Quadruple therapy as first choice for eradication of H. pylori due to clarithromycin-resistance

Helicobacter pylori is associated with benign and malignant diseases of the upper gastrointestinal tract. Increasing antibiotic resistance has made alternative treatments necessary.

Diagnosis of Helicobacter pylori infection: 13C urea breath test or the stool antigen test as “test and treat strategy”. BMJ, 2012.

Empirical triple therapy (proton-pump inhibitor, clarithromycin, amoxicillin) is currently the first choice for eradication of Helicobacter pylori. As antibiotic resistance to clarithromycin (which has a crucial role in eradication) has increased. The eradication rate with triple therapy has gradually decreased below 80%, and even less.

The aim of this study reported in The Lancet was to assess the efficacy and safety of a new, single-capsule treatment versus the gold standard for H. pylori eradication (triple therapy).

A randomised, open-label trial of adults with H. pylori infection compared the efficacy and safety of:

- quadruple therapy: 10 days of quadruple therapy with omeprazole plus a single three-in-one capsule containing bismuth, metronidazole, and tetracycline

- standard therapy: 7 days of omeprazole, amoxicillin, and clarithromycin (editor note: why not 14 days of therapy?)

H. pylori eradication was established by negative 13C urea breath tests at 28 and 56 days after the end of treatment.

The eradication rates were 80% in the quadruple therapy group versus 55% in the standard therapy group.

The study authors concluded that quadruple therapy should be considered for first-line treatment in view of the rising prevalence of clarithromycin-resistant H. pylori. Quadruple therapy provides superior eradication with similar safety and tolerability to standard therapy.

References:

Helicobacter pylori eradication with a capsule containing bismuth subcitrate potassium, metronidazole, and tetracycline given with omeprazole versus clarithromycin-based triple therapy: a randomised, open-label, non-inferiority, phase 3 trial. The Lancet, Volume 377, Issue 9769, Pages 905 - 913, 12 March 2011.

Quadruple or triple therapy to eradicate H pylori. The Lancet, Volume 377, Issue 9769, Pages 877 - 878, 12 March 2011.

H. pylori eradication provides benefits to patients with functional dyspepsia http://goo.gl/UwxsT

H. pylori image courtesy of www.hpylori.com.au.

Don’t just swallow, check the evidence first - it applies to diet, medications, and more

The wrong approach

According to the food conglomerate Danon: “Evidence is increasing that even mild dehydration plays a role in the development of various diseases.” It’s a campaign, sponsored by the producers of Volvic, Evian, and Badoit bottled waters, to get us all to drink more water.

But what and where is this evidence? A doctor replies: “This is not only nonsense, but is thoroughly debunked nonsense.”

The right approach

Worried by the fact that European guidelines classified almost all older people as being at high risk of cardiovascular disease, Norway has developed its own guidelines that use differential risk thresholds according to age.

Compared with the European guidelines, the total sum of life gained is about the same, but the number of patients treated is considerably lower.

How does clinical evidence work?



Ben Goldacre's Moment of Genius on BBC4 radio:

"Clinical trials in medicine are designed to be free from bias. They test, as objectively as possible, the effectiveness of a particular intervention.

When you bring the results of all these individual trials together, however, how do you weigh up what evidence is relevant and what is not? In 1993, a method of "systematic review" was introduced that enables us to get the clearest possible view of the evidence."

References:

Don’t just swallow, check the evidence first. Godlee 343. BMJ, 2011.

Image source: Plastic bottles before processing. Wikipedia, dierk schaefer, Creative Commons Attribution 2.0 License.

BMJ, the first medical journal to launch a website in 1996, shows a blog-like redesign

See the video here: Make the most of the new bmj.com. Editor-in-Chief Fiona Godlee and David Payne explain the redesigned bmj.com website, and some of the new features:



And, of course, you can follow BMJ on:

- Twitter
twitter.com/bmj_latest

- Facebook
facebook.com/bmjdotcom

- YouTube
youtube.com/user/BMJmedia

References:

Welcome to the new design. BMJ.

First snowmobile front flip landed and winter sport trauma (video)

Heath Frisby lands the first snowmobile front flip in competition:



This is what happens when the things don't go as planned: Colten Moore flies 120 feet into the air and then hits the snow hard in Snowmobile Freestyle Finals... (video below). He not only survived but went on to win Winter X Games Gold later.



Not all extreme winter sport champions are so lucky though, and some of them have barely escaped death, with life-altering injuries: Kevin Pearce reflects on Sarah Burke's death (USA Today).

Start metformin early when diabetes type II is first diagnosed

Initiating metformin soon after diabetes diagnosis and while A1C is low might preserve β-cell function, prolong the effectiveness of metformin, reduce lifetime glycemic burden, and prevent diabetes complications.

These findings support the current treatment algorithm for hyperglycemia management that recommends metformin initiation when diabetes is first diagnosed.

References:

Secondary Failure of Metformin Monotherapy in Clinical Practice. Diabetes Care March 2010 vol. 33 no. 3 501-506.

First official antismoking campaign was launched in 1604 by James I of England

From the BMJ:

Monarchs and their heirs are not always noted for their rational medical advice. But James VI of Scotland, who became James I of England in 1603, was different.

Published anonymously in 1604 but immediately credited to the king, A Counterblaste to Tobacco flew in the face of prevailing medical opinion by outlining some of the chief health risks of smoking more than three centuries before scientists made the connection.

Possibly the first official antismoking campaign, the royal pamphlet highlighted cost and passive smoking as two of the most powerful arguments against tobacco, while it lamented that addiction, peer pressure, and fashion were among the most difficult obstacles to overcome.

A Counterblaste to Tobacco is written in Early Modern English and refers to medical theories of the time (e.g. the four humours). In it, King James I blames Native Americans for bringing tobacco in Europe, complains about passive smoking, warns of dangers to the lungs, and decries tobacco's odour as "hatefull to the nose."

James's dislike of tobacco led him to authorize an excise tax and tariff of six shillings and eight pence per pound of tobacco imported, or £1 per three pounds, a large sum of money for the time.

References:
Royal insights on smoking - Moore 340: c1408 - BMJ.

Image source: James I, VI by John de Critz, c.1606, Wikipedia, public domain.

A Counterblaste to Tobacco. Wikipedia.

Twitter comments:

@CardioNP: 400+ yrs later I still wade thru smoke to enter the hospital.

The First Journal Club on Twitter - Then and Now

The first journal club on Twitter in 2008

I think we started the first medical journal club on Twitter at the Allergy and Immunology program of Creighton University back in 2008. Please let me know if you are aware of an earlier journal club focused on medical articles and broadcasted or held exclusively on Twitter prior to that date. We published an abstract at the annual meeting of the The American College of Allergy, Asthma and Immunology (ACAAI) in 2009, with collaborators from Creighton University, Louisiana State University (LSU) in Shreveport and Cleveland Clinic. The abstract and the poster are embedded below:

The Utility of a Real-time Microblogging Service for Journal Club in Allergy and Immunology. Dimov, V.; Randhawa, S.; Auron, M.; Casale, T. American College of Allergy, Asthma & Immunology (ACAAI) 2009 Annual Meeting. Ann Allergy Asthma Immunol., Vol 103:5, Suppl. 3, A126, Nov 2009.

Purpose

Internet-based services are an important source for communication and reference information for fellows in training in allergy and immunology. Our aim was to explore the utility of the free microbloging service Twitter.com to make the journal club educational activity more interactive.

Methods

We used the text message and Internet interfaces of the free microblogging service Twitter (http://twitter.com/) owned by Twitter, Inc. to post updates and summaries from the journal club activities at an Allergy and Immunology fellowship training program at an academic center. The updates were posted on a web site provided free of charge at http://twitter.com/AllergyNotes and simultaneously distributed to the cell phones of subscribers via text messages. The web site was freely available and comment were open to visitors. One fellow in training was assigned to update the microblogging service from his cell phone with the label "#JCAllergy" for easy referral and later retrieval from the Internet search interface.

Results

Five articles were discussed during a 2-hour journal club teaching session and 24 updates with links were posted on Twitter.com. The updates were followed in real time by 2 fellows at an Allergy and Immunology training program in a different state (not physically present at the meeting). Five fellows (out of 7, 71.4%) at two training programs expressed a favorable opinion of the use of the microblogging service to post updates from journal club.

Conclusion

The microblogging service Twitter can be used to share information from journal club in allergy and immunology and thus serves as an easy to implement form of distant learning for trainees and community allergists. The service is free to use and requires minimal equipment limited to an Internet-connected computer or a basic cell phone (not a smartphone) with activated text messaging service. A potential limitation of this approach may be the distractions that the reporting journal club participant may experience while simultaneously sending text messages and listening to the presentations. Twitter allows an immediate feedback from the journal club participants, following the updates from remote locations, which can enhance the educational aspects of this activity.

The concept of a journal club on Twitter has its own limitations inherent to the publishing medium and the enthusiasm of the participants. After a few months, we decided that the concept was interesting but ultimately the discussion of a journal article requires more than 140 characters.



The worldwide journal club on Twitter in 2011

In June 2011, a medical student and a junior doctor in the UK launched the idea of a journal club exclusively on Twitter. The social network and publishing medium of Twitter has grown tremendously from approximately 40 million accounts in 2008 to 150 million in 2011. The networks mass effect and the infectious enthusiasms of the two founders ensured a large participation in this new journal club on Twitter: http://twitjc.wordpress.com

I wish them best of success in this new educational endeavor. I think it is a great effort and it should be strongly encouraged.

My general comment on the 2008 concept, and this new 2011 version of journal club on Twitter, was that “we need to go beyond this 1950s model rather than adapt it to social media”. To be exact, Sir William Osler established the first formalized journal club at McGill University in Montreal in 1875 (http://j.mp/aGEvB0), but the concept itself seemed to get traction after the 1950s.

I think it would be a good idea to ask the participants themselves what they would like to see in a journal club on Twitter, i.e. "crowdsource" the community. This can be done via a Google Forms poll with a free text option for additional suggestions.

Dr. Stuart Flanagan tweeted that this could be an opportunity to develop or even reinvent the Journal Club model, and it could be a very exciting project. I agree, and will try to add a few specific ideas in a future blog post.

If we stay just on Twitter, this may look like another topical Twitter chat. For example, what are the major differences between "Journal Club on Twitter" and a Twitter chat on a topic?

In addition, Twitter may not be the best way for article discussion. It is just the popular tool at this time. Google Buzz is an alternative service that works well for this purpose but the major problem is that very few people use it. Buzz is a better medium than Twitter for a journal club from a technical point of view. It is easier to follow the conversation threads - this is one its main advantages and Facebook has it too. The search function of Buzz works well while Twitter Search traditionally “forgets” tweets older than 7 days.

Please have a look at the transcript of the first edition of #twitjc and you will realize how challenging is to follow a conversation on Twitter: http://www.scribd.com/doc/57191306/TwitJC-Transcript-5-6-2011

Reading a 30-page Twitter chat transcript with all @ handles, hashtags and timestamps included is not for everyone. Some editing of the transcript would make it more readable. We tried this with the original journal club in 2008, on a much smaller scale of course: http://allergynotes.blogspot.com/2008/12/allergy-and-immunology-journal-club-on.html

How about Journal Club on Facebook? I don't think that JC on either Facebook or Twitter (or blog comments) take the concept to a fundamentally new level.

In any case, Cleveland Clinic, ever the innovator, actually has a Journal Club on Facebook. Dr. Neil Mehta wrote a great summary on their model, using Google Reader and Facebook, check it out here: http://goo.gl/rnw2P



In conclusion, from personal experience, I would say that you can only learn when people criticize your project - it is the most helpful kind of feedback that you typically get for free.

Please consider visiting the website and Twitter account of this new Twitter Journal Club (http://twitjc.wordpress.com), follow the hashtag #TwitJC and enjoy the new editions.

Comments from Twitter:

@DrVes: Did you find #TwitJC useful? @EugenieReich is looking for scientists to be interviewed in Nature. I think the second event was very engaging and useful. That said, #TwitJC is more a Twitter chat on a topic/article rather than a Journal Club as we think of it in the U.S. This brings me to the third tweet on the topic: Do we need separate #meded tags for different parts of the world? http://bit.ly/maPEwm

@amcunningham: well, it's a journal club the way we think of it in the UK... A noisy, hectic one!- but gets the job done :) #TwitJC

@DrVes: Right. Different from what we typically do here, e.g. discuss every detail of a recent (very recent) article, focused on one topic.

Related reading:

Twitter Journal Club: yet another ‘revolution’ in scientific communication? BMJ http://t.co/NrB7KAJ - Any plans for Google+ Journal Club now?

Virtual Journal Club for Hospital Medicine by the Washington University in St. Louis

International Urology Journal Club via Twitter: 12-Month Experience http://buff.ly/NErFFk
Surgical Opinion: Keys to a Successful International Journal Club on Twitter http://buff.ly/NErPwl

First Gunshot Victim in the New World - National Geographic Video

Archaeologists in Peru have discovered the 500-year-old skeleton of a man who died from a gunshot wound. Experts believe he's the first shooting victim in the New World.