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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 &lt, 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 (&lt, 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.

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.

BACKGROUND & AIMS: After a first Helicobacter pylori eradication attempt, approximately 20% of patients will remain infected. The aim of the current study was to assess the effectiveness and safety of second-line empiric treatment in Europe. METHODS: This international, multicenter, prospective, noninterventional registry aimed to evaluate the decisions and outcomes of H pylori management by European gastroenterologists. All infected adult cases with a previous eradication treatment attempt were registered with the Spanish Association of Gastroenterology-Research Electronic Data Capture until February 2021. Patients allergic to penicillin and those who received susceptibility-guided therapy were excluded. Data monitoring was performed to ensure data quality. RESULTS: Overall, 5055 patients received empiric second-line treatment. Triple therapy with amoxicillin and levofloxacin was prescribed most commonly (33%). The overall effectiveness was 82% by modified intention-to-treat analysis and 83% in the per-protocol population. After failure of first-line clarithromycin-containing treatment, optimal eradication (>90%) was obtained with moxifloxacin-containing triple therapy or levofloxacin-containing quadruple therapy (with bismuth). In patients receiving triple therapy containing levofloxacin or moxifloxacin, and levofloxacin-bismuth quadruple treatment, cure rates were optimized with 14-day regimens using high doses of proton pump inhibitors. However, 3-in-1 single capsule or levofloxacin-bismuth quadruple therapy produced reliable eradication rates regardless of proton pump inhibitor dose, duration of therapy, or previous first-line treatment. The overall incidence of adverse events was 28%, and most (85%) were mild. Three patients developed serious adverse events (0.3%) requiring hospitalization. CONCLUSIONS: Empiric second-line regimens including 14-day quinolone triple therapies, 14-day levofloxacin-bismuth quadruple therapy, 14-day tetracycline-bismuth classic quadruple therapy, and 10-day bismuth quadruple therapy (as a single capsule) provided optimal effectiveness. However, many other second-line treatments evaluated reported low eradication rates. ClincialTrials.gov number: NCT02328131.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented disruptions in fellowship training programs worldwide. In gastroenterology, the strain in healthcare service provision and the emphasis on preventing viral transmission has adversely impacted hands-on training opportunities, with trainees facing the constant pressure to meet training requirements under the continuous threat of viral transmission. Emerging evidence highlight the scale of the problem, specifically with regard to endoscopy competence due to cancellation of elective endoscopic procedures, provision of inpatient and outpatient consultative care as well as academic education and the mental well-being of trainees. As such, it has been necessary for trainees, trainers and training programs collectively to adapt to these challenges and incorporate novel and adaptive solutions to circumvent these training barriers. This review aims to summarise data on the global impact of COVID-19 on gastroenterology training and the practical interventions that could be implemented. (Acta gastroenterol. belg., 2021, 84, 627-635).

Helicobacter pylori (Hp) management has undoubtedly resulted in a notable economic burden on healthcare systems globally, including Greece. Its cost has never been estimated so far, especially during the recent 10-year unprecedented financial crisis. Direct medical and procedural costs for one attempt “outpatient” Hp eradication treatment were estimated as the following: (I) first-line regimens: 10 and 14 days standard triple, 10 and 14 days sequential, 10 and 14 days concomitant non-bismuth quadruple, 14 days hybrid, (II) second-line salvage regimens: 10 and 14 days levofloxacin-containing triple regimens. Treatment costs using prototypes and/or generic drugs were calculated. Drug prices were collected and confirmed from two official online medical databases including all medicines approved by the Greek National Organization for Medicines. Regimens based on generics were more affordable than prototypes and those including pantoprazole yielded the lowest prices (mean: 27.84 €). Paradoxically, 10-day concomitant and 14-day hybrid regimens (currently providing good (90–94%) first-line eradication rates in Greece) cost the same (mean: 34.76 €). The expenditures for Hp eradication treatment regimens were estimated thoroughly for the first time in Greece. These data should be taken into account by Public Health policymakers both in Greece and the European Union, aiming for a better and less expensive therapeutic approach. © 2020 by the authors. Licensee MDPI, Basel, Switzerland.

Introduction: Antibiotic resistance is the major factor affecting our ability to cure Helicobacter pylori infection. Quadruple therapy is currently recommended ; however, triple therapy with two antibiotics may be sufficient in those patients without clarithromycin resistance. Aims & Methods: To evaluate the effectiveness of the treatments according to the clarithromycin H. pylori resistance in Europe. International multicenter prospective non-interventional European Registry on H. pylori Management (Hp-EuReg) aiming to evaluate the decisions and outcomes of H. pylori infection. Infected adult patients diagnosed with culture registered at AEG-REDCap e- CRF from 2013 to 2019. Per-protocol (PP) analysis was performed based on the presence or absence of clarithromycin bacterial resistance. Results: Overall, 5, 036 patients were included: 1, 747 (35%) were resistant and 3, 289 (65%) sensitive to clarithromycin. The overall eradication rate was higher in clarithromycin-susceptible patients (91% vs. 84% ; p< 0.001). Triple therapy with a PPI, clarithromycin and amoxicillin achieved over 90% eradication rates in clarithromycin- susceptible patients. However, in those with clarithromycin- resistance, optimal effectiveness was only achieved when treated with quadruple therapy with a PPI, clarithromycin, amoxicillin and bismuth. Conclusion: Classic triple therapy with a PPI, clarithromycin and amoxicillin achieves optimal results (>90%) in patients susceptible to clarithromycin. However, when clarithromycin resistance is unknown, quadruple therapy with a PPI, clarithromycin, amoxicillin and bismuth may be a better treatment option.

Introduction: Antibiotic resistance is the major factor affecting our ability to cure Helicobacter pylori infection. Understanding the different H. pylori antibiotic resistances could be the key to improve treatment effectiveness. Aims & Methods: To evaluate the H. pylori antibiotic resistance both prior and after one or several eradication treatments, in order to provide the most appropriate recommendations for the eradication of H. pylori. International multicenter prospective non-interventional European Regis-try on H. pylori Management (Hp- EuReg) aiming to evaluate the decisions and outcomes of H. pylori infection by European gastroenterologists. Infected adult patients diagnosed with culture and with a result of the antibiotic resistance test registered at AEG- REDCap e-CRF from 2013 to 2019. Per-protocol (PP) analysis was performed. The antibiotic bacterial resistances were described by treatment line. Results: A total of 32, 447 patients were included, and culture was performed in 3, 474 (11%). In naïve patients, 21% reported single clarithromycin resistance, and 11% dual (clarithromycin and metronidazole) resistance. Antibiotic resistance increased markedly from the first treatment, reaching over 37% dual resistance in second-line treatment. Conclusion: In Europe, culture testing to determine antibiotic resistance against H. pylori is scarce. H. pylori single clarithromycin resistance remains high (>15%) in all treatment lines, and greater than 20% in naïve patients. Dual or triple resistances are frequent and increase remarkably after the first treatment failure. Resistance to amoxicillin or tetracycline is exceptional.

Introduction: Bacterial antibiotic resistance changes over time based on multiple factors. It is essential to study these trends to apply preventive strategies to help reducing such resistances.Aims & Methods: To conduct a time-trend analysis of the antibiotic resistance to H. pylori infection in the European Registry on H. pylori (Hp-EuReg). International multicenter prospective non- interventional European Registry on H. pylori Management (Hp-EuReg) aiming to evaluate the decisions and outcomes of H. pylori infection by European gastroenterologists. All infected adult patients diagnosed with culture and with a result of the antibiotic resistance test were registered at AEG-REDCap e-CRF from 2013 to 2019.Results: A total of 32, 447 patients were included, and culture was performed in 3, 474 (11%), where 2, 483 näive patients were included for analysis. Resistance to at least one antibiotic was described in 57% of the patients. Resistance to metronidazole (27%) was most frequent, whereas resistance to tetracycline and amoxicillin was below 1%. Clarithromycin resistance remained above 15% throughout the studied years. A significant decrease in the metronidazole resistance rate was observed between 2013 (38%) and 2018 (21%).Conclusion: In naïve patients, resistance to clarithromycin remained above 15% in the period 2013-2019. A progressive decrease in metronidazole resistance was observed. No increasing or decreasing trend was observed in the bacterial resistance to other antibiotics.

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 most frequently prescribed first-line treatments were as follows: PPI + C + M (n = 285) and PPI + B + T + M (classic or Pylera(R); n = 250). In first line, the efficacy of PPI + C + M was 69%, while PPI + B + T + M reached 91% (P < .001). In second line, after the failure of PPI + C + M, two rescue options showed similar efficacy: PPI + B + T + M (78%) and PPI + C + levofloxacin (L) (71%) (P > .05). In third line, after the failure of PPI + C + M and PPI + C + L, PPI + B + T + M was successful in 75% of cases. Conclusion In patients allergic to penicillin, a triple combination with PPI + C + M should not be generally recommended as a first-line treatment, while a quadruple regimen with PPI + B + T + M seems to be a better option. As a rescue treatment, this quadruple regimen (if not previously prescribed) or a triple regimen with PPI + C + L could be used but achieved suboptimal (

Introduction: The best approach for Helicobacter pylori management remains unclear. An audit process is essential to ensure clinical practice is aligned with best standards of care.Aims & Methods: International 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 up to April 2020. Variables included: demographics, previous eradication attempts, prescribed treatment, adverse events, and outcomes. Modified intention-to-treat (mITT) and per-protocol (PP) analyses were performed and data were subject to quality review to ensure information reliability.Results: In total 36, 319 patients from 29 European countries were evaluated and 24, 882 (70%) first-line empirical H. pylori treatments were included for analysis. Triple therapy with amoxicillin and clarithromycin was most commonly prescribed (40%), followed by concomitant treatment (19%) and bismuth quadruple (Pylera®) (10%) achieving 83%, 91% and 95% mITT eradication rate, respectively. Over 90% effectiveness was obtained only with 10 and 14-day bismuth quadruple or 14-day concomitant treatment (Table). Longer treatment duration, higher acid inhibition and compliance were associated with higher eradication rates.Conclusion: Management of H. pylori infection by European gastroenterologists is heterogeneous. Only quadruple therapies lasting at least ten days are able to achieve over 90% eradication rates.

Management of Helicobacter pylori infection is evolving and in this 4th edition of the Maastricht consensus report aspects related to the clinical role of H pylori were looked at again in 2010. In the 4th Maastricht/Florence Consensus Conference 44 experts from 24 countries took active part and examined key clinical aspects in three subdivided workshops: (1) Indications and contraindications for diagnosis and treatment, focusing on dyspepsia, non-steroidal anti-inflammatory drugs or aspirin use, gastro-oesophageal reflux disease and extraintestinal manifestations of the infection. (2) Diagnostic tests and treatment of infection. (3) Prevention of gastric cancer and other complications. The results of the individual workshops were submitted to a final consensus voting to all participants. Recommendations are provided on the basis of the best current evidence and plausibility to guide doctors involved in the management of this infection associated with various clinical conditions.

Background To date it is not known whether gastric juice vitamin C levels are influenced by Helicobacter pylori CagA(+) strains. The aim of the present study, therefore, was to study the impact of H. pylori CagA status on gastric juice vitamin C levels. Materials and methods We studied 30 H. pylori(+) patients, and the results were compared with 10 endoscopically and histologically normal H. pylori(−) subjects (control group) who were similar to the H. pylori(+) group in terms of age and sex. In all patients, gastric juice vitamin C levels were determined and the severity of gastritis was graded on a scale of 0 (absent) to 3 (severe). CagA was determined by immunoblotting the sera from patients against H. pylori antigens. Results Among 30 H. pylori(+) patients, 20 were CagA(+) and 10 CagA(−). In the entire group of H. pylori(+) patients, the median gastric juice vitamin C levels (mg L−1) were 16.35 (range 3.5–33.6) and were significantly lower (P

A system-of-systems (SoS) approach for wavelength-division multiplexing (WDM) and time-division multiplexing (TDM) fiber-to-the-home (FTTH) telecommunication networks is presented. Cost evolution curves for individual systems as well for whole FTTH WDM and TDM networks are presented. The analysis can be exploited for a fast and accurate analysis of FTTH deployment costs in dense urban, urban, and suburban areas from the technoeconomic point of view, which is of paramount importance for telecom operators, equipment vendors, regulators, and policy makers. The impact of delaying the deployments or adopting different rollout strategies is also investigated and presented. The SoS emergent behavior is further revealed using exploratory modeling. The results reveal that in all cases, the WDM solution is more expensive than TDM. The total cost for suburban areas is almost six times higher than in dense urban areas and four times than urban areas. © 2012 IEEE.

The deployment of next generation access networks (NGAs) is investigated from technical, regulatory and investment perspectives. A brief review of the possible network architectures and deployment scenarios of NGAs is provided. Risk calculations of these NGA scenarios are performed based on a fully detailed techno-economic model. Furthermore, the effectiveness of the European Commission's Recommendation on regulated access to NGAs, aiming to tackle the regulatory trade-off between encouraging investments and promoting competition, is discussed. © 2012 IEEE.

Idiopathic pulmonary haemosiderosis is a rare disease of unknown autoimmune aetiology, mainly affecting children and adolescents. A variety of coexisting autoimmune diseases have been described, including coeliac disease. We describe the case of a man, aged 19 yrs, presenting with a one year history of recurrent haemoptysis. Gluten and gliadin antibodies were positive, and the jejunal biopsy revealed villous atrophy consistent with the diagnosis of coeliac disease. Bronchoalveolar lavage fluid analysis showed a mean haemosiderin score (Golde index) of 240, and a local suppressor/cytotoxic profile on immunocytology. Both clinical and immunological improvement was obtained after a month of gluten-free diet. These immunological findings provide new insight into the pathogenesis of this disease.

Passive optical networks (PONs) are being widely considered as a means to implement fiber-to-the-home (FTTH) and deliver broadband access to business and home users. However, technical and consequently regulatory and economic complexities arise in light of their deployment. In this paper, an evaluation of the business prospects of time division multiplexed (TDM) and wavelength division multiplexed (WDM) PON architectures for FTTH deployments under different rollout conditions is performed, based on the ECOSYS techno-economic methodology and tool. The importance of various cost components (fiber installation, optoelectronic components, etc.) is discussed. Using sensitivity analysis, the effect of various parameters such as duct availability, cost of civil works, etc. on the prospects of the investment are investigated. These results reveal several important techno-economic aspects that should be considered by telecom operators, regulators, and policy makers towards a successful FTTH deployment strategy. © 2010 Optical Society of America.

Due to the increasing demand in data rates telecom operators are faced with the question of when to upgrade their access network infrastructure toward fiber-to-the-home (FTTH). In this paper a techno-economic study of fiber-to-the-cabinet/very high bit rate digital subscriber line (FTTC/VDSL) and FTTH deployments is performed. The economics and risks associated with the incumbents decision to invest in dense urban and urban areas are analyzed using both discount cash flow (DCF) analysis and real options analysis (ROA). The results revealed that in the case of investment subsidization, the option value to expand in a later phase can significantly improve the financial metrics of the business cases. The analysis made is based on the ECOSYS techno-economic methodology and tool. © 2009 OSA.