Review for 10.1186/s12876-021-02027-6 (2021)

Reviewer’s report
Title: 
Eradication of Helicobacter pylori may improve dyspepsia in the elderly
for the long term
Version: 
0 
Date: 
30 Apr 2021
Reviewer's report:
The topic explored by the authors is interesting, but some sentences and
conclusion could be not completely supported. Dyspepsia in Helicobacter pylori
infected subjects is frequent and Maasticht and Kyoto reccomendations are in
favour of H.p. eradication to improve dyspepsia. For elderly people, no specific
recomendation are present in literature. The relationship beetwen Hp infection
and upper GI diseases in elderly has been recognized in the past in several
papers: 
A Pilotto 1, M Franceschi, G Leandro, M Rassu, L Bozzola, G Valerio, F Di
Mario Influence of Helicobacter pylori infection on severity of oesophagitis and
response to therapy in the elderly 
Dig Liver Dis . 2002 May;34(5):328-31.
Aliment Pharmacol Ther
A Pilotto 1, M Franceschi, G Leandro, L Bozzola, M Rassu, G Soffiati, F Di
Mario, G Valerio Cure of Helicobacter pylori infection in elderly patients:
comparison of low versus high doses of clarithromycin in combination with
amoxicillin and pantoprazole 2001 Jul;15(7):1031-6. 
Aliment Pharmacol Ther
A Pilotto 1, F Di Mario, M Franceschi, G Leandro, G Battaglia, B Germanà, R
Marin, G Valerio Pantoprazole versus one-week Helicobacter pylori eradication
therapy for the prevention of acute NSAID-related gastroduodenal damage in
elderly subjects. Aliment Pharmacol Ther
. 2000 Aug;14(8):1077-82.
.A Pilotto, M Franceschi, G Valerio, F Di Mario, G Leandro Helicobacter pylori
infection in elderly patients with peptic ulcer Age Ageing, 1999 Jul;28(4):412-4. 
A Pilotto 1, F Rumor, M Franceschi, G Leandro, R Novello, G Soffiati, M
Scagnelli, F Di Mario, G Valerio Lack of association between Helicobacter
pylori infection and extracardiac atherosclerosis in dyspeptic elderly subjects
PMID: 10459790 DOI: 10.1093/ageing/28.4.367
J Gastroenterol Hepatol
A Pilotto 1, M Franceschi, G Leandro, L Bozzola, A Fortunato, M Rassu, S Meli,
G Soffiati, M Scagnelli, F Di Mario, G Valerio . Efficacy of 7 day lansoprazole-
based triple therapy for Helicobacter pylori infection in elderly patients 
1999
May;14(5):468-75. doi: 10.1046/j.1440-1746.1999.01893.x.
A Pilotto 1, M Franceschi, F Di Mario, G Leandro, L Bozzola, G Valerio The
long-term clinical outcome of elderly patients with Helicobacter pylori-
associated peptic ulcer disease. 1998;44(3):153-8. doi: 10.1159/000022000.
J Clin Gastroenterol
A Pilotto 1, M Rassu, L Bozzola, G Leandro, M Franceschi, F Furlan, S Meli, M
Scagnelli, F Di Mario, G Valerio Cytotoxin-associated gene A-positive
Helicobacter pylori infection in the elderly. Association with gastric atrophy and
intestinal metaplasia . 1998 Jan;26(1):18-22. doi: 10.1097/00004836-199801000-
00006.
The effect of Helicobacter pylori infection on NSAID-related gastroduodenal
damage in the elderly. Eur J Gastroenterol Hepatol . 1997 Oct;9(10):951-6. doi:
10.1097/00042737-199710000-00006.
A Pilotto 1, M Franceschi, G Leandro, F Di Mario, G Valerio
A Pilotto 1, M Franceschi, G Leandro, F Di Mario, G Valerio The effect of
Helicobacter pylori infection on NSAID-related gastroduodenal damage in the
elderly Eur J Gastroenterol Hepatol . 1997 Oct;9(10):951-6.
A Pilotto 1, F Di Mario, M Franceschi, G Leandro, G Soffiati, M Scagnelli, L
Bozzola, G Valerio Cure of Helicobacter pylori infection in the elderly: effects of
eradication on gastritis and serological markers. Aliment Pharmacol Ther . 1996
Dec;10(6):1021-7.
A Pilotto 1, R Fabrello, M Franceschi, M Scagnelli, F Soffiati, F Di Mario, A
Fortunato, G Valerio Helicobacter pylori infection in asymptomatic elderly
subjects living at home or in a nursing home: effects on gastric function and
nutritional status. Age Ageing . 1996 May;25(3):245-9. 
We suggest to include in bibliography some on these papers. In particular, the
sentence opening the discussion: "This is the first report....." appears inadeguate.
I suggest to include in both background and discussion papers related with Hp
eradication schedules in elderly as well as Hp infection and dyspepsia and Hp
eradication and dyspepsia.
Dyspepsia is closely influenced by fluttuation lasting the time and this is true
also for the relationship beetwen Hp eradication and improvement of dyspepsia,
as reported in this paper: Francesco di Mario 1, Nicoletta Stefani, Nadia Dal Bò,
Massimo Rugge, Alberto Pilotto, Giulia Martina Cavestro, Lucas Giovanni
Cavallaro, Angelo Franzé, Gioacchino Leandro Natural course of functional
dyspepsia after Helicobacter pylori eradication: a seven-year survey. Dig Dis Sci
. 2005 Dec;50(12):2286-95.
The study lasting a period of 7 years after Hp eradication showed a fluttuation in
dyspeptic symptoms after Hp eradication.
On this subject, the authors reported that in a subgroup of elderly patients the
answers to the questionaire have been obtained after 54.8 months, but aonly
results after one year were reported in the paper. I suggest to clarify.
Other comments and suggestion
We suggest to detail which symptoms improved and possible related
mechanisms 
In elderly, atrophic gastritis is increasing. We suggest to report data on the
frequency of atrophic gastritis in studied population beside the autoimmune
gastritis correctly mentioned.
We believe that the control group (N) is not appropriate for the aims of the study.
A proper control group, to me, could be an elderly Hp positive population not
treated and with an adeguate follow-up. At present the study is consistent only
with the demonstartion that younger people have a better response to eradication
teraphy in comparison with elderly.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
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from apparent manipulation?
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