Cure can be Achieved by Conversion to Microwave Ablation following Atezolizumab-Bevacizumab Therapy in Unresectable Hepatocellular Carcinoma.

Introduction: Atezolizumab/bevacizumab is the recommended first-line systemic therapy for unresectable hepatocellular carcinoma (uHCC) and may facilitate curative conversion through resection and locoregional therapies. However, there have been very few reports on curative conversion using microwave ablation (MWA). This study aimed to determine the curative conversion rate with MWA using atezolizumab-bevacizumab as the first-line treatment in patients with uHCC, and to compare the characteristics and survival of patients with and without curative conversion. Methods: Consecutive patients with uHCC who were started on atezolizumab-bevacizumab from May 2021 and December 2023 in a single tertiary center were included. Objective response (ORR) and disease control rate (DCR) were based on the RECIST 1.1 and mRECIST criteria. Results: Twenty consecutive patients with uHCC (60% advanced-stage) were included, 90% exceeding the up-to-7 criteria. The ORR and DCR were 35% and 60%, and 35% and 55% using RECIST and mRECIST, respectively. Five (25%) patients underwent successful curative conversion with MWA (4 advanced and 1 intermediate stage) despite a median HCC size of 6.1 (range: 2.4-7.3) cm. Two of these patients were tumor and drug-free 132-133 weeks from the 1st atezolizumab-bevacizumab dose. Patients who underwent curative conversion had significantly longer survival than those who did not. (p=0.024) Other factors associated with survival were male sex, Child-Pugh class A, and an objective response. Conclusions: Despite the relatively large tumor size, successful curative conversion with MWA was achieved with first-line atezolizumab-bevacizumab in uHCC. However, data from prospective multicenter trials are required to determine whether this strategy is universally applicable.

Unchanging prevalence of late presentation to care among patients with chronic hepatitis B.

BACKGROUND AND STUDY AIMS: A recent consensus defines a delay in hepatitis B (HBV) diagnosis as presentation with late (hepatocellular carcinoma or decompensated cirrhosis) or advanced (fibrosis ≥ 3) stage disease. We aimed to determine the prevalence of late and advanced stage presentation among chronic HBV (CHB) patients and to determine factors associated with late and advanced stage presentation. METHODS: Consecutive CHB patients seen from 1 January 2007 to 31 December 2018 were included and analyzed on January 2019. Time periods were divided into 2 periods (2007-2012 vs. 2013-2018). Patients were also divided into "Presentation with late stage" and "Presentation with advanced stage," and compared with "timely HBV diagnosis." RESULTS: Out of the 782 patients, 138 (17.6%) presented with late stage while 67 (8.6%) presented with advanced stage, with no difference between the 2 time periods. Compared to patients with "timely HBV diagnosis," presentation with either late or advanced stage was more likely to be male, older, and diabetic patients, resorting to alcohol misuse and having abnormal liver chemistries (low albumin, high aspartate aminotransferase [AST], alanine aminotransferase [ALT], and international normalized ratio [INR]). Presentation with late stage liver disease was also associated with hepatitis B e antigen (HBeAg)-negative status and no family history of HBV. On multivariate analysis, male gender, older age, and alcohol misuse were associated with presentation with either late or advanced stage liver disease. CONCLUSIONS: A quarter of CHB patients already have significant liver injury at the time of initial HBV diagnosis. The fact that presentation with late or advanced disease has not changed in 12 years emphasizes the importance of universal screening in endemic countries.

Comparison of clinical and metabolic profiles of lean versus non-lean nonalcoholic fatty liver disease.

BACKGROUND: Data on nonalcoholic fatty liver disease (NAFLD) in the Philippines are scarce. We aimed to compare the clinical and biochemical profiles of lean (BMI<23) vs. non-lean (BMI≥23) NAFLD patients. METHODS: Consecutive patients diagnosed with NAFLD on ultrasound in two outpatient hepatology clinics from February 2007-January 2017 were included. Patients with significant alcohol intake, alternative causes of steatosis, and incomplete data were excluded. RESULTS: A total of 663 patients (57.9% male) were included. Most patients were non-lean (88.1%) and had an elevated alanine aminotransferase (ALT) (63%). Cirrhosis or hepatocellular carcinoma (HCC) were already present in 8.4% on initial consultation. Concomitant hepatitis B was equally common in patients with and without cirrhosis (20.7% vs. 17.5%; p=0.660) or HCC (17.9% vs. 12.8%; p=0.415). Independent factors associated with HCC/cirrhosis on initial consultation were older age (OR=1.038), low albumin (OR=0.428), high BARD score (BMI, AST/ALT ratio, T2 diabetes mellitus; OR=2.548) and the presence of symptoms (OR=1.808). Compared to lean NAFLD patients, non-lean patients were more likely to be younger (51.5±14.4 vs. 55±14.3; p=0.003), have DM (47.9% vs. 29.1%; p=0.002), hypertension (57.5% vs. 38%; p=0.001), dyslipidemia (73.1% vs. 54.4%; p=0.001) and metabolic syndrome (60.3% vs. 30.4%; p<0.0001), abnormal metabolic parameters (LDL-C, HDL-C, triglycerides, uric acid and FBS), and with elevated ALT (65.2% vs. 46.8%; p=0.002) and AST (41.1±29.6 vs. 35.3±28.3; p=0.008). CONCLUSIONS: The proportion of lean NAFLD was 11.9%. Although metabolic derangements and its clinical consequences were present in about a third of lean patients, these were still more common in non-lean NAFLD. Cirrhosis or HCC were already present in a significant proportion (8.4%) of NAFLD patients on initial presentation.

The 2014 Hepatology Society of the Philippines consensus statements on the diagnosis and treatment of hepatitis C

Hepatitis C virus (HCV) infection is a devastating disease that is increasingly being diagnosed among Filipinos, especially in at-risk populations. There are disease-specific nuances in the evaluation and management of this infection. Furthermore, advances in the field brought about by clinical research are rapidly moulding the way we evaluate and manage HCV patients. Evidently, consensus statements formulated by experts in the field are needed in order to serve as a guide to physicians who see HCV patients in the clinic. With this in mind, the Hepatology Society of the Philippines spearheaded the formation of these statements which aimed to address issues in the diagnosis, evaluation, treatment, and follow-up care of patients with HCV infection.Recommendations on the specific tests to perform in the evaluation of HCV patients before, during and after treatment, and first-line treatment of patients with acute and chronic HCV infection were provided. Treatment algorithms for chronic HCV infection, divided according to viral genotype, were also devised. We acknowledge the limitations brought about by the local inavailability of some drugs/treatment regimens in the local setting at the time of the formulation of these statements. As such, these statements will be revised as soon as new data become locally applicable.  

Hepatitis B infection among adults in the philippines: A national seroprevalence study.

AIM: To determine the prevalence of hepatitis B surface antigen (HBsAg) seropositivity among adult Filipinos. METHODS: Testing for HBsAg was performed on serum samples from persons aged ≥ 20 years old who participated in the National Nutrition and Health Survey (NNHeS) conducted in 2003. Information on age, sex, marital status, educational attainment, employment status, and income were collected. For this study, marital status was classified as never married or otherwise (i.e., married, divorced, separated, widowed); educational attainment was classified as high school graduate or below or at least some tertiary education; and employment status was classified as currently employed or currently unemployed. Annual income was divided into 4 quartiles in Philippine pesos (PhP): Q1, ≤ PhP 53064; Q2, PhP 53065-92192; Q3, PhP 92193-173387; and Q4, ≥ PhP 173388. Prevalence estimates were weighted so that they represented the general population. Social and demographic factors were correlated with HBsAg seropositivity. Multivariate analysis was used to determine independent predictors of HBsAg seropositivity. RESULTS: A total of 2150 randomly selected adults, 20 years and over, out of the 4753 adult participants of NNHeS were tested for HBsAg. The HBsAg seroprevalence was 16.7% (95%CI: 14.3%-19.1%), which corresponded to an estimated 7278968 persons infected with hepatitis B. There was no significant difference between males and females (17.5% vs 16.0%; P = 0.555). This corresponded to an estimated 3721775 men and 3557193 women infected with hepatitis B. The HBsAg seroprevalence peaked at age 20-39 years old, with declining prevalence in the older age groups. The only independent predictor of HBsAg seropositivity was the annual income, with persons in the highest income quartile being less likely to be HBsAg positive (age-adjusted OR = 0.51; 95%CI: 0.30-0.86) compared to subjects in the lowest income quartile. Sex, marital status, educational attainment, and employment status were not found to be independent predictors of HBsAg seropositivity. CONCLUSION: The high HBsAg seroprevalence among adults in the Philippines classifies the country as hyperendemic for HBV infection and appears unchanged over the last few decades.

Temperature-dependent electrode repositioning for multiple overlapping radiofrequency ablation in ex vivo porcine livers.

PURPOSE: Overlapping ablations can be used to increase radiofrequency ablation volume. Our goal was to determine, in a porcine model, the relationship of ablation size and temperature for single ablation, and to compare the extent of necrosis resulting from temperature-dependent electrode positioning versus fixed-distance dual ablation. MATERIALS AND METHODS: The experiments were performed in two parts (single and dual ablations). During single ablation in ex vivo porcine livers, maximum necrotic diameter was compared with the diameters at the level at which temperatures reached 60°C, 55°C, and 50°C. Dual ablations were performed using 60°C (group 60C), 55°C (group 55C), and 50°C (group 50C), and distances of 3 cm (group 3cm) and 4.1cm (group 4.1cm) as the starting point (RFA2-start) for the second ablation. RESULTS: The maximum necrotic diameter (3.3 ± 0.6 cm) and the necrotic diameters reached at 60°C (2.8 ± 0.8 cm) and 55°C (2.2 ± 0.7 cm) were significantly greater than that at 50°C (0.9 ± 0.5cm; P < .05). In dual ablations, there was no difference between RFA2-start and the maximum diameter of the preceding and subsequent ablations in all temperature-dependent dual ablations (groups 60C, 55C, and 50C) and in group 3cm. (P > .05) However, there was a significant difference between RFA2-start and maximum diameter of the preceding and subsequent ablations in Group 4.1cm (P = .038), resulting in dumbbell-shaped necrosis. CONCLUSIONS: The necrotic diameter proportionally decreases with the temperature in single ablation. Withdrawing the electrode up to 50° or by 3 cm before reablating results in fusion of the two ablation zones versus withdrawal of 4.1 cm, which results in incomplete necrosis in between two ablation zones.

Combined percutaneous radiofrequency ablation and ethanol injection for hepatocellular carcinoma in high-risk locations.

OBJECTIVE: The purpose of this study was to investigate whether combining percutaneous ethanol injection (PEI) with radiofrequency ablation in the management of hepatocellular carcinoma (HCC) in high-risk locations improves treatment outcomes. SUBJECTS AND METHODS: We compared the outcome of management of high-risk tumors with PEI and radiofrequency ablation (n = 50) or radiofrequency ablation alone (n = 114) with the outcome of radiofrequency ablation of non-high-risk tumors (n = 44). We also compared the survival rates of patients with and those without high-risk HCC. PEI was performed into the part of the tumor closest to a blood vessel or vital structure before radiofrequency ablation. RESULTS: The study included 142 patients with 208 HCCs managed with radiofrequency ablation. Despite larger tumor sizes (2.8 +/- 1 cm vs 1.9 +/- 0.7 cm vs 2.5 +/- 0.1 cm for the high-risk radiofrequency plus PEI, non-high-risk radiofrequency, and high-risk radiofrequency groups, respectively; p < 0.001), the primary effectiveness rate of high-risk radiofrequency ablation and PEI (92%) was similar to that of non-high-risk radiofrequency ablation (96%). The primary effectiveness rate of high-risk radiofrequency ablation and PEI was slightly higher (p = 0.1) than that of high-risk radiofrequency ablation (85%). The local tumor progression rates (21% vs 33% vs 24% at 18 months) of the three respective groups were not statistically different (p = 0.91). Patients with and those without high-risk tumors had equal survival rates (p = 0.42) after 12 (87% vs 100%) and 24 (77% vs 80%) months of follow-up. Independent predictors of primary effectiveness were a tumor size of 3 cm or less (p = 0.01) and distinct tumor borders (p = 0.009). Indistinct borders (p = 0.033) and non-treatment-naive status of HCC (p = 0.002) were associated with higher local tumor progression rates. The only predictor of survival was complete ablation of all index tumors (p = 0.001). CONCLUSION: The combination of radiofrequency ablation and PEI in the management of HCC in high-risk locations has a slightly higher primary effectiveness rate than does radiofrequency ablation alone. A randomized controlled study is warranted.

Tenofovir monotherapy is effective in hepatitis B patients with antiviral treatment failure to adefovir in the absence of adefovir-resistant mutations.

BACKGROUND/AIMS: We sought to identify mutations associated with treatment failure to adefovir (ADV) and to determine virologic response to tenofovir (TDF) alone and in combination with emtricitabine (FTC) in these patients. METHODS: Serum samples prior to and after the change in treatment to TDF/TDF+FTC from 13 patients were analyzed by direct sequencing and clonal analysis. RESULTS: ADV-resistant mutations, rtA181V and rtN236T, were detected on direct sequencing in 3 of 8 patients who had virologic breakthrough. Among patients with suboptimal virologic response, rtA181T, rtI233V, and rtN236T were present on clonal analysis in 3 patients. Ten patients received TDF, 8 achieved virologic response. One had ADV-resistance at baseline and persistence of ADV-resistant mutations during TDF treatment, addition of FTC resulted in a further decrease in HBV DNA. Another patient had no ADV-resistance at baseline, and selection of ADV-resistant mutations during TDF treatment. All 3 patients who received TDF+FTC had undetectable HBV DNA within 3-12 months including 2 who had ADV-resistance at baseline. CONCLUSIONS: TDF monotherapy is effective for patients with virologic breakthrough or suboptimal response to ADV, but combination therapy with a nucleoside analogue should be considered in patients with ADV-resistance. No novel mutations were detected.

Treatment of hepatocellular carcinoma using internally cooled electrodes. A prospective comparison of modified automated vs. manual pulsed radiofrequency algorithms.

OBJECTIVES: To compare the effectiveness of modified automated and manual pulsed radiofrequency (RF) algorithms using internally cooled electrodes for hepatocellular carcinoma (HCC). METHODS: Seventy-seven treatment-naive cirrhotic patients with 102 HCC (< or =4 cm) underwent 109 sessions of ultrasound-guided percutaneous RF ablation using a 17-gauge, 20-cm-long, single internally cooled electrode. Patients were assigned alternatively: 40 patients to the modified automated algorithm group and 37 patients to the manual algorithm group. The mean tumor diameters were 2.34 +/- 0.9 and 2.25 +/- 0.7 cm in the automated and manual groups, respectively (p = 0.56). Primary technique effectiveness and local tumor progression were compared between the two groups. RESULTS: More overlapping ablations (n = 112) were required in the manual than in the automated group (n = 82) to achieve similar primary technique effectiveness rates of 96.1 and 94.1%, respectively. After a mean follow-up period of 26.7 +/- 1.1 months, the local tumor progression rates at 12 and 18 months were 4 and 20% in the manual group and 12 and 24% in the modified automated group (p = 0.3). Only tumors >3 cm were independently associated with local tumor progression (odds ratio 1.25; 95% CI 1.06-2.34, p = 0.03). CONCLUSIONS: The manual algorithm requires more overlapping ablations and treatment sessions in order to achieve similar primary technique effectiveness and local tumor progression rates compared with the modified automated algorithm.

Erosive esophagitis in the Philippines: a comparison between two time periods.

BACKGROUND: In Asia, the incidence of gastroesophageal reflux disease diagnosed through endoscopy has increased from 3-9% to 14-16% in the last decade. The aim of this study was to determine the prevalence of erosive esophagitis (EE) over a span of 10 years in a tertiary care facility in the Philippines. METHODS: All patients diagnosed with EE from 1994 to 1997 (period A) and from 2000 to 2003 (period B) were included in the study. The modified Savary-Miller and Los Angeles classifications were used to grade EE for periods A and B, respectively. RESULTS: A total of 15 981 upper endoscopies were evaluated for this study. There was no significant difference in the male: female ratio (period A 1.43:1 vs period B 1.25:1, P = 0.459) and in the mean age of patients with EE (period A 46.4 vs period B 47.5, P = 0.395). The prevalence of EE was significantly higher (P < 0.0001) in period B (6.3%) as compared to period A (2.9%). However, despite a higher prevalence, more patients had mild esophagitis in period B as compared to period A. Conversely, there were more patients with esophageal ulcers (18.6%vs 5.9%, P < 0.001), esophageal strictures (2.3%vs 0%, P = 0.003), and hiatal hernia (15.8%vs 7.5%, P = 0.001) in period A. The presence of concomitant Barrett's esophagus was not significantly different between the two time periods (period A 3.2%vs period B 5%, P = 0.367). CONCLUSIONS: The prevalence of EE was higher in 2000-2003 than in 1994-1997, although the complications associated with the disease diminished. The prevalence of concomitant Barrett's esophagus remained stable.

Low risk of hepatitis B virus recurrence after withdrawal of long-term hepatitis B immunoglobulin in patients receiving maintenance nucleos(t)ide analogue therapy.

Hepatitis B virus (HBV) recurrence rates of 0-16% had been reported in patients maintained on nucleoside analogues (NA) after hepatitis B immunoglobulin (HBIG) discontinuation after orthotopic liver transplantation (OLT). However, follow-up in most studies was short. We aimed to determine the long-term risk of HBV recurrence using this strategy. All HBV patients who received > or =7 doses of intravenous HBIG after OLT, with no HBV recurrence while receiving HBIG, and who eventually discontinued HBIG and were maintained on NA, were included. HBV recurrence was defined as HBsAg-positive or HBV DNA > or =5 log copies/mL on 2 consecutive occasions. Twenty-one patients met the inclusion criteria. Immediate post-OLT prophylaxis was combination HBIG and NA in 15 patients, whereas 6 patients received HBIG monotherapy for 62-109 months before NA was added. HBIG was discontinued a median of 26 (range, 0.2-121) months after OLT. Median follow-up post-HBIG discontinuation was 40 (range, 5-51) months. Only 1 patient, who had 12 months of HBIG and was noncompliant to NA therapy, had HBV recurrence, 34 months after HBIG discontinuation. One patient had HBV DNA of 3.3 log copies/mL 47 and 48 months after HBIG discontinuation but remained HBsAg-negative. Lamivudine-resistant mutations were detected in both patients. Probability of HBV recurrence was 0% and 9% at 2 and 4 years after HBIG discontinuation. Three patients had 1-2 episodes of transiently detectable HBV DNA. All were HBV DNA and HBsAg negative on repeated tests over a period of 2-36 months. Maintenance therapy with NA after discontinuation of long-term HBIG therapy is associated with a low risk of HBV recurrence after OLT in compliant HBV patients.

Comparison of clinical outcomes in chronic hepatitis B liver transplant candidates with and without hepatocellular carcinoma.

Patients with hepatocellular carcinoma (HCC) receive a higher MELD score and may undergo liver transplantation (OLT) earlier compared to patients with cirrhosis, potentially decreasing waiting list mortality. However, post-OLT survival may be reduced by recurrence of HCC. We compared clinical outcomes between patients with HBV-cirrhosis and no HCC and patients with HBV-HCC. A total of 279 patients (HBV-cirrhosis = 183; HBV-HCC = 96) in the US HBV-OLT study were followed for a median of 30.2 months from listing. Patients with HCC were older, more likely to be Asian, and had less severe liver impairment than patients with HBV-cirrhosis. Despite a higher rate of OLT in patients with HCC (78.1% vs. 51.4%; P < 0.001), intention-to-treat (ITT) survival (73% vs. 78%) and survival without OLT (82% vs. 79%) at 5 years were similar for patients with and without HCC. Cox regression analysis identified higher albumin, lower MELD, no HCC at listing, and being transplanted to be associated with better ITT survival. Ninety-four patients with HCC (including 19 new HCC) and 75 with HBV-cirrhosis underwent OLT. Post-OLT survival (83% vs. 90%) and HBV recurrence (11% vs. 10%) at 3 years were similar, while disease (HBV and/or HCC) recurrence (19% vs. 10%; P = 0.043) was higher in patients with HBV-HCC vs. HBV-cirrhosis. Disease recurrence was the only independent predictor of post-OLT survival. In conclusion, despite more advanced liver disease and a lower rate of transplantation, ITT survival of patients listed for HBV-cirrhosis was comparable to those with HBV-HCC, possibly related to beneficial effects of antiviral therapy.

Evolution of multi-drug resistant hepatitis B virus during sequential therapy.

Multi-drug resistant hepatitis B virus (HBV) has been reported in hepatitis B patients who received sequential antiviral therapy. In vitro studies showed that HBV constructs with mutations resistant to lamivudine and adefovir have marked reduction in sensitivity to combination of lamivudine and adefovir, whereas constructs with mutations resistant to either drug remain sensitive to the other drug. We conducted this study to determine whether mutations conferring resistance to multiple antiviral agents co-locate on the same HBV genome in vivo and to describe the evolution of these mutations. Sera from six patients who had been found to have multi-drug resistant HBV mutations to lamivudine+adefovir, lamivudine+hepatitis B immunoglobulin (HBIG), or lamivudine+entecavir on direct sequencing were cloned after nested polymerase chain reaction (PCR). Analysis of 215 clones from 11 samples with multi-drug resistant mutations on direct sequencing showed that 183 (85%) clones had mutations to both therapies on the same genome; 31 clones had lamivudine-resistant mutants only. Clonal analysis of serial samples from three patients showed progressive evolution from all clones with lamivudine-resistant HBV mutations only to mixtures of clones that have multi-drug resistant mutations and clones that have lamivudine-resistant HBV mutations only, and ultimately all clones having multi-drug resistant HBV mutations. In conclusion, mutations conferring resistance to multiple antiviral agents co-locate on the same viral genome, suggesting that combination therapy directed against mutants resistant to each treatment may not be adequate in suppressing multi-drug resistant HBV. De novo combination therapy may prevent the emergence of multi-drug resistant mutants.

Update on viral hepatitis: 2005.

PURPOSE OF REVIEW: This review aims to provide a concise summary of relevant developments in the treatment and prevention of viral hepatitis based on publications between December 2004 and November 2005. RECENT FINDINGS: Long-term therapy with lamivudine was shown to reduce the incidence of adverse clinical outcomes in patients with chronic hepatitis B. This benefit was, however, diminished in patients with viral breakthrough. Combination therapy (peginterferon or telbivudine plus lamivudine) decreased the risk of antiviral resistance but did not improve response compared with monotherapy. Entecavir and tenofovir were shown to be effective in suppressing lamivudine-resistant hepatitis B. A shorter duration of peginterferon-ribavirin treatment was shown to be feasible in genotype 2/3 hepatitis C patients. Relapsers to previous standard interferon-based therapy had higher sustained virological response rates than previous non-responders when retreated with peginterferon-ribavirin. Hepatitis C patients with advanced liver disease may achieve sustained virological response with peginterferon-ribavirin treatment, but the complication rate was high. SUMMARY: New insights into the management of viral hepatitis have been gained over the past year. The problem of antiviral resistance in chronic hepatitis B is real and treatment options need to keep evolving. Advances have been made in hepatitis C treatment including patients with genotypes 2 or 3 infection and decompensated cirrhosis.

Changing trends in peptic ulcer prevalence in a tertiary care setting in the Philippines: a seven-year study.

BACKGROUND AND AIMS: The declining global prevalence of peptic ulcer disease (PUD) might be because of the decreasing prevalence of Helicobacter pylori (Hp) infection. The aims of the present study were to determine the prevalence of PUD during a 7-year period and to investigate its relationship with the prevalence of Hp infection during the same period. METHODS: All upper gastrointestinal endoscopies carried out at Santo Tomas Hospital in Manila from January 1996 to December 2002 were evaluated. Endoscopies reporting gastric ulcers (GU) and duodenal ulcers (DU) with Hp status were analyzed. RESULTS: A total of 15 341 endoscopies were evaluated. Overall, 2600 (16.95%) GU and 1575 (10.27%) DU were identified. There was a decreasing trend in the prevalence of GU (P < 0.0001) and DU (P < 0.0001) during the study period. Overall PUD prevalence declined from 35.87% in 1996 to 18.80% in 2002. This decline was seen for both GU and DU (20.05 vs 14.34%, and 15.83 vs 7.02%, respectively). The prevalence of Hp infection decreased significantly from 1996 to 2002 for both GU and DU (68.13 vs 33.48%, P < 0.0001; and 76.67 vs 36.50%, P < 0.0001, respectively). The decrease in Hp prevalence was significantly related to the decrease in ulcer prevalence (r = 0.97, P = 0.0004 for GU; r = 0.89, P = 0.0079 for DU; and r = 0.92, P = 0.0035 for all PUD). The prevalence of bleeding secondary to PUD remained stable during the 7-year period (P = 0.87). CONCLUSIONS: During the 7-year period, there was a significant decline in the prevalence of PUD. This decline in PUD prevalence was associated with a corresponding decrease in Hp prevalence.