SUMMARYAim: To compare the efficacy of different regimens in patients in whom previous Helicobacter pylori eradication therapy has failed. Methods: In this study named StratHegy patients (n ¼ 287) were randomized to receive one of three empirical triple therapy regimens or a strategy based on antibiotic susceptibility. The empirical regimens were omeprazole, 20 mg b.d., plus amoxicillin, 1000 mg b.d., and clarithromycin, 500 mg b.d., for 7 days (OAC 7 ), clarithromycin, 500 mg b.d., for 14 days (OAC 14 ) or metronidazole, 500 mg b.d., for 14 days (OAM 14 ). In the susceptibility-based strategy, patients with clarithromycin-susceptible strains received OAC 14 , whilst the others received OAM 14 . The 13 C-urea breath test was performed before randomization and 4-5 weeks after eradication therapy.Results: In the intention-to-treat analysis, the eradication rates for empirical therapies were as follows: OAC 7 , 47.4% (27/57); OAC 14 , 34.5% (20/58); OAM 14 , 63.2% (36/57); it was 74.3% (84/113) for the susceptibilitybased treatment (P < 0.01 when compared with OAC 7 and OAC 14 ). In patients receiving clarithromycin, the eradication rates were 80% for clarithromycin-susceptible strains and 16% for clarithromycin-resistant strains; in patients receiving OAM 14 , the eradication rates were 81% for metronidazole-susceptible strains and 59% for metronidazole-resistant strains. Conclusions: Eradication rates of approximately 75% can be achieved with second-line triple therapy based on antibiotic susceptibility testing. If susceptibility testing is not available, OAM 14 is an appropriate alternative.

The first case of cobalamin deficiency with megaloblastic anaemia in a patient under long-term omeprazole therapy is presented. This patient received omeprazole at a daily dose of 40-60 mg for 4 years as treatment for a gastro-oesophagal reflux complicated by peptic oesophagitis. Seric vitamin B12 was dramatically decreased at 80 pmol L-1. The Schilling test was normal (13%) with crystalline [57Co] cobalamin and it was at 0% with [57Co] cobalamin-labelled trout meat. All other assimilation tests were normal except an expiratory hydrogen breath test performed with lactulose. The haematological status was restored after intramuscular treatment with cobalamin. In conclusion, prolonged omeprazole therapy can be responsible for a cobalamin deficiency due to protein-bound cobalamin malabsorption.

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Cytomegalovirus colitis in immunocompetent patients has rarely been reported without another severe illness. The prognosis is usually bad, leading to toxic megacolon or death due to multi-organ system failure. We report a case of a self-limited cytomegalovirus colitis in a young patient with no risk factor for CMV infection or associated disease. This suggests that self-limiting CMV colitis may be more frequent than is usually believed, and its prognosis may be better in young patients with normal immune functions. Therefore it should be sought systematically even in immunocompetent young patients.

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