AIMS:Selective cyclooxygenase (COX)-2 inhibitors have recently been implicated as enhancing risk of myocardial infarction (MI). Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective COX-2 inhibitors, so we investigated the hypothesis that they too increase risk of MI. METHODS:We conducted a case-control study with direct structured interview of cases and controls. Cases were all subjects (N = 205) with a first nonfatal MI who had no previously recognized cardiovascular disease. Community controls (N = 258) were randomly selected from the same practice as the index case. Hospital controls (N = 205) were those admitted at the same time as index cases for nonmyocardial conditions not influenced by NSAID use. The effects of aspirin, NSAIDs and previously recognized influences on MI were investigated by unconditional logistic regression analysis. RESULTS:NSAID use was associated with an increase risk of MI with an odds ratio of 1.77 (1.03, 3.03) vs. community controls and 2.61 (1.38, 4.95) vs. hospital controls. These values were 5.00 (1.18, 21.28) and 7.66 (0.87, 67.48), respectively, in aspirin users. Results were similar when naproxen was grouped with aspirin. Odds ratios for smoking and for use of antidiabetic medication were 3.91 (2.52, 6.04) and 3.92 (1.25, 12,33), respectively, vs. community controls. CONCLUSIONS:Like selective COX-2 inhibitors, non-selective NSAIDs [corrected] are associated with an increased risk of MI. The extent to which this reflects interference with aspirin warrants further investigation.

Aim:To investigate the role of Helicobacter pylori, expressing the virulence marker CAGA (cytotoxin associated gene product A) in ulcer complications and its interaction with nonsteroidal anti‐inflammatory drugs (NSAIDs) and other risk factors.Design:Case control study using conditional logistic regression analysis.Setting:University and City Hospitals, Nottingham.Subjects:203 consecutive patients with ulcer bleeding and 203 age‐ and sex‐matched controls.Results:Ulcer bleeding was more likely with positive H. pylori serology (odds ratio = 3.3, 95% CI: 1.7–6.6 for CagA positive, but only OR = 1.6, 95% CI: 0.7–3.7 for CagA negative serology), current smoking (OR 2.2, 95% CI: 1.04–4.7), aspirin ≤ 300 mg daily (OR 7.7, 95% CI: 2.8–20.6), all other nonsteroidal anti‐inflammatory drugs (NSAIDs: OR 10.6, 95% CI: 3.1–35.7 for ≤ 1 defined daily dose lower and OR 22.6, 95% CI: 6.2–82.0 for higher doses) and past ulcer history (OR 5.6, 95% CI: 2.3–14.1). Aspirin ≤ 300 mg daily was used by 25.1% of patients vs. 7.4% of controls. Smoking only enhanced risk in the presence of H. pylori, with a synergistic interaction (interaction odds ratio = 4.9, 2.4–9.9, P=0.002). Conversely, risks with non‐aspirin NSAIDs were reduced in the presence of H. pylori, particularly if CagA‐positive (interaction odds ratio=0.21, 0.05–0.9, P=0.03).Conclusions:CagA positive H. pylori infection is associated with an increased risk of ulcer bleeding. The risk from non‐aspirin NSAIDs is even higher, but is less in H. pylori infected people. Low‐dose aspirin is now commonly associated with ulcer bleeding.

INTRODUCTIONPharmacotherapy for upper gastrointestinal bleeding has been difficult to evaluate because clinical end points are infrequent and affected by other factors.AIMSTo evaluate whether blood in the stomach at endoscopy reflected severity of bleeding, predicted clinical outcomes, and could be altered by therapeutic agents.METHODSWe studied 414 consecutive admissions with suspected upper gastrointestinal bleeding. Patients were randomised to receive lansoprazole 60 mg followed by 30 mg four times daily, tranexamic acid 2 g followed by 1 g four times daily, both drugs, or placebo for four days, until discharge or a clinical end point occurred. Logistic regression analysis was used to determine predictors of endoscopic changes and clinical outcomes, and to investigate the effects of drug treatments on blood in the stomach.RESULTSOf 414 patients with suspected upper gastrointestinal bleeding, 379 were endoscoped. Upper gastrointestinal bleeding was confirmed in 316. Sixteen required surgery within 30 days and 16 died on the index admission. Trial treatments were evaluable on a per protocol basis in 228 patients. The amount of blood in the stomach was found to reflect initial risk, with significant associations with high risk categorisation (odds ratio 3.7 (95% confidence interval 1.5–9.4) for more than a trace v none/trace), age (1.5 (1.1–1.9) per decade), and initial pulse (1.02 (1.00–1.04) per beat), and to predict rebleeding (9.2 (4.6–18.7)) and surgery (8.2 (2.9–22.9)). Other stigmata were less significant in these respects. The amount of blood in the stomach at endoscopy was reduced significantly by both lansoprazole (0.22 (0.07–0.63)) and tranexamic acid (0.27 (0.09–0.81)), although there was no evidence of synergy.CONCLUSIONSBlood in the stomach reflects clinical features in patients with acute upper gastrointestinal bleeding and is reduced by treatment with lansoprazole and tranexamic acid.

Background: one-week triple therapy regimen combining a PPI with two antibiotics is frequently recommended as first intent treatment to eradicate H pylori. Data on a 7-day regimen based on RBC and two antibiotics show high eradication rates.Aim: to compare a 7-day course of RBC or Omeprazole and two antibiotics in eradicating Hp and healing duodenal ulcers (DU) Methods: patients with Hp + active DU were included in a randomized, controlled, multicentre study.Hp status was assessed by means of rapid urease test and histology (2 biopsies from the antrum and 2 from the corpus) at index endoscopy and one months after treatment.Patients were randomized to: RBC 400 mg bid + Amoxycillin 1 g bid + Clarithromycin 500 mg bid for 7 days (group A) or to Omeprazole 20 mg bid + Amoxycillin 1 g bid + Clarithromycin 500 mg bid for 7 days (group B).Hp eradication was defined if all tests performed were negative.Results: 61 patients (45 males, mean age 44.2 years, range 19-80) were included.The two groups had similar clinical and demographic features.Twenty-eight patients were enrolled in group A and 33 in group B. Sixteen patients (group A:I0; group B:6) dropped out of the study.Mean ulcer size was 8.5 mm (range 5-15).At per-protocol analysis, Hp was eradicated in 11/18 subjects of the group A (61%, C.I. 35-82) and in 20/27 of the group B (74%, C.I. 53-88)(p=0.276).No patient discontinued the treatment because of untoward effects; two complained of stomatits (1 in group A; I in group B).Ulcer healing was achieved in 18/18 patients (100%) in group A and in 27/28 patients in group B (96.4%).Conclusions: our preliminary data confirm that 7-day regimens with two antibiotics and Omeprazole or Ranitidine Bismuth Citrate are effective and safe in healing duodenal ulcers.The eradication rate with both regimens was far from optimal.

Background—Most ulcers are caused, one can deduce, by Helicobcter pylori or by use of non-steroidal anti-inflammatory drugs (NSAIDs). Whether both together are worse than one alone is something that is quite unknown. Aim—To study both factors in order to see whether they interact together positively. Method—A case control study of ulcer bleeding in elderly patients chosen without weeding. Results—NSAID usage increased risk substantially. So did H pylori infection (but relative risk less than three). Neither seemed to interact. Their actions were discretely intact. Conclusion—H pylori effects ulcer bleeding in an adverse manner but does not make the risk of NSAIDs worse.

Introduction Since acid suppression and inhibition of fibrinolysis may improve outcome in established upper gastrointestinal bleeding; we tested whether lansoprazole (LAId) or tranexamic acid (TRAN3, alone and in combination, reduced bleeding evident at endoscopy in uoseleeted patients admitted because of a history of haematemesis or melaena. Methods: 414 patients were randomised to treatment with lansoprazole (60rag then 30rag qds), tranexamic acid (1.5 g then 1 g qds) both drugs or placebo for up to 4 days. 228 patients met eligibility requirements and were considered to have had a definite upper GI bleed. Logistic regression analysis was used to identified significant determinants of finding blood in the stomach(vs none/trace) at endoscopy. Re~ult~ Endoscopy was at 19h (median, IQR 12-23) after admission. High risk patients (old, shocked or liver disease) were 3.04 times (95% CI I. 168.01, p=0.024) more likely to have blood than other patients. The odds ratio increased by 0.03 (0-0.06) for each year of age (t)=0.021) and by 0.02 (95% CI 0-0.04) for each beat per minute of the initial pulse (p=0.070). Percenta~,e of oatients with blood in the stomach Placebo LAN TRAN Both % with blood 35.2% (19/54) 15.5%(9/58) 19,3%(11/57) 19%(11/58) Odds ratio 1 0.14 0.30 0.26 95% CI NA (0.05-0.43) (0.11-0.85) (0.09-0.76 p vs placebo NA 0.0006 0.024 0.014 Compared with 1, treatment with 5 or more doses reduced the probability of finding blood in the stomach (p=0.001, odds ratio 0.08(0.02-0.35)). No differences between groups was observed in deaths up to 30 days (4.3% (18/414) overall, 2.2%(5/228) in definite bleeds) or adverse events. CONCLUSION: This study shows that acid inhibition with lansoprazole and inhibition of fibrinolysis by tranexamic acid can influence established upper GI bleeding but whether there is synergism with both treatments is less dear. ROLE OF HELICOBACTER PYLOR[ IN CHRONIC GASTRITIS. R.Colin, A.Cortot, M.D.Diebold, S.Richardson, M.A.Bigard, Rouen CHU-Franee.

Twelve patient information leaflets concerning common gastrointestinal diseases were produced by the British Digestive Foundation and evaluated to determine whether patients knew more about their disease if they received a leaflet. Eleven hundred and fifty patients attending gastroenterology clinics in the United Kingdom were assessed by postal questionnaire of whom half had received a leaflet relevant to their diagnosis six weeks before assessment. Seven hundred and fifty one replied (398 leafleted, 353 non-leafleted). Most patients found the leaflets helpful and easy to understand; few found them worrying. They were regarded as a better source of information than doctors, particularly for information about the characteristics of the illness and side effects of treatment. In all diagnostic groups assessed the patients' knowledge of their disease was significantly greater if they had received a leaflet than if they had not. Individual responses by patients without leaflets showed that fundamental misconceptions persisted about digestive diseases. The British Digestive Foundation leaflets are an effective means of imparting disease related information to patients.