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sensationalism, skepticism and scientific salesmanship

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Controversy The case for Helicobacter pylori eradication in India: sensationalism, skepticism and scientific salesmanship Vineet Ahuja Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029 W ith tenacity and a prepared mind” the duo “challenged prevailing dogmas”, said a press release from the Nobel Assembly at Karolinska Institute in Stockholm, Sweden announcing that the 2005 Nobel prize in Physiology or Medicine had been awarded to Robin Warren and Barry Marshall for their discovery that a bacterium named Helicobacter pylori causes most peptic ulcers. 1,2 It is somewhat discomforting that this Journal has commissioned a debate on the need for treating H. pylori infection at a time when triumph of the ulcer-bug theory formed ‘news of the week’ for many journals and even the lay press. It thus appears unjust to wield, or at least an inopportune time for wielding, a coroner’s scalpel to exhume the odyssey. Why are we still reluctant to embrace this concept? Was it an unbridled sensationalism for over a decade that has spurred a rebound vociferous skepticism? In the year 2006, a debate on the proficiency of H. pylori eradication would be classified as an “unfair duel”. Not the David vs. Goliath kind where the underdog wins but a duel where the result is not merely a writing on the wall but is deeply etched and engraved. Nevertheless, it provides a good opportunity to place on record the evidence that has led to the acceptance of H. pylori eradication as treatment for peptic ulcer disease. In pursuit of this objective, this article will focus on four central concepts: i) Is there irrefutable evidence that H. pylori causes peptic ulcer and gastric cancer? ii) Does eradication of H. pylori infection alter the natural history of these diseases? iii) Has the beneficial effect been exaggerated? and, iv) What are the diseases in which benefit of H. pylori eradication remains unproven? Evidence that H. pylori causes peptic ulcer and gastric cancer Peptic ulcer H. pylori infection has a strong association with chronic active gastritis and duodenal ulcer (DU). Ingestion of H. pylori has been shown to produce acute antral gastritis. 3,4,5 H. pylori infection can be detected in 90% of patients with DU and 70% of those with gastric ulcers. 6 A critique published in 1991 deter- Copyright © 2006 by Indian Society of Gastroenterology mined that there was strong association between H. pylori and DU, but that evidence for biological gra- dient and temporality and supportive experimental evidence was insufficient. 7 Since then, plenty of new evidence has become available. Sipponen et al showed that 11% of individuals with H. pylori infection developed DU over a 10- year follow up, in contrast to fewer than 1% of non- infected individuals.
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