Intravenous esomeprazole for prevention of peptic ulcer re-bleeding: rationale/design of Peptic Ulcer Bleed study

BACKGROUND

A limited number of trials have investigated the efficacy of proton pump inhibitors for peptic ulcer bleeding, and some study design issues have been identified.

AIM

To present the design of a large trial evaluating the effects of intravenous esomeprazole on clinical outcomes in high-risk patients who have undergone endoscopic haemostasis for peptic ulcer bleeding.

METHODS

The Peptic Ulcer Bleed study is an international, randomized, double-blind, placebo-controlled trial comparing either esomeprazole 80 mg intravenous bolus infusion for 30 min followed by esomeprazole 8 mg/h intravenously for 71.5 h, or placebo infusion for 72 h, after successful endoscopic haemostasis in patients with peptic ulcer bleeding and associated high-risk stigmata. All patients will receive once daily oral esomeprazole 40 mg for 27 days after intravenous therapy. The primary end point is the rate of clinically significant re-bleeding during the first 72 h after endoscopy. Secondary end points include: rate of re-bleeding during the first 7 and 30 days after treatment; length of hospitalization; mortality; blood transfusion; endoscopic re-treatment and surgery.

RESULTS

Expected 2008.

CONCLUSIONS

The carefully designed protocol and quality control measures represent a pragmatic approach to contemporary challenges in peptic ulcer bleeding management and, it is hoped, qualify the Peptic Ulcer Bleed study as a new standard for future interventional studies.

Weight changes after vertical banded gastroplication

AIMS

This study assessed the patterns of weight change in response to surgical treatment for obesity.

METHODS

Vertical Banded Gastroplication (VBG) was performed during the period 1994-2000. Patients were required to follow a liquid diet (800 kcals)for 12 weeks before surgery. The same diet plus a multivitamin capsule (Forceval) was followed for 12 weeks postoperatively, after which normal foods were introduced. Data from 23 patients, 16 women and 7 men, aged 33-63 years (mean, SD; 42 +/- 8 yrs), with BMI from 38 to 69 kg/m2 (52.5 +/- 8.1 kg/m2) at the time of the surgery were available for analysis. Follow up was 3 to 7 years (mean 4 years).

RESULTS

An initial weight loss of 44.4 +/- 24.3 kg (min 11.5, max 110.5 kg) was reached during the first two years (mean BMI decrease 15.8 kg/m2). However a regain in weight (36% of the initial weight loss = 5.6 kg/m2) up to 3 to 7 years after surgery was usual. Average annual regain was 13.6 kg (n=17), 9.45 kg (n=11) and 0.8 kg (n=8) during the 3rd, 4th and 5th year after surgery). Five participants reached a BMI below 30 but only one, BMI < 25, has maintained all the weight loss after 5years.

CONCLUSIONS

Weight lossfollowing VBG ceased after twoyears with a subsequent substantial weight regain. Auxiliary therapies to counteract weight regain are necessary after VBG.

Electrocardiographic abnormalities and uremic cardiomyopathy

BACKGROUND

Progressive renal disease is associated with an increased risk of cardiovascular death, specifically sudden death. We investigated the link between uremic cardiomyopathy, QT interval and dispersal, and arrhythmias (by ambulatory ECG monitoring) in patients at different stages of progressive renal disease.

METHODS

In a cross-sectional study we investigated 296 patients with nondiabetic renal disease (53 transplant recipients, 55 hemodialysis patients, and 188 throughout the range of chronic renal failure). Patients underwent echocardiography, ECG, and ambulatory blood pressure and ECG monitoring.

RESULTS

Left ventricular mass was increased from the earliest stages of renal disease (near-normal renal function), the predominant pattern being eccentric left ventricular hypertrophy (LVH). There was a progressive increase in LVH with loss of renal function, so that more than 80% of patients on renal replacement therapy have LVH, the dominant pattern being concentric LVH. The prevalence of diastolic dysfunction increased in parallel with changes in left ventricular mass but systolic dysfunction and ventricular dilatation did not. Increased QT interval and QT dispersal were associated with poor renal function (maximal in dialysis patients), and were linked to LVH and other echocardiographic abnormalities. Arrhythmias were uncommon on ambulatory recording but were more common with poor renal function, in the presence of uremic cardiomyopathy, and increased QT interval and dispersal.

CONCLUSION

LVH is present from the earliest stages of progressive renal disease. This, and other forms of uremic cardiomyopathy, is linked to increased QT interval and dispersal, and with minor rhythm abnormalities, providing a link with the high risk of sudden death in this population.

Clinical and psychometric validation of a questionnaire module, the EORTC QLQ-STO 22, to assess quality of life in patients with gastric cancer

The purpose of this study was to define the measurement properties and clinical validity of the European Organisation for Research and Treatment of Cancer (EORTC) questionnaire module to assess health-related quality of life (HRQL) in gastric cancer. The EORTC gastric cancer module, QLQ-STO 22, was administered with the QLQ-C30, core questionnaire, to 219 patients undergoing treatment with curative or palliative intent before and after treatment. Reliability and validity of the module was tested and patients' debriefing comments analysed. Compliance rates were high, questionnaires well accepted and less than 4% of items had missing data. Multi-trait scaling analyses and face validity refined the module to five scales and four single items. Scales distinguished between clinically distinct groups of patients and demonstrated treatment-induced changes over time. Test-retest scores demonstrated good reliability. The EORTC QLQ-STO 22 demonstrates psychometric and clinical validity that supports its use to supplement the EORTC QLQ-C30 to assess quality of life in patients with gastric cancer undergoing surgery, surgery and chemoradiotherapy, palliative chemotherapy, palliative surgery and best supportive care.

Consensus recommendations for use of central venous access devices in haemophilia

Venous access is essential for delivery of haemophilia factor concentrate. Wherever possible, peripheral veins remain the route of choice, and the use of central venous access devices (CVADs) should be limited to cases of clear need in patients with caregivers able to exercise diligence in CVAD care and should continue no longer than necessary. CVADs are of recognized value for repeated administration of coagulation factors in haemophilia, particularly for prophylaxis and immune tolerance therapy and in young children. Evidence to guide best practices has been fragmentary, and standardized methods for CVAD usage have yet to be established. We have developed management recommendations based upon available published evidence as well as extensive clinical experience. These recommendations address patient and CVAD selection; CVAD placement, care and removal; caregiver/patient guidance; and complications, including infection and thrombosis. In the absence of inhibitors, ports are recommended, primarily because of fewer associated infections than with external catheters. For patients with inhibitors, ports also appear to be associated with fewer infections. Infection is the most frequent complication, and recommendations to prevent and treat infections are supported by extensive clinical data and experience. Strict adherence to handwashing and aseptic technique are essential elements of catheter care. Evidence-based data regarding the detection and treatment of CVAD-related thrombotic complications are limited. Caregiver education is an integral part of CVAD use and the procedural practices of users should be regularly re-assessed. These recommendations provide a basis for sound current CVAD practice and are expected to undergo further refinements as new evidence is compiled and clinical experience is gained.

Extramedullary myeloid cell tumours localised to the mediastinum: a rare clinicopathological entity with unique karyotypic features

Extramedullary myeloid cell tumour (EMMT) localised to the mediastinum is a rare manifestation of acute myeloid leukaemia, forming less than 4% of all cases of EMMT. In contrast to other types of EMMT, cytogenetic characteristics of this rare entity are relatively unknown. This report describes a patient with EMMT who had evidence of superior vena cava syndrome and normal peripheral blood counts at diagnosis. The results from an initial biopsy specimen were consistent with a diagnosis of mediastinal large B cell lymphoma. A diagnosis of acute myeloid leukaemia was made three months after initial diagnosis by bone marrow examination. Review of the initial biopsy specimen showed strong positivity for myeloperoxidase, revealing that the patient had been initially misdiagnosed as having large B cell lymphoma. Cytogenetic studies revealed a near triploid and near tetraploid karyotype with structural abnormalities in 12 and three metaphases, respectively. Review of the literature showed that a near tetraploid or triploid karyotype is found in most of the reported cases of mediastinal EMMT. Thus, the presence of a near triploid/tetraploid karyotype and mediastinal EMMT may represent a specific subset of EMMT. The biological relevance of this observation is discussed.

Pteridium aquilinum (bracken fern) toxicity in cattle in the humid Chaco of Tarija, Bolivia

We studied the toxicity caused by chronic ingestion of Pteridium aquilinum (bracken) in cattle in the humid Chaco of Tarija, Bolivia. Bovine enzootic haematuria (BEH) and Carcinoma of the esophagus (CE) affected the herds. Sick animals showed caquexia, anemia, leucopenia and urine that turned from pink to intense red color with the presence of blood clots. Cattle grazed in the humid forests of the mountains where P aquilinum represented more than 50% of the plants. P aquilinum var arachnoideum and P aquilinum var Caudatum were present. Toxic norsesquiterpene, ptaquiloside, was identified in both varieties. Carcinomas were in the urinary bladders and esophagus of 100% and 50% of the cattle, respectively. Control of the intoxication could be difficult due to geographic characteristics of this Bolivian region.

Allele associations reveal four prominent haplotypes at the human interleukin-6 (IL-6) locus

We have examined four polymorphic elements in the human interleukin-6 (IL-6) locus and described their allele distribution in 73 unrelated, healthy individuals from the West-of-Scotland. These comprised three single nucleotide polymorphisms (SNP) in the 5' promoter region of the gene and one VNTR in the 3' region of IL-6. A statistical consideration of the relationship between alleles at each locus was carried out. Of a total of 12 possible haplotypes observed in the population, the analysis suggested that four were prominent. These accounted for 41.1%, 28.1%, 14.4% and 3.4% respectively; in total, 87% of the haplotypes present. Frequently, these proposed haplotypes were supported by homozygosity across all four loci within individuals. We propose that these haplotypes be identified as IL6.0103, IL6.0204, IL6.0207 and IL6.0307, in recognition of their frequency in this population and the alleles that they contain.

The endothelium and cytokine secretion: the role of peroxidases as immunoregulators

The endothelium is frequently exposed to many proinflammatory mediators. The present study was done to determine the effects of human recombinant myeloperoxidase (MPO) and porcine eosinophil peroxidase (EPO) on certain endothelial cell (HUVEC) functions. The following areas were evaluated: (1) production of reactive oxygen intermediates (ROI), (2) cytokine secretion, and (3) regulation of mRNA cytokine transcripts. Both MPO and EPO induced the production of ROI, but an enzymatically inactive form of MPO (iMPO) was the most effective. Enzymatically inactive MPO, but not MPO, induced the secretion of interleukins 6 and 8 and granulocyte-monocyte colony-stimulating factor. A ribonuclease protection assay indicated that both iMPO and MPO upregulated mRNA cytokine transcripts; however, the former was markedly more effective. The simultaneous addition of EPO and iMPO resulted in a decrease in cytokine-specific mRNA. These data indicate a major role for peroxidases in the regulation of inflammation.

Effects of a glyconutrient on macrophage functions

Previous studies have shown that mannosylated bovine serum albumin (mBSA) enhances the respiratory burst (RB), phagocytosis, and killing of Candida albicans and Escherichia coli by resident murine peritoneal macrophages (Mphi). Upregulation of the above Mphi functions was associated with the binding of mBSA to the macrophage mannose receptor. The present study was done to determine if certain glyconutrients could stimulate Mphi functions in a similar manner. Resident peritoneal murine Mphi collected from C57BL/6 mice were exposed to the glyconutrients for 10 and 60 min. The RB was measured using chemiluminescence. Both phagocytosis and killing were measured after incubation with each of the following microorganisms: Candida albicans, Escherichia coli and Staphylococcus aureus. The percent phagocytosis and killing were determined using fluorescence microscopy. Results indicated that certain glyconutrients, caused a dose and time dependent effect on Mphi-induced killing of all three microorganisms.

The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics

OBJECTIVE

Pharmacologic agents have been used in the prehospital setting for facilitating endotracheal intubation (ETI). The purpose of this study was to determine the utility of intravenous midazolam for prehospital patients who require pharmacologic relaxation to facilitate ETI.

METHODS

Data were reviewed retrospectively using paramedic charts from an eight-month period for a three-county state EMS system.

RESULTS

There were 26,133 paramedic dispatches during the study period. Six hundred eighty-three ETIs were attempted, including 72 midazolam-facilitated intubations (MFIs). The most common indications for MFI were "clenched teeth," "gag," and "combativeness." Successful MFI was achieved in 45 of 72 cases (62.5%). Midazolam-facilitated intubation was less successful for trauma patients (41.2%) than for medical patients (69.1 %) (p = 0.04). Of the 58 failed conventional ETIs that occurred during the study period, 25 (43.1%) were identified as having one or more indications for the use of MFI. Although the use of intravenous midazolam was effective in facilitating ETI, a high MFI failure rate (37.5%) was noted.

CONCLUSION

Although it is of limited efficacy, MFI is underutilized and should be considered by medical direction as a pharmacologic adjunct to ETI in selected field patients.

Malignant ovarian germ cell tumours -- a survival and prognostic analysis

The medical records and histopathology of all ovarian germ cell tumours (OGCT) in a tertiary centre between 1980 and 1996 were reviewed. Response, overall survival (OS), relapse-free survival (RFS) and prognostic factors were analysed. Sixty-seven patients with OGCT were identified and treated, including 33 dysgerminomas, 18 immature teratomas, 10 endodermal sinus tumours, and 6 mixed tumours. Fifty-three patients (79%) received conservative surgery, 24 (36%) had residual disease post-primary surgery, and 43 (64%) had chemotherapy. Complete response was achieved in 62 patients (93%), 4 out of 5 patients who relapsed were successfully salvaged; OS and RFS at 5 years were 89% and 76%, respectively. Advancing stage of disease was the only significant adverse prognostic factor (p = 0.0001 for OS, and 0.0003 for RFS at 5 years). Out of 44 women with the potential to conceive following treatment, there were 16 successful pregnancies. None of the children born subsequent to the chemotherapy were reported to have any congenital abnormalities. The review indicates a high cure rate in OGCT with combined surgery and chemotherapy and that conservative surgery and preservation of fertility are feasible.

Micrometastases in esophagogastric cancer: high detection rate in resected rib segments

BACKGROUND & AIMS

Micrometastases within bone marrow indicate a poor prognosis. We prospectively examined micrometastases in patients undergoing resection of esophagogastric cancers for (1) prevalence in rib marrow; (2) comparative detection rates in rib and iliac crest marrow; (3) responsiveness to neoadjuvant therapy; and (4) viability and tumorigenicity.

METHODS

In 50 consecutive patients, marrow was obtained before manipulation of the primary tumor. Micrometastatic cells were detected by staining contaminant cytokeratin-18-positive cells. Viability and tumorigenicity were determined by culture and xenograft.

RESULTS

Micrometastases were detected in rib marrow from 88% of patients (44 of 50). When bilateral iliac crest marrow was also obtained, micrometastases were found in 15% (4 of 27) compared with 89% (24 of 27) for ribs (P < 0.001). Detection rates were independent of histological type or nodal status and were similar in patients with and without neoadjuvant therapy. Metastatic cells were cultured from rib marrow of 5 of 7 patients and were tumorigenic in nude mice.

CONCLUSIONS

Most patients undergoing resection of esophagogastric malignancies have micrometastases in rib marrow. Detection rates based on iliac crest marrow are underestimates. Hematogenous spread of metastatic cells is independent of histological type or nodal status. The metastatic cells are viable, tumorigenic, and resistant to neoadjuvant therapy.

Perpetuation of inflammation associated with experimental arthritis: the role of macrophage activation by neutrophilic myeloperoxidase

Rheumatoid arthritis (RA) is characterized by an abnormal cellular and cytokine infiltration of inflamed joints. This study addresses a previously unrecognized interaction between neutrophilic-myeloperoxidase (MPO) and macrophages (Mphi) which could explain the perpetuation of inflammation associated with RA. A monoarticular arthritis was induced in female Lewis rats by injection of streptococcal cell wall extracts (PG-APS). After swelling and erythema subsided, joints were re-injected with one of the following: porcine MPO or partially inactivated MPO (iMPO). Injection with either MPO or iMPO induced a 'flare' of experimental RA. Blocking the Mphi-mannose receptor by mannans, ablated exacerbation of disease. These results indicate that MPO or iMPO can play a pivotal role in the perpetuation but not initiation of this RA model.

Small cell carcinoma of the oesophagus

Small cell carcinoma of the oesophagus is an uncommon malignancy. Only 272 cases have been reported to date. Inconsistency in therapeutic approaches reflects the paucity of individual experience and the unsatisfactory response to current management strategies. We report 11 cases drawn from a series of 1012 cases of oesophageal malignancy and perform a statistical analysis on treatment and survival data of 189 cases drawn from the world literature. Small cell carcinoma of the oesophagus was seen to have an incidence of 1%. Seven of 11 patients were female. A variety of therapeutic modalities were employed, and the median survival was 6.6 months. Statistical analysis of these and worldwide data showed a significant survival advantage for patients who received multimodality therapy.

Macrophage-mediated candidacidal activity is augmented by exposure to eosinophil peroxidase: a paradigm for eosinophil-macrophage interaction

Various disease states are associated with eosinophilia and the release of eosinophil peroxidase (EPO) into the microenvironment. The present study targets the effects of low levels of EPO on macrophage (M phi) phagocytosis and intracellular killing of Candida albicans as well as M phi oxidative activity measured as the luminescence product of luminol dioxygenation. Resident murine peritoneal M phi were exposed to various concentrations of EPO. Chemiluminescence data indicate that nanomolar concentrations of EPO markedly enhanced the dioxygenation activity (respiratory burst) of M phi. In other studies, the exposure of M phi to 0.17 microM EPO for 10 min. enhanced M phi-mediated candidacidal activity 10 fold. The above data indicate that EPO enhances certain M phi functions. Also the results illustrate a previously un-recognized interaction between eosinophils and M phi and implicate yet another possible role for EPO in host defenses against disease.

K-casein gene phylogeny of higher ruminants (Pecora, Artiodactyla)

To assess phylogenetic relationships among the higher ruminants (infraorder Pecora, order Artiodactyla), we analyzed K-casein DNA sequences, including 434 nucleotides of the fourth exon. The higher ruminant families Bovidae, Cervidae, Giraffidae, and Antilocapridae each have monophyletic K-casein sequences. Maximum parsimony and distance analyses identify Giraffidae as a sister group to either Cervidae or a Bovidae-Cervidae clade and Antilocapridae as a sister group to a Bovidae-Cervidae-Giraffidae clade. At a higher level these four families occur as a monophyletic clade relative to Tragulidae and Suidae. Within Cervidae, the subfamily Odocoileinae is monophyletic and Cervinae and Muntiacinae occur as independent lineages within a separate clade. Within Bovidae, the subfamilies Bovinae and Caprinae are monophyletic. Genera within Cervinae (Cervus, Elaphurus) and Bovinae (Bison, Bos) are paraphyletic. There is intraspecific allelic variation in Cervus elaphus, Odocoileus hemionus, and Bison bison. The rate of K-casein fourth exon DNA sequence evolution is estimated to be about 0.004 nucleotide substitutions per million years. The K-casein phylogeny is discussed relative to other molecular and morphological data.

Lasiodiplodia theobromae isolated from a subcutaneous abscess in a Cambodian immigrant to Australia

A patient from Cambodia presented at a hospital in Melbourne with a persistent subcutaneous abscess of the right buttock. Septate fungal hyphae were seen in biopsy tissue. Lasiodiplodia theobromae was isolated and identified by the formation of pycnidia that produced typical conidia. The abscess was managed by drainage and debridement only. We briefly review the history and importance of the fungus as a wound parasite in tropical horticulture and its relatively rare occurrence in human infections. The significance of this fungus in Australian horticulture and its potential as an opportunistic human pathogen is noted. This paper records the first isolation of L. theobromae from a human lesion in Australia and the second isolation from a subcutaneous lesion worldwide.

[Expression and clinical significance of the AgNOR and PCNA in Barrett's adenocarcinoma and its precancerous lesions]

In order to investigate the expression of AgNOR and PCNA in malignant Barrett's esophagus and benign Barrett's esophagus with or without dysplasia, 50 specimens and biopsies were examined using silver-staining and immunohistochemical methods. The results showed that the expression of AgNOR and PCNA in malignant Barrett's esophagus were higher than those in benign Barrett's esophagus with dysplasia, which were in turn higher than those in benign Barrett's esophagus without dysplasia. The difference between malignant group and other groups was significant. The results suggest that AgNOR and PCNA may be useful as an adjunct in screening patients with Barrett's esophagus for early malignant change, especially in high-grade dysplasia group.