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Original article
Identification of serologically active Helicobacter pylori antigens related to alterations in serum pepsinogen levels
Identificación de antígenos de Helicobacter pylori serológicamente activos relacionados con alteraciones en los niveles de pepsinógenos en suero
Rodolfo González Segoviaa,
Corresponding author
rgonzals@correo.uaa.mx

Corresponding author.
, Yolanda Romo Lozanoa, Martín Gerardo Rodríguezb, Angelina Lizbeth Montañez Floresa, Juan González Macíasc
a Departamento de Microbiología, Universidad Autónoma de Aguascalientes, Av. Universidad 940, CP 20100, Aguascalientes, Mexico
b Departamento de Fisiología y Farmacología, Universidad Autónoma de Aguascalientes, Av. Universidad 940, CP 20100, Aguascalientes, Mexico
c Servicio de Gastroenterología, Unidad Médica de Atención Ambulatoria del IMSS, Av. de la Convención de 1914 Nte. No. 102, Col. Industrial, CP 20030, Aguascalientes, Mexico
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This last pathology is related to the higher mortality rate associated with <span class="elsevierStyleItalic">H&#46; pylori</span>&#46; Studies indicate that the relative risk of developing gastric cancer is 2&#8211;3 times higher in individuals infected with the bacteria compared to uninfected people<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">38</span></a>&#46; Worldwide&#44; gastric cancer is an important oncologic problem&#44; recently being considered the fifth most frequent malignancy and the third cause of death related to cancer&#44; with around 780<span class="elsevierStyleHsp" style=""></span>000 annual deaths related to this disease worldwide<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The evolutionary course for the development of gastric cancer was initially characterized before the discovery of <span class="elsevierStyleItalic">H&#46; pylori</span> and later&#44; through multiple studies&#44; it was correlated with the presence of the bacterium in the gastric mucosa<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">15&#44;34</span></a>&#46; The process begins with the transformation of the normal mucosa to the development of chronic superficial gastritis &#40;non-atrophic gastritis&#41; caused by gastric colonization of the bacterium and characterized by high secretory glandular activity that generally causes conditions of hyperchlorhydria<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">27</span></a>&#46; Some individuals with chronic superficial gastritis show a transition from chronic superficial gastritis to the development of glandular atrophy &#40;chronic atrophic gastritis&#41;&#44; characterized by loss of parietal cells and subsequent reduction in acid secretion<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">14</span></a>&#46; The feedback mechanisms for the reduction of HCl generated by glandular atrophy can cause the alteration of the levels of some gastric hormones&#46; Particularly&#44; the elevation of the hormone gastrin is established as an important risk factor for malignancy due to its mitogenic effect on gastric mucosal cells that promotes hyperplasia of these cells<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">31&#44;35</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Pepsin is an important gastric hydrolytic enzyme formed from a family of inactive polypeptide precursors called pepsinogens&#46; According to their physical and electrophoretic characteristics&#44; pepsinogens are classified into 2 main types&#44; pepsinogen I &#40;PGI&#41; and pepsinogen II &#40;PGII&#41;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">5</span></a>&#46; Both zymogens are expressed in the human stomach by chief cells and mucosal neck cells&#46; However&#44; while PGI presents an expression restricted only to the gastric cells mentioned above&#44; PGII is produced by cells of other anatomical portions of the stomach such as cardia&#44; pylorus and duodenal cells of Brunner&#39;s glands<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">18</span></a>&#46; Pepsinogens are mainly excreted into the stomach lumen although about 1&#37; of the total proenzyme produced enters the bloodstream&#46; There are multiple studies that show that serum levels of PGI and PGII correlate with pathological conditions present in the stomach such as chronic atrophic gastritis and intestinal metaplasia<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">6</span></a>&#46; During these pathologies&#44; it has been identified that the PGI&#47;PGII ratio in serum is altered as a consequence of the modification of the number of gastric cells that produce both zymogens<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">20</span></a>&#46; In the case of advanced glandular atrophy&#44; a decrease in PGI has been identified as a consequence of the destruction of the cells that produce this proenzyme&#44; and an increase in PGII due to the replacement of principal cells by Brunner&#39;s glands that produce PGII<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Immunoenzymatic diagnostic methods such as immunoblot are widely used in serological epidemiological studies because they are non-invasive procedures<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">36</span></a>&#46; Using the immunoblot analysis&#44; various studies have made it possible to identify the correlation between the development of gastroduodenal pathologies and seropositivity toward specific <span class="elsevierStyleItalic">H&#46; pylori</span> antigens<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">32</span></a>&#46; Non-cardiac gastric carcinoma has been identified as a pathology that presents a high association with CagA protein seropositivity with more significant correlations by the immunoblot analysis with respect to other methodologies<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">26</span></a>&#46; However&#44; the association of alterations in serum pepsinogen levels as indicator parameters of gastric mucosal involvement and formation of atrophic lesions have not been sufficiently studied in correlation with seropositivity toward specific bacterial antigens&#46; In the present study&#44; an analysis was carried out to determine possible correlations in the development of gastroduodenal diseases caused by <span class="elsevierStyleItalic">H&#46; pylori</span> with serological markers such as PGI and PGII levels and seroactivity toward <span class="elsevierStyleItalic">H&#46; pylori</span> antigens using a total protein extract of the bacterium&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Methodology</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Subjects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The study considered individuals over 18 years of age who attended the Endoscopy Unit of Clinic 10 of the IMSS in the city of Aguascalientes&#44; Mexico&#46; The patient group included individuals whose clinical history and endoscopic analyses &#40;UGI Endoscopy&#41; determined the existence of gastric pathology associated with <span class="elsevierStyleItalic">H&#46; pylori</span> infection&#46; The patient group was subclassified into individuals with and without glandular atrophy&#44; determined by histopathological analyses performed on biopsies of the gastric body and pyloric antrum collected during endoscopy&#46; Glandular atrophy was defined as the loss of normal &#40;native&#41; glands&#44; accompanied by the presence of fibrosis and fibromuscular proliferation in the lamina propria&#46; The control group included asymptomatic individuals to the existence of gastric diseases related to <span class="elsevierStyleItalic">H&#46; pylori</span> infection&#44; identified by the clinical history and endoscopic analysis of the volunteers&#46; Individuals who had received <span class="elsevierStyleItalic">H&#46; pylori</span> eradication treatment or the administration of proton pump inhibitor drugs in the last 6 weeks were not included in the study&#46; All the individuals included in the study signed an informed consent letter&#46; The study adhered to the Declaration of Helsinki and was approved by the Bioethics Committee of the Autonomous University of Aguascalientes CIB-UAA-26&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Collection of serological samples</span><p id="par0045" class="elsevierStylePara elsevierViewall">Blood samples were collected by venipuncture in the forearm&#46; After allowing coagulation for 2&#8211;5<span class="elsevierStyleHsp" style=""></span>h at room temperature&#44; the sample was centrifuged and serum specimens were stored at &#8722;70<span class="elsevierStyleHsp" style=""></span>&#176;C until use&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050"><span class="elsevierStyleItalic">H&#46; pylori</span> protein extract</span><p id="par0050" class="elsevierStylePara elsevierViewall">One clinical isolate of <span class="elsevierStyleItalic">H&#46; pylori</span> cagA&#43; bacteria was used&#44; previously characterized by biochemical tests &#40;urease and catalase&#41;&#44; Gram stain and molecular analysis for PCR amplification of <span class="elsevierStyleItalic">ureC</span> and <span class="elsevierStyleItalic">cagA</span><a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">19&#44;33</span></a>&#46; The bacteria were grown on 8&#37; sheep blood agar plates at 37<span class="elsevierStyleHsp" style=""></span>&#176;C for 72<span class="elsevierStyleHsp" style=""></span>h in a microaerophilic atmosphere&#46; The soluble protein extract was obtained by sonication in phosphate buffered saline &#40;PBS&#44; pH 7&#46;4&#41;&#44; 1&#37; triton X-100 and a mixture of protease inhibitors &#40;EDTA 1<span class="elsevierStyleHsp" style=""></span>mM&#44; PMSF 1<span class="elsevierStyleHsp" style=""></span>mM&#44; aprotinin 0&#46;6<span class="elsevierStyleHsp" style=""></span>&#956;M and leupeptin 2<span class="elsevierStyleHsp" style=""></span>&#956;M&#41;&#44; the insoluble material was removed by centrifugation&#46; In the supernatant obtained&#44; the protein concentration was quantified by the Bradford method with reading at 595<span class="elsevierStyleHsp" style=""></span>nm in a spectrophotometer &#40;7305-Jenway&#41; and the protein extract was stored at &#8722;70<span class="elsevierStyleHsp" style=""></span>&#176;C until use&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Determination of anti-HP antibodies by the ELISA assay</span><p id="par0055" class="elsevierStylePara elsevierViewall">The 96-well ELISA plates were sensitized with <span class="elsevierStyleItalic">H&#46; pylori</span> protein extract &#40;9<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml&#41; in carbonate buffer pH 9&#46;6 &#40;7&#46;3<span class="elsevierStyleHsp" style=""></span>mM Na<span class="elsevierStyleInf">2</span>CO<span class="elsevierStyleInf">3</span>&#44; 17&#46;4<span class="elsevierStyleHsp" style=""></span>mM NaHCO<span class="elsevierStyleInf">3</span>&#41; for 24<span class="elsevierStyleHsp" style=""></span>h &#40;4<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; then washed 4 times with PBS&#46; It was blocked for 1<span class="elsevierStyleHsp" style=""></span>h with 100<span class="elsevierStyleHsp" style=""></span>&#956;l&#47;well PBS-Tween 3&#37; powdered milk&#44; then 50<span class="elsevierStyleHsp" style=""></span>&#956;l of the serum sample &#40;1&#58;200 dilution&#41; were added and incubated at 37<span class="elsevierStyleHsp" style=""></span>&#176;C for 1<span class="elsevierStyleHsp" style=""></span>h&#44; followed by 4 washes with PBS&#46; A volume of 50<span class="elsevierStyleHsp" style=""></span>&#956;l of anti-IgG conjugated to alkaline phosphatase &#40;Cat&#46; 6760&#44; AbCam&#41; in 1&#58;300 dilution was added to the plate with incubation at 37<span class="elsevierStyleHsp" style=""></span>&#176;C for 1<span class="elsevierStyleHsp" style=""></span>h&#44; followed by 4 washes with PBS&#46; For development&#44; p-nitrophenyl phosphate tablets &#40;Cat&#46; N9389&#44; Sigma&#41; were used according to the manufacturer&#39;s instructions&#46; The plate was read in an ELISA reader &#40;ELX800&#44; Biotek&#41; at 405<span class="elsevierStyleHsp" style=""></span>nm&#46; The <span class="elsevierStyleItalic">cutoff</span> point to determine serological positivity to <span class="elsevierStyleItalic">H&#46; pylori</span> was based on the formula&#58; <span class="elsevierStyleItalic">Cutoff</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">X</span><span class="elsevierStyleInf">neg</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#46;13<span class="elsevierStyleItalic">X</span><span class="elsevierStyleInf">pos</span>&#44; where <span class="elsevierStyleItalic">X</span><span class="elsevierStyleInf">neg</span> corresponds to the absorbance present in the negative control serum &#40;newborn serum&#41; and <span class="elsevierStyleItalic">X</span><span class="elsevierStyleInf">pos</span>&#44; absorbance of the positive control serum<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">12</span></a>&#46; The <span class="elsevierStyleItalic">cutoff</span> obtained was applied to discriminate serological positivity in both populations&#44; such as a parameter related to the interaction of bacterial infection with the individual&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Polyacrylamide gel electrophoresis and immunoblot</span><p id="par0060" class="elsevierStylePara elsevierViewall">The protein extract of <span class="elsevierStyleItalic">H&#46; pylori</span> &#40;170<span class="elsevierStyleHsp" style=""></span>&#956;g&#41; was loaded into a comb with a wide well &#40;6<span class="elsevierStyleHsp" style=""></span>cm&#41; and was separated by vertical 10&#37; polyacrylamide gel electrophoresis &#40;SDS-PAGE&#41; and subsequently electrotransferred to a PVDF membrane &#40;Inmobilon&#44; Merck Millipore&#41; for 24<span class="elsevierStyleHsp" style=""></span>h&#46; The membrane was cut into strips and stored at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C to be used individually later&#46; To perform the immunoblot&#44; the membrane strips were blocked for 24<span class="elsevierStyleHsp" style=""></span>h with TBS &#40;buffer Tris&#8211;HCl saline pH 7&#46;5&#41; with 1&#37; milk powder&#44; followed by 3 washes with TTBS &#40;TBS at 0&#46;2&#37; Tween 20&#41; to later incubate for 2<span class="elsevierStyleHsp" style=""></span>h with agitation in TBS 1&#37; milk with the serum samples from each individual in 1&#58;500 dilution&#46; Subsequently&#44; 3 washes were performed with TTBS followed by a 2-h incubation in TBS at 1&#37; milk with the anti-IgG antibody conjugated with alkaline phosphatase &#40;Cat&#46; AB6760&#44; AbCam&#41; at 1&#58;9000 dilution&#46; Three washes were performed with TTBS and the BCIP&#47;NBT chromogenic substrate &#40;Cat&#46; B-5655&#44; Sigma&#41; was added to the manufacturer&#39;s instructions for the development and identification of bands&#46; The dilutions of the antibodies &#40;primary&#47;secondary&#41; used in the study were optimized based on the absence of bands using a negative control serum for <span class="elsevierStyleItalic">H&#46; pylori</span> &#40;newborn individual serum&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Analysis of seroactive antigens in the immunoblot</span><p id="par0065" class="elsevierStylePara elsevierViewall">The bands in the immunoblot strips from each serum sample were considered seroactive antigens and were manually measured to determine their corresponding molecular weight &#40;kDa&#41;&#44; performing a linear regression analysis between the distances of each band and the weight marker included in the electrophoretic migration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In order to eliminate serological reactivity toward very low frequency antigens from the study and improve the statistical analysis of seroactive antigens&#44; those immunoblot bands that were present in 5 or fewer individuals in both the patient and the control group were not considered&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Determination of pepsinogen I and II in serum</span><p id="par0070" class="elsevierStylePara elsevierViewall">The analysis was performed applying an antigen capture ELISA protocol using commercial assays for the quantification of both pepsinogens &#40;Cat&#46; RAB0722 and RAB0723&#44; Sigma-Aldrich&#41;&#46; The manufacturer&#39;s instructions were followed considering a dilution of the serological samples of 1&#58;10 in PBS&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistic analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">The comparisons between continuous variables were made using the Student&#39;s <span class="elsevierStyleItalic">t</span>-test and one-way ANOVA followed by Dunnett&#39;s multiple comparison&#46; Categorical variables were represented as percentage and simple frequency&#44; and were analyzed using the Fisher&#39;s exact test&#46; The binary regression analysis to determine the odds ratio &#40;OR&#41; was performed using the McNemar&#39;s method&#46; For statistical calculations&#44; Prisma GraphPad Software &#40;ver6&#46;0c&#41; and QuickCalcs &#40;<a href="http://www.graphpad.com/">www&#46;graphpad&#46;com</a>&#41; were used&#46; Spearman&#39;s bivariate correlation analysis was performed by applying the formula&#58; <span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#40;6&#8721;<span class="elsevierStyleItalic">d</span><span class="elsevierStyleSup">2</span>&#41;&#47;n&#40;n<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>1&#41;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">16</span></a>&#46; The correlation was considered either positive&#47;negative and either high&#47;moderate&#47;low &#40;high&#44; <span class="elsevierStyleItalic">&#961;</span> value of 0&#46;7&#8211;0&#46;9&#59; moderate&#44; <span class="elsevierStyleItalic">&#961;</span> value of 0&#46;5&#8211;0&#46;7&#59; low <span class="elsevierStyleItalic">&#961;</span> value &#60;0&#46;5&#59; no association <span class="elsevierStyleItalic">&#961;</span> value &#60;0&#46;1&#41; according to the scale described by Mukaka<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">17</span></a>&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Description of the populations studied</span><p id="par0080" class="elsevierStylePara elsevierViewall">The characteristics of the studied populations are indicated in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The gender comparison between the individuals included in the group of patients with gastroduodenal pathology and the control group indicated an equivalent male&#8211;female ratio between the groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;303&#41;&#46; Similarly&#44; the average age between both populations did not show a significant difference &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;070&#41;&#46; Within the patient population&#44; it was identified that 30&#46;8&#37; of the subjects presented manifestation of glandular atrophy&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Antibody titers and identification of seroactive anti-<span class="elsevierStyleItalic">H&#46; pylori</span></span><p id="par0085" class="elsevierStylePara elsevierViewall">The determination of anti-<span class="elsevierStyleItalic">H&#46; pylori</span> by ELISA <span class="elsevierStyleItalic">cut-off</span> analysis identified that the total number of individuals in the patient group was seropositive for the bacterium&#44; while in the control group this positivity was present in 80&#37; of the individuals &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;032&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; However&#44; the antibody titer evaluated by optical density readings showed that the average absorbance values in the patient and control populations were statistically equivalent &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;449&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Additionally&#44; the serological samples from the study groups were used to identify the existence of seroactive antigens toward <span class="elsevierStyleItalic">H&#46; pylori</span> through an immunoblot analysis&#46; The average number of seroactive antigens identified for each individual in the patient group was similar to the control group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;167&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; When the molecular weights of the bands obtained in the immunoblot typing of the seroactive antigens corresponding to all the individuals analyzed in both groups were considered&#44; a total of 31 different antigens were identified &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Through a frequency analysis&#44; it was determined that 9 of the identified seroactive antigens exhibited a significant differential frequency between both study groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Finding that in 8 of them &#40;116&#46;7&#44; 61&#46;9&#44; 54&#46;9&#44; 45&#46;6&#44; 38&#46;3&#44; 36&#46;6&#44; 33&#46;8 and 30&#46;1<span class="elsevierStyleHsp" style=""></span>kDa&#41; there was a significantly higher frequency in the group of patients in relation to the control group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and with an odd ratio greater than 1&#46;7 &#40;1&#46;70&#44; 1&#46;73&#44; 1&#46;73&#44; 2&#46;93&#44; 1&#46;73&#44; 1&#46;86&#44; 1&#46;86 and 2&#46;1 OR&#44; respectively&#41;&#46; In contrast&#44; only the 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa seroactive antigen was more frequent in the control group &#40;0&#46;537 OR&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In order to discover a possible relationship between the presence of glandular atrophy and serological reactivity toward the 9 previously identified antigens with differential frequency&#44; a comparison of their frequency was conducted between the subgroups of patients with atrophy and those without atrophy &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; This analysis revealed that only 5 showed a differential frequency &#40;68&#46;8&#44; 61&#46;9&#44; 36&#46;5&#44; 33&#46;8 and 30&#46;1<span class="elsevierStyleHsp" style=""></span>kDa&#41;&#44; which was related to a greater presence in patients without glandular atrophy&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Study of pepsinogen levels in serum</span><p id="par0100" class="elsevierStylePara elsevierViewall">Using an antigen-capture ELISA assay&#44; the serum concentration of gastric zymogens PGI and PGII was determined in both populations&#46; In the case of PGI&#44; the serum levels of the individuals from both the patient and control groups showed statistically equivalent average values &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;142&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The average level of PGII was significantly higher in the patient group &#40;21&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;88<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; compared to the control group &#40;11&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;35<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; The average PGI&#47;PGII ratio was considerably higher in the control group compared to the patients &#40;6&#46;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;25 and 3&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;54<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; To analyze the relationship of the levels of gastric zymogens in relation to the presence of glandular atrophy in the patient population&#44; these were classified into atrophy and non-atrophy subgroups&#46; It was found that the subgroup of patients with atrophy was the only one that showed a significantly lower average level of PGI compared to the control group &#40;36&#46;14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;65 and 64&#46;51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;08<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The mean serological concentration of PGII in the control individuals &#40;11&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;35<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; was significantly lower than that observed for the atrophy and non-atrophy subgroups &#40;28&#46;65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;15 and 17&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;48<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The mean PGI&#47;PGII ratio in both patient subgroups was lower relative to controls &#40;6&#46;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;25&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#44; highlighting that the lowest PGI&#47;PGII ratio identified was observed in individuals with glandular atrophy &#40;1&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;91&#41;&#44; being statistically lower than the mean value in patients without atrophy &#40;4&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;47&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0026&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Association of seroactive anti-<span class="elsevierStyleItalic">H&#46; pylori</span> with levels of pepsinogens</span><p id="par0105" class="elsevierStylePara elsevierViewall">Subsequently&#44; it was sought to know if the serological activity toward the 9 differential antigens was related to alterations in the levels of pepsinogens in serum&#46; For which purpose&#44; the average levels of PGs present in seropositive and seronegative individuals for each seroactive antigen in both study groups were compared &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Seropositivity toward the 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen was related in the control group with a decrease in PGII levels in relation to seronegative individuals &#40;7&#46;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;28 vs 13&#46;94<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;31&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41; as well as with an increase in the PGI&#47;PGII ratio &#40;7&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;01 vs 5&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;90&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46; In the patient group&#44; the 54&#46;9<span class="elsevierStyleHsp" style=""></span>kDa seroactive antigen was associated with a highly significant increase in PGII in relation to seronegative patients &#40;27&#46;70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;46 vs 16&#46;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;99&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0018&#41; and a decrease in the PGI&#47;PGII ratio &#40;2&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83 vs 4&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;73&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#41;&#46; Control individuals with serological activity toward the 33&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen were associated with a highly significant increase in PGII &#40;20&#46;39<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;62 vs 10&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;06&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0064&#41;&#46; Serological activity toward the remaining antigens &#40;116&#46;7&#44; 61&#46;9&#44; 45&#46;6&#44; 38&#46;3&#44; 36&#46;5 and 30&#46;1<span class="elsevierStyleHsp" style=""></span>kDa&#41; was not related to differences in pepsinogen levels between seropositive and seronegative individuals for both groups&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Bivariate correlation analysis of pepsinogen levels</span><p id="par0110" class="elsevierStylePara elsevierViewall">Finally&#44; a bivariate Spearman&#39;s analysis was performed on the total number of patients and subgroups of patients with and without atrophy to discover possible correlations between pepsinogen levels and anti-<span class="elsevierStyleItalic">H&#46; pylori</span> antibody titers&#44; number of seroactive antigens and age &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; The levels of PGI exhibited a moderate inverse correlation only with the anti-<span class="elsevierStyleItalic">H&#46; pylori</span> values of absorbance &#40;ABS&#41; in individuals with atrophy &#40;<span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;670&#41;&#46; The serum concentration of PGII had a high positive correlation with anti-<span class="elsevierStyleItalic">H&#46; pylori</span> ABS in the total number of patients &#40;<span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;813&#41; and in the subgroup without atrophy &#40;<span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;812&#41; as well as a moderate correlation in the patients with atrophy &#40;<span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;690&#41;&#46; This zymogen also correlated positively with age&#44; but only in the control group &#40;<span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;534&#41;&#46; The PGI&#47;PGII ratio showed high inverse correlations with anti-<span class="elsevierStyleItalic">H&#46; pylori</span> ABS in all the patients&#44; with or without atrophy &#40;<span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;811&#44; &#8722;0&#46;761 and &#8722;0&#46;853&#44; respectively&#41; contrasting with the low association present in the control&#46; Age in the subgroup of patients without atrophy had a moderate inverse correlation &#40;<span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;553&#41; with the PGI&#47;PGII ratio&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The levels of gastric zymogens PGI and PGII in serum are important indicators of the integrity and functionality of the gastric mucosa<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">13</span></a>&#46; In our study&#44; the lowest mean PGI values were found in the subpopulation of patients classified as having glandular atrophy&#46; Several previous studies indicate that low levels of this zymogen &#40;&#60;50<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; together with a low pepsinogen ratio &#40;PGI&#47;PGII<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>4&#41; can be considered important diagnostic markers of atrophic glandular disorders<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">44</span></a>&#46; However&#44; recent studies show that the decrease in PGI concentration associated with a low PGI&#47;PGII ratio may be a parameter with a more specific prognostic value for the identification of malignant processes such as intestinal metaplasia<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">3</span></a>&#46; Alterations in the gastric mucosa are related to elevated PGII levels &#40;&#62;12<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; together with a low pepsinogen ratio&#44; but it is also considered a marker of active inflammation at this site<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">9&#44;37</span></a>&#46; In our study&#44; the mean values of these two parameters considering the total number of patients and the subgroups with and without atrophy were consistent with the existence of alteration and inflammation of the gastric mucosa&#44; contrary to what was observed in the control individuals whose average serological levels of PGII and pepsinogen ratio were within the normal range&#46; The low PGI&#47;PGII ratio has been shown to be one of the main serological markers for the diagnosis of atrophic gastritis<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">29</span></a>&#46; Consistent with the above&#44; the subgroup of patients classified endoscopically with atrophic mucosa in our study exhibited the lowest values of this relationship&#44; being significantly lower with respect to the subgroup of patients without atrophy and the control population&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Altered levels of pepsinogens in blood in association with anti-<span class="elsevierStyleItalic">H&#46; pylori</span> antibody titers have also been used as prognostic markers of risk for the development of gastric pathologies&#44; including the generation of carcinogenesis&#46; These findings have even made it possible to establish gastric cancer risk criteria considering these markers<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">40</span></a>&#46; In order to search for potential complementary indicators related to the humoral response to the bacterium&#44; the existence of <span class="elsevierStyleItalic">H&#46; pylori</span> seroactive antigens related to gastric pathology associated with the bacterium was studied&#46; The immunoblot analysis performed for our study populations identified a total of 31 different antigens with serological reactivity to the bacterium&#46; Previous analyzes have identified equivalent amounts of serologically active anti-<span class="elsevierStyleItalic">H&#46; pylori</span>&#46; In a study through two-dimensional gels and using serum from infected individuals&#44; 29 seroactive antigens were identified<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">10</span></a>&#46; Of the seroactive antigens identified in our study&#44; it was shown that nine exhibited a differential frequency between both groups&#46; According to the calculated theoretical molecular weight&#44; five of these antigens &#40;116&#46;7&#44; 61&#46;9&#44; 38&#46;3&#44; 36&#46;6 and 30&#46;1<span class="elsevierStyleHsp" style=""></span>kDa&#41; show a molecular weight close to bands that are usually analyzed in commercial protocols for serological diagnosis of <span class="elsevierStyleItalic">H&#46; pylori</span> by immunoblot&#44; which include the molecules CagA &#40;116<span class="elsevierStyleHsp" style=""></span>kDa&#41;&#44; UreB &#40;61<span class="elsevierStyleHsp" style=""></span>kDa&#41;&#44; UreA &#40;30<span class="elsevierStyleHsp" style=""></span>kDa&#41; and the 37 and 35<span class="elsevierStyleHsp" style=""></span>kDa proteins<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">41</span></a>&#46; An important serological marker of bacterial infection is vacuolating cytotoxin A &#40;89<span class="elsevierStyleHsp" style=""></span>kDa&#41;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">43</span></a>&#46; Seroactivity was identified toward an antigen &#40;88&#46;7<span class="elsevierStyleHsp" style=""></span>kDa&#41; with a size similar to that reported for this cytotoxin&#59; however&#44; its frequency was equivalent between both groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#41;&#44; probably due to the high seropositivity toward <span class="elsevierStyleItalic">H&#46; pylori</span> in the individuals of the control group&#46; Despite the fact that the VacA protein is considered an important pathogenic factor of the bacterium&#44; the equivalent serological reactivity in both groups toward an antigen similar in size to VacA could be explained by the existence of polymorphisms in various regions of the <span class="elsevierStyleItalic">vacA</span> gene that generates strains with different degrees of pathogenicity&#44; a situation that was not determined in our study<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">8</span></a>&#46; The differential seroactivity identified for the 33&#46;8&#44; 45&#46;6&#44; 54&#46;9 and 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigens was of interest as they are molecules that are not included as specific diagnostic markers of infection&#46; However&#44; previous works report a humoral response to <span class="elsevierStyleItalic">H&#46; pylori</span> proteins &#40;33&#44; 34&#44; 45 and 54<span class="elsevierStyleHsp" style=""></span>kDa&#41; of a size equivalent to 3 of these seroantigens that are associated with gastroduodenal pathologies caused by this bacterium<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">23&#8211;25&#44;28</span></a>&#46; Although these antigens are related to gastric pathologies associated with <span class="elsevierStyleItalic">H&#46; pylori</span>&#44; they have not been shown to be specific indicators of gastric colonization of the bacterium to be included as markers of infection&#46; The lack of specificity with <span class="elsevierStyleItalic">H&#46; pylori</span> infection could perhaps be a consequence of possible cross-responses with antigens from other bacteria&#46; Antibodies against antigens from the periodontal bacterium <span class="elsevierStyleItalic">Campylobacter rectus</span> and other important pathogens have shown cross antigenicity with the 54<span class="elsevierStyleHsp" style=""></span>kDa protein of <span class="elsevierStyleItalic">H&#46; pylori</span><a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">7&#44;23</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Since the modification of the levels of pepsinogens in serum is a risk condition for the development of gastric pathologies&#44; it was of interest to find that the serological positivity of three antigens identified with differential seropositivity &#40;33&#46;8&#44; 68&#46;8 and 54&#46;9<span class="elsevierStyleHsp" style=""></span>kDa&#41; in the two groups of study were related to alterations in the PG levels&#46; The increase in the level of PGII related to the seroactivity of the 33&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen in the control group may not be as relevant as a pathological marker&#44; since it has been reported that the alteration in only some of the pepsinogens without being linked to changes in the PGI&#47;PGII relationship has less diagnostic value for pathologies such as atrophic gastritis<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">3&#44;9</span></a>&#46; The humoral response to the 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen could act as a potential serological factor linked to protection against the development of gastroduodenal pathologies&#46; This considering its higher frequency in the control group in relation to the patients &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;53&#41; and that its seropositivity also in the control group was associated with PGII levels and PGI&#47;PGII ratio in ranges of higher normality than the average levels of seronegative individuals&#46; Since there are no previous reports that identify the 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen as an immunodominant antigen of <span class="elsevierStyleItalic">H&#46; pylori</span>&#44; it is important to study it further to find out if it could be useful for prognostic purposes&#46; Although the identity of the 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen is unknown&#44; the serological activity toward this antigen could be related to the neutralization of the proinflammatory activity of the bacterium&#44; as is the case of outer membrane proteins that directly or through the functional activation of the Type IV Secretion System of <span class="elsevierStyleItalic">H&#46; pylori</span> are linked to inflammatory processes<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">39</span></a>&#46; The serological activity toward the 54&#46;9<span class="elsevierStyleHsp" style=""></span>kDa antigen was the only one in the group of patients that was related to altered values of pepsinogens indicative of processes of inflammation and atrophy of the gastric mucosa&#44; since patients seropositive to this antigen showed increased average levels of PGII and a lower mean PGI&#47;PGII ratio compared to seronegative patients&#46; The identification of the serological activity of this antigen as a possible pathological marker in our study is consistent with pioneering work on the humoral immune response to <span class="elsevierStyleItalic">H&#46; pylori</span>&#44; which shows that serum IgG antibodies against the Hp54K &#40;54<span class="elsevierStyleHsp" style=""></span>kDa&#41; protein of <span class="elsevierStyleItalic">H&#46; pylori</span> homologous to chaperonins of the cpn60 family present in various bacteria&#44; correlates with the severity of inflammation in gastric mucosa both in acute and chronic inflammation in patients<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">21</span></a>&#46; It is of interest to further study the seroactivity toward this antigen as a serological parameter that could be associated with the enhancement of inflammatory processes that could affect the gastric mucosa during <span class="elsevierStyleItalic">H&#46; pylori</span> infection&#44; improving the prognostic indicators of damage&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Since glandular atrophy is an important factor related to the promotion of neoplastic processes&#44; an attempt was made to relate it to the serological reactivity of the 9 identified antigens&#46; Although none of the seroactive antigens exhibited higher frequencies related to the subgroup of patients with glandular atrophy&#44; the frequency of 5 of them&#44; including the 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen&#44; occurred more frequently in individuals without atrophy&#46; This result supports the possibility that serological activity toward the 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen could be considered a protective factor against the development of severe gastric pathologies&#46; However&#44; this analysis did not find a correlation with the alterations in the PGs previously identified for the seroactivity of the 54&#46;9<span class="elsevierStyleHsp" style=""></span>kDa antigen&#44; a situation possibly related to the low number of samples studied from patients with atrophy&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Finally&#44; the Spearman&#39;s bivariate analysis revealed the potential correlation between serum levels of pepsinogens and various parameters of the population studied&#46; The anti-<span class="elsevierStyleItalic">H&#46; pylori</span> antibody titer was the factor that presented the highest correlations with respect to the pepsinogen levels in the group of patients including the subgroups of patients with and without atrophy&#46; This result confirms the observations that have been previously made in multiple works that indicate that the high concentration of antibodies against the bacterium linked to altered levels of pepsinogens is a relevant parameter for the serological diagnosis of various gastric pathologies<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In conclusion&#44; given that the humoral response to <span class="elsevierStyleItalic">H&#46; pylori</span> together with the serological analysis of pepsinogen levels are important markers related to gastric mucosal damage&#44; the identification in this study of serum alterations in pepsinogen levels related to seropositivity to antigens 33&#46;8&#44; 54&#46;9 and 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa of <span class="elsevierStyleItalic">H&#46; pylori</span> generates a precedent to deepen their study as possible prognostic serological markers&#46; However&#44; a weakness of our work was the analysis of a small number of samples limited to a single geographic region&#46; Considering the diversity of gastric pathologies associated with <span class="elsevierStyleItalic">H&#46; pylori</span>&#44; to confirm the results obtained in our study&#44; it is necessary to analyze populations with a much larger number of individuals&#44; as well as the inclusion of samples from different geographic regions to also consider ethnic and environmental factors&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0145" class="elsevierStylePara elsevierViewall">This work was carried out with the support of the <span class="elsevierStyleGrantSponsor" id="gs1">Autonomous University of Aguascalientes</span> through the Basic Biomedical Research Program &#40;Institutional Project PIBB-19-5&#41;&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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              "titulo" => "Association of seroactive anti-H&#46; pylori with levels of pepsinogens"
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              "titulo" => "Bivariate correlation analysis of pepsinogen levels"
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          "titulo" => "Conflicts of interest"
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        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-06-22"
    "fechaAceptado" => "2023-04-14"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1763774"
          "palabras" => array:5 [
            0 => "<span class="elsevierStyleItalic">Helicobacter pylori</span>"
            1 => "Pepsinogen"
            2 => "Seroactive antigens"
            3 => "Glandular atrophy"
            4 => "Serological diagnosis"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1763773"
          "palabras" => array:5 [
            0 => "<span class="elsevierStyleItalic">Helicobacter pylori</span>"
            1 => "Pepsin&#243;geno"
            2 => "Ant&#237;genos seroactivos"
            3 => "Atrofia glandular"
            4 => "Diagn&#243;stico serol&#243;gico"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "highlights" => array:2 [
      "titulo" => "Highlights"
      "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0005" class="elsevierStylePara elsevierViewall">Serum concentration of pepsinogens and seroantigens of <span class="elsevierStyleItalic">H&#46; pylori</span> were determined&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Helicobacter pylori</span> seroantigens&#44; possible indicators of atrophic mucosa&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0015" class="elsevierStylePara elsevierViewall">We observed a humoral response anti-<span class="elsevierStyleItalic">H&#46; pylori</span> and altered serum pepsinogen levels&#46;</p></li></ul></p></span>"
    ]
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Gastric adenocarcinoma is associated with <span class="elsevierStyleItalic">Helicobacter pylori</span> infection&#46; The transition to a carcinogenic process is preceded by glandular atrophy and serum levels of pepsinogen I and II &#40;PGI and PGII&#41; correlate with this type of gastric lesions&#46; Possible associations of serum PG levels in relation to the frequency of serological activity against <span class="elsevierStyleItalic">H&#46; pylori</span> antigens were studied&#46; Serum samples from patients with gastric pathology associated with <span class="elsevierStyleItalic">H&#46; pylori</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; and asymptomatic individuals as controls &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41; were used&#46; Seroactive antigens were identified by immunoblot using a protein extract of <span class="elsevierStyleItalic">H&#46; pylori</span>&#46; The antibody titers anti-<span class="elsevierStyleItalic">H&#46; pylori</span> and the concentration of PGs in serum was determined by ELISA&#46; Thirty-one seroactive antigens were identified&#44; nine of which exhibited a differential frequency between both groups &#40;116&#46;7&#44; 68&#46;8&#44; 61&#46;9&#44; 54&#46;9&#44; 45&#46;6&#44; 38&#46;3&#44; 36&#46;5&#44; 33&#46;8 and 30&#46;1<span class="elsevierStyleHsp" style=""></span>kDa&#41; and only 3 were related to altered levels of PGs in serum&#46; In the control group&#44; the seropositivity of the 33&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen was related to an increase in PGII&#44; while the 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigen was related to normal PG values &#40;decreased PGII and elevated PGI&#47;PGII levels&#41; indicating that seropositivity to this antigen could be a protective factor to gastric pathology&#46; The seropositivity of the 54&#46;9<span class="elsevierStyleHsp" style=""></span>kDa antigen was related to altered values of PGs indicative of inflammation and gastric atrophy &#40;increased in PGII and decreased in PGI&#47;PGII&#41;&#46; The identification of serum alterations in pepsinogen levels related to seropositivity to <span class="elsevierStyleItalic">H&#46; pylori</span> 33&#46;8&#44; 54&#46;9 and 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa antigens sets a precedent for further study as possible prognostic serological biomarkers&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El adenocarcinoma g&#225;strico se asocia con la infecci&#243;n por <span class="elsevierStyleItalic">Helicobacter pylori</span>&#46; La transici&#243;n a un proceso de carcinog&#233;nesis est&#225; precedida por atrofia glandular&#44; y los niveles s&#233;ricos de pepsin&#243;geno I y II &#40;PGI y PGII&#41; se correlacionan con este tipo de lesiones g&#225;stricas&#46; El objetivo del trabajo fue estudiar posibles asociaciones de los niveles de pepsin&#243;genos &#40;PG&#41; en suero en relaci&#243;n con la frecuencia de actividad serol&#243;gica hacia ant&#237;genos de <span class="elsevierStyleItalic">H&#46; pylori</span>&#46; Se utilizaron muestras de suero de pacientes con patolog&#237;a g&#225;strica asociada a <span class="elsevierStyleItalic">H&#46; pylori</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; y de individuos asintom&#225;ticos como controles &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41;&#46; Los ant&#237;genos seroactivos se identificaron mediante inmunoblot utilizando un extracto proteico de <span class="elsevierStyleItalic">H&#46; pylori</span>&#46; Los t&#237;tulos de anticuerpos anti-<span class="elsevierStyleItalic">H&#46; pylori</span> y la concentraci&#243;n de PG en suero se determinaron por ELISA&#46; De los 31 ant&#237;genos seroactivos identificados&#44; 9 presentaron una frecuencia diferencial entre ambos grupos &#40;116&#44;7&#59; 68&#44;8&#59; 61&#44;9&#59; 54&#44;9&#59; 45&#44;6&#59; 38&#44;3&#59; 36&#44;5&#59; 33&#44;8 y 30&#44;1<span class="elsevierStyleHsp" style=""></span>kDa&#41; y solo 3 se relacionaron con niveles alterados de PG en suero&#46; En el grupo control&#44; la seropositividad del ant&#237;geno de 33&#44;8<span class="elsevierStyleHsp" style=""></span>kDa se relacion&#243; con un aumento de PGII&#44; mientras que el ant&#237;geno de 68&#44;8<span class="elsevierStyleHsp" style=""></span>kDa se relacion&#243; con valores normales de PG &#40;PGII disminuido y PGI&#47;PGII elevado&#41;&#44; sugiriendo que la seropositividad a este ant&#237;geno podr&#237;a ser un factor protector frente a patolog&#237;as g&#225;stricas&#46; La seropositividad del ant&#237;geno de 54&#44;9<span class="elsevierStyleHsp" style=""></span>kDa se relacion&#243; con valores alterados de PG indicadores de inflamaci&#243;n y atrofia g&#225;strica &#40;aumento de PGII y disminuci&#243;n de PGI&#47;PGII&#41;&#46; La identificaci&#243;n de alteraciones s&#233;ricas en los niveles de pepsin&#243;geno relacionadas con la seropositividad a los ant&#237;genos de 33&#44;8&#59; 54&#44;9 y 68&#44;8<span class="elsevierStyleHsp" style=""></span>kDa de <span class="elsevierStyleItalic">H&#46; pylori</span> sienta un precedente para futuros estudios como posibles biomarcadores serol&#243;gicos pron&#243;sticos&#46;</p></span>"
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1809
            "Ancho" => 1675
            "Tamanyo" => 110876
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Immunoblot analysis to determine seroactive antigens &#40;SAA&#41;&#46; Results show a control individual &#40;<span class="elsevierStyleBold">1</span>&#41; seropositive for SAA of 68&#46;8<span class="elsevierStyleHsp" style=""></span>kDa &#40;arrow on the left&#41; as well as a patient &#40;<span class="elsevierStyleBold">2</span>&#41; with seropositivity for SAA of 54&#46;9 and 33&#46;8<span class="elsevierStyleHsp" style=""></span>kDa &#40;arrows on the right&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 718
            "Ancho" => 2508
            "Tamanyo" => 95836
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Serum concentration of pepsinogens determined by antigen capture ELISA&#46; Results are indicated for control group &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41; and total patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; as well as for the subgroups of patients with atrophy &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41; and without atrophy &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#41;&#46; &#40;A&#41; Pepsinogen I&#44; &#40;B&#41; pepsinogen II&#44; and &#40;C&#41; pepsinogen I&#47;pepsinogen II ratio &#40;PGI&#47;PGII&#41;&#46; ANOVA&#44; Dunnett&#39;s multiple comparison test was used to distinguish the level of significance based on &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; <span class="elsevierStyleSup">&#42;&#42;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01 and <span class="elsevierStyleSup">&#42;&#42;&#42;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 compared to the control group&#46; The mean value<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation is represented&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Control &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;070&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;53&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;37&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;303&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Female&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;46&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;62&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;303&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Non-atrophy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;69&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atrophy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;30&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HP seropositivity&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;81&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;032&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-HP &#40;ABS<span class="elsevierStyleSup">492nm</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;09<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;449&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGII&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGII&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGII&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PGII&nbsp;\t\t\t\t\t\t\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos