ObjectiveThe best approach for Helicobacter pylori management remains unclear. An audit process is essential to ensure clinical practice is aligned with best standards of care.DesignInternational multicentre prospective non-interventional registry starting in 2013 aimed to evaluate the decisions and outcomes in H. pylori management by European gastroenterologists. Patients were registered in an e-CRF by AEG-REDCap. Variables included demographics, previous eradication attempts, prescribed treatment, adverse events and outcomes. Data monitoring was performed to ensure data quality. Time-trend and geographical analyses were performed.Results30 394 patients from 27 European countries were evaluated and 21 533 (78%) first-line empirical H. pylori treatments were included for analysis. Pretreatment resistance rates were 23% to clarithromycin, 32% to metronidazole and 13% to both. Triple therapy with amoxicillin and clarithromycin was most commonly prescribed (39%), achieving 81.5% modified intention-to-treat eradication rate. Over 90% eradication was obtained only with 10-day bismuth quadruple or 14-day concomitant treatments. Longer treatment duration, higher acid inhibition and compliance were associated with higher eradication rates. Time-trend analysis showed a region-dependent shift in prescriptions including abandoning triple therapies, using higher acid-inhibition and longer treatments, which was associated with an overall effectiveness increase (84%–90%).ConclusionManagement of H. pylori infection by European gastroenterologists is heterogeneous, suboptimal and discrepant with current recommendations. Only quadruple therapies lasting at least 10 days are able to achieve over 90% eradication rates. European recommendations are being slowly and heterogeneously incorporated into routine clinical practice, which was associated with a corresponding increase in effectiveness.

SUMMARY BackgroundThe decreasing efficacy of H. pylori eradication treatments over time makes the search for better regimens and adjuvant medications a priority.

Background Bismuth‐containing quadruple therapy has been suggested as first‐line and rescue alternative for Helicobacter pylori eradication. Our objective was to perform a meta‐analysis evaluating the efficacy and safety of single capsule Pylera® (bismuth, metronidazole, and tetracycline) plus a proton‐pump inhibitor (PPI) in any line of treatment. Methods Studies were selected up to October 2018. Outcomes were eradication and adverse events (AEs) rates pooled using the generic inverse variance method. Results In total, 30 studies (6482 patients) were included in the systematic review. The intention‐to‐treat (ITT) efficacy was 90% (95% CI: 87%‐92%, 21 studies, I2 = 88%) in first‐line therapy, 89% (95% CI: 86%‐93%, 12 studies, I2 = 78%) in second‐line and 82% (95% CI: 78%‐87%, nine studies, I2 = 60%) in third‐line; with no differences by the type or dosage of PPI used. For metronidazole‐resistant infection, the ITT efficacy as first‐line therapy was 93% (95% CI: 90%‐96%, six studies, I2 = 0%). In second‐line therapies where patients had been previously treated with clarithromycin, the ITT efficacy was 90% (95% CI: 87%‐93%, 11 studies, I2 = 78%). The overall incidence of AEs was 43% (95% CI: 35%‐50%, 24 studies, I2 = 92%) and they were mostly mild. In nearly 3% of the cases, treatment was interrupted due to AEs. Conclusions A 10‐day treatment with Pylera® achieved an effective eradication rate of approximately 90% both in first‐ and second‐line therapy. This applies regardless of the type and dose of the PPI, in patients with clarithromycin‐ or metronidazole‐resistant strains, and in those previously treated with clarithromycin.

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Background: Bacterial antibiotic resistance changes over time depending on multiple factors; therefore, it is essential to monitor the susceptibility trends to reduce the resistance impact on the effectiveness of various treatments. Objective: To conduct a time-trend analysis of Helicobacter pylori resistance to antibiotics in Europe. Methods: The international prospective European Registry on Helicobacter pylori Management (Hp-EuReg) collected data on all infected adult patients diagnosed with culture and antimicrobial susceptibility testing positive results that were registered at AEG-REDCap e-CRF until December 2020. Results: Overall, 41,562 patients were included in the Hp-EuReg. Culture and antimicrobial susceptibility testing were performed on gastric biopsies of 3974 (9.5%) patients, of whom 2852 (7%) were naive cases included for analysis. The number of positive cultures decreased by 35% from the period 2013–2016 to 2017–2020. Concerning naïve patients, no antibiotic resistance was found in 48% of the cases. The most frequent resistances were reported against metronidazole (30%), clarithromycin (25%), and levofloxacin (20%), whereas resistances to tetracycline and amoxicillin were below 1%. Dual and triple resistances were found in 13% and 6% of the cases, respectively. A decrease (p < 0.001) in the metronidazole resistance rate was observed between the 2013–2016 (33%) and 2017–2020 (24%) periods. Conclusion: Culture and antimicrobial susceptibility testing for Helicobacter pylori are scarcely performed (<10%) in Europe. In naïve patients, Helicobacter pylori resistance to clarithromycin remained above 15% throughout the period 2013–2020 and resistance to levofloxacin, as well as dual or triple resistances, were high. A progressive decrease in metronidazole resistance was observed.

Brglez Jurecic 14 | José María Huguet 15 | Noelia Alcaide 16 | Irina Voynovan 17 | José María Botargues Bote 18 | Inés Modolell 19 | Jorge Pérez Lasala 20 | Inés Ariño 21 | Laimas Jonaitis 22 | Manuel Dominguez-Cajal 23 | György Buzas 24 | Frode Lerang 25 | Monica Perona 26 | Dmitry Bordin 17 | Toni Axon 27 | Antonio Gasbarrini 28 | Ricardo Marcos Pinto 29 | Yaron Niv 30 | Limas Kupcinskas 22 | Ante Tonkic 31 | Marcis Leja 32 | Theodore Rokkas 33 | Lyudmila Boyanova 34 | Oleg Shvets 35 | Marino Venerito 36 | Peter Bytzer 37 | Adrian Goldis 38 | Ilkay Simsek 39 | Vincent Lamy 40 | Krzysztof Przytulski 41 | Lumír Kunovský 42 | Lisette Capelle 43 | Tomica Milosavljevic 44 | María Caldas 1 | Ana Garre 1 | Francis Mégraud 45 | Colm O'Morain 46 | Javier P. Gisbert 1 | On behalf of the Hp-EuReg Investigators Abstract Background: Experience in Helicobacter pylori eradication treatment of patients allergic to penicillin is very scarce. A triple combination with a PPI, clarithromycin (C), and metronidazole (M) is often prescribed as the first option, although more recently the use of a quadruple therapy with PPI, bismuth (B), tetracycline (T), and M has been recommended. Aim: To evaluate the efficacy and safety of first-line and rescue treatments in patients allergic to penicillin in the "European Registry of H pylori management" (Hp-EuReg). Methods: A systematic prospective registry of the clinical practice of European gastroenterologists (27 countries, 300 investigators) on the management of H pylori infection. An e-CRF was created on AEG-REDCap. Patients with penicillin allergy were analyzed until June 2019. Results: One-thousand eighty-four patients allergic to penicillin were analyzed. The Additional supporting information may be found online in the Supporting Information section. How to cite this article: Nyssen OP, Perez-Aisa Á, Tepes B, et al; On behalf of the Hp-EuReg Investigators. Helicobacter pylori first-line and rescue treatments in patients allergic to penicillin: Experience from the European Registry on H pylori management (Hp-EuReg). Helicobacter. 2020;25:e12686.

Background: Vitamin A and carotenoids are involved in signalling pathways regulating gene expression in many organs, including the brain. The dopaminergic system is a target of retinoic acid action in the central nervous system. The aim of this review is to assess the epidemiological evidence on the association between blood levels or dietary intakes of vitamin A and carotenoids and risk of Parkinson's disease (PD). Methods: PubMed and ISI Web of Science were searched for relevant papers from 1990 to April 2013. Data reported in epidemiological studies assessing the association between vitamin A and/or carotenoids (α-carotene, β-carotene, β-cryptoxanthin, lutein, lycopene, zeaxanthin and canthaxanthin) and PD were extracted for a narrative synthesis and meta-analysis. Results: Thirteen papers were included out of a total of 362 potentially relevant; of these, eight contributed to the meta-analysis. No statistically significant pooled estimate between micronutrient and PD was detected. Forest plots suggest possible non-significant inverse pooled estimates of α-carotene and β-carotene and risk of PD. A significant association between lutein intake and PD risk was detected in case-control studies only. Conclusions: Data published to date are insufficient for drawing definite conclusions about the epidemiological evidence on the association between blood levels or dietary intakes of vitamin A and carotenoids and the risk of PD. Results should be interpreted particularly cautiously given the limitation of the present meta-analysis and the potential publication bias. Authors are urged to follow more closely the recommendations for reporting epidemiological studies in order to enhance the capacity for synthesising the evidence.

BackgroundWriting therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched.Data sourcesDatabases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015).Review methodsFour TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately underInternational Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost–consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines.ObjectivesTo review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom.ResultsFrom 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) –0.61, 95% confidence interval (CI) –0.96 to –0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted acrossallof the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD –0.06, 95% CI –0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD –0.04 95% CI –0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use; and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW.LimitationDifficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure.ConclusionsOverall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative.Study registrationThis study is registered as PROSPERO CRD42012003343.FundingThe National Institute for Health Research Health Technology Assessment programme.