Vicente Ortiz

Contribution of obesity to hepatitis C-related fibrosis progression.

OBJECTIVE:Hepatitis C virus (HCV) disease progression is variable. Identification of factors predictive of rapid progression is an important goal for improving patient management. The aim of this study was to evaluate the predictive role of several variables, including some that are etiologically related to the nonalcoholic steatohepatitis (NASH) syndrome such us obesity, in fibrosis progression in both patients with elevated and normal transaminase levels.METHODS:A total of 114 chronic HCV-infected (HCV-RNA positive) patients were recruited prospectively between 2000 and 2001. All patients had at least one liver biopsy. The annual change in fibrosis stage (fibrosis progression rate) was assessed from the time of presumed infection (fibrosis = 0) among those who had only one biopsy (n = 97) or between two biopsies if these were available (n = 17). Based on published data, we arbitrarily defined a patient as a rapid progressor when the fibrosis progression rate was >0.2 U/yr. Potential predictors of rapid progression were: age at infection and biopsy, sex, significant alcohol intake (>50 g/day), risk factor of HCV acquisition (based on answers to a questionnaire), obesity (based on body mass index [BMI]), autoantibodies, iron overload (ferritin, transferrin saturation), diabetes, hyperlipidemia, anti-HBcore IgG, genotype, and viral load.RESULTS:The median fibrosis progression rate was 0.05 U/yr (range 0–1.58 yr). In all, 22 patients (19%) were rapid progressors. Variables associated with progression by multivariate analysis included: advanced age at infection (p = 0.0001), BMI ≥25 (p = 0.01), and ALT >1.5 times upper limit of normal (p = 0.01). Among patients with ALT >1.5 times upper limit of normal, these variables were advanced age at infection, BMI ≥25, diabetes and transferrin saturation >45. Among those with normal ALT levels, only BMI ≥30 was predictive of progression.CONCLUSIONS:Obesity, advanced age at infection, and elevated ALT levels predict rapid disease progression, suggesting that measures aimed at weight reduction may play a significant role in hepatitis C management. The natural history of hepatitis C is independent of the presence of autoimmunity markers.

Second-Line Rescue Therapy With Levofloxacin After H. pylori Treatment Failure: A Spanish Multicenter Study of 300 Patients

AIM:Quadruple therapy is generally recommended as second-line therapy after Helicobacter pylori (H. pylori) eradication failure. However, this regimen requires the administration of four drugs with a complex scheme, is associated with a relatively high incidence of adverse effects, and bismuth salts are not available worldwide anymore. Our aim was to evaluate the efficacy and tolerability of a triple second-line levofloxacin-based regimen in patients with H. pylori eradication failure.METHODS:Design: Prospective multicenter study. Patients: in whom a first treatment with proton pump inhibitor-clarithromycin-amoxicillin had failed. Intervention: A second eradication regimen with levofloxacin (500 mg b.i.d.), amoxicillin (1 g b.i.d.), and omeprazole (20 mg b.i.d.) was prescribed for 10 days. Outcome: Eradication was confirmed with 13C-urea breath test 4–8 wk after therapy. Compliance with therapy was determined from the interview and the recovery of empty envelopes of medications. Incidence of adverse effects was evaluated by means of a specific questionnaire.RESULTS:Three hundred consecutive patients were included. Mean age was 48 yr, 47% were male, 38% had peptic ulcer, and 62% functional dyspepsia. Almost all (97%) patients took all the medications correctly. Per-protocol and intention-to-treat eradication rates were 81% (95% CI 77–86%) and 77% (73–82%). Adverse effects were reported in 22% of the patients, mainly including nausea (8%), metallic taste (5%), abdominal pain (3%), and myalgias (3%); none of them were severe.CONCLUSION:Ten-day levofloxacin-based rescue therapy constitutes an encouraging second-line strategy, representing an alternative to quadruple therapy in patients with previous proton pump inhibitor-clarithromycin-amoxicillin failure, being simple and safe.

Value of Heartburn for Diagnosing Gastroesophageal Reflux Disease in Severely Obese Patients

Objective: To evaluate the prevalence of gastroesophageal reflux disease (GERD) in severely obese patients and the association between symptoms and objective data of GERD in this population.

On-Demand Therapy with Rabeprazole in Nonerosive and Erosive Gastroesophageal Reflux Disease in Clinical Practice: Effectiveness, Health-Related Quality of Life, and Patient Satisfaction

On-demand therapy is effective for maintaining symptoms control in nonerosive gastroesophagealreflux disease (GERD). Our aim was to assess the clinical effectiveness of on-demand therapy witha proton pump inhibitor (PPI) in mild GERD (nonerosive and low-grade esophagitis), its impact onhealth-related quality of life (HRQoL), and the degree of patient satisfaction. Fifty-five patients (17with nonerosive GERDand 38 with low-grade esophagitis) were treated with rabeprazole, 20 mg/day.The healed patients started on-demand therapy. We evaluated symptoms (clinical questionnaire),HRQoL (SF-36 questionnaire), and patient satisfaction (visual analogue scale). Of the 55 patientsincluded, 51 started on-demand therapy for 6 months. Symptom control (heartburn <twice a week)was achieved in over 85% of the patients. The mean (SD) amount of PPI used was 0.3 (0.19)tablet/day. The patient satisfaction score at the end of the acute phase was 98 (range, 0-100) andremained high (90; range, 10-100) and stable during on-demand therapy. Short-term treatmentnormalized the HRQoL scores, which were subsequently maintained during on-demand therapy.On-demand therapy is useful for the clinical management of patients with mild GERD, allowingadequate symptoms control, limiting PPI consumption, and affording important patient satisfactionwith normalization of HRQoL.

Manifestations of Gastroesophageal Reflux and Response to Omeprazole Therapy in Patients with Chronic Posterior Laryngitis: An Evaluation Based on Clinical Practice

Our aims were to describe clinical characteristics of patients with chronic posterior laryngitis and to predict the response to omeprazole therapy. Ninety-one patients with posterior laryngitis were evaluated by a questionnaire, esophageal manometry and pH recording, and endoscopy. Patients were treated with omeprazole, 20 mg twice daily for 3 months. Therapy was continued another 3 months if necessary. Clinical manifestations of reflux occurred in 84 (92%) patients, abnormal acid reflux in 53 (65%) cases, and esophagitis in 6 of 50 (12%). After 3 months of therapy significant improvement occurred in 30 of 70 patients (41%). Continuing therapy for 3 more months increased the response to 65% (45 of 69 cases). Response to therapy was associated with lower age and lower duration of laryngeal symptoms, but a consistent prediction of the response could not be made. In conclusion, patients with posterior laryngitis frequently present with manifestations of gastroesophageal reflux. Response to therapy can not be predicted with certainty.

Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication

BACKGROUND Cardiomyotomy, often associated with an antireflux technique, is effective in the management of achalasia, although gastroesophageal reflux (GER) may occur after the procedure. Patient-centered measures, ie, health-related quality of life (HRQoL) and satisfaction, should be included in the evaluation of the patients. METHODS A study was made of the incidence of GER (symptoms, upper endoscopy and 24-hour pH monitoring), HRQoL (Short Form-36 Health Survey), and satisfaction after open-access cardiomyotomy and 180-degree anterior fundoplication in 28 consecutive patients, with a minimum postoperative follow-up of 12 months. RESULTS Mean age was 45 years (range 15 to 80) and 68% were female. In 8 subjects (all with heartburn) GER morbidity was present (4 with esophagitis and 4 with positive pH study), and 6 patients required proton pump inhibitors. Short Form-36 scores after surgery were similar to those found in the general population. Patient satisfaction was high and was more related to the absence of dysphagia than to the presence of GER symptoms. CONCLUSIONS Gastroesophageal reflux is relatively frequent after cardiomyotomy and partial fundoplication, although the efficacy of proton pump inhibitor treatment minimizes its clinical significance.

Genetic Variability of Hepatitis C Virus NS3 Protein in Human Leukocyte Antigen-A2 Liver Transplant Recipients with Recurrent Hepatitis C

The association between the severity of chronic hepatitis C and the variability of the hepatitis C virus (HCV) genome remains controversial, but to our knowledge few data are available to date regarding T‐cell epitope coding regions in transplant patients. In the current study, we identified 21 human leukocyte antigen (HLA)‐A2‐positive Spanish patients with chronic hepatitis C, 14 immunosuppressed liver transplant recipients, and 7 immunocompetent controls. Alanine aminotransferase, aspartate aminotransferase, viral load, and rate of fibrosis progression were determined. Genetic distances of HCV isolates and variations in epitopes of the HCV nonstructural 3 protein (NS3‐1393 LIFCHSKKK and NS3‐1406 KLVALGINAV) were compared between patients with slow or fast progression of fibrosis. Isolates from transplant patients with fast progression were found to be more divergent (P =.03), had a higher mean value of synonymous (dS) variations (P =.02), and some were differentiated in a phylogenetic tree, compared with isolates from patients with slow progression. The HLA‐A2‐restricted NS3‐1406 epitope was found to be more variable (20 of 21 isolates differed from the prototype) compared with the A3‐restricted NS3‐1392 epitope (19% vs. 1.25% variation). A shift in the viral peptide was not detected in a subset of transplant patients, but was evident in two of three nontransplant patients with follow‐up. There was no correlation noted between a particular amino acid variation and fibrosis progression (slow or fast) in either transplant or nontransplant patients. The results of the current study suggest that 1) there may be different HCV‐1b strains in our geographic area, 2) immunosuppression appears to have little effect in amino acid variation at the HCV NS3‐1406 epitope, and 3) variations over time might be more frequent in nonimmunosuppressed patients. (Liver Transpl 2004;10:217–227.)

The effects of thiopurine therapy on health-related quality of life in Inflammatory Bowel Disease patients

BackgroundThe effect of thiopurine immunomodulators on health-related quality of life (HRQoL) in patients with inflammatory bowel disease (IBD) has been controversial. The aims were to evaluate the HRQoL in patients with IBD treated with thiopurines and assess the short- and long-term impacts of the treatment on HRQoL.MethodsNinety-two consecutive patients who started treatment with thiopurines were prospectively included. Evaluation of HRQoL was performed at months 0, 6, and 12 using two questionnaires, the Short-Form Health Survey (SF-36) and the Inflammatory Bowel Disease Questionnaire (IBDQ).ResultsBaseline score of IBDQ was 4,6, range (2,31-6,84), with an impairment of the five dimensions of HRQoL compared with inactive patients. Results obtained in 8 dimensions of SF-36 showed worse HRQoL than Spanish general population. At 6 months patients had a significant improvement in overall IBDQ score -5,8 (1,58 -6,97)- and also in all IBDQ dimensions. All the 8 dimensions of SF-36 obtained a significant improvement. At twelve months score of IBDQ was 6,1, range (2,7-6,98), with improvement in all dimensions compared with baseline and 6 months. SF-36 showed a similar significant improvement in all subscales.ConclusionsThiopurine immunomodulators alone or with other treatments have a positive and long lasting impact on HRQoL of IBD patients.

Impact of gastroesophageal reflux disease on the quality of life of Spanish patients: the relevance of the biometric factors and the severity of symptoms.

Background Gastroesophageal reflux disease (GERD) has a negative impact on health-related quality of life (HRQoL). Aim (i) To evaluate HRQoL in the general Spanish population with GERD. (ii) To analyze the influence of biometric factors and symptoms profile on HRQoL. Materials and methods A multicenter and population-based evaluation was performed. Surveys were sent out to the general population and 335 responders (16%) fulfilled symptomatic criteria of GERD. They filled out two HRQoL questionnaires [Short Form-36 (SF-36) and Quality of Life in Reflux and Dyspepsia]. Biometric factors and symptoms profile were collected. The SF-36 physical and mental component summary scores were calculated. Results Two hundred and fifty-two individuals (75.2%) participated. SF-36 and Quality of Life in Reflux and Dyspepsia (QoLRAD) punctuations were lower compared with the general population. Female sex, severity of symptoms, and nocturnal symptoms were associated with a greater deterioration of HRQoL. Obese participants had a negative impact on the physical component summary score, but mental component summary score was better than in participants with normal weight. Adjusted by age, punctuations of smokers, exsmokers, and nonsmokers were similar. No differences in HRQoL with regard to alcohol consumption were observed. Conclusion In participants who fulfill symptomatic criteria of GERD, the HRQoL is very deteriorated. The factors that worsen the QoL are being female, increase in BMI, and nocturnal symptoms.

Constipation during pregnancy : a longitudinal survey based on self-reported symptoms and the Rome II criteria

An increase in the prevalence of constipation during pregnancy has been suggested to occur. We designed a prospective study to evaluate the prevalence of constipation during pregnancy and puerperium, to investigate possible associations with eating habits and lifestyle, and to evaluate the frequency of laxative use. A structured questionnaire was developed addressing demographics, obstetric characteristics, lifestyle, eating habits, variables required for the diagnosis of constipation, and laxative use to evaluate the prevalence of constipation during pregnancy and puerperium. The questionnaire was administered in the obstetric clinic in the first trimester of pregnancy, and by telephone in the second and third trimesters, and in the puerperal period. The prevalence of self-reported constipation in these time periods was 45.4, 37.1, 39.4, and 41.8%, respectively. Prevalence defined by the Rome II criteria for the same time periods was 29.6, 19, 21.8, and 24.7%. These values were similar to the data previously reported for the female population. Agreement between the self-reported and Rome II results was moderate. The self-reported criterion showed high sensitivity in all time periods, using the Rome II criterion as gold-standard. No factor was associated with variations in the prevalence of constipation during pregnancy, though an increase was recorded in the consumption of fruit, vegetables, fiber, and water. The prevalence of constipation during pregnancy and puerperium is similar to that recorded among the female population from the same geographic area.