Clinical Review, by: L Fuccio, research fellow et al, Department of Internal Medicine and Gastroenterology, University of Bologna.
BMJ, 15 September 2008

• The prevalence of H pylori varies widely and is about 50% in international population studies. Helicobacter pylori is one of the most common human infections, and about half of the world’s population carries this organism. Since its discovery in 1984, H pylori has been recognised as a major cause of several upper gastrointestinal diseases.
• Triple and quadruple multidrug regimens are standard treatment
• Resistance to clarithromycin and metronidazole and lack of adherence to treatment are the main predictors of treatment failure
• The choice of the most effective regimen should be based on the prevalence of antibiotic resistance, especially resistance to clarithromycin and metronidazole
• Individualised treatment based on antimicrobial susceptibility has a limited role in H pylori eradication strategies
• The overall risk of reinfection is estimated at 3.4% per patient year in developed countries, rising to 8.7% in developing countries

BMJ 2008;336:1062-1066 (10 May).
Clinical Review

By: J R Fraser Cummings, specialist registrar, Satish Keshav, consultant gastroenterologist, Simon P L Travis, consultant gastroenterologist (Gastroenterology Unit, John Radcliffe Hospital, Oxford)

Summary points

• Biological therapies have radically changed the management of Crohn’s disease but must be used judiciously with great awareness of possible adverse events
• Treatment strategies for the disease are rapidly evolving, with immunomodulator and biological therapy being considered in patients who have indicators for developing early severe disease
• Clinical indicators of a poor prognosis (at diagnosis) include perianal or stricturing disease, weight loss >5 kg, or the need for steroids
• Treatment of active disease with mesalazine is little better than placebo; mesalazine is used mainly to reduce the risk of relapse after small intestinal resection
• Access to specialist services, parallel medical and surgical clinics, nurse specialists, dietitians, pharmacists, and other allied professionals is as important as the medication

Publication of standards of care should drive improvement in the care and provision of resources for patients with Crohn’s disease

BMJ 2008;336:2-3 (5 January).
Proton pump inhibitors have been a tremendous therapeutic advance and have transformed the lives of patients with previously intractable symptoms, say editorialists Ian Forgacs and Aathavan Loganayagam. But the drugs are being overused, and side effects – although rare – should not be overlooked.

Rapid Response by Dr Raymond C Seidler, GP, NSW, Australia:

• “Perhaps it would be salutary to consider how rare it is now to see patients with perforated ulcers or even serious gastric or duodenal ulceration.
• These were commonplace in my early days of general practice 25 years ago. The proton pump inhibitors as a class are effective.”