Esomeprazole 20 mg on-demand is more acceptable to patients than continuous lansoprazole 15 mg in the long-term maintenance of endoscopy-negative gastro-oesophageal reflux patients: the COMMAND Study

BACKGROUND

Symptom relief, through adherence to appropriate maintenance therapy, is the sole objective of treatment for patients with endoscopy-negative gastro-oesophageal reflux disease.

AIM

To compare the efficacy of 'on-demand' treatment with esomeprazole 20 mg vs. continuous treatment with lansoprazole 15 mg daily in patients with endoscopy-negative gastro-oesophageal reflux disease.

METHODS

Endoscopy-negative gastro-oesophageal reflux disease patients who achieved complete resolution of heartburn after short-term (2-4 weeks) treatment with esomeprazole 20 mg (n = 774) were randomized to receive either esomeprazole 20 mg on-demand (n =311) or lansoprazole 15 mg continuous daily treatment (n = 311) for 6 months.

RESULTS

Significantly more patients were willing to continue taking esomeprazole on-demand than lansoprazole continuous therapy after 6 months (93% vs. 88%; P = 0.02). This superior outcome was achieved despite patients on esomeprazole requiring medication only 38% as often as those on lansoprazole, leading to direct cost savings of more than one-third (36%). Furthermore, patients receiving esomeprazole 20 mg on-demand were more satisfied with their treatment after 1 month compared with patients taking lansoprazole 15 mg continuously.

CONCLUSIONS

In patients with endoscopy-negative gastro-oesophageal reflux disease, esomeprazole 20 mg on-demand is more acceptable to patients and is an economically more effective treatment than lansoprazole 15 mg continuously.

Netrin 1 mediates spinal cord oligodendrocyte precursor dispersal

In spinal cord, oligodendrocyte precursors that give rise to myelin-forming cells originate in a restricted domain of the ventral ventricular zone. During development, these cells migrate widely throughout the spinal cord. Netrin 1 is expressed at the ventral ventricular zone during oligodendrocyte precursors emigration, and, in vitro, netrin 1 acts as chemorepellent and antagonizes platelet-derived growth factor (PDGF) chemoattraction. Oligodendrocyte precursors express the netrin receptors DCC and UNC5 and function-blocking anti-DCC antibody inhibits chemorepulsion of ventral spinal cord explants and netrin-secreting cells. In spinal cord slice preparations, addition of function-blocking anti-DCC antibody or netrin 1 dramatically inhibits oligodendrocyte precursor migration from the ventral ventricular zone. These data indicate the initial dispersal of oligodendrocyte precursors from their localized origin is guided by a chemorepellent response to netrin 1.

The chemokine receptor CXCR2 controls positioning of oligodendrocyte precursors in developing spinal cord by arresting their migration

Spinal cord oligodendrocytes originate in the ventricular zone and subsequently migrate to white matter, stop, proliferate, and differentiate. Here we demonstrate a role for the chemokine CXCL1 and its receptor CXCR2 in patterning the developing spinal cord. Signaling through CXCR2, CXCL1 inhibited oligodendrocyte precursor migration. The migrational arrest was rapid, reversible, concentration dependent, and reflected enhanced cell/substrate interactions. White matter expression of CXCL1 was temporo-spatially regulated. Developing CXCR2 null spinal cords contained reduced oligodendrocytes, abnormally concentrated at the periphery. In slice preparations, CXCL1 inhibited embryonic oligodendrocyte precursor migration, and widespread dispersal of postnatal precursors occurred in the absence of CXCR2 signaling. These data suggest that population of presumptive white matter by oligodendrocyte precursors is dependent on localized expression of CXCL1.

Eruption process of upper permanent canine

The purpose of this study was to investigate normal eruptive pattern of upper permanent canine. One hundred and fifty-one panoramic radiographs were used. Inclination of upper canine and lateral incisor, length and horizontal and vertical positions of cusp and root apex of the canine were evaluated. The canine erupted with increasing distal inclination and with no significant changes of the lateral incisor. Developmental changes of the canines relative to palatal plane and midline were shown by figures.

Glial cell migration directed by axon guidance cues

Widespread myelination by oligodendrocytes is essential for the normal functioning of the vertebrate CNS. Oligodendrocyte precursors initially arise in restricted regions of the neuroepithelium and migrate relatively long distances to their final destinations. The signals that guide this migration have remained poorly understood, but recent studies suggest that glial precursors use similar molecular cues to those that guide axons through the complex terrain of the developing CNS. For example, in the developing optic nerve, glial-precursor migration from the brain towards the retina is guided by netrin-1 and semaphorin 3a. These studies suggest a novel mechanism governing glial precursor migration and provide new insights into development and the potential to direct CNS injury repair.

Developmental changes of mandibular permanent canines and premolars in early mixed dentition

This study investigated the developmental changes of mandibular permanent canines and premolars in early mixed dentition using panoramic radiographs. Positions of cusps and root apices of the teeth relative to the inferior border of mandible were evaluated. The developmental stages of the teeth were divided into three stages. There were few changes in the inclination of the three teeth. The permanent canine began to erupt before stage 2 and the second premolar began to erupt after stage 2. The distance between the inferior border of the mandible and apices of the three teeth was almost fixed in early mixed dentition.

Localization of first permanent molars in lateral cephalometric and panoramic radiographs from early mixed dentition to early permanent dentition

Changes in position and mesiodistal angulations of maxillary and mandibular first permanent molars from early mixed dentition to early permanent dentition were measured on panoramic radiographs and compared with the values measured on lateral cephalometric radiographs. It was found that the maxillary and mandibular first permanent molars were uprighted gradually, drifted mesially and vertically, and that the changes in mesiodistal angulations were clearly on the panoramic radiographs in comparison with the cephalometric radiographs.

Morphological characteristics of the deciduous teeth

The morphology of the deciduous teeth was investigated. The mean mesiodistal crown dimensions of the deciduous canine, first and second molars and the mean buccolingual crown dimensions of the deciduous second molars in both dental arches of boys were significantly larger than that of girls. The upper deciduous first molar of girls was slender buccolingually and the lower deciduous second molar of boys was slender mesiodistally.

Cephalometric studies of children with long and short faces

The purpose of this study was to investigate the facial morphologic characteristics in children with long and short faces. Lateral cephalometric radiographs of 46 children with long faces and 42 children with short faces were used. Both boys and girls with long faces exhibited upright incisors, excessive upper dentoalveolar development, shorter posterior face height, shorter ramus height and mandibular body, greater gonial angle and backward rotation of mandible when compared with those with short faces.

Treatment of anterior crossbite with bilateral posterior crossbite in early mixed dentition: a case report

A case report of a 7-year-old boy who had Class III skeletal pattern is presented. The maxilla was deficient in anteroposterior and transverse dimensions, causing a slightly concave profile, a crossbite relationship of most of the anterior and posterior teeth, and upper anterior crowding. The rapid palatal expansion therapy effectively uprighted the posterior segments and developed the arches. Alignment, leveling and development of a good functional occlusion was accomplished with the .022" x .028" standard edgewise appliance.

Does better disease-related education improve quality of life? A survey of IBD patients

The importance of health-related quality of life (HRQOL) assessment in patients with chronic disorders such as inflammatory bowel disease (IBD) is now acknowledged by researchers. Of the many factors that may influence HRQOL, patient knowledge of the condition and disease-related information provision have hitherto not been studied. In all, 250 patients with inactive IBD (UC = 128, CD = 122) were randomly chosen from our IBD clinic. Two sets of questionnaires [initially a standard questionnaire to assess level of disease-related information by a patient information score (PIS), followed by a HRQOL questionnaire] were sent to each patient. In the PIS, a score of 7 or more indicated satisfactory disease-related knowledge and in the HRQOL, a score less than 51 suggested a normal QOL, and a score above 60 significantly impaired QOL. A total of 168 patients (66%) returned both the questionnaires (UC = 91, CD = 77). The mean QOL in patients with UC and CD was 62.2+/-8.3 and 63.9+/-9.5 respectively, (P = NS). 99 patients (59%) had significantly impaired QOL (mean score 65+/-7.6) with only 12 patients (8%), 6 in each group, having a normal QOL. Mean PIS score for the patients was 7.04+/-0.1; 53% of the UC patients and 75% of the CD patients (P = 0.006) were considered well informed (ie, PIS scores of 7 or more). The mean PIS for UC patients was 6.5+/-0.4 vs 7.5+/-0.2 for the CD group (P = 0.001). There was, however, no correlation seen between the QOL and PIS scores, both for UC and CD patients (R = 0.3). In conclusion, most patients with IBD have impaired QOL, despite of having inactive disease. The level of disease-related knowledge appears to be better in patients with CD, although that does not seem to affect QOL.

Tooth-position, arch-size, and arch-shape in the primary dentition

Tooth positions and dental arch forms are related to the growth of the cranio-facial complex. To determine the positions of primary teeth and size and shape of the primary dental arches, sixty dental casts of young children (thirty boys and thirty girls) with normal occlusions were examined. In all casts the coordinates of cusp tips of primary canines and molars, and mesial and distal line angles of primary canines and incisors were digitized. The computer-generated curves were made for the maxillary and mandibular arches using a polynomial model. The results show that there were three major cusp-to-fossa and one cusp-to-marginal ridge relations in primary molar intercuspation. On average, girl's dental arches were smaller than boy's dental arches. The mean curves of mandibular arches in anterior segments were gentler than those of maxillary arches.

Descriptive classification of variations in primary mandibular first molars

Variability in tooth morphology can play a significant role in the achievable results of restorative treatment. This study identified the variations of morphology of the primary mandibular first molar (Type I and II coronal outline and Type A-F cusp alignment.) Type I coronal outline was found more frequently (86 percent) than Type II (14 percent). 93 percent of the primary mandibular first molars comprise four cusps, 5 percent comprise five cusps, and 2 percent comprise 3 cusps (F). Among the four-cusp group, 70 percent had an oblique transverse ridge (C), 25 percent had a poorly developed transverse ridge (A). Among the five-cusp-group, 67 percent had a distal cusp (E), and 33 percent had a fifth lingual cusp (D). The most frequent combination of coronal outline and cusp alignment was Type I-C (60 percent), and followed by Type I-B (22 percent), II-C (5 percent), and II-A (4 percent).

Components of anterior crossbite in the primary dentition

The craniofacial and dental components of anterior crossbite children with a full primary dentition were investigated by means of a cephalometric and correlation study. A group of thirty-two Taiwanese children with anterior crossbite was compared to a group of thirty-two normal occlusion subjects. The facial profile polygon method was used for assessing morphological characteristics of craniofacial pattern. According to the results, early signs of anterior crossbite are present in the primary dentition. A smaller anterior cranial base, a retruded positioning of the maxilla and a smaller interincisal angle were found in the anterior crossbite children. A correlation analysis between all the cephalometric measurements was carried out, and the significance of the differences between correlation coefficients of the two groups was calculated. the normal occlusion group shows negative correlation between interincisal angle and FH-SGn angle. The anterior crossbite group shows positive correlation between FH-NPog angle and U1-FH angle.

Eruption process of the second molar

The second molar is located at the distal of the first molar, and we must be aware of its stage of development when we plan to move the first molar distally. Few researchers have investigated the development of second molars. The purpose of this study was to observe the eruption process of the maxillary and mandibular second molars by using 238 panoramic radiographs. The developmental stages of the second molar were divided into four stages: the whole crown calcified = stage 1; beginning root formation = stage 2; initial formation of the radicular bifurcation = stage 3; and the root length is equal to the crown height = stage 4. The mesiodistal crown width of the first and second molars, axial inclination and eruption rate of the second molar, and the space available for emergence of the second molar at each stage were measured, and the statistical analysis was made to assess the developmental changes. It was learned that the mandibular second molars began to erupt at stage 3 and the maxillary second molars at stage 2. The axial inclination of the mandibular second molars maintained almost the same angle and the maxillary second molars were uprighted gradually from stage 1 to 4. The available space increased significantly from stage 1 to 2 in both second molars. It is suggested that the space available for emergence of the second molar is prepared before stage 2, and then the tooth begins to erupt. As the maxillary second molars, there was further increase in the available space after stage 3. Negative correlation was seen between the mesiodistal crown width of the mandibular second molar and the available space in stage 2. Positive correlation was seen between the mesiodistal crown width of maxillary second molar and the available space in stage 3. It is suggested that greater increase in the space available for emergence of the second molar could be expected in the maxillary dental arch, if the mesiodistal crown width of the second molar required it.

The graded effect of hyperhomocysteinemia on the severity and extent of coronary atherosclerosis

It is not clear to what extent methylenetetrahydrofolate reductase (MTHFR) gene and hyperhomocysteinemia effect the severity and extent of coronary atherosclerosis in Asian populations. We examined the MTHFR genotypes and plasma homocysteine (HCY) concentrations in 192 Taiwanese and investigated their relationship with coronary artery disease (CAD), and the severity and extent of coronary atherosclerosis. The distribution of MTHFR genotypes was similar in 116 CAD patients and 76 non-CAD subjects. Homozygosity was noted in 8% of CAD patients and 13% of non-CAD subjects (P=0.33; 95% CI, 0. 2-1.6). The geometric mean of HCY values was higher in CAD patients (11.10+/-1.51 micromol/l) than in non-CAD subjects (9.21+/-1.55 micromol/l) (P=0.003). HCY levels were higher in patients with multi-vessel disease (P<0.05) or in patients with > or = 90% stenotic lesions (P=0.005), compared with non-CAD subjects. The CAD risks in the top two HCY quartiles (> or = 14.0 and 10.1-13.9 micromol/l) were 4.0 (95% CI, 1.7-9.2) and 3.2 (95% CI, 1.4-7.4) times higher than in the lowest quartile (< or = 7.9 micromol/l) (P=0.001 and 0.007, respectively). Linear regression analysis showed significant correlations between HCY concentrations and the severity and extent of atherosclerosis (P=0.0001 for both). In conclusion, hyperhomocysteinemia appears to have a graded effect on the risk of CAD as well as the severity and extent of coronary atherosclerosis. Our findings do not support the homozygous genotype of MTHFR as a genetic risk factor for CAD in this Taiwanese population. Perhaps a further study including assessment of vitamin status is needed to better clarify the relationship between MTHFR genotypes and CAD.

Vasculitic small bowel perforation masquerading as spontaneous bacterial peritonitis in a patient with decompensated liver disease

We report on a young patient with decompensated alcohol-induced liver disease (Child-Pugh score C) who presented with clinical, biochemical and radiological evidence suggestive of spontaneous bacterial peritonitis. She was however subsequently found to have multiple small bowel perforations, which were diagnosed only at laparotomy. The histology of the bowel showed evidence of vasculitis. This case illustrates two important points. Firstly, even if a patient has all the prerequisites to develop spontaneous bacterial peritonitis, a secondary cause of peritonitis (eg. bowel perforation or intra-abdominal abscess) must always be considered as a differential diagnosis and a repeat ascitic tap is mandatory after 48 h of antibiotic therapy to confirm a decrease in the white cell count. Secondly, it shows the rare co-existence of alcoholic liver disease and vasculitis.

Reaction of cyclohexylamine with hypochlorite and enhancement of oxidation of plasma sulfhydryl groups by hypochlorite in vitro

In this study we investigated the reaction of cyclamate and its major metabolite, cyclohexylamine (CyhNH2), with NaOCl. NaOCl at 100 microM was allowed to react with various concentrations of cyclamate and CyhNH2, and the reactivity was compared with those of reduced glutathione (GSH) and ascorbic acid. The results showed that CyhNH2 was less reactive with NaOCl than GSH but was slightly more reactive than ascorbic acid at concentrations below 50 microM. CyhNH2 at 75 and 100 microM did not further decrease NaOCl. Cyclamate was much less reactive than CyhNH2, with only 43% loss in NaOCl at 100 microM cyclamate. When human blood plasma was incubated with 0.75 microM NaOCl, inclusion of CyhNH2 enhanced oxidation of sulfhydryl groups in a concentration-dependent manner, with complete oxidation of SH groups at 7.5 mM CyhNH2. Cyclamate had no effect. This enhancement by CyhNH2 suggests the formation of reactive products from the reaction of CyhNH2 with NaOCl. Absorption spectra demonstrated that reaction of CyhNH2 with NaOCl at pH 7.4 produced N-monochloramine, as evidenced by the appearance of a new peak at 245 nm and by the disappearance of the 292-nm peak of NaOCl. Cyclamate, which contains a sulfamic acid instead of a primary amine, also reacted with NaOCl at pH 7.4, but the reaction was much less pronounced and the product was probably not monochloramine since the peak was at 270 nm rather than at 245 nm. Because cyclamate is an important sweetener in many countries for people with diabetes mellitus, the possibility exists that CyhNH2 may enhance oxidation of important proteins by HOCl/OCl-.

Differential excretion of leucocyte granule components in inflammatory bowel disease: implications for pathogenesis

1. Faecal excretion of the leucocyte primary granule component, myeloperoxidase, and of the secondary granule component, lactoferrin, were compared in inflammatory bowel disease and infective diarrhoea. 2. Faecal lactoferrin correlated with faecal myeloperoxidase in both inflammatory bowel disease (P = 0.0018; n = 32) and infective diarrhoea (P = 0.00013; n = 37), but inflammatory bowel disease was associated with a much higher faecal excretion of lactoferrin but lower excretion of myeloperoxidase than infective diarrhoea. As a consequence, the median ratio of lactoferrin/myeloperoxidase excretion (both expressed as ng/mg of protein) for inflammatory bowel disease was 7.5 (range 3.5-21.3) with similar values for ulcerative colitis (n = 18) and Crohn's disease (n = 14) compared with only 0.9 (range 0.4-2.3; P < 0.0001) for infective diarrhoea. In inflammatory bowel disease faecal lactoferrin and myeloperoxidase excretion remained increased even in clinical remission. 3. In subsequent immunohistochemical studies to assess the possible explanation for these findings, lactoferrin and myeloperoxidase were demonstrated within crypt abscesses and surface mucus, both in inflammatory bowel and in infective diarrhoea mucosal samples. There was a slight increase in the number of lactoferrin-containing cells in the mucosal samples from ulcerative colitis and in the submucosa of samples from Crohn's disease compared with infective diarrhoea, but these changes were not sufficient to account for the marked increase in faecal lactoferrin excretion in inflammatory bowel disease. 4. In all mucosal samples, including those from normal mucosa, lactoferrin was also shown to be contained within mast cells. 5. These results could best be explained by a different mechanism for leucocyte activation in inflammatory bowel disease compared with infective diarrhoea, and are compatible with selective secretion of secondary granule components, which include lactoferrin but not myeloperoxidase, as a result of leucocyte activation by N-formylated bacterial peptides in inflammatory bowel disease.

The production of neuraminidase and fucosidase by Helicobacter pylori: their possible relationship to pathogenicity

The pathogenicity of enterobacteria often correlates with their production of neuraminidase (sialidase). Forty-nine Helicobacter pylori isolates have therefore been examined for their production of neuraminidase and other glycosidases. All 49 isolates produced considerable neuraminidase (median 228 IU/microg protein, interquartile range 121-370), pH optimum 7.5. Nine of the 49 also produced fucosidase (median 23 IU/microg protein, interquartile range 12-39), pH optimum 7.0. Production of these enzymes did not correlate with bacterial Cag A expression or duodenal ulceration. Neutrophils exposed to neuraminidase show increased adherence to endothelium so the neuraminidase production by H. pylori could partly explain the predominant neutrophil inflammatory infiltrate seen in H. pylori-associated gastritis. Inhibition of this enzyme by use of neuraminidase-inhibitors could be a useful therapeutic approach.

Faecal mucinase activity assessed in inflammatory bowel disease using 14C threonine labelled mucin substrate

Previous studies have shown the presence in faeces of sulphatases, sialidases, glycosidases, and proteases relevant to mucus degradation, but the relative role of these enzymes in the degradation of colonic mucus has been unclear. A total mucinase assay using 14C threonine biologically labelled human colonic mucin as substrate was therefore developed in this study. Faecal mucinase activity of a pooled normal faecal filtrate was capable of removing 80% of the 14C threonine label from mucin within eight hours incubation, but 20% remained intact despite prolonged incubation. The pH profile of mucinase activity is broad (pH 4.5-9.5) suggesting contribution from multiple enzymes. Mucinase activity was reduced by preincubation with 100 micrograms/ml chymostatin (82.8%), 0.5 mg/ml EDTA (91.6%), and 4 g/l bismuth subsalicylate (72.0%). All 55 faecal samples studied contained detectable mucinase activity, measured as dpm release/micrograms protein/hour, which was greater in samples from patients with ulcerative colitis (n = 17, median 52.7, interquartile range 32.9-66.9), than controls (n = 26, 34.4, 26.8-40.4, p < 0.02) or patients with Crohn's disease (n = 12, 35.5, 17.5-55.7, p < 0.05). There was, however, no significant difference in faecal mucinase activity between inactive and active ulcerative colitis. These results suggest that faecal mucinase activity is one factor contributing to the thin mucus layer in ulcerative colitis and represents a potential target for drug treatment.

Increased faecal mucin sulphatase activity in ulcerative colitis: a potential target for treatment

Colonic mucin is heavily sulphated and it has been shown that enzymatic desulphation by faecal bacterial sulphatases greatly increases its susceptibility to degradation by faecal glycosidases. A possible role for faecal mucin sulphatase in the pathogenesis of inflammatory bowel disease has therefore been explored. Faecal mucin sulphatase activity assayed using 35S mucin as substrate was increased in ulcerative colitis (median 80.2 units/g pellet weight (range 6.9-1063; 95% confidence intervals (CI): 45.2 to 293.8, n = 22) compared with 11.3 units/g (range 3.0-53.5; 95% CI: 8.7 to 29.8, n = 17) in healthy controls (p < 0.01), where one unit released 1000 dpm free sulphate/hour from 35S mucin (1680 dpm/microgram). Patients with active ulcerative colitis had higher sulphatase activity (median 146; 95% CI: 98 to 253 units/g, n = 10) than those with inactive ulcerative colitis (median 42.2; CI: 22.5 to 81.6 units/g, n = 12) (p < 0.05). Longitudinal studies in patients with ulcerative colitis show fluctuations of faecal mucin sulphatase activity corresponding to clinical disease activity in six of seven patients. Faecal mucin sulphatase activity was not significantly increased in Crohn's disease (median 36.6, range 5.7-106.6; 95% CI: 22.9 to 65.3 units/g, n = 14). The bismuth salts, bismuth subcitrate and bismuth subsalicylate were found to inhibit faecal mucin sulphatase activity at concentrations achievable therapeutically. The increased faecal mucin sulphatase activity in ulcerative colitis could be the result of greater intraluminal substrate (mucin) availability leading to bacterial enzyme induction, but would probably result in more rapid degradation of secreted mucin and represents a potential target for treatment.

Increased rate of sialylation of colonic mucin by cultured ulcerative colitis mucosal explants

Sialylation of mucus glycoproteins confers charge and increased resistance to enzymatic degradation. The hypothesis that mucus sialylation might be altered in ulcerative colitis has been studied using in vitro culture of mucosal biopsies for 24 h with 3H N-acetyl mannosamine as a specific sialic acid precursor. Rectal biopsies were obtained at colonoscopy from patients with clinically inactive ulcerative colitis (n = 9) and controls (n = 12) who were patients found to have a normal colonoscopy performed for iron deficiency anaemia or altered bowel habit. The incorporation of 3H N-acetyl mannosamine into mucin was increased in ulcerative colitis (n = 9; 150; 113.3-393.2 dpm/micrograms mucin, median and interquartile ranges), compared with controls (n = 12; 33.6; 19.7-68.4 dpm/micrograms; p < 0.01). The ratio of incorporation into mucin of 3H N-acetyl mannosamine/14C N-acetyl galactosamine was also increased in ulcerative colitis (3.27; 1.93-4.98 dpm/dpm), compared with controls (1.35; 1.24-1.7 dpm/dpm; p < 0.001) suggesting that the increased incorporation of N-acetyl mannosamine probably reflects an increase in the average extent of sialylation per mucin oligosaccharide chain rather than an increase in the number of oligosaccharide chains. This increase in mucin sialylation seems unlikely to have a pathogenic role in the development of colitis but provides further evidence for the similarity between the alterations that occur in ulcerative colitis, colonic polyposis and malignancy.