Full automation of spinal stereotactic radiosurgery and stereotactic body radiation therapy treatment planning using Varian Eclipse scripting

The purpose of this feasibility study is to develop a fully automated procedure capable of generating treatment plans with multiple fractionation schemes to improve speed, robustness, and standardization of plan quality. A fully automated script was implemented for spinal stereotactic radiosurgery/stereotactic body radiation therapy (SRS/SBRT) plan generation using Eclipse v15.6 API. The script interface allows multiple dose/fractionation plan requests, planning target volume (PTV) expansions, as well as information regarding distance/overlap between spinal cord and targets to drive decision‐making. For each requested plan, the script creates the course, plans, field arrangements, and automatically optimizes and calculates dose. The script was retrospectively applied to ten computed tomography (CT) scans of previous cervical, thoracic, and lumbar spine SBRT patients. Three plans were generated for each patient — simultaneous integrated boost (SIB) 1800/1600 cGy to gross tumor volume (GTV)/PTV in one fraction; SIB 2700/2100 cGy to GTV/PTV in three fractions; and 3000 cGy to PTV in five fractions. Plan complexity and deliverability patient‐specific quality assurance (QA) was performed using ArcCHECK with an Exradin A16 chamber inserted. Dose objectives were met for all organs at risk (OARs) for each treatment plan. Median target coverage was GTV V100% = 87.3%, clinical target volume (CTV) V100% = 95.7% and PTV V100% = 88.0% for single fraction plans; GTV V100% = 95.6, CTV V100% = 99.6% and PTV V100% = 97.2% for three fraction plans; and GTV V100% = 99.6%, CTV V100% = 99.1% and PTV V100% = 97.2% for five fraction plans. All plans (n = 30) passed patient‐specific QA (>90%) at 2%/2 mm global gamma. A16 chamber dose measured at isocenter agreed with planned dose within 3% for all cases. Automatic planning for spine SRS/SBRT through scripting increases efficiency, standardizes plan quality and approach, and provides a tool for target coverage comparison of different fractionation schemes without the need for additional resources.

The risk of oesophageal adenocarcinoma in a prospectively recruited Barrett's oesophagus cohort

BACKGROUND

Varying rates of oesophageal adenocarcinoma (OAC) complicating Barrett's oesophagus (BO) have been reported. Recent studies and meta-analyses suggest a lower incidence, questioning the value of endoscopic surveillance.

AIM

We aimed to retrospectively examine the rate of OAC, risk factors and causes of death in a prospectively recruited BO cohort.

METHODS

Data from patients with BO from a cohort from 1982-2007 were studied. Patients were subdivided into surveyed, failed to attend surveillance and unfit for surveillance. Standardised mortality ratios (SMR) were calculated for common causes of death. Cox proportional hazards models were used to determine which factors were associated with progression to OAC.

RESULTS

In total, 671 BO patients (61% male) were studied; 37 (76% male) were diagnosed with OAC. OAC incidence was 0.47% per annum and stable across three decades (1982-1991 0.56%, 1992-2001 0.46%, 2002-2012 0.41% (p = 0.8)). All-cause mortality was increased for the whole cohort (SMR 163(95% CI 145-183)). Mortality from OAC appeared higher in patients who failed to attend surveillance (SMR 3216(95% CI 1543-5916)) compared with surveyed (SMR 1753(95% CI 933-2998)) and those unfit for surveillance due to co-morbidity (SMR 440(95% CI 143-1025)). Multivariable analysis identified low-grade dysplasia (HR 4.4(95% CI 1.56-12.43), p = 0.005) and length of BO (HR 1.2(95% (1.1-1.3)), p < 0.001)) as associated with OAC.

CONCLUSIONS

Progression to OAC appeared stable over three decades at 0.47% per annum. Patients with BO had a modest increase in all-cause mortality and a large increase in OAC mortality, particularly if fit for surveillance. Low-grade dysplasia and the length of the BO segment were associated with developing OAC.

Local approaches to hereditary breast cancer

The diagnostic and local treatment modalities of hereditary breast cancer (HBC) are evolving based on emerging evidence from new imaging, radiotherapy and surgical studies. The optimal selection of diagnostic and therapeutic strategies for the individual HBC patient remains an area of active research in this relatively new patient population. In this context, some rational pathways of intervention are currently available to both reduce cancer risk in mutation carriers without a cancer diagnosis, as well as to reduce the risk of recurrence or new cancers among the carriers already diagnosed with a malignancy. It is encouraging to notice to what degree certain interventions have successfully reduced both the risk of malignancy and the anxiety associated with this genetic diagnosis. This updated report aims at summarizing the most recent findings, while it identifies the areas of uncertainty that remain, and continue to present difficult challenges, particularly among younger HBC patients.

A role for iron in Wnt signalling

There is an emerging body of evidence implicating iron in carcinogenesis and in particular colorectal cancer, but whether this involves Wnt signalling, a major oncogenic signalling pathway has not been studied. We aimed to determine the effect of iron loading on Wnt signalling using mutant APC (Caco-2 and SW480) and wild-type APC (HEK-293 and human primary fibroblasts) containing cell lines. Elevating cellular iron levels in Caco-2 and SW480 cells caused increased Wnt signalling as indicated by increased TOPFLASH reporter activity, increased mRNA expression of two known targets, c-myc and Nkd1, and increased cellular proliferation. In contrast wild-type APC and beta-catenin-containing lines, HEK 293 and human primary fibroblasts were not responsive to iron loading. This was verified in SW480 cells that no longer induced iron-mediated Wnt signalling when transfected with wild-type APC. The cell line LS174T, wild type for APC but mutant for beta-catenin, was also responsive suggesting that the role of iron is to regulate beta-catenin. Furthermore, we show that E-cadherin status has no influence on iron-mediated Wnt signalling. We thus speculate that excess iron could exacerbate tumorigenesis in the background of APC loss, a common finding in cancers.

Small intestinal lactase status, frequency distribution of enzyme activity and milk intake in a multi-ethnic population

The aims of the study were to investigate the prevalence of primary lactase deficiency, frequency distribution of lactase activity and the relationship between lactose intake and lactase activity in three ethnic groups resident in Birmingham. Seventy-two white, 103 Indian and 58 Afro-Caribbean adult dyspeptic patients had distal duodenal biopsies taken for disaccharidase assay at endoscopy. Ten percent of whites, 51% Indians and 81% Afro-Caribbeans had primary lactase deficiency (sucrase/lactase ratio > 4). There was a generalized unexplained depression of disaccharidase activities in the Indians. Frequency distribution of lactase activity for the whole population showed a negative skew without evidence of trimodality. Lactose intake and symptoms attributed to lactose were assessed in a subgroup of 20 whites, 20 Indians and 18 Afro-Caribbeans by questionnaire. Lactose intake did not differ between lactase persistent and deficient subjects both within each racial group and between the groups. Diarrhoea, bloating and cramps were not significantly more common in lactase deficient than lactase persistent individuals.

Hypertension and fatty liver: guilty by association?

Essential hypertension is associated with the metabolic syndrome, insulin resistance and the development of fatty liver. Fatty liver disease is a spectrum of liver diseases ranging from simple hepatic steatosis through steato-hepatitis to cirrhosis and hepatoma. The purpose of this review is to discuss the evidence for an association between essential hypertension and non-alcoholic fatty liver disease, and to consider the diagnosis and management of non-alcoholic fatty liver disease. We conclude that it is important to consider the diagnosis of fatty liver disease in hypertensive patients, to measure the liver function tests at diagnosis and not to ignore minor elevations of serum aminotransferases. Hypertensive patients with raised liver enzymes should be referred for further assessment, particularly if risk factors for progressive liver disease, such as obesity and diabetes, are present.

Continuous treatment of Barrett's oesophagus patients with proton pump inhibitors up to 13 years: observations on regression and cancer incidence

BACKGROUND

There is little evidence that treatment of patients with Barrett's oesophagus with proton pump inhibitors over periods up to 6 years results in major regression of Barrett's oesophagus.

AIM

To determine if longer periods of treatment with proton pump inhibitors lead to significant regression of Barrett's oesophagus, and to determine the incidence of oesophageal adenocarcinoma in the proton pump inhibitor-treated patients.

METHODS

We analysed prospectively-collected data on Barrett's oesophagus patients treated with proton pump inhibitors for 1-13 years.

RESULTS

188 patients with Barrett's oesophagus and intestinal metaplasia, were treated for 1-13 years with a proton pump inhibitor (966 years of treatment; mean 5.1 years). No change in length was seen during treatment but 48% of patients developed squamous islands (25% after 1-3 years; 100% at 12-13 years). Squamous islands correlated with treatment duration and male sex but not with proton pump inhibitor dose or patient age. Six patients developed dysplasia and three males developed adenocarcinoma during treatment (cancer incidence 0.31%).

CONCLUSIONS

Proton-pump inhibitor treatment over 1-13 years does not shorten the Barrett's oesophagus segment but squamous islands appear in many patients. The incidence of oesophageal adenocarcinoma was low in these proton pump inhibitor-treated patients compared with published series.

Coeliac disease in South Asians resident in Britain: comparison with white Caucasian coeliac patients

BACKGROUND

The catchment population of our hospital is ethnically diverse and we have seen a number of patients of South Asian origin with coeliac disease. We have suspected that there are differences compared with white Caucasian coeliacs, especially with respect to iron-deficiency anaemia and vitamin D deficiency at presentation.

AIMS

To compare the clinical and laboratory features of South Asian adult coeliac patients with adult white Caucasian coeliacs.

METHODS

We reviewed the notes of patients attending the adult coeliac clinic over the past 10 years. All patients were older than 16 years at diagnosis. There were 40 South Asians and 90 white Caucasians. Symptoms, haematology, biochemistry, endomysial antibody status, HLA alleles and small bowel histology at presentation were compared between the two racial groups.

RESULTS

There were significant differences between the racial groups. South Asians were younger at presentation than the Caucasian patients (mean age 27 years compared with 47 years respectively, P<0.0001); they were less likely to have 'irritable bowel syndrome' symptoms (P<0.01), but more likely to have features of vitamin D deficiency (P<0.03). Their haemoglobin (P<0.05), mean cell volume (P<0.0004), serum iron (P<0.01), transferrin saturation (P<0.05), serum 1,25-dihydroxyvitamin D3 (P<0.002), and levels were lower, while serum alkaline phosphatase levels were higher (P<0.04) than in white Caucasian coeliac patients. There were no differences with respect to serum folate, vitamin B12, serum calcium, alanine aminotransferase and small bowel histology. IgA class endomysial antibody positivity was similar in the two groups (88.5% for South Asians compared with 73.5% for white Caucasians). White Caucasian patients were significantly more likely to be DQ2-positive than the South Asian patients (97.2% compared with 83.3%, P=0.02).

CONCLUSION

South Asians with coeliac disease are less likely to present with 'irritable bowel syndrome' symptoms, but more likely to have features of vitamin D deficiency and iron deficiency, and have a higher alkaline phosphatase than white Caucasians. The differences in HLA alleles seen in South Asians with coeliac disease compared with white Caucasian patients suggests that among the South Asians, non-HLA regions may play a stronger role in disease susceptibility and presentation.

Ethnic differences in cirrhosis of the liver in a British city: alcoholic cirrhosis in South Asian men

AIMS AND METHODS

We studied the ethnic origin of cirrhotic patients retrospectively over the 14-year period 1987-2000 and compared the ethnic make-up of the cirrhotic patients with the ethnic make-up of the local catchment population.

RESULTS AND CONCLUSIONS

Of 381 cirrhotics, 64.1% were white, 29.1% South Asian, 4.7% Afro-Caribbeans and 2.1% other races. These proportions were different from those of the local community in that South Asians were over-represented and Afro-Caribbeans were under-represented. Alcohol was the commonest cause of cirrhosis (60.9%) and South Asian non-Moslem males with alcoholic cirrhosis were over-represented and were younger at diagnosis than white alcoholic cirrhotics.

Triple therapy for Helicobacter pylori eradication: a comparison of pantoprazole once versus twice daily

BACKGROUND

Proton pump inhibitor-based triple therapy is recommended as treatment for Helicobacter pylori eradication. The proton pump inhibitor may be given once or twice daily. However, little information is available on how these two treatment strategies compare.

METHODS

H. pylori-positive patients (two positive test results) with endoscopy-proven healed duodenal ulcer or non-ulcer dyspesia were randomly allocated to 1 week of double-blind treatment with pantoprazole 40 mg once or twice daily, plus clarithromycin 250 mg and metronidazole 400 mg twice daily. Eradication was defined as a negative 13C-urea breath test (13C-UBT) and histology, 4-5 weeks post-treatment. The follow-up phase comprised 12 months off therapy, with 13C-UBT at 6 and 12 months.

RESULTS

Two hundred and four patients received treatment: pantoprazole once daily (x1), n=104; twice daily (x2), n=100. Eradication rates were 84% in both the pantoprazole x1 and pantoprazole x2 groups by modified intention-to-treat analysis and 89% and 87%, respectively, by per protocol analysis. Metronidazole resistance was found in 44% of pre-treatment cultures of H. pylori. Eradication rates were similar in susceptible (72%) and resistant (75%) strains. During follow-up, recrudescence of infection occurred in 3/118 patients.

CONCLUSION

When using pantoprazole plus clarithromycin and metronidazole, the proton pump inhibitor can be used once daily without loss of efficacy.

Reduced cadherin/catenin complex expression in celiac disease can be reproduced in vitro by cytokine stimulation

Celiac disease is characterized by a chronic immune response to dietary gluten, in which T cell responses result in elevated mucosal levels of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1, interferon (IFN)-gamma, and transforming growth factor (TGF)-beta, which induce profound mucosal remodeling associated with increased enterocyte proliferation, apoptosis, and migration. Reduced intestinal expression of the morphoregulatory cell adhesion molecule E-cadherin, which forms complexes with beta-catenin, can increase enterocyte proliferation and migration. However, its mechanism of action in gastrointestinal inflammatory conditions and any involvement in celiac disease is unknown. In this study, we describe changes in E-cadherin and beta-catenin expression in celiac disease tissue and determine the effect of cytokines on their expression in an in vitro model. We assessed E-cadherin and beta-catenin expression in intestinal biopsies from 24 patients with celiac disease, 12 patients with treated celiac disease, and 10 healthy patients by immunohistochemistry, Western blotting, and confocal microscopy. Using Caco-2 cells, we examined the effect of TNF-alpha, IL-1, IFN-gamma, and TGF-beta on E-cadherin expression. E-cadherin transcription was assessed in both intestinal biopsies and Caco-2 cells by in situ hybridization and RT-PCR, respectively. A marked reduction in protein expression of E-cadherin and beta-catenin that returns to normal levels after treatment was observed in celiac disease; this reduction was associated with reduced levels of E-cadherin mRNA. E-cadherin expression in Caco-2 cells was significantly reduced after TNF-alpha, IL-1, and IFN-gamma stimulation. The effect of TNF-alpha on E-cadherin expression was maximal after stimulation for 48 hours and also induced modest reductions in beta-catenin expression. The action of TNF-alpha on E-cadherin was reversible and was shown to act at the transcriptional level. These results demonstrate the novel findings that E-cadherin and beta-catenin expression are reversibly down-regulated in celiac disease and that such changes in epithelial cadherin/catenin complexes may be mediated by cytokines acting on cadherin transcription.

Ethnic differences in gastro-oesophageal reflux disease

OBJECTIVES

To see whether the anecdotal statement that gastro-oesophageal reflux disease is less common in blacks than in white Caucasians is true.

DESIGN

Study of the racial origin of adult patients who, at endoscopy, have oesophageal damage due to gastro-oesophageal reflux.

SETTING

Gastroenterology unit of a teaching hospital in inner city Birmingham, UK.

MAIN OUTCOME MEASURE

Ethnicity and endoscopic grade of oesophageal damage (reflux oesophagitis) were recorded in every patient in whom oesophageal damage due to gastro-oesophageal reflux was diagnosed.

RESULTS

Over the eight-year period 1989-1996, 1101 patients with endoscopically diagnosed grades I-V reflux oesophagitis have been seen, of whom 893 (81.9%) were white, 156 (14%) were Indian and 52 (5%) were Afro-Caribbeans. There were fewer patients with reflux oesophagitis from the two non-white ethnic groups than would be expected from their prevalence in the catchment population, and severe reflux oesophagitis was less common than expected in the two non-white groups. In all groups, patients with grades III, IV and V reflux oesophagitis were older than patients with grades I and II disease. Whites tended to be older than Afro-Caribbeans or Indians.

CONCLUSION

There were fewer non-whites with reflux oesophagitis than would be expected but the reasons for this are unclear. This study has been useful as a pilot but further studies are needed in ethnically mixed non-migrant populations both in hospital, primary care and the community to clarify racial differences in reflux oesophagitis.

Measurement of small intestinal permeability markers, lactulose, and mannitol in serum: results in celiac disease

To date, tests of small intestinal passive permeability have involved the ingestion of test molecules whose permeation is assessed indirectly by measuring their urinary recovery. Excretion ratios of marker molecules (eg, lactulose-to-mannitol excretion ratio, LMER) are useful clinically. Measurement of permeability markers in serum would improve the convenience of the tests. Our aim was to assess small intestinal permeability in celiac patients using serum lactulose and mannitol levels with calculation of lactulose to mannitol serum ratios (LMSR) and to compare the results with the standard methods using urinary recoveries. Twenty-four newly diagnosed celiacs and 10 control subjects were studied; 10 celiacs were restudied while established on a gluten-free diet. Test subjects and patients ingested 10 g lactulose and 2.5 g mannitol in 50 ml water. In 10 untreated celiacs and the controls, blood was taken from 0 to 120 min and all urine was collected for 6 hr. The remaining 14 untreated and the 10 treated celiacs had a single serum sample taken 60 min after ingestion of the test solution. At 1 hr after ingestion, the mean mannitol level in normals (0.156 mmol/liter) was significantly higher than in untreated celiacs (0.06 mmol/liter). The 1-hr mean serum lactulose level in normals (0.125 micromol/liter) was significantly lower than in untreated celiacs (0.56 micromol/liter). The median 1-hr LMSR in untreated celiacs was 0.42 compared with 0.039 in normals and 0.08 in treated celiacs. There was a significant correlation between LMSR and LMER. Permeability testing using serum measurements of lactulose and mannitol gave comparable results in celiac patients to the tests using urinary recovery of the permeability markers and may prove to be more convenient, especially in pediatric patients.

Continuous treatment with omeprazole 20 mg daily for up to 6 years in Barrett's oesophagus

BACKGROUND

Because of the malignant potential of Barrett's oesophagus, an aim of treatment is to cause the columnar epithelium to regress. A logical approach is to decrease acid reflux which is an important aetiological factor in Barrett's oesophagus. Treatment with omeprazole 20-80 mg over 1-3 years has yielded conflicting but largely disappointing results.

AIM

To determine if treatment of Barrett's oesophagus with omeprazole 20 mg daily for up to 6 years can cause regression of the Barrett's epithelium.

PATIENTS AND METHODS

Forty-seven patients with Barrett's oesophagus were treated in an open prospective study. Nine patients were treated for 2 years, 12 for 3 years, 10 for 4 years, eight for 5 years and eight for 6 years. Patients were endoscoped at 1-2-year intervals and endoscoped at the end of the treatment period.

RESULTS

No significant shortening of the length of the Barrett's segment was seen during any treatment period, although omeprazole controlled reflux symptoms and was well tolerated. Macroscopic squamous islands appeared in 55% of patients, mostly in the first 2-3 years although in five patients they appeared later in treatment.

CONCLUSION

Treatment of Barrett's oesophagus with omeprazole 20 mg daily for periods of up to 6 years did not cause regression in the length of the Barrett's segment, but it did lead in over half of the patients to partial re-epithelialization in the form of squamous islands.

Incidence of duodenal ulcer healing after 1 week of proton pump inhibitor triple therapy for eradication of Helicobacter pylori. The Lansoprazole Helicobacter Study Group

BACKGROUND

A number of clinical studies have assessed the efficacy of short-term twice-daily Helicobacter pylori eradication regimens but few have investigated the proportion of patients in whom duodenal ulcer disease was healed with these regimens.

AIM

To compare the safety and efficacy of four 1-week H. pylori eradication regimens in the healing of H. pylori associated duodenal ulcer disease.

METHODS

Following endoscopic confirmation of duodenal ulcer disease and a positive CLO test, patients underwent a 13C-urea breath test to confirm H. pylori status. Treatment with one of four regimens: LAC, LAM, LCM or OAM, where L is lansoprazole 30 mg b.d., A is amoxycillin 1 g b.d., M is metronidazole 400 mg b.d., C is clarithromycin 250 mg b.d., and O is omeprazole 20 mg b.d., was assigned randomly to those patients who were H. pylori positive, with 62 (LAC), 64 (LAM), 61 (LCM) and 75 (OAM) patients in each treatment group. Follow-up breath tests and endoscopies were performed at least 28 days after the end of treatment.

RESULTS

Duodenal ulcer disease was healed 28 days after treatment in 53/62 (85.5%) patients who were treated with LAC, 52/64 (81.3%) of patients treated with LAM, 49/61 (80.3%) of patients treated with LCM and 60/75 (80.0%) of patients treated with OAM (intention-to-treat analysis, n = 262, assumed unhealed if no follow-up endoscopy was performed). All the treatments were of similar efficacy (P = 0.85, chi-squared test) with regard to the healing of duodenal ulcer disease.

CONCLUSIONS

The four 1-week treatment regimens were equally effective in healing H. pylori associated duodenal ulcer disease.

Lactase haplotype frequencies in Caucasians: association with the lactase persistence/non-persistence polymorphism

A genetic polymorphism is responsible for determining that some humans express lactase at high levels throughout their lives and are thus lactose tolerant, while others lose lactase expression during childhood and are lactose intolerant. We have previously shown that this polymorphism is controlled by an element or elements which act in cis to the lactase gene. We have also reported that 7 polymorphisms in the lactase gene are highly associated and lead to only 3 common haplotypes (A, B and C) in individuals of European extraction. Here we report the frequencies of these polymorphisms in Caucasians from north and south Europe and also from the Indian sub-continent, and show that the alleles differ in frequency, the B and C haplotypes being much more common in southern Europe and India. Allelic association studies with lactase persistence and non-persistence phenotypes show suggestive evidence of association of lactase persistence with certain alleles. This association was rather more clear in the analysis of small families, where haplotypes could be determined. Furthermore haplotype and RNA transcript analysis of 11 unrelated lactase persistent individuals shows that the persistence (highly expressed) allele is almost always on the A haplotype background. Non-persistence is found on a variety of haplotypes including A. Thus it appears that lactase persistence arose more recently than the DNA marker polymorphisms used here to define the main Caucasian haplotypes, possibly as a single mutation on the A haplotype background. The high frequency of the A haplotype in northern Europeans is consistent with the high frequency of lactase persistence.

Sucrosemia in untreated celiac disease: a potential screening test

During studies to develop serum tests of small intestinal permeability, we detected an unidentified disaccharide in HPLC traces of sera from untreated celiacs. This present study aimed to identify the disaccharide and determine whether the presence of the disaccharide in the serum after an oral challenge had potential as a simple screening test for celiac disease. The disaccharide was identified as sucrose by incubation studies of sera with disaccharidases. Twenty untreated celiacs, 15 treated celiacs, and 20 normal or dyspeptic controls were studied for the presence of sucrose in their serum after an oral load (8 g). The results in celiacs were compared with the presence of serum IgA endomysial antibodies. The 10 normal controls were also given a larger sucrose challenge (50 g). Ten of the untreated celiacs and 10 controls had their brush border disaccharidase activities measured. Sucrose eluted in the same position as the unidentified disaccharide in the HPLC trace and the latter could be removed by incubation with sucrase. All untreated celiacs but none of the treated celiacs had sucrose in their serum after the 8-g oral challenge. None of the controls had sucrose in their serum after the 8-g or 50-g challenges. Three untreated celiacs were IgA endomysial antibody negative as were all the treated cases. Brush border sucrase activity was low in untreated celiac disease. The presence of sucrose in the serum after an oral load shows promise as a noninvasive test for celiac disease.

One week triple therapy for Helicobacter pylori: a multicentre comparative study. Lansoprazole Helicobacter Study Group

BACKGROUND

Eradication of Helicobacter pylori cures and prevents the relapse of duodenal ulceration and also results in histological resolution of chronic active gastritis.

AIM

To compare four treatment regimens lasting seven days of a proton pump inhibitor and two antibiotics in the eradication of H pylori.

PATIENTS

Men or women with H pylori positive duodenal ulceration or gastritis, or both.

METHODS

A single blind, prospectively randomised, parallel group, comparative, multicentre study. After a positive CLO test, patients underwent histology, H pylori culture, and a 13C urea breath test to confirm H pylori status. Treatment with one of four regimens: LAC, LAM, LCM, or OAM, where L is 30 mg of lansoprazole twice daily, A is 1 g of amoxycillin twice daily, M is 400 mg of metronidazole twice daily, C is 250 mg of clarithromycin twice daily, and O is 20 mg of omeprazole twice daily, was assigned randomly. A follow up breath test was done at least 28 days after completing treatment.

RESULTS

H pylori eradication (intention to treat) was 104/121 (86.0%) with LAC, 87/131 (66.4%) with LAM, 103/118 (87.3%) with LCM, and 94/126 (74.6%) with OAM. There was a significant difference (p < 0.001) in the proportion of patients in whom eradication was successful between LAC and LCM when compared with LAM, but no significant difference (p = 0.15) between LAM and OAM. Metronidazole resistance before treatment was identified as a significant prognostic factor with regard to eradication of H pylori. The regimens which contained metronidazole were significantly less effective than those without metronidazole in the presence of pretreatment resistant H pylori. There was no difference among the treatment groups with regard to the incidence and severity of adverse events reported.

CONCLUSIONS

All four treatment regimens were safe and effective in eradicating H pylori in the patient population studied. LAC was the most efficacious treatment in patients with pretreatment metronidazole resistant H pylori, and was significantly better than LAM and OAM in this group of patients.

An analytical method for the quantitation of mannitol and disaccharides in serum: a potentially useful technique in measuring small intestinal permeability in vivo

An electrochemical-HPLC method for the determination of mannitol and lactulose is presented which may facilitate routine testing of intestinal permeability by requiring only a single blood sample instead of a 6-hour urine collection. Chromatographic conditions are described which allow separation of the closely related sugars lactulose and the dietary disaccharides lactose and sucrose. Preliminary results in normal controls and patients with untreated coeliac disease are presented.

Severe hepatitis E infection during pregnancy

In areas with endemic hepatitis E virus (HEV), acute liver failure secondary to hepatitis E infection is common in pregnancy and associated with a mortality rate of up to 20%. However, there is little information on the clinical course of severe hepatitis E infection during pregnancy in non-endemic areas such as the UK. Here we describe two cases of severe hepatitis E in pregnancy in patients returning from the Indian subcontinent. These cases were diagnosed by the detection of IgM anti-HEV antibody using an enzyme immunoassay with recombinant hepatitis E viral antigens. The first case describes acute hepatic failure, with coagulopathy and encephalopathy, warranting intensive therapy and elective ventilation. In the other case, the patient had severe hepatitis with coagulopathy. Both cases spontaneously resolved with no foetal loss. These cases highlight the need for suspicion of HEV infection in patients returning from endemic areas and presenting with acute non-A non-B hepatitis, especially when pregnant. Furthermore, the intensive treatment of acute liver failure caused by HEV may reduce the high mortality reported in Asia.

Small intestinal permeability to mannitol and lactulose in the three ethnic groups resident in west Birmingham

BACKGROUND/AIMS

Asymptomatic residents of tropical countries have differences in small intestinal morphology and permeability compared with residents of temperate zones. The aim of this study was to investigate small intestinal permeability and morphology in three ethnic groups resident in Birmingham, UK.

METHODS

28 white patients, 101 Indian (Indian subcontinent), and 49 Afro-Caribbean adult patients with dyspepsia had endoscopic distal duodenal biopsies and a hyperosmolar lactulose/mannitol permeability test. Twenty normal white subjects had the permeability test.

RESULTS

Lactulose/mannitol excretion ratios (LMER) were: white subjects 0.022 (median), white patients 0.022, Indians 0.031, Afro-Caribbeans 0.033. Differences between the immigrant groups and the two white groups were significant (p < 0.001); 33% of Indians and 45% of Afro-Caribbeans had LMER outside the range of the white groups. Afro-Caribbeans born in the UK had significantly lower LMER than those born abroad (p < 0.05); a similar trend was seen in Indians. Villous height/mucosal thickness ratios, calculated from small intestinal biopsy specimens, were lower in the immigrant groups and correlated inversely with LMER (r = 0.28; p < 0.05). Time resident in the tropics also correlated inversely with LMER.

CONCLUSIONS

There were significant differences in small intestinal permeability and morphology between immigrants resident in a Western country and the native white population. The data suggested that these differences were related to environmental factors.

Lansoprazole versus ranitidine in the maintenance treatment of reflux oesophagitis

AIMS

To assess the relative efficacies of lansoprazole 15 mg once daily, lansoprazole 30 mg once daily and ranitidine 300 mg b.d. in the maintenance treatment of reflux oesophagitis for 12 months.

METHODS

Multicentre, out-patient, double-blind, parallel group, prospectively randomized clinical trial. Patients with grade 0, asymptomatic oesophagitis after 8 weeks of treatment with lansoprazole 30 mg once daily were randomized to receive lansoprazole 30 mg once daily (L30) (n = 75), lansoprazole 15 mg once daily (L15) (n = 86) or ranitidine 300 mg b.d. (R600) (n = 74) for 12 months. Endoscopy was repeated at 6 and 12 months, and symptomatic assessment was made every 3 months. Efficacy was primarily assessed by the time to endoscopically confirmed relapse (oesophagitis grade > or = 1) and the proportion of patients who relapsed during the 12-month study period. Severity of symptoms were secondary efficacy measures.

RESULTS

For all patients randomized with at least one post-baseline endoscopy (intent-to-treat principle) both lansoprazole 15 mg (P < 0.001) and lansoprazole 30 mg (P < 0.001) were significantly superior to ranitidine 600 mg with respect to time to endoscopic relapse. There was no difference between the lansoprazole groups (P = 0.11). There was evidence of relapse in 27 of 86 (31.4%), 15 of 75 (20.0%) and 50 of 74 (67.6%) of the patients treated with lansoprazole 15 mg and 30 mg and ranitidine 600 mg, respectively. Patients receiving treatment with either lansoprazole dosages experienced significantly less severe heartburn and regurgitation than those patients treated with ranitidine. There were no differences between the treatment groups with respect to the severity or incidence of adverse events. No clinically significant laboratory changes were observed in any of the treatment groups. Serum gastrin levels were elevated in all treatment groups, and most markedly in those patients receiving lansoprazole, but there was no significant difference between the treatments. Morphological and immunohistochemical examination of the gastric biopsies revealed no clinically relevant changes from baseline in any of the treatment groups.

CONCLUSION

Both lansoprazole 15 mg and lansoprazole 30 mg once daily are significantly more effective than high-dose ranitidine in maintaining reflux oesophagitis in remission.

Effect of water-loading on the performance of polyethylene glycol as a marker of small intestinal permeability

1. Polyethylene glycol has been used extensively to measure small intestinal permeability in vivo. However, polyethylene glycol seems to traverse the intestinal mucosa in much greater quantities than sugar molecules of equivalent M(r). In addition, the recovery of the lowest M(r) polymers of administered polyethylene glycol has been found to be both low and unreliable. 2. To compare the behaviour of a range of polyethylene glycol polymers with sugar probes in vivo, a combined polyethylene glycol/mannitol/lactulose probe was administered sequentially to healthy individuals in the fasted state and under conditions of water-loading. Timed hourly urine collections were made for 6 h. 3. Mannitol and lactulose recoveries were all within the normal range and were unaffected by co-administration of water. The lactulose/mannitol recovery ratios did not vary significantly over the 6 h collection period. In contrast, the recovery of total polyethylene glycol was significantly greater when subjects were water-loaded. Furthermore, proportionally greater quantities of polyethylene glycol M(r) 370 than M(r) 854 were recovered towards the end of the collection period than at the start. 4. Our results show that, in contrast to lactulose and mannitol, excretion of low-medium M(r) polyethylene glycol polymers is highly dependent on co-administration of water. Furthermore, the differential rate of excretion of the low compared with the high M(r) polyethylene glycol polymers suggests that the volume of distribution of the individual polymers may vary with M(r), and smaller polyethylene glycol molecules may undergo considerable renal tubular reabsorption.

Endoscopy and computed tomography in the diagnosis and follow up of oesophageal leiomyoma

Leiomyoma of the oesophagus, although the commonest benign oesophageal tumour, is still rare compared with malignant tumours of the oesophagus. Leiomyomas of the oesophagus are usually diagnosed on barium swallow or histological examination after section. Five cases of leiomyoma of the oesophagus are reported where diagnosis was made by the combination of barium swallow, upper gastrointestinal endoscopy, and computed tomography and all but one patient were followed up for one to four years. The endoscopic biopsy specimens were non-specific in all five patients but none showed any evidence of malignancy. None of the five patients had a history of dysphagia. This paper describes a conservative approach to medical treatment in asymptomatic oesophageal leiomyoma rather than surgical excision as commonly published. It also emphasises the importance of negative endoscopic pinch biopsy specimens and the role of computed tomography in the diagnosis of oesophageal leiomyoma.

Long term continuous omeprazole treatment of patients with Barrett's oesophagus

BACKGROUND

The metaplastic columnar epithelium in Barrett's oesophagus has malignant potential.

AIM

To determine whether decreasing acid reflux leads to regression of Barrett's epithelium.

METHOD

Twenty-four patients with Barrett's oesophagus were treated with omeprazole 20 mg o.m. in an open, prospective study; 11 were treated for 12 months, and 13 for 24 months. Another group of 17 patients with Barrett's oesophagus was treated with an H2-receptor antagonist in standard dosage for 12-36 (mean 23) months. Patients were assessed endoscopically.

RESULTS

No evidence of significant shortening of the length of Barrett's oesophagus was seen in any patient treated for 12 or 24 months with omeprazole. Similarly, no shortening of the length of Barrett's oesophagus was seen in any patient treated with an H2-receptor antagonist. However, 6 of 11 patients treated with omeprazole for 12 months, and 7 of 13 treated for 24 months, developed macroscopic squamous islands visible below the squamo-columnar junction. This was not seen in any patient treated with an H2-receptor antagonist.

CONCLUSION

Although there can be reappearance of squamous epithelium in Barrett's oesophagus of some patients during treatment with omeprazole 20 mg o.m. over 12-24 months, a significant shortening of the columnar lined segment is not seen.

Symptomatic cardiomyopathy as a presentation in Whipple's disease

A patient presenting with congestive cardiac failure and anaemia underwent investigation which led to the diagnosis of Whipple's disease, associated with dilated cardiomyopathy. Conventional antibiotic therapy for Whipple's disease resulted in resolution of the traditional features of Whipple's disease and a marked improvement in the patient's heart failure.

24 hour ambulatory oesophageal pH monitoring in uncomplicated Barrett's oesophagus

The aim of this study was to compare acid reflux in 16 patients with uncomplicated Barrett's oesophagus with 37 patients with reflux oesophagitis and 10 control subjects of comparable age. All patients had 24 hour ambulatory pH monitoring within one week of endoscopy. The controls differed significantly from the other groups in all indices of reflux but there was no difference between the Barrett's oesophagus patients and the reflux oesophagitis patients in any index of reflux over the total 24 hour period. Barrett's oesophagus patients differed significantly, however, with respect to the percentage time pH < 4 and the number of reflux episodes of > five minutes during the supine period when compared with patients with grade I reflux oesophagitis, but not when compared with patients with grade II and III reflux oesophagitis. Barrett's oesophagus patients with associated grade II reflux oesophagitis had more reflux than those with no oesophagitis or grade I reflux oesophagitis. Within each disease group patients > or = 50 years had more acid reflux than patients < 50 years. The severity of acid reflux in patients with uncomplicated Barrett's oesophagus was no greater than in patients with reflux oesophagitis of comparable age. It seems probable that other factors must be important in the development of Barrett's oesophagus.

Phytase activity in the human and rat small intestine

Phytate is the major storage form of phosphorus in seeds and so is a common dietary constituent. Excessive ingestion of undegraded phytates can cause mineral deficiencies in humans. In addition, phytic acid is antineoplastic in animal models of both colon and breast carcinoma. There have been no previous studies quantifying phytase activity in the human small intestine although it is present in animals. Small intestinal phytase and alkaline phosphatase activity and distribution was measured in vitro in mucosal homogenates from two human small intestinal specimens obtained from transplant donors. Rat intestine was also studied for comparison. Phytase activity was found in human small intestine at low values (30 times less than that in rat tissue and 1000-fold lower than alkaline phosphatase in the same tissue). The activity was greatest in the duodenum and lowest in the ileum. In conclusion, the normal human small intestine has very limited ability to digest undegraded phytates. Although this may have adverse nutritional consequences with respect to metabolic cation imbalances, the presence of undigested phytate in the colon may protect against the development of colonic carcinoma.

Benign intracranial hypertension during prednisolone treatment for inflammatory bowel disease

Benign intracranial hypertension (BIH, pseudotumour cerebri) is a rare condition with unknown aetiology although hormonal influences have been implicated. It occurs spontaneously, particularly in young obese women, and is associated with several drug treatments including corticosteroids. Two young adult women are described in whom headache and papilloedema in association with raised intracranial pressure occurred during prednisolone treatment for inflammatory bowel disease. This provides further evidence of the risk of BIH during corticosteroid treatment and has not been described before in adults with this condition. Advice is given to gastroenterologists to use corticosteroids with caution in adults, particularly young, fertile female patients. The treatment of a severe relapse of colitis in a patient who has had one episode of steroid related BIH remains a dilemma.

Diffusion of polyethylene glycol-400 across lipid barriers in vitro

1. Polyethylene glycol has been used extensively as a probe to measure passive small-intestinal permeability in vivo. However, there has been some uncertainty as to its suitability for use as an indicator of the permeation of water-soluble molecules across the intestinal wall because it seems to traverse the mucosa in much greater quantities than sugar molecules of equivalent M(r). 2. We have measured the permeation of polyethylene glycol-400 and lactulose from aqueous solution across pure lipid solvents in vitro. We found considerable transport of polyethylene glycol-400 across chloroform (1.03 g h-1 m-2) but no movement across petroleum ether. 3. However, in a separate experiment in which phospholipid (egg lecithin) was dissolved in the petroleum ether, permeation of polyethylene glycol-400 did occur (0.13 g h-1 m2), implying interaction of polyethylene glycol-400 with the phospholipid. No permeation of lactulose was seen in any of the experiments. 4. Our results suggest that, because of its interaction with lipid solvents, polyethylene glycol-400 is unsuitable as a probe to measure passive intestinal permeability in vivo.

A comparison of roxatidine and ranitidine for the acute treatment of duodenal ulcer

Roxatidine acetate is a new histamine H2-antagonist of about twice the potency of ranitidine on a weight-for-weight basis. Two hundred and thirty-two patients participated in a double-blind randomized trial of duodenal ulcer healing comparing 300 mg ranitidine nocte with 150 mg roxatidine nocte. Endoscopy was repeated fortnightly to 4 weeks in each of four participating centres. Usual exclusion criteria applied but NSAID users were allowed. There were no important demographic differences between treatment recipients. Three analyses were used: protocol (dropouts and violators not included), intention-to-treat I (dropouts considered failures), and intention-to-treat II (dropouts considered failures, but violators outcome included). Healing rates differed markedly (but not significantly) with each analysis. After 2 weeks of treatment ulcers had healed in 51% versus 45% using the intention to treat I analysis with roxatidine and ranitidine, respectively; by the protocol analysis the healing proportions were 60% and 55%. These differences between treatments were not significant. After 4 weeks of treatment healing rates ranged from 71% to 83% on roxatidine and between 69% and 84% on ranitidine depending on the analysis. Differential healing proportions of smokers and non-smokers were non-significant (83% vs. 79%). Both drugs were well tolerated and adverse events were similar with each agent. Roxatidine should prove as effective as ranitidine for acute duodenal ulcer treatment.

Small bowel morphology in British Indian and Afro-Caribbean subjects: evidence of tropical enteropathy

Distal duodenal biopsy specimens taken from 30 white, 35 Indian, and 20 Afro-Caribbean residents of West Birmingham during routine endoscopy for dyspepsia, were assessed by dissecting microscopy and morphometry. Finger-shaped villi were significantly less frequent in the Indian and Afro-Caribbean subjects than in the white subjects when assessed by dissecting microscopy (p less than 0.005), and both immigrant groups had decreased mucosal thickness (p less than 0.01), villous height (p less than 0.001), villous:crypt ratios (p less than 0.01) and enterocyte height (p less than 0.05) compared with the white group. In the Indian subjects, villous height and villous:crypt ratios correlated significantly with the time since the last visit to the Indian subcontinent (p less than 0.005). Serum alkaline phosphatase values were significantly higher in the Indian subjects compared with the whites (p less than 0.02), and serum globulins were increased in both the Afro-Caribbean and Indian subjects (p less than 0.01). There were no correlations between morphometric indices and body habitus or biochemical or haematological indices and the long term effect of the morphological changes is not clear.

Coeliac disease and malignancy of the duodenum: diagnosis by endoscopy, successful treatment of the malignancy, and response to a gluten free diet

A patient presented with subtotal villous atrophy and a malignant duodenal tumour of uncertain histogenesis. He was successfully treated by resection and chemotherapy and the small bowel mucosa recovered on a gluten free diet. The tumour was diagnosed at upper gastrointestinal endoscopy when barium studies and abdominal computed tomography were normal, thus making this one of the earliest coeliac malignancies diagnosed.

Enzymes degrading bacterial chemotactic F-met peptides in human ileal and colonic mucosa

Bacterial chemotactic F-met peptides have been identified in culture supernatants of intestinal bacteria and in human faecal dialysates. These potent inflammatory agents could play a role in intestinal inflammatory disorders should they cross the epithelial barrier of the gut. We have identified mucosal peptidases which degrade F-met-leu-phe (FMLP) in ileal and colonic mucosal biopsies obtained at colonoscopy. A carboxypeptidase, inhibited by D-L-benzyl succinate (BzS), accounted for more than 60% of total FMLP-ase activity, other uncharacterized peptidases contributing the rest of the activity against the intact peptide. An F-met deformylase, inactive against di- and tri-peptides, cleaves released F-met completing the degradation. Total FMLP-ase, carboxypeptidase and F-met deformylase activities were measured in serial mucosal biopsies from 15 control patients undergoing colonoscopy for occult bleeding with negative findings and from 15 patients with ulcerative colitis (UC) and 10 with Crohn's disease (CD). Highest activities were found in terminal ileum and lowest in the rectum. Total FMLP-ase and carboxypeptidase activities were similar in controls and UC patients but were substantially reduced in CD, especially in the terminal ileum (controls 493 +/- 146 and 116 +/- 73 nmol/100 micrograms protein per h, respectively and CD 231 +/- 96 and 41 +/- 36 nmol/100 micrograms protein per h, respectively (P = 0.0018 and 0.015). F-met deformylase activities were similar in all groups. There was no correlation between enzyme activity and severity of inflammation. FMLP degrading peptidases probably contribute to the mucosal barrier of the gut in regions of high bacterial colonization, limiting intestinal absorption and inflammatory responses to these potent bacterial products in the intestinal lumen.

Acute upper gastrointestinal haemorrhage in patients aged 80 years or more

We report a series of 103 admissions of patients aged 80 years or more with acute upper gastrointestinal haemorrhage to one hospital over a four-year period. A cause was eventually found during 81.5 per cent of admissions and of these, 57 per cent had bled from chronic peptic ulcers. After 64 per cent of admissions, the patient received a blood transfusion and in 25 per cent, the blood transfusion exceeded 5 units. Nine patients had surgery for peptic ulcer during admission but no operations were performed in patients with other causes of upper gastrointestinal haemorrhage. Patients with peptic ulcer, when compared to patients with other causes for haemorrhage, were more likely to have symptoms of upper gastrointestinal disease before presentation. They were also more likely to continue to bleed, to bleed again, to require surgery, and to die as a consequence of haemorrhage. Eighteen admissions (17.5 per cent) ended with death but in only 11 (10.5 per cent) did the patient die directly because of haemorrhage. Nine of these bled from a peptic ulcer, one from oesophageal varices and one from an unknown cause. Patients who died from haemorrhage, when compared to all others, were more likely to have bled from a peptic ulcer and to have significant co-existing disease, to have ingested non-steroidal antiinflammatory drugs or aspirin before admission, to have raised blood urea level and low systolic blood pressure at admission and to have required blood transfusion of more than 5 units. Our study has shown that upper gastrointestinal haemorrhage secondary to peptic ulceration is a serious and often fatal condition in the elderly. Identification and effective monitoring of those at particular risk of death may be essential if mortality is to be reduced.

Veno-occlusive disease of the liver secondary to ingestion of comfrey

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Erosive gastritis and gastrointestinal bleeding in a female runner. Prevention of the bleeding and healing of the gastritis with H2-receptor antagonists

A 33-yr-old female runner presented with upper gastrointestinal symptoms and iron deficiency anemia. She was found to have erosive gastritis that was present when she exercised and which was associated with symptoms. Gastrointestinal blood loss during exercise periods was confirmed by measuring fecal blood loss using 51Cr-labeled red cells. Symptoms, gastritis, and blood loss disappeared with cessation of running or with H2-receptor antagonist therapy.

Treatment of Barrett's esophagus with H2 blockers

The effect of the H2 receptor antagonists, cimetidine and ranitidine, on Barrett's esophagus was assessed in a retrospective study. There was no evidence of regression of Barrett's epithelium in the 22 patients treated for a mean of 13 months with 800-1,600 mg/day cimetidine, or in the 13 patients treated for a mean of 5.7 months with 300 mg/day ranitidine. Eight of 12 esophageal (Barrett's) ulcers healed on cimetidine therapy over a mean period of 8.7 months, and eight of nine esophageal ulcers healed on ranitidine therapy over a mean period of 3.5 months. We conclude that short-term treatment with H2 blockade does not cause regression of Barrett's esophagus, although such treatment can heal esophageal ulcers.