Late results of a randomized clinical trial comparing total fundoplication versus calibration of the cardia with posterior gastropexy

BACKGROUND

The aim was to perform a prospective randomized study in patients with chronic gastro-oesophageal reflux treated either by total fundoplication or calibration of the cardia with posterior gastropexy. Late follow-up considered subjective and objective parameters, and related outcome to the presence of Barrett's oesophagus.

METHODS

A total of 164 patients were randomized to fundoplication (n = 76) or calibration of the cardia (n = 88). They were evaluated by clinical questionnaire, upper gastrointestinal endoscopy with biopsies, oesophageal manometry and gastro-oesophageal reflux studies, including scintigraphy and 24-h oesophageal pH monitoring.

RESULTS

There were no operative deaths. There was 95 per cent follow-up at a mean of 85 months. The mean recurrence rate for both operations was near 40 per cent at 10 years, but patients without Barrett's oesophagus had a recurrence rate after both operations of around 23 per cent compared with 83 per cent after 10 years for those with Barrett's oesophagus (P < 0.0001). Low-grade dysplasia developed in 13 per cent of the patients with Barrett's oesophagus. There were significant differences in all objective parameters in a comparison of patients with Visick I or II and those with Visick III or IV disease at the late assessment.

CONCLUSION

Both total fundoplication and calibration of the cardia with posterior gastropexy had similar subjective and objective late results. However, results were significantly worse in patients with Barrett's oesophagus.

Ror2, encoding a receptor-like tyrosine kinase, is required for cartilage and growth plate development

Receptor tyrosine kinases often have critical roles in particular cell lineages by initiating signalling cascades in those lineages. Examples include the neural-specific TRK receptors, the VEGF and angiopoietin endothelial-specific receptors, and the muscle-specific MUSK receptor. Many lineage-restricted receptor tyrosine kinases were initially identified as 'orphans' homologous to known receptors, and only subsequently used to identify their unknown growth factors. Some receptor-tyrosine-kinase-like orphans still lack identified ligands as well as biological roles. Here we characterize one such orphan, encoded by Ror2 (ref. 12). We report that disruption of mouse Ror2 leads to profound skeletal abnormalities, with essentially all endochondrally derived bones foreshortened or misshapen, albeit to differing degrees. Further, we find that Ror2 is selectively expressed in the chondrocytes of all developing cartilage anlagen, where it essential during initial growth and patterning, as well as subsequently in the proliferating chondrocytes of mature growth plates, where it is required for normal expansion. Thus, Ror2 encodes a receptor-like tyrosine kinase that is selectively expressed in, and particularly important for, the chondrocyte lineage.

[Clinical and endoscopic findings and magnitude of gastric and duodenal reflux in patients with cardial intestinal metaplasia, short Barrett esophagus, compared with controls]

BACKGROUND

The diagnosis of patients with short segments of intestinal metaplasia in the distal esophagus, has increased in recent years.

AIM

To assess the clinical, pathological and functional features of patients with esophageal intestinal metaplasia.

PATIENTS AND METHODS

A prospective study was performed in 95 control subjects, 115 patients with cardial intestinal metaplasia and 89 patients with short Barret esophagus with intestinal metaplasia. All had clinical and endoscopic assessments, esophageal manometry and determination of 24 h esophageal exposure to acid and duodenal content.

RESULTS

Control patients were younger and, in this group, the pathological findings in the mucosa distal to the squamous-columnar change, showed a preponderance of fundic over cardial mucosa. In patients with intestinal metaplasia and short Barret esophagus, there was only cardial mucosa, that is the place where intestinal metaplasia implants. Low grade dysplasia was only seen in the presence of intestinal metaplasia. Gastroesophageal sphincter pressure decreased and gastric and duodenal reflux increased along with increases in the extension of intestinal metaplasia.

CONCLUSIONS

These findings confirm the need to obtain multiple biopsies from the squamous-columnar mucosal junction in all patients with gastroesophageal reflux symptoms, for the detection of early pathological changes of Barret esophagus and eventual dysplasia.

Plasma-electrolytes in natives to hypoxia after marathon races at different altitudes

PURPOSE

It is well known that altitude natives differ from sea level natives in aspects of fluid and electrolyte homeostasis.

METHODS

To evaluate exercise and environmental influences on the electrolyte and water status in hypoxia adapted subjects, we investigated 11 well-trained marathon runners (33.7 +/- 0.7 yr, 60.5 +/- 1.9 kg), native to an altitude above 2600 m, before and after two marathon races. One competition was held at moderate altitude (AM, 2650 m, 14 degrees C, 55% RH, running time 3 h 6 min +/- 22 min) and another under tropical conditions (HM, 470 m, 28 degrees C, 70% RH, running time 2 h 54 min +/- 30 min). Blood samples were taken 3 d before, immediately after, 1 h after, and 24 h after the races.

RESULTS

The loss in body fluid was calculated to be 2.15 L during AM and 5.05 L during HM, respectively. It was compensated mostly by ingested fluids without electrolyte content and by metabolically produced water, which led to hyponatremia during AM (plasma [Na+] from 144.3 +/- 0.7 to 131.7 +/- 2.1 mmol x L(-1)). Severe dehydration without significant changes in plasma [Na+] could be detected after HM. Serum antidiuretic hormone concentrations and serum aldosterone concentrations significantly increased during both races and remained at a high level for at least 1h after both competitions. Serum atrial natriuretic peptide (ANP) concentrations were at a high level at rest, increasing during HM, and decreasing during AM.

CONCLUSION

Under tropical conditions, we found a severe state of dehydration characterized by an extended ANP-response, which was not prevented by water intake during the race. Under hypoxic conditions, however, we found that hyponatremia had developed. This can be partly explained by pure water intake and metabolically produced water, and also, possibly, by a special hypoxia-induced effect.

Gallbladder carcinoma during laparoscopic cholecystectomy: is it associated with bad prognosis?

Laparoscopic cholecystectomy is the treatment of choice for gallstone disease. The ultrasonogram has failed for the early detection of gallbladder cancer, especially if inflammation (chronic or acute) is present. Incidental gallbladder could be an important cancer finding during laparoscopic cholecystectomy, due to the potential cancer cell dissemination during the procedure. In our Department, 6500 laparoscopic cholecystectomies have been performed in the last 5 years and in 15 cases (0.23%) gallbladder cancer was found during surgery or after histological examination of the resected gallbladder. In none of these 15 patients was pre-operative diagnosis of gallbladder carcinoma postulated. When re-evaluation of the pre-operative ultrasonograms was done, it was possible to observe signs suggesting the presence of neoplastic infiltration in 4 of them (28.6%). During videoscopic exploration, also in 4 patients, the suspicion of gallbladder cancer was noted. Laparoscopic cholecystectomy was completed in 9 patients. In 2 of them, in situ or mucosal invasion was demonstrated with a long survival. One patient presented recurrence at the biliary hilum 2,5 years after surgery. Six patients were re-operated and in 4 of them peritoneal or port site metastasis was found; all died early (4.5 month median survival). The other 2 patients were submitted to liver bed resection and lymph node dissection. These patients are free of cancer recurrence after 15 months of follow-up. Six patients were converted to open surgery, performing palliative procedures and died before the 12 month follow-up. The suspicion of pre-operative gallbladder cancer is generally unlikely to be confirmed based on ultrasonographic signs; but, in some cases with high suspicion, further investigation (TAC, tumor markers, etc.) must be indicated in order to avoid poor results. Laparoscopic cholecystectomy could be associated with bad prognosis, and then, when gallbladder cancer is suspected during the laparoscopic procedure, conversion to open surgery could be the best choice.

[Preliminary results of horizontal gastroplasty with Roux in Y anastomosis in patients with severe and morbid obesity]

BACKGROUND

Morbidly obese subjects have a high incidence of complications. The poor results of dietary treatments, has prompted the search of new therapies for obesity and among these, surgical procedures.

AIM

To report the long term results of horizontal gastroplasty with Roux en Y anastomosis in morbidly obese subjects.

PATIENTS AND METHODS

Fifty patients with an initial body mass index of 41.3 +/- 6 kg/m2 have been subjected to a horizontal gastroplasty with Roux en Y anastomosis. During the study period, surgical techniques were modified, reducing the gastric pouch size, adding a truncal vagotomy, cholecystectomy, and increasing the length of the Roux en Y loop from 70 to 100 cm. Twenty five patients have been followed for two years.

RESULTS

There was no operative mortality and one patient had an anastomotic leak that required 35 days of hospitalization. During follow up, in one patient, the stapled suture line loosened. After two years of follow up, weight decreased from 112 +/- 19 to 77.2 +/- 14 kg.

CONCLUSIONS

Horizontal gastroplasty with Roux en Y anastomosis achieved an adequate weight loss with a low rate of complications in this group of morbidly obese subjects.

Improved outcome for acute lymphoblastic leukemia in children of a developing country: results of the Chilean National Trial PINDA 87

BACKGROUND

The National Chilean Pediatric Oncology Group, PINDA, reports the first prospective, nonrandomized trial for acute lymphoblastic leukemia (ALL), using a modified version of the Berlin-Frankfurt-Munster protocol (ALL BFM 86). The aim of this study was to classify immunophenotypes, to decrease cranial irradiation, and to assess whether this protocol would improve the survival rate.

PROCEDURE

From June, 1987, to June, 1992, 444 unselected children were diagnosed with ALL. Of them, 425 were evaluable. Therapy was stratified by risk. Standard-risk (SR) and high-risk (HR) patients received protocols I, M, II, and maintenance therapy. Very-high-risk (VHR) patients received protocol E instead of protocol M. All patients received a prephase treatment consisting of prednisone and intrathecal methotrexate (MTX). HR and VHR patients received cranial irradiation (12-18 Gy). The following changes were made to the ALL BFM 86 protocol: in protocol M, MTX 1 g/m2 instead of 5 g/m2; in protocol E, citarabine 1 g/m2 instead of 2 g/m2; mithoxantrone and ifosfamide were substituted by teniposide and cyclophosphamide.

RESULTS

Immunophenotypes: pro-B-ALL, 14%; common ALL, 67.4%; pre-B-ALL, 4.3%; T-ALL, 10%; undifferentiated leukemia (AUL), 4.3%. The overall 5-year event-free survival (EFS) rate was 60% +/- 2% (SE). The 5-year EFS rate for each risk group was: SR 75%, HR 62%, VHR 28%, with a median follow-up of 6.5 years (range 4.5-9.5 years). The cumulative incidence of central nervous system (CNS) relapse was 5.4%.

CONCLUSIONS

We have been able successfully to perform a nationwide study. Our strategy to adapt the BFM protocol to our population of patients trial was effective in improving the EFS. The immunophenotype distribution is similar to that in other reported series.

Optimization of the encapsulation and release of beta-lactoglobulin entrapped poly(DL-lactide-co-glycolide) microspheres

The goal of the present paper was to optimize the encapsulation of beta-lactoglobulin (BLG) within poly(lactide-co-glycolide) (PLGA) microparticles prepared by the multiple emulsion solvent evaporation method. The role of the pH of the external phase and the introduction of the surfactant Tween 20, in the modulation of the entrapment and release of BLG from microparticles, was studied. Reducing the solubility of BLG by decreasing the pH of the external phase to a value close to the pI of BLG resulted in a better encapsulation with, however, a larger burst release effect. By contrast, Tween 20 was shown to increase the encapsulation efficiency of BLG and reduce considerably the burst release effect. In fact, Tween 20 was shown to be responsible for removing the BLG molecules that were adsorbed on the particle surface. In addition, Tween 20 reduced the number of aqueous channels between the internal aqueous droplets as well as those communicating with the external medium. Thus, the more dense structure of BLG microspheres could explain the decrease in the burst release. These results constitute a step ahead in the improvement of an existing technology in controlling protein encapsulation and delivery from microspheres prepared by the multiple emulsion solvent evaporation method.

Humoral immune response and antigenemia in sheep experimentally infected with Schistosoma bovis. Cross-reactivity with Fasciola hepatica antigens

Circulating antigen level, IgG antibody response to worm antigens and to excretory/secretory products (ES), and specificity to Fasciola hepatica antigens were determined in 6 Schistosoma bovis-infected sheep at weekly intervals for 15 wk. A noninfected control group was included. An enzyme-linked immunosorbent assay (ELISA) sandwich and a double-antibody ELISA test was used for antibody and antigen detection, respectively. The infection induced an early and relatively low IgG response to adult worm extract. This response was significantly elevated by 3 wk postinfection (PI), reached its maximum level at 9 wk PI, and was followed by a subsequent decrease. The response to ES antigens was slightly higher than that to adult worms, although the response started later, at 8 wk PI, and remained at its maximum level until 15 wk. A remarkable level of cross-reactivity was observed when adult F. hepatica extract was used. However, a low degree of cross-reactivity was found with ES antigen. The ELISA for circulating antigens was performed at weekly intervals for 8 wk. Antigens were detected as early as the first week of infection, although differences were statistically significant from week 5 onward. The highest values were observed at 7 week PI.

[Effects of dehydroepiandrosterone on blood cells of the rat]

The effects of dehydroepiandrosterone (DHEA) on haemoglobin, hematocrit and white cell counts values were studied in male and female rats, castrated rats and pregnant rats. After 5 continuous days of DHEA administrated subcutaneously (80 mg/kg/d; body w.) haemoglobin and hematocrit values were similar those values obtained before the treatment. White cell counts were reduced (40%) in female no castrated rats due to a significantly lymphopenia. The white cell counts were increased in castrated rats and with DHEA administration there were reduced to the initial values. Estradiol treatment had the same effect as DHEA on castrated rats. These data suggest that DHEA administrated to castrated or sexually active male and female rats affects the white cells without important effects on red blood cells.

Angiopoietins 3 and 4: diverging gene counterparts in mice and humans

The angiopoietins have recently joined the members of the vascular endothelial growth factor family as the only known growth factors largely specific for vascular endothelium. The angiopoietins include a naturally occurring agonist, angiopoietin-1, as well as a naturally occurring antagonist, angiopoietin-2, both of which act by means of the Tie2 receptor. We now report our attempts to use homology-based cloning approaches to identify new members of the angiopoietin family. These efforts have led to the identification of two new angiopoietins, angiopoietin-3 in mouse and angiopoietin-4 in human; we have also identified several more distantly related sequences that do not seem to be true angiopoietins, in that they do not bind to the Tie receptors. Although angiopoietin-3 and angiopoietin-4 are strikingly more structurally diverged from each other than are the mouse and human versions of angiopoietin-1 and angiopoietin-2, they appear to represent the mouse and human counterparts of the same gene locus, as revealed in our chromosomal localization studies of all of the angiopoietins in mouse and human. The structural divergence of angiopoietin-3 and angiopoietin-4 appears to underlie diverging functions of these counterparts. Angiopoietin-3 and angiopoietin-4 have very different distributions in their respective species, and angiopoietin-3 appears to act as an antagonist, whereas angiopoietin-4 appears to function as an agonist.

A polysorbate-based non-ionic surfactant can modulate loading and release of beta-lactoglobulin entrapped in multiphase poly(DL-lactide-co-glycolide) microspheres

PURPOSE

The goal of the present paper was to investigate the role of a surfactant, Tween 20, in the modulation of the entrapment and release of beta-lactoglobulin (BLG) from poly (DL-lactide-co-glycolide) microspheres.

METHODS

Poly(DL-lactide-co-glycolide) microspheres containing BLG were prepared by a water-in-oil-in-water emulsion solvent procedure. Tween 20 was used as a surfactant in the internal aqueous phase of the primary emulsion. BLG entrapment efficiency and burst release were determined. Displacement of BLG from microsphere surface was followed by confocal microscopy observations and zeta potential measurements, whereas morphological changes were observed by freeze-fracture electron microscopy.

RESULTS

Tween 20 was shown to increase 2.8 fold the encapsulation efficiency of BLG without any modification of the stability of the first emulsion and the viscosity of the internal aqueous phase. In fact, Tween 20 was shown to be responsible for removing the BLG molecules that were adsorbed on the particle surface or very close to the surface as shown by confocal microscopy and zeta potential measurements. Tween 20 reduced the number of aqueous channels between the internal aqueous droplets as well as those communications with the external medium. Thus, the more dense structure of BLG microspheres could explain the decrease of the burst release.

CONCLUSIONS

These results constitute a step forward in the improvement of existing technology in controlling protein encapsulation and delivery from microspheres prepared by the multiple emulsion solvent evaporation method.

Mycoplasma penetrans bacteremia and primary antiphospholipid syndrome

Mycoplasma penetrans, a rare bacterium so far only found in HIV-infected persons, was isolated in the blood and throat of a non-HIV-infected patient with primary antiphospholipid syndrome (whose etiology and pathogenesis are unknown).

Fasciola hepatica: partial characterization of circulating antigens

Antigens present in sera from Fasciola hepatica-infected goats were partially characterized by means of polyacrylamide gel electrophoresis of immunoprecipitates obtained by counterimmunoelectrophoresis. Agar containing the 2 immunoprecipitin lines, agar containing no precipitin lines, a crude extract of F. hepatica, and normal rabbit IgG were assayed. The electrophoretic pattern of 1 precipitin line showed, apart from the light and heavy chains of IgG and other faint bands, 2 prominent polypeptides of about 70 and 85 kDa. The other precipitin line showed a similar pattern, but with the 70-kDa band absent.

Changing the pH of the external aqueous phase may modulate protein entrapment and delivery from poly(lactide-co-glycolide) microspheres prepared by a w/o/w solvent evaporation method

The milk model protein, beta lactoglobulin (BLG), was encapsulated into microspheres prepared by a multiple emulsion/solvent evaporation method. The effect of the pH of the outer aqueous phase on protein encapsulation and release as well as on microsphere morphology has been investigated. At all tested pH values, the encapsulation efficiency was shown to decrease with increasing the initial amount of BLG. This was correlated with the reduced stability of the primary emulsion as the initial BLG increased. In addition, reducing the solubility of BLG in the external aqueous phase by decreasing the pH to the isoelectric point of BLG (pI 5.2) resulted in an improved protein encapsulation. Moreover, it was shown that combining pH modification and optimal stability of the first emulsion yielded microspheres with a high encapsulation efficiency. However, release kinetic studies revealed that a significant burst release was observed with microspheres loaded with large amounts of BLG, especially when prepared in a medium at pH 5.2. This burst effect was attributed to morphology changes in the microsphere surface which was characterized by the presence of pores or channels able to accelerate the release of BLG. These pores were assumed to result from the presence of large amounts of protein molecules on the microsphere surface, that aggregate during microsphere formation at pH 5.2. Indeed, single adsorption experiments have shown that BLG had a higher affinity for the particle surface when the pH was close to the pI. Thus, reducing the solubility of a protein in the external aqueous phase allows the product of microspheres with a better encapsulation efficiency, although this benefit is provided by a strong adsorption of the protein on microsphere surface.

[Clinical and laboratory characteristics of patients with pathologic chronic gastroesophageal reflux]

BACKGROUND

Sixty percent of adults has typical symptoms of gastroesophageal reflux in Chile.

AIM

To report the clinical and laboratory features of patients with gastroesophageal reflux.

PATIENTS AND METHODS

Five hundred thirty-four patients (255 male) with gastroesophageal reflux were included in a prospective protocol that included clinical analysis, manometry and endoscopy in all patients, barium swallow in 427, scintigraphy in 195, acid reflux test in 359, 24 h pH in 175, and differential potential of gastroesophageal mucosa in 73 patients.

RESULTS

There was no correlation between the severity of symptoms and the endoscopical severity. Patients with Barret esophagus were 12 years older, were male in a greater proportion and had a higher proportion of manometrically incompetent sphincters than patients with esophageal reflux but without esophagitis or with erosive esophagitis. Severity of acid reflux, measured with 24 h pH monitoring was proportional to the endoscopical damage of the mucosa. There was a close relationship between the mucosal change limit determined with differential potentials and with endoscopy. No short esophagi were found.

CONCLUSIONS

Patients with symptoms of gastroesophageal reflux must be assessed using several objective measures to determine the severity of their pathological alterations.

[Intestinal trichobezoar: report of a case]

Trichobezoars are rare medical entities that must be considered in the differential diagnosis of patients with abdominal mass. We describe a case of an unsuspected intestinal trichobezoar in a nine years old girl. The patient presented an acute lower abdominal pain. We found an echogenic abdominal mass in the pelvic sonography. A double contrast barium enema was scheduled and a rapid relief of symptoms during the preparation of it was accomplished with the expulsion of a mass of hair.

'Carditis': an objective histological marker for pathologic gastroesophageal reflux disease

In a prospective endoscopic and bioptic study, 141 control subjects and 359 patients with symptoms of gastroesophageal reflux (GER) were included to determine the prevalence of cardial epithelium inflammation or 'carditis' and to determine the prevalence of Helicobacter pylori in this area. Two biopsies at the antrum, four distal to the squamous-columnar junction and two proximal in the esophageal mucosa, were taken. Patients with gastroesophageal reflux were divided into four groups, according to the severity of endoscopic findings: patients without esophagitis, patients with erosive esophagitis, patients with short-segment and long-segment Barrett's esophagus (BE). Control subjects had normal histological findings at the cardia in 90% of cases, fundic mucosa being present twice as cardial epithelium. Carditis was present in 8% of cases and intestinal metaplasia (IM) in 2%. On the contrary, patients with GER had carditis in nearly 50% of cases. Intestinal metaplasia was present in 12% of cases with GER without esophagitis or erosive esophagitis, in 35% of cases with short-segment BE and in 65% of the cases with long-segment BE. IM at the antrum was present in only 5% of cases. Helicobacter pylori at the squamous-columnar junction was present in 13% of control subjects and in 30% of the patients with GER. It is concluded that carditis is an easy and objective marker for the presence of chronic gastroesophageal reflux and the presence of Helicobacter pylori at this region must be carefully evaluated in order to determine some pathogenic role for the development of Barrett's esophagus.