculoskeletal conditions: when is 'rehabilitation' appropriate?

Multidisciplinary rehabilitation has established efficacy in few musculoskeletal conditions. It is likely to be effective in the context of chronic back pain and possibly other types of chronic pain, and in frail older people with hip fractures. The principles of multidisciplinary rehabilitation, which include time-limited and goal-directed interventions, can be used in other musculoskeletal interventions but there have not yet been sufficient randomized trials to determine its effectiveness. Multidisciplinary rehabilitation is relatively costly and therefore is not likely to be cost effective unless it achieves return to work in people in the working-age group, or averts the need for residential care in frail older people.     

Clopidogrel in acute coronary syndrome: when, how much, how long?

Summary An important part of the therapy management of acute coronary syndrome (ACS) consists of antiplatelet drugs. Whereas the administration of acetylsalicylic acid (ASA) is well established, the guidelines recommend the additive use of clopidogrel in patients with ACS without persisting ST-elevation. Clopidogrel should be added to ASA as soon as possible in patients with a non-invasive treatment strategy and continued for more than 1 month (class 1A) and up to 9 months (class 1B). In patients for whom a percutaneous coronary intervention (PCI) is planned, an additional loading-dose of 300 mg clopidogrel should be given on top of ASA (100 mg).These recommendations are based on data recently published in the CURE and CREDO trials, which however should be critically discussed: In these trials, an absolute risk reduction of only 2% could be documented by additive use of clopidogrel. The combined endpoint of cardiovascular death, myocardial infarction and stroke is significantly reduced, but there was no improvement taken the individual endpoints alone. In additional, the data for duration of clopidogrel therapy were determined by taken the mean follow-up of these studies. The efficacy of the dual antiplatelet therapy should be discussed in the context of an increased frequency of major bleedings (in total 1%) and should be considered against a reasonable cost effective background.An adequate therapy with clopidogrel in patients presenting ACS should be confirmed by further trials. Until more detailed data are available, the guideline recommendations should be implemented based on of patients individual risk.     

Thromboprophylaxis in non-surgical patients: who, when and how?

Because of the serious lack of useable, relevant information, most recommendations for prevention of thrombosis in non-surgical patients are extrapolations from much larger clinical trials experienced in surgery. Directly relevant evidence comes predominantly from very small randomized trials, many of them open label and carried out more than 20 years before the introduction of more recent and important changes in clinical care that may have substantially reduced the baseline thrombosis risk. In these early studies, low-dose heparin and low-molecular-weight heparins prevented subclinical deep vein thrombosis in ischaemic stroke, myocardial infarction and among elderly medical inpatients. Although it is likely that these drugs also prevent subclinical deep vein thrombosis after spinal cord injury or other major trauma, and when patients require intensive medical care, the supporting evidence in these circumstances comes mainly from cohort studies and poorly controlled comparisons. In contrast, the heparins have not reduced mortality or demonstrably prevented pulmonary embolism after ischaemic stroke or among elderly medical inpatients in large and well-conducted clinical endpoint trials, from which no clinically important benefit could be demonstrated. From analyses it is suggested that such benefit is probably more difficult to demonstrate for medical than for surgical patients. In the absence of sufficient information that is specific to medical patients, various forms of prophylaxis known to be effective in surgery will continue to be applied in high-risk individuals. After venous thromboembolism, it now appears that the best duration of oral anticoagulant therapy to prevent a recurrence is determined to a greater extent by whether the thrombotic episode was idiopathic or triggered by a clinically recognizable cause, whether it was transient or continuing, and whether the deep vein thrombosis was extensive, limited to the calf veins or was a first or recurrent event.     

Endoscopic ultrasound in chronic pancreatitis: Where are we now?

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be...     

Transplantation in CML in the TKI era: who,when, and how?

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Controversies in liver biopsy: Who,where, when,how, why?

Liver biopsy continues to have a central role in the evaluation of patients with suspected liver disease. The procedure is often indicated to evaluate otherwise unexplained liver biochemical test abnormalities, but the precise degree of serum aminotransferase elevations that should prompt a liver biopsy is controversial, as is the need for liver biopsy in all patients with suspected nonalcoholic fatty liver disease and chronic hepatitis C. Standard liver biopsy is contraindicated in patients with severe coagulopathy and ascites, although the degree of coagulopathy that contraindicates a liver biopsy is controversial. A transjugular approach is an alternative in patients with coagulopathy or ascites. Controversy surrounds all the technical aspects of liver biopsy, particularly the choice of needle (cutting vs suction) and the use of ultrasound to mark or guide the biopsy site. Bleeding is the major complication of liver biopsy, with a risk of 0.3%; cutting needles are more likely to cause hemorrhage than are suction needles. Traditionally, liver biopsy has been the province of the hepatologist/ gastroenterologist. However, an increasing number of liver biopsies are performed by radiologists. The implications of this trend with respect to patient outcome, safety, and training of fellows is unclear.     

Fecal biomarkers in inflammatory bowel disease: how,when and why?

Introduction: Over the last thirty years knowledge on fecal biomarkers (FM) has substantially increased. Nowadays these non-invasive inflammation markers are used in the daily management of inflammatory bowel disease (IBD). The interest in investigating FM was motivated by the need of a simple, quick, disposable and less invasive marker of disease activity, which might remove the need for endoscopy when following up with patients.

Areas covered: Current literature was reviewed for articles regarding the role of FM in IBD diagnosis, activity, flare prediction, medication and surgical treatment response as well as how FM may differ in adult and paediatric IBD patient populations.

Expert commentary: Although FM is relevant in IBD patient follow-up, there isn’t enough data regarding FM reference values for different ages, different disease subtypes, disease localization/extension or response to therapy. Serial measurements of FM for each patient may be useful in accessing relapse in most patients. FM presented more consistent results when used as a predictive tool of relapse after ileocecal surgery in Crohn’s disease. Ongoing research will clarify FM role in decision-making IBD daily practice.     

Screening for hepatocellular carcinoma: Why,when, how?

Hepatocellular carcinoma (HCC) is a major public health concern in many areas of the world, and its incidence is increasing in the United States and other countries. Screening for HCC in patients with cirrhosis has been advocated to identify those with small lesions who would benefit from transplantation or surgical resection. Despite these recommendations, several issues regarding screening remain controversial. No randomized, controlled trials have confirmed that surveillance for HCC reduces disease-specific mortality. In addition, the most appropriate screening test and optimal screening interval have not yet been defined. Clearly, these unresolved questions have a major impact on the cost-effectiveness of a screening program either at the population or the clinic level. A few studies, however, have suggested that screening may be cost-effective because a minor survival benefit could result in a cost that is acceptable to decision makers.     

Lipid reduction in acute coronary syndrome: How much, when, and how?

The use of statins for secondary prevention after acute coronary syndrome is well established. In recent years, trials have investigated the dose of statins used and timing of administration. Initiation of statin therapy as early as 1 day after an acute coronary syndrome event has been shown to be effective in reducing major adverse cardiovascular events. The benefit of early statin use is linked to reduction in inflammation and increased compliance with therapy. In addition, intensive therapy further reduces events and inflammation, as reflected by decreased C-reactive protein. Given the findings of these recent studies, early and intensive lipid-lowering therapy with a statin is justified and safe.     

Novel therapies vs hematopoietic cell transplantation in myelofibrosis: who,when, how?

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