1614
hospital and did not go outside during or after the PDT. The unusually strong reaction in adjacent skin could, to some extent, at least be a result of enhanced penetration of ALA through the damaged skin of XP because ALA in aqueous solution passes readily through abnormal, but not through normal, keratin.5 The mechanism of the delayed but persistent reaction to PDT remains unclear, just as the abnormal UVR-induced erythema production is not understood in XP. It cannot be explained by the DNA-repair defect in XP cells because the main target of PDT is cell membranes rather than DNARepair does not seem to be a significant factor when PDT is applied to XP cells; cell inactivation by PDT in vitro was found to be equally effective in DNA-repair efficient and deficient cells.’ In this case topical PDT was successful; the delayed, but enhanced phototoxic reaction of adjacent normal skin to PDT suggests that care should be exercised when considering systemic PDT in XP. PDT with haematoporphyrin derivative or ’Photofrin II’ in XP could be associated with unexpectedly strong and much more persistent photosensitivity than that seen normally. Department of Dermatology, University of Graz, A-8036 Graz, Austria
PETER WOLF HELMUT KERL
significantly
lower in group A than in groups B and C combined
(p < 0’001), whereas no significant difference was observed between group B and group C: DU relapses in group:
ABC
22/39 (6 %)
3/30 (10%))
33/75 (44 % )
The results of this study confirm that long-term eradication of H pylori prevents ulcer recurrence, whereas clearance in the immediate post-treatment period without long-term eradication does not.
physicians who took part in this trial: G. Minoli Hospital, Como); A. Prada and P. G. Mandelli (Regional Hospital, Rho); U. Comin and A. M. Fertitta (C. Cantu’ Hospital, Abbiategrasso); F. Turpini, L. Villani (University of Pavia); L. Piazzi and V. Colombetti (Regional Hospital, Bolzano); S. Gullini and L. Cavazzini (S Anna Hospital, Ferrara); M. Curzio and M. Comaggia (Multizonal Hospital, Varese); S. Brunati and R. Negri (Fomaroli Hospital, Magenta); and P. Bodini and G. Bertoli (Regional Hospital, Cremona). We thank the following and V. Terruzzi (Valduce
Department of Human Pathology, University of Pavia, 27100 Pavia, Italy,
R. FIOCCA E. SOLCIA
and Policlinico S Matteo, Pavia Gist-Brocades Farma, Cologno Mon.
B. SANTORO
1. Kraemer KH. Xeroderma 2.
3. 4. 5.
6.
7.
pigmentosum. In: Demis DJ, ed. Clinical dermatology. Philadelphia: Lippincott, 1990; 4, unit 19-7: 1-33. Dougherty TJ. Photosensitizers therapy and detection of malignant tumors. Photochem Photobiol 1987; 45: 879-89. Manyak MJ, Russo A, Smith PD, Glatstein E. Photodynamic therapy J Clin Oncol 1988; 6: 380-91. Robinson PJ, Carruth JAS, Fairris GM. Photodynamic therapy: a better treatment for widespread Bowen’s disease. Br J Dermatol 1988; 119: 59-61. Kennedy JC, Pottier RH, Pross DC. Photodynamic therapy with endogenous protoporphyrin IX: basic principles and present clinical experience. J Photochem Photobiol B Biol 1990; 6: 143-48. Kondo S, Mamada A, Miyamoto C, Keong CH, Satoh Y, Fujiwara Y. Late onset of skin cancers in 2 xeroderma pigmentosum group F siblings and a review of 30 Japanese xeroderma pigmentosum patients in groups D, E and F. Photodermatology 1989; 6: 89-95. Gomer CJ, Rucker N, Murphree AL Differential cell photosensitivity following porphyrin photodynamic therapy. Cancer Res 1988; 48: 4539-42.
Duodenal ulcer relapse after eradication of Helicobacter pylori SIR,-Evidence has been accumulating suggesting a close connection between duodenal ulcer (DU) and Helicobacter pylori infection of the stomach. Three studies1-3 have shown that H pylori status after treatment may predict DU recurrence: the frequency of ulcer relapse ranged from 79% to 89% in Hpylori positive and from 0 to 27% in H pylori negative cases of healed DU. In a multicentre, prospective study we evaluated recurrences in 144 patients with H pylori positive DU, healed after antibacterial and/or anti-secretory drug therapy and followed up for six months. After the first endoscopy, with two antral and two corpus biopsies, 167 males and 94 females were enrolled on the basis of both a positive urease test and histologically detected H pylori. They were randomly assigned to four treatment groups: (1) colloidal bismuth subcitrate (’DeNol’; two tablets twice daily for 6 weeks; (2) colloidal bismuth (as above) plus amoxycillin 1 g twice daily for 10 days; (3) ranitidine 300 mg at night for 6 weeks; or (4) ranitidine (as above) plus amoxycillin 1 g twice daily for 10 days. 244 patients completed treatment and were re-examined 6 weeks later by endoscopy with multiple biopsies. Ulcers had healed in 89 of 97 H pylori cleared patients and in 117 of the 147 patients who still had H pylori (p 0-01). No maintenance therapy was given and 144 of the 206 initially healed patients were re-examined six months later. Relapse rates were 44% (16/36) in patients treated with bismuth alone, 28% (11/39) in those on bismuth plus amoxycillin; 53% (20/38) in patients allocated to ranitidine alone; and 35% (11/31) in those on ranitidine plus amoxycillin. We also calculated relapse rates another way, by categorising patients as: (A) Hpylori "cleared/eradicated" (free of H pylori at 6 weeks and at 6 months); (B) "cleared/not eradicated" (free at 6 weeks but positive at 6 months); and (C) "not cleared/not eradicated" (H pylori colonisation at 6 weeks and at 6 months). The DU relapse rate was =
1.
Coghlan JG, Gilligan D, Humphries H, et al. Campylobacter pylori and recurrence of duodenal ulcers. a 12-month follow-up study. Lancet 1987; ii: 1109-11. 2. Marshall BJ, Goodwin CS, Warren JR, et al. Prospective double-blind trial of duodenal ulcer relapse after eradication of Campylobacter pylori. Lancet 1988; ii 1437-41. 3. Rauws EAJ, Tytgat GNJ. Cure of duodenal ulcer associated with eradication of Helicobacter pylori. Lancet 1990; 335: 1233-35.
Imported heterosexual HIV infection in London SIR,-In the UK the main source of information on numbers of heterosexuals with HIV infection is the Communicable Disease Surveillance Centre (CDSC), which collates data from physicians looking after AID S patients and from laboratories that test for HIV antibody. CDSC lists heterosexuals by exposure category. Injecting drug users (ID Us) and their sexual contacts make up the largest group but there is no breakdown into UK nationals and those from abroad. After haemophiliacs, the largest category is "other partner abroad". Although the CDSC states that this figure "includes persons from, or who have lived in, WHO transmission pattern II countries", the wording implies that most of this category are residents of the UK. A CDSC paper on travel, heterosexual intercourse, and HIV-1 infection! concentrates on the need for identification of these travellers and their health education. People with HIV infection are seen at St Thomas’ Hospital in the drug dependency unit, the haemophilia centre, or in a dedicated outpatient HIV unit attached to the department of genitourinary medicine. Out of 548 HIV-antibody-positive patients who have attended the outpatient HIV unit up to May, 1991, we have identified and reviewed the case-notes of 113 heterosexuals. 17 (15%) had had an AID S-defining illness; 8 were IDUs (all foreign), 8 were Africans, and 1 was a foreign contact of an IDU. The 113 patients consisted of 52 IDUs, 13 contacts of IDUs, 39 other partner abroad (34 Africans), 2 contacts of bisexual men, 2 recipients of blood transfusion in Africa, 1 contact of an African living in the UK, 1 haemophiliac, 1 contact of a blood transfusion patient in the UK, and 2 patients for whom risk factors have not yet been established: Risk factor
High-risk partner Other partner abroad Other partner UK Under investigation
Injecting drug use Blood factor Blood transfer
20 of the 52 IDUs ten other countries,
were
No 16 39 1 2 52 1 2
bom in the UK. The others
including Italy (13) and Eire (6). 5
°
came from of 13 contacts
hospital and did not go outside during or after the PDT. The unusually strong reaction in adjacent skin could, to some extent, at least be a result of enhanced penetration of ALA through the damaged skin of XP because ALA in aqueous solution passes readily through abnormal, but not through normal, keratin.5 The mechanism of the delayed but persistent reaction to PDT remains unclear, just as the abnormal UVR-induced erythema production is not understood in XP. It cannot be explained by the DNA-repair defect in XP cells because the main target of PDT is cell membranes rather than DNARepair does not seem to be a significant factor when PDT is applied to XP cells; cell inactivation by PDT in vitro was found to be equally effective in DNA-repair efficient and deficient cells.’ In this case topical PDT was successful; the delayed, but enhanced phototoxic reaction of adjacent normal skin to PDT suggests that care should be exercised when considering systemic PDT in XP. PDT with haematoporphyrin derivative or ’Photofrin II’ in XP could be associated with unexpectedly strong and much more persistent photosensitivity than that seen normally. Department of Dermatology, University of Graz, A-8036 Graz, Austria
PETER WOLF HELMUT KERL
significantly
lower in group A than in groups B and C combined
(p < 0’001), whereas no significant difference was observed between group B and group C: DU relapses in group:
ABC
22/39 (6 %)
3/30 (10%))
33/75 (44 % )
The results of this study confirm that long-term eradication of H pylori prevents ulcer recurrence, whereas clearance in the immediate post-treatment period without long-term eradication does not.
physicians who took part in this trial: G. Minoli Hospital, Como); A. Prada and P. G. Mandelli (Regional Hospital, Rho); U. Comin and A. M. Fertitta (C. Cantu’ Hospital, Abbiategrasso); F. Turpini, L. Villani (University of Pavia); L. Piazzi and V. Colombetti (Regional Hospital, Bolzano); S. Gullini and L. Cavazzini (S Anna Hospital, Ferrara); M. Curzio and M. Comaggia (Multizonal Hospital, Varese); S. Brunati and R. Negri (Fomaroli Hospital, Magenta); and P. Bodini and G. Bertoli (Regional Hospital, Cremona). We thank the following and V. Terruzzi (Valduce
Department of Human Pathology, University of Pavia, 27100 Pavia, Italy,
R. FIOCCA E. SOLCIA
and Policlinico S Matteo, Pavia Gist-Brocades Farma, Cologno Mon.
B. SANTORO
1. Kraemer KH. Xeroderma 2.
3. 4. 5.
6.
7.
pigmentosum. In: Demis DJ, ed. Clinical dermatology. Philadelphia: Lippincott, 1990; 4, unit 19-7: 1-33. Dougherty TJ. Photosensitizers therapy and detection of malignant tumors. Photochem Photobiol 1987; 45: 879-89. Manyak MJ, Russo A, Smith PD, Glatstein E. Photodynamic therapy J Clin Oncol 1988; 6: 380-91. Robinson PJ, Carruth JAS, Fairris GM. Photodynamic therapy: a better treatment for widespread Bowen’s disease. Br J Dermatol 1988; 119: 59-61. Kennedy JC, Pottier RH, Pross DC. Photodynamic therapy with endogenous protoporphyrin IX: basic principles and present clinical experience. J Photochem Photobiol B Biol 1990; 6: 143-48. Kondo S, Mamada A, Miyamoto C, Keong CH, Satoh Y, Fujiwara Y. Late onset of skin cancers in 2 xeroderma pigmentosum group F siblings and a review of 30 Japanese xeroderma pigmentosum patients in groups D, E and F. Photodermatology 1989; 6: 89-95. Gomer CJ, Rucker N, Murphree AL Differential cell photosensitivity following porphyrin photodynamic therapy. Cancer Res 1988; 48: 4539-42.
Duodenal ulcer relapse after eradication of Helicobacter pylori SIR,-Evidence has been accumulating suggesting a close connection between duodenal ulcer (DU) and Helicobacter pylori infection of the stomach. Three studies1-3 have shown that H pylori status after treatment may predict DU recurrence: the frequency of ulcer relapse ranged from 79% to 89% in Hpylori positive and from 0 to 27% in H pylori negative cases of healed DU. In a multicentre, prospective study we evaluated recurrences in 144 patients with H pylori positive DU, healed after antibacterial and/or anti-secretory drug therapy and followed up for six months. After the first endoscopy, with two antral and two corpus biopsies, 167 males and 94 females were enrolled on the basis of both a positive urease test and histologically detected H pylori. They were randomly assigned to four treatment groups: (1) colloidal bismuth subcitrate (’DeNol’; two tablets twice daily for 6 weeks; (2) colloidal bismuth (as above) plus amoxycillin 1 g twice daily for 10 days; (3) ranitidine 300 mg at night for 6 weeks; or (4) ranitidine (as above) plus amoxycillin 1 g twice daily for 10 days. 244 patients completed treatment and were re-examined 6 weeks later by endoscopy with multiple biopsies. Ulcers had healed in 89 of 97 H pylori cleared patients and in 117 of the 147 patients who still had H pylori (p 0-01). No maintenance therapy was given and 144 of the 206 initially healed patients were re-examined six months later. Relapse rates were 44% (16/36) in patients treated with bismuth alone, 28% (11/39) in those on bismuth plus amoxycillin; 53% (20/38) in patients allocated to ranitidine alone; and 35% (11/31) in those on ranitidine plus amoxycillin. We also calculated relapse rates another way, by categorising patients as: (A) Hpylori "cleared/eradicated" (free of H pylori at 6 weeks and at 6 months); (B) "cleared/not eradicated" (free at 6 weeks but positive at 6 months); and (C) "not cleared/not eradicated" (H pylori colonisation at 6 weeks and at 6 months). The DU relapse rate was =
1.
Coghlan JG, Gilligan D, Humphries H, et al. Campylobacter pylori and recurrence of duodenal ulcers. a 12-month follow-up study. Lancet 1987; ii: 1109-11. 2. Marshall BJ, Goodwin CS, Warren JR, et al. Prospective double-blind trial of duodenal ulcer relapse after eradication of Campylobacter pylori. Lancet 1988; ii 1437-41. 3. Rauws EAJ, Tytgat GNJ. Cure of duodenal ulcer associated with eradication of Helicobacter pylori. Lancet 1990; 335: 1233-35.
Imported heterosexual HIV infection in London SIR,-In the UK the main source of information on numbers of heterosexuals with HIV infection is the Communicable Disease Surveillance Centre (CDSC), which collates data from physicians looking after AID S patients and from laboratories that test for HIV antibody. CDSC lists heterosexuals by exposure category. Injecting drug users (ID Us) and their sexual contacts make up the largest group but there is no breakdown into UK nationals and those from abroad. After haemophiliacs, the largest category is "other partner abroad". Although the CDSC states that this figure "includes persons from, or who have lived in, WHO transmission pattern II countries", the wording implies that most of this category are residents of the UK. A CDSC paper on travel, heterosexual intercourse, and HIV-1 infection! concentrates on the need for identification of these travellers and their health education. People with HIV infection are seen at St Thomas’ Hospital in the drug dependency unit, the haemophilia centre, or in a dedicated outpatient HIV unit attached to the department of genitourinary medicine. Out of 548 HIV-antibody-positive patients who have attended the outpatient HIV unit up to May, 1991, we have identified and reviewed the case-notes of 113 heterosexuals. 17 (15%) had had an AID S-defining illness; 8 were IDUs (all foreign), 8 were Africans, and 1 was a foreign contact of an IDU. The 113 patients consisted of 52 IDUs, 13 contacts of IDUs, 39 other partner abroad (34 Africans), 2 contacts of bisexual men, 2 recipients of blood transfusion in Africa, 1 contact of an African living in the UK, 1 haemophiliac, 1 contact of a blood transfusion patient in the UK, and 2 patients for whom risk factors have not yet been established: Risk factor
High-risk partner Other partner abroad Other partner UK Under investigation
Injecting drug use Blood factor Blood transfer
20 of the 52 IDUs ten other countries,
were
No 16 39 1 2 52 1 2
bom in the UK. The others
including Italy (13) and Eire (6). 5
°
came from of 13 contacts
