Conventional Versus Traction-Assisted Endoscopic Submucosal Dissection for Esophageal, Gastric, and Colorectal Neoplasms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Endoscopic submucosal dissection (ESD) is increasingly being utilized for the resection of superficial gastrointestinal neoplasms. However, the long procedure time poses a technical challenge for conventional ESD (C-ESD). Traction-assisted ESD (T-ESD) was developed to facilitate the procedure by reducing its duration. This study compares the efficacy and safety of C-ESD versus T-ESD in the treatment of esophageal, gastric, and colorectal neoplasms. Nine randomized controlled trials (RCTs) were analyzed. Traction-assisted ESD exhibited shorter mean dissection times for the esophagus and colorectal regions and lower perforation rates in colorectal cases. No significant differences were observed in en bloc resection or bleeding rates. Traction-assisted ESD proves to be more efficient in mean procedure time for esophageal and colorectal cases and safer in perforation rates for colorectal cases, but similar rates are noted for en bloc resection or bleeding.

Spirulina Platensis Attenuates Rebound Dyspeptic Symptoms After Proton Pump Inhibitors' Discontinuation: Phase 2 Placebo-controlled Trial

Context

Rebound acid hypersecretion after cessation of proton pump inhibitors (PPIs) can provoke dyspeptic symptoms. The search for alternatives to minimize the dyspeptic rebound symptoms after PPI discontinuation is warranted. Spirulina platensis, a dietary supplement made from blue-green algae, might be an alternative.

Objective

The study intended to assess whether Spirulina platensis, through its anti-inflammatory and analgesic properties, can minimize rebound symptoms after PPI withdrawal.

Design

The research team performed a randomized, phase 2, double-blinded, placebo-controlled clinical trial.

Setting

The study took place at São Vicente de Paulo Hospital (trial registry number NCT04988347) in Passo Fundo, Brazil.

Participants

Participants were 45 Brazilian patients in the clinical practice of two of the research team's member between November 2010 and February 2012, who were using PPIs regularly.

Interventions

Participants underwent clinical and endoscopic evaluations after a 28-day run-in phase of 40 mg/day of pantoprazole. In the absence of a large hiatal hernia, peptic ulcer, or severe reflux esophagitis, participants stopped using PPIs, and the research team randomly assigned them to receive either 1.6g/day of spirulina or of a placebo for two months, followed by clinical and endoscopic reevaluations.

Outcome measures

Using an intention-to-treat analysis, the primary outcomes postintervention were dyspepsia and typical reflux symptoms, either the appearance or maintenance of symptoms of >50% from baseline.

Results

The median time of continuous PPI use was 32 months. The research team excluded two participants due to large hiatal hernias. Among the remaining 43 participants, 18 received spirulina (42%), and 25 used a placebo (58%). Two months later, 12 participants who had received spirulina (67%) and 18 who had received the placebo (72%) completed the study (P = .968). Rebound dyspepsia occurred in 10 out of 18 patients treated with spirulina (55.56%) and in 22 out of 25 patients treated with placebo (88%), with relative risk=0.63, CI95% (0.41-0.98), and P = .039. Reflux symptoms postintervention occurred in 72% and 76%, with the relative risk=0.95, CI95% (0.66-1.36), and P > .05, respectively. No significant side effects occurred in either group. The findings from endoscopy and gastric histology didn't differ between groups.

Conclusions

A two-month course of Spirulina platensis was able to attenuate rebound dyspepsia but not reflux symptoms after PPI discontinuation. Considering its good safety profile, spirulina might be useful to relieve dyspeptic symptoms after PPI discontinuation.

The brain-esophagus axis in subjects with and without obesity assessed by esophageal acid perfusion and functional brain imaging

Background

Gastroesophageal reflux disease (GERD) has a complex pathophysiology and a heterogeneous symptom profile. The brain-esophageal axis in GERD has been studied with functional brain imaging during the last decades, but data from obese patients was just recently reported. A comparison of such a group with non-obese subjects is lacking in the literature. This study aimed to evaluate heartburn perception and brain connectivity responses during esophageal acid stimulation in subjects with and without obesity, controlling for the presence of typical reflux symptoms.

Methods

In this cross-sectional study, 25 patients with obesity (body mass index ≥30 kg/m2) and 46 subjects without obesity underwent functional magnetic resonance imaging (fMRI) of the brain with esophageal water and acid perfusion. The fMRI paradigm and connectivity were assessed.

Results

About two-thirds of the participants had reflux symptoms. Heartburn perception during fMRI did not differ between subjects with and without obesity. The presence of reflux symptoms was associated with lower activation in frontal brain regions during acid perfusion compared to water perfusion. Compared to subjects without obesity, patients with obesity presented significantly lower connectivity within the anterior salience network. Corrected clusters included left caudate, left putamen and left anterior cingulate gyrus.

Conclusions

The brain-esophagus axis showed differences between subjects with and without obesity. Even without symptomatic differences following esophageal acid perfusion, patients with reflux symptoms showed less brain activation in frontal areas, while obese individuals presented lower connectivity within the anterior salience network.

Association between masticatory dysfunction and gastroesophageal reflux disease: A population-based study in the elderly

BACKGROUND

Caries and periodontal disease may cause tooth losses and chewing difficulty, especially in the elderly. Ingesting poorly chewed food may delay gastric emptying and favour the development of gastroesophageal reflux disease (GERD).

OBJECTIVE

This study investigated the association between masticatory dysfunction and GERD in the elderly from a rural area in southern Brazil.

METHODS

This census invited all 489 elderly from a city to participate. The study used a GERD symptoms questionnaire, followed by an oral examination. Masticatory dysfunction was analysed based on the chewing difficulty for some food groups. Tooth loss and chewing self-perception were also considered as exposure variables. Poisson regression determined the association among variables by calculating the prevalence ratio [PR (95% confidence interval)].

RESULTS

The response rate was 93.1% (n = 455, average age of 70.9 years, 50.5% men). The prevalence of GERD in this population was 36.9%. GERD was associated with chewing difficulty for vegetables (PR = 1.54), meats (PR = 1.34) and cereals (PR = 1.43) but not with poor chewing self-perception (PR = 0.80) and tooth loss (PR = 1.22). GERD was also associated with xerostomia (PR = 1.63) and the female gender (PR = 1.35).

CONCLUSION

Elderly people from a rural area with a reduced number of teeth present chewing difficulty and a high prevalence of GERD, indicating an association between GERD and masticatory dysfunction.

Reduced mastication is a risk factor for Rome IV postprandial distress syndrome in patients investigated with upper endoscopy

BACKGROUND AND AIMS

Reduced mastication could force the stomach to do extra work on crushing food and contribute to dyspeptic symptoms. This study aimed to assess the relationship between mastication and dyspepsia.

METHODS

This cross-sectional study involved 209 consecutive patients referred for elective upper endoscopy. Before endoscopy, an expert dentist performed an oral examination and scored chewing function in three levels (normal, regular, and reduced), and applied questionnaires for assessment of dyspepsia (Rome IV), xerostomia, and mastication (normal, regular, and reduced). A reduced masticatory function was defined when an oral examination or mastication questionnaire rated the chewing as poor. Associations between mastication, confounders, and dyspepsia were estimated by prevalence ratio [PR (95% Confidence Interval)] using Poisson regression.

RESULTS

Thirty-four patients showed relevant organic conditions in the upper gastrointestinal tract (moderate to severe reflux oesophagitis, peptic ulcer, neoplasia, and surgical modification) and were excluded. Among 175 patients with non-organic diseases (aging 51.3 ± 15.7 years; 61.7% women), 50 (28.6%) had reduced mastication, and 125 (71.4%) had normal/regular mastication. After adjusting for age and xerostomia, reduced mastication was associated with postprandial distress syndrome [PR = 1.93 (95%CI 1.27 - 2.91)] but not with epigastric pain syndrome [PR = 1.09 (95%CI 0.75 - 1.60)].

CONCLUSIONS

In patients referred for upper digestive endoscopy, reduced mastication was associated with postprandial distress syndrome but not with epigastric pain syndrome. An interdisciplinary approach with dentists and physicians might benefit dyspeptic patients with postprandial distress syndrome.

Disruption of the brain-esophagus axis in obese patients with heartburn

Obesity is a risk factor for gastroesophageal reflux disease. Studies addressing the brain-esophagus axis in obese are lacking. In obese with and without heartburn, we assessed: (i) the brain responses to esophageal acid perfusion during functional brain imaging; (ii) esophageal impedance baseline before and after acid perfusion; and (iii) abdominal fat distribution. In this exploratory study, 26 obese underwent functional magnetic resonance imaging (fMRI) of the brain combined with esophageal acid perfusion. Esophageal impedance baseline was determined before and after fMRI, followed by tomographic quantification of the abdominal fat. Among 26 obese (54% men, 39.7 years old, 33.5 kg/m2), there were 17 with heartburn and 9 without heartburn. Before fMRI, the esophageal impedance baseline was lower in obese with heartburn than without heartburn (median 1187 vs. 1890 Ω; P = 0.025). After acid perfusion, impedance baseline decreased in obese with heartburn (from 1187 to 899 Ω; P = 0.011) and was lower in this group than in obese without heartburn (899 vs. 1614 Ω; P = 0.001). fMRI task-residual analysis showed that obese with heartburn presented higher functional connectivity in several brain regions than obese without heartburn. Abdominal fat area did not differ between obese with and without heartburn either for total (72.8 ± 4.4% vs. 70.3 ± 6.0%; P = 0.280), subcutaneous (42.2 ± 9.0% vs. 37.4 ± 9.0%; P = 0.226), or visceral (30.6 ± 7.9% vs. 33.0 ± 7.8%; P = 0.484). In subjects with obesity, the brain-esophagus axis is disrupted centrally with higher functional brain connectivity and peripherally with decreased esophageal mucosa integrity in the presence of heartburn.

Short-term intestinal effects of water intake in fibre supplementation in healthy, low-habitual fibre consumers: a phase 2 clinical trial

A randomised clinical trial was conducted on 20 healthy, low-habitual fibre consumers to assess the short-term effects of water intake (2 l/day) on fibre supplementation with wheat bran, pectin, and green banana flour. During the 14-days trial, fibre intake doubled in both fibre (n = 10) and fibre/water (n = 10) interventions (p < 0.001), whereas daily water intake increased from 538 to 1990 ml in the fibre/water group (p < 0.001). Weekly bowel movements increased similarly in both interventions (fibre: 6.8-8.8; fibre/water: 8.6-10; p < 0.01), while faecal weight (71-126 g; p = 0.009) increased in the fibre/water group. This group showed higher counts of faecal Bacteroides and Prevotella, Faecalibacterium prausnitzii, and Bifidobacterium, whereas both interventions decreased the count of Desulfovibrio. Transient abdominal symptoms occurred less frequently in the fibre/water than in the fibre group (3 vs. 9 participants; p = 0.020). In healthy, low-habitual fibre consumers, short-term water intake helps the intestinal adaptation to fibre supplementation.CLINICAL TRIAL REGISTRATION NUMBER: NCT02838849.

Reduced masticatory function predicts gastroesophageal reflux disease and esophageal dysphagia in patients referred for upper endoscopy: A cross-sectional study

BACKGROUND

The role of mastication on gastroesophageal reflux disease (GERD) is unknown.

AIMS

To assess whether reduced masticatory function predicts GERD and esophageal dysphagia in patients investigated with upper endoscopy.

METHODS

In this cross-sectional study, 179 adult patients referred for elective upper gastrointestinal endoscopy agreed to participate. Before endoscopy, an expert dentist performed an oral examination and scored chewing function in three levels (normal, regular, and reduced). Patients replied questionnaires for assessment of GERD (heartburn, regurgitation, and dysphagia), xerostomia, and mastication (normal, regular, and reduced). Poor chewing was defined when either oral examination or mastication questionnaire rated the chewing function as reduced. Associations of mastication with GERD and dysphagia were estimated using Poisson regression.

RESULTS

Eleven patients were excluded. Among 168 analyzed (aging 49.8 ± 15.5 years; 58.9% women), 46 had reduced masticatory function (27.4%), and 122 had regular/normal mastication (72.6%). Reduced mastication was associated with GERD [PR = 1.38 (95%CI 1.12 - 1.70)], adjusting for age, and with esophageal dysphagia [PR = 2.03 (95%CI 1.02 - 4.04)], adjusting for age and xerostomia.

CONCLUSIONS

In outpatients referred for upper gastrointestinal endoscopy, reduced masticatory function defined by an expert dentist may be a risk factor for GERD and esophageal dysphagia.

OPERA tau neutrino charged current interactions

The OPERA experiment was designed to discover the vτ appearance in a vμ beam, due to neutrino oscillations. The detector, located in the underground Gran Sasso Laboratory, consisted of a nuclear photographic emulsion/lead target with a mass of about 1.25 kt, complemented by electronic detectors. It was exposed from 2008 to 2012 to the CNGS beam: an almost pure vμ beam with a baseline of 730 km, collecting a total of 1.8·1020 protons on target. The OPERA Collaboration eventually assessed the discovery of vμ→vτ oscillations with a statistical significance of 6.1 σ by observing ten vτ CC interaction candidates. These events have been published on the Open Data Portal at CERN. This paper provides a detailed description of the vτ data sample to make it usable by the whole community.

Predictive Factors of Gastroesophageal Reflux Disease in Bariatric Surgery: a Controlled Trial Comparing Sleeve Gastrectomy with Gastric Bypass

OBJECTIVE

To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) in patients with obesity.

METHODS

Patients with class II or III obesity were treated with LSG or LRYGB. Procedure choice was based on patients and surgeon preferences. GERD symptoms, endoscopy, barium swallow X-ray, esophageal manometry, and 24-h pH monitoring were obtained before and 1 year after surgery.

RESULTS

Seventy-five patients underwent surgery (83% female, 39.3 ± 12.1 years, BMI of 41.5 ± 5.1 kg/m²): 35 (46.7%) had LSG and 40 (53.3%) LRYGB. LSG patients had lower BMI (40.3 ± 4.0 kg/m² vs. 42.7 ± 5.7 kg/m²; p = 0.041) and trend toward lower prevalence of GERD (20% vs. 40%; p = 0.061). One year after surgeries, GERD was more frequent in LSG patients (74% vs. 25%; p < 0.001) and all LSG patients with preoperative GERD continue to have GERD postoperatively. De novo GERD occurred in 19 of 28 (67.9%) of LSG patients and 4 of 24 (16.7%) patients treated with LRYGB (OR 10.6, 95%CI 2.78-40.1). Independent predictors for post-operative GERD were as follows: LSG (OR 12.3, 95%CI 2.9-52.5), preoperative esophagitis (OR 8.5, 95% CI 1.6-44.8), and age (OR 2.0, 95%CI 1.1-3.4).

CONCLUSIONS

One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB. LSG was the strongest predictor for GERD in our trial. Preoperative counseling and choice of bariatric surgical options must include a detailed assessment and discussion of GERD-related surgical outcomes.

A simple and efficient Solid-Phase Microextraction - Gas Chromatography - Mass Spectrometry method for the determination of fragrance materials at ultra-trace levels in water samples using multi-walled carbon nanotubes as innovative coating

The occurrence of emerging contaminants is becoming of increasing importance to assess the impact of anthropogenic activities onto the environment. The present study reports for the first time the development and validation of an efficient method for the simultaneous determination of fragrance materials in water samples based on the use of a novel multiwalled carbon nanotubes (MWCNTs)-based solid-phase microextraction coating. Helical MWCNTs were selected as adsorbent material due to their outstanding extraction performance. The multicriteria method of desirability functions allowed the optimization of the experimental conditions in terms of extraction time and extraction temperature. Validation proved the reliability of the method for the determination of the analytes at ultra-trace levels, obtaining detection limits in the 0.2-13 ng/L range, good precision, with relative standard deviations lower than 20% and recovery rates in the 80 ± 12%-111 ± 11%. Superior enrichment factors compared to commercial fibers were also calculated. Finally, applicability to real sample analysis was demonstrated.

Lactobacillus brevis CD2 attenuates traumatic oral lesions induced by fixed orthodontic appliance: A randomized phase 2 trial

OBJECTIVE

To evaluate the effect of the probiotic Lactobacillus brevis CD2 on the prevention of early traumatic oral lesions induced by a fixed orthodontic appliance.

SETTINGS AND SAMPLE POPULATION

Twenty orthodontic patients (14-57 yo) were recruited from a private clinic.

SUBJECTS AND METHODS

In a phase 2, double-blind clinical trial, all patients were randomly allocated (1:1 ratio) to a 21-day course of soluble tablets containing L brevis CD2 (4 billion colony-forming units after breakfast, lunch and dinner) or placebo, starting at the day of orthodontic appliance placement. The primary outcomes were days with oral lesions and lesion-related pain [ranging between 0 (no pain) and 10 (maximum pain)]. Oral health-related quality of life was measured using OHIP-14 before and after treatments.

RESULTS

All patients completed the study. Ten were treated with L brevis (28.1 ± 13.3 yo, 70% women), and 10 received placebo (27.5 ± 9.1 yo, 60% women). The oral lesions lasted significantly less time (P = .018) in patients treated with L brevis (2.5 ± 1.0 days) than with placebo (4.9 ± 3.0 days). Pain score was significantly lower (P = .039) when L brevis was used [median (min-max): 0 (0-4) vs. 3 (0-5)]. OHIP-14 scores were not significantly different between treatments.

CONCLUSIONS

Lactobacillus brevis CD2 reduced almost 50% the persistence of traumatic oral lesions in patients with fixed orthodontics. Yet, there was no improvement in quality of life compared to placebo, suggesting that such differences in persistency and pain related to oral lesions may be considered clinically irrelevant.

Predictors of dental erosions in patients evaluated with upper digestive endoscopy: a cross-sectional study

The most studied medical condition related with dental erosions is gastroesophageal reflux disease (GERD). The aim of this study was to assess other predictors of dental erosions besides GERD in outpatients referred for upper digestive endoscopy. In a cross-sectional study, we prospectively evaluated 235 patients who underwent upper digestive endoscopy. Patients were interviewed and examined by a trained dentist before the endoscopies, addressing dental health as well as clinical information and food intake. Dental erosion was classified using Basic Erosive Wear Examination score. Potential predictors for dental erosions were: gender, age, chronic use of antidepressants and proton pump inhibitors (PPI), diabetes mellitus, body mass index, heartburn and acid regurgitation scores, chocolate intake, reflux esophagitis and hiatal hernia. Overall prevalence of dental erosions was 23.4%. The most parsimonious Poisson regression model for dental erosions considered age, chocolate intake and acid regurgitation as predictors. Dental erosions were associated with acid regurgitation in patients younger than 50 years [adjusted prevalence ratio (PR) = 1.8 (95% CI 1.1-2.9)] and with chocolate intake in patients older than 50 years [PR = 2.1 (95% CI 1.2-3.9]. The surfaces most eroded were palatine/lingual (n = 25) and occlusal (n = 25), followed by vestibular (n = 5). In outpatients evaluated with upper digestive endoscopy, the variables associated with dental erosions were age younger than 50 years, acid regurgitation and chocolate intake. Referral for dental evaluation should be considered for young patients with GERD and frequent acid regurgitation.

Migrating INFN-T1 from CREAM-CE/LSF to HTCondor-CE/HTCondor

The INFN Tier-1 datacentre provides computing resources to several HEP and Astrophysics experiments. These are organized in Virtual Organizations submitting jobs to our computing facilities through Computing Elements, acting as Grid interfaces to the Local Resource Manager. We are phasing-out our current LRMS (IBM/Platform LSF 9.1.3) and CEs (CREAM) set to adopt HTCondor as a replacement for LSF and HTCondor-CE in place of CREAM. A small instance has been set up to practice with the cluster management and evaluate the feasibility of our migration plans to a new LRMS and CE set. A second cluster instance has been setup to work on production. A number of management tools have been adapted or rewritten in order to integrate the new system with the existing infrastructure. Two different accounting solution for the HTCondor-CE have been implemented, and the more reliable one have been adopted. A python tool has been written to disentangle the management of HTCondor machines from our puppet instance, and to enable a quicker configuration of the cluster nodes. The monitoring tools tied to the old system are being adapted to also work on the new one. Finally, the most relevant setup steps have been documented in a public wiki page and a support mailing has been created to help other INFN sites willing to migrate their LRMS and CE to HTCondor. This document reports about our experience with HTCondor-CE on top of HTCondor and the integration of this system into our infrastructure.

Are Lactobacillus salivarius G60 and inulin more efficacious to treat patients with oral halitosis and tongue coating than the probiotic alone and placebo? A randomized clinical trial

BACKGROUND

The combination of probiotics and prebiotics might be useful to treat oral halitosis. The aim of this study was to assess the effect of Lactobacillus salivarius G60 (LS) and inulin on oral halitosis and tongue coating.

METHODS

In this double-masked, randomized, phase II clinical trial, 45 patients (aged 35 ± 15 years, 66% female) with oral halitosis and tongue coating were allocated to three treatment groups (n = 15) using gums of oral dissolution (one gum every 12 hours) for 10 days. Each gum contained LS (1 billion colony forming units [CFUs]) + inulin (1 g), LS (1 billion CFU) or placebo. Primary outcomes were organoleptic test, Halimeter, and tongue coating, whereas secondary outcomes were quality of life (QOL) and treatment safety. Generalized linear models were used, adjusting for age and sex. In vitro tests were performed to verify whether LS interacts with inulin and whether LS inhibits the growth of Porphyromonas gingivalis and Prevotella intermedia.

RESULTS

Forty-four patients (97%) completed the study. Patients treated with LS + inulin showed greater reduction in halitosis measured by Halimeter compared with placebo (adjusted post-intervention average: 96.7 versus 142.5 ppb; P = 0.003), whereas LS and placebo did not differ (115.7 versus 142.5 ppb; P = 0.097). Organoleptic measurements and coating index showed a similar decrease for all groups. QOL improved in patients treated with LS + inulin compared with placebo (P = 0.029). Side effects were mild and transient in all groups. LS did not metabolize inulin but inhibited the growth of P. gingivalis and P. intermedia after 72 hours.

CONCLUSIONS

Treatment with L. salivarius G60 combined or not with inulin showed significant decrease in the outcomes organoleptic test, Halimeter, and coating index, improving oral halitosis. However, no significant difference was obtained between the groups.

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

OBJECTIVE

Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.

DESIGN

We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.

RESULTS

Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.

CONCLUSION

With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

Influences of Screw Access Hole and Mechanical Cycling on the Fracture Load of Implant-Supported Crowns

PURPOSE

To assess the influence of a screw access hole (SAH) and mechanical cycling on the fracture load of implant-supported crowns (ISCs) manufactured with screw-retained (s) or cement-retained (c) abutments with either metal (M) or zirconia (Z) infrastructure.

MATERIALS AND METHODS

Six groups of restorations were made based on type of infrastructure (M or Z), fixation (s or c), and whether they underwent aging (a) with mechanical cycling: Zc, Zs, Zsa, Mc, Ms, and Msa. All ISCs were porcelain veneered and tested for compression to failure in distilled water (37°C) using a universal testing machine. ISCs from groups Zsa and Msa were mechanically cycled (106 cycles; 2 Hz, 100 N) in distilled water before compressive testing. Fractographic principles were followed to assess the fracture surfaces. The fracture load data were statistically analyzed using one-way analysis of variance and Tukey test (α = .05). The relationships between experimental group and failure mode were analyzed using chi-square test (α = .05).

RESULTS

Regardless of the infrastructure material, cement-retained ISCs (Zc and Mc) showed higher fracture load values than screw-retained ISCs (Zs, Zsa, Ms, and Msa) (P < .001), which were statistically similar to each other (P > .05). Aging had no effect on the fracture load of ISCs. There was a significant relationship between failure mode and experimental group (P < .001). Catastrophic fractures were found only in Zc and Zs. All metal-based ISCs failed from chipping reaching the metal infrastructure.

CONCLUSION

Cement-retained ISCs showed higher fracture resistance than screw-retained prostheses. No catastrophic failures were found for metal-based ISCs. Aging did not affect the fracture load, but did affect the failure mode of ISCs.

Final Results of the OPERA Experiment on ν_{τ} Appearance in the CNGS Neutrino Beam

The OPERA experiment was designed to study ν_{μ}→ν_{τ} oscillations in the appearance mode in the CERN to Gran Sasso Neutrino beam (CNGS). In this Letter, we report the final analysis of the full data sample collected between 2008 and 2012, corresponding to 17.97×10^{19} protons on target. Selection criteria looser than in previous analyses have produced ten ν_{τ} candidate events, thus reducing the statistical uncertainty in the measurement of the oscillation parameters and of ν_{τ} properties. A multivariate approach for event identification has been applied to the candidate events and the discovery of ν_{τ} appearance is confirmed with an improved significance level of 6.1σ. |Δm_{32}^{2}| has been measured, in appearance mode, with an accuracy of 20%. The measurement of the ν_{τ} charged-current cross section, for the first time with a negligible contamination from ν[over ¯]_{τ}, and the first direct evidence for the ν_{τ} lepton number are also reported.

Juice Test for Identification of Nonerosive Reflux Disease in Heartburn Patients

Background/Aims

Evaluation of esophageal clearance by orange juice swallowing could be useful to identify different categories of gastroesophageal reflux disease. We determined whether a juice test at the beginning of esophageal pH monitoring can identify nonerosive reflux disease (NERD) among heartburn patients.

Methods

Multiple swallows of orange juice (pH 3) were performed at the beginning of esophageal pH monitoring in 71 heartburn patients off acid-suppressive therapy. The area between pH drop below 5 and recovery to 5 was calculated from pH tracings and named Delta5 (mmol·L⁻¹·sec). Fifteen healthy subjects served to determine Delta5 cutoff (95th percentile). Patients were classified as NERD, non-NERD (a mix of reflux hypersensitivity, functional heartburn, and undetermined), and erosive disease depending on acid exposure, reflux symptom analysis, and upper endoscopy.

Results

Delta5 cutoff in healthy subjects was 251 mmol·L⁻¹·sec. Among 71 patients, 23 had NERD, 26 had non-NERD, and 22 had erosive disease. Compared to non-NERD, Delta5 was higher in both NERD (median [interquartile range]: 316 [213–472] vs 165 [105–225]; P < 0.01) and erosive disease (310 [169–625] vs 165 [105–225]; P < 0.01). An elevated Delta5 (> 251 mmol·L⁻¹·sec) showed sensitivity of 74% and specificity of 81% for identification of NERD. Positive and negative likelihood ratios were 3.84 and 0.32 respectively, whereas test accuracy was 78%.

Conclusions

A juice test with calculation of Delta5 helps in the identification of true NERD among heartburn patients with endoscopy-negative reflux disease. In these patients, an elevated Delta5 could make prolonged reflux testing unnecessary.

Acute Myelocytic Leukemia and Chronic Myelomonocytic Leukemia Simultaneously with Resectable Breast Cancer: A Report of two Cases

This report describes 2 patients who developed acute myelocytic leukemie (AML) type M2 and chronic myelomonocytic leukemia (CMML) of the FAB classification, respectively 2 months and 2 weeks after diagnosis of operable breast cancer. The patient with AML showed pancytopenia 2 months before the diagnosis of AML, had a normal karyotype, and showed a good response to chemotherapy. The patient with CMML had a normal karyotype, and she was treated with hydroxyurea and supportive therapy. The 2 patients had no previous exposure to irradiation or cytotoxic therapy. These cases show that breast cancer and either leukemia or myelodysplastic syndrome may be associated even without previous irradiation or combination chemotherapy.

Diagnostic Accuracy of a New Tumor Serologic Marker, CA 19-9: Comparison with CEA

Two hundred and twenty-one hospitalized patients underwent serum determination of CA 19-9, a recently developed tumor marker assay, and CEA. Among these, 53 had a gastrointestinal (GI) cancer, 59 a GI benign disease, 52 a non-GI cancer, and 57 a non-GI benign disease. CA 19-9 assay was more accurate than CEA to detect malignancy, especially of GI source (69.8% sensitivity vs. 24.5% in GI patients); when a cutoff level of 41 ng/ml for CA 19-9 was considered, only 6 false-positive cases were found and both markers showed excellent specificity (94.9% for CEA and 89.9% for CA 19-9 in gastric, hepatobiliary and pancreatic cancer). We conclude that CA 19-9 is a useful GI tumor marker and it seems to be better than CEA in some pathologic situations.

Thermal Lesions Induced by 480 KHz Localized Current Field in Guinea Pig and Pig Liver

We evaluated the type, dimension and histopathological evolution of thermal lesions induced in guinea pig and pig liver by radiofrequency electrode needles at various temperatures for different exposure times. The greatest useful necrosis volume was induced by a needle of 1.1 mm diameter and exposed tip 10 mm long at 90 °C and 120 seconds exposure time. It was an ellipsoid with the biggest diameter of about 14 mm diameter and length of about 18 mm. It seems possible that liver tumors of not more than 20 mm diameter in patients without surgical prospects could be destroyed, ultrasonography guiding the needle into the tumor and using the temperature and exposure time mentioned above.

240 Hepatocellular Carcinomas: Ultrasound Features, Tumor Size, Cytologic and Histologic Patterns, Serum Alpha-Fetoprotein and HBs Ag

Two hundred and forty cases of hepatocellular carcinomas (HCC), diagnosed by ultrasonography and fine needle biopsy, were studied. The following parameters were investigated: 1. echo features (240 cases) – hypoechoic, 54; hyperechoic, 56; complex, 112; isoechoic with halo, 18; 2. tumor size (240 cases) – single tumor under 4.5 cm, 30; single tumor over 4.5 cm, 74; multiple masses or diffuse, 136; 3. cytologic pattern (240 cases) – well and medium differentiated, 144; pleomorphic, 43; poorly differentiated, 28; unclassified, 25; 4. histologic pattern (157 cases) – trabecular, 74; solid, 42; acinar, 1; mixed, 2; unclassified, 38; 5. alpha-fetoprotein (AFP) level (185 cases) – under 20 ng/ml, 79; between 20 and 320 ng/ml, 40; over 320 ng/ml, 66; 6. HBs Ag (208 cases) – present in 56 cases; 7. cirrhosis (102 cases) –present in 79 cases. Some of the above parameters were correlated with one another. There was: 1. a highly significant frequency of the hypoechoic feature among small HCC; 2. a percentage of AFP-producing tumors increasing with tumor size; 3. no relationship between AFP production and cytologic or histologic pattern; 4. no relationship between tumor size and cytologic or histologic pattern. However, among the small HCC, all the 9 HCC with a diameter of less than 3 cm showed a trabecular pattern and well-differentiated cells. Cirrhosis was present in every patient with a small HCC. Since the discovery of a small HCC is an incidental ultrasonographic finding in the context of severe liver disease, ultrasonographic monitoring of cirrhotic patients is the best available strategy to screen for small HCC.

Subacute stress and chronic stress interact to decrease intestinal barrier function in rats

Psychological stress increases intestinal permeability, potentially leading to low-grade inflammation and symptoms in functional gastrointestinal disorders. We assessed the effect of subacute, chronic and combined stress on intestinal barrier function and mast cell density. Male Wistar rats were allocated to four experimental groups (n = 8/group): 1/sham; 2/subacute stress (isolation and limited movement for 24 h); 3/chronic crowding stress for 14 days and 4/combined subacute and chronic stress. Jejunum and colon were collected to measure: transepithelial electrical resistance (TEER; a measure of epithelial barrier function); gene expression of tight junction molecules; mast cell density. Plasma corticosterone concentration was increased in all three stress conditions versus sham, with highest concentrations in the combined stress condition. TEER in the jejunum was decreased in all stress conditions, but was significantly lower in the combined stress condition than in the other groups. TEER in the jejunum correlated negatively with corticosterone concentration. Increased expression of claudin 1, 5 and 8, occludin and zonula occludens 1 mRNAs was detected after subacute stress in the jejunum. In contrast, colonic TEER was decreased only after combined stress, and the expression of tight junction molecules was unaltered. Increased mast cell density was observed in the chronic and combined stress condition in the colon only. In conclusion, our data show that chronic stress sensitizes the gastrointestinal tract to the effects of subacute stress on intestinal barrier function; different underlying cellular and molecular alterations are indicated in the small intestine versus the colon.

Discovery of τ Neutrino Appearance in the CNGS Neutrino Beam with the OPERA Experiment

The OPERA experiment was designed to search for ν_{μ}→ν_{τ} oscillations in appearance mode, i.e., by detecting the τ leptons produced in charged current ν_{τ} interactions. The experiment took data from 2008 to 2012 in the CERN Neutrinos to Gran Sasso beam. The observation of the ν_{μ}→ν_{τ} appearance, achieved with four candidate events in a subsample of the data, was previously reported. In this Letter, a fifth ν_{τ} candidate event, found in an enlarged data sample, is described. Together with a further reduction of the expected background, the candidate events detected so far allow us to assess the discovery of ν_{μ}→ν_{τ} oscillations in appearance mode with a significance larger than 5σ.

PCR for the diagnosis of abdominal angiostrongyliasis in formalin-fixed paraffin-embedded human tissue

To date the diagnosis of abdominal angiostrongyliasis (AA) depends on the histological identification of Angiostrongylus costaricensis (AC) in surgical specimens. However, microscopic evaluation is time consuming and often fails in identifying the parasite. We tested whether PCR might help in the diagnosis of AA by identifying parasite DNA in formalin-fixed paraffin-embedded (FFPE) tissue. We used primers based on DNA from Angiostrongilus cantonensis. Four groups of FFPE intestinal tissue were tested: (1) confirmed cases (n = 20), in which AC structures were present in the target tissue; (2) presumptive cases (n = 20), containing changes secondary to AC infection in the absence of AC structures; (3) negative controls (n = 3), consisting of normal colonic tissue; and (4) tissue affected by other parasitoses (n = 7), including strongyloidiasis, ascaridiasis, schistosomiasis, and enterobiasis. Most lesions of confirmed cases were located in small and/or large bowel (90%), as compared with presumptive cases, in which 70% of lesions were in appendix (P = 0.0002). When confronted with cases of other parasitoses, PCR showed sensitivity of 55%, specificity of 100% and positive predictive value of 100%. In presumptive cases PCR was positive in 4 (20%). All specimens from negative controls and other parasitoses were negative. In conclusion, the PCR technique showed intermediate sensitivity and optimal specificity, being clinically relevant when positive for abdominal angiostrongyliasis. It allowed a 20% gain in diagnosis of presumptive cases. PCR might help in the diagnosis of abdominal angiostrongyliasis, particularly when the pathologists are not experienced with such disease.

Effect of nortriptyline on brain responses to painful esophageal acid infusion in patients with non-erosive reflux disease

BACKGROUND

Non-erosive reflux disease (NERD) patients generally present with heartburn as the main symptom. Antidepressants might help to relieve heartburn by acting on the esophagus-brain axis. We aimed to assess the effect of nortriptyline on behavioral and brain responses to painful esophageal acid infusion in NERD patients evaluated with functional magnetic resonance imaging (fMRI).

METHODS

In a randomized double-blind crossover design, 20 NERD patients off proton pump inhibitors (36.1 ± 9.3 years, 75% women) were assigned to 21 days of nortriptyline and placebo, in counterbalanced order, with a 21 days washout period in between both treatment periods. Changes in acid-induced brain response on fMRI and heartburn perception were assessed and at the end of each treatment.

KEY RESULTS

Nortriptyline significantly reduced the acid-induced brain response in prefrontal cortex (median [IQR]: -1.9 [-4.5 to -0.1] vs -0.3 [-2.5 to 2.3]; p = 0.050), caudate (-3.0 [-5.1 to -0.01] vs 0.48 [-1.9 to 3.1]; p = 0.029), insula (-2.4 [-4.8 to -0.6] vs -0.2 [-1.5 to 1.5]; p = 0.029), cingulate (-4.2 [-8.8 to -0.1] vs -0.6 [-1.8 to 3.0]; p = 0.017), and hippocampus (-2.7 [-6.0 to 0.5] vs -0.04 [-2.3 to 1.9]; p = 0.006) in comparison with placebo. However, there was no significant difference between nortriptyline and placebo in clinical outcomes and side effects.

CONCLUSIONS & INFERENCES

Nortriptyline decreased the brain response to esophageal acid infusion more markedly than placebo, but without clinical significance.

Comfort, safety and quality of upper gastrointestinal endoscopy after 2 hours fasting: a randomized controlled trial

Background

Upper gastrointestinal endoscopy has been performed after fasting 8 or more hours, which can be harmful to the patients. We assessed comfort, safety and quality of endoscopy under moderate sedation after 2 hours fasting for clear liquids.

Methods

In this clinical trial, patients referred for elective endoscopy were randomly assigned to a fasting period of 8 hours (F8) or a shorter fasting (F2), in which 200 ml of clear liquids were ingested 2 hours before the procedure. Endoscopists blinded to patients fasting status carried out the endoscopies. Comfort was rated by the patients, whereas safety and quality were determined by the endoscopists.

Results

Ninety-eight patients were studied (aging 48.5 ± 16.5 years, 60% women): 50 patients (51%) in F2 and 48 in F8. Comfort was higher in F2 than F8 in regard to anxiety (8% vs. 25%; P = 0.029), general discomfort (18% vs. 42%; P = 0.010), hunger (44% vs. 67%; P = 0.024), and weakness (22% vs. 42%; P = 0.034). Regurgitation of gastric contents into the esophagus after endoscopic intubation did not differ between F2 and F8 (26% vs. 19%; P = 0.471). There was no case of pulmonary aspiration. Gastric mucosal visibility was normal in most patients either in F2 or F8 (96% vs. 98%; P = 0.999).

Conclusions

Elective upper GI endoscopy after 2 hours fasting for clear liquids was more comfortable and equally safe compared to conventional fasting. This preparation might be cautiously applied for patients in regular clinical conditions referred for elective endoscopy.

Trial registration

SAMMPRIS ClinicalTrial.gov number, NCT01492296

Gastric yield pressure and gastric yield volume to assess anti-reflux barrier in a porcine model

Anti-reflux barrier (ARB) resistance may be useful to test new treatments for gastroesophageal reflux (GER). The ARB has been estimated by increasing gastric yield pressure (GYP) and gastric yield volume (GYV) in animal models but has not been validated. This study aimed to develop an experimental model suitable for assessing the ARB resistance to increasing intragastric pressure and volume and its reproducibility in a seven-day interval. Ten two-month-old female Large-White swine were studied. Intragastric pressure and volume were recorded using a digital system connected to a Foley catheter inserted through gastrostomy into the stomach. GYP and GYV were defined as the gastric pressure and volume able to yield gastric contents into the esophagus detected by esophageal pH. A sudden pH drop below 3 sustained during 5 min was considered diagnostic for gastric yield. Animals were studied again after seven days. On days 0 and 7, there were no significant differences for GYP (mean ± SD = 7.66 ± 3.02 mmHg vs. 7.07 ± 3.54 mmHg, p = .686) and GYV (636.70 ± 216.74 ml vs. 608.30 ± 276.66 ml; p = .299), respectively. Concordance correlation coefficient (ρc) was significant for GYP (ρc = 0.634, 95% CI = 0.141-0.829, p = .006), but not for GYV (ρc = 0.291, 95% CI = -0.118 to 0.774, p = .196). This study demonstrated an experimental model, assessing the ARB resistance. GYP seems to be a more reliable parameter than GYV for assessment of ARB resistance.

Update on endoscopic diagnosis, management and surveillance strategies of esophageal diseases

In the last few decades, upper gastrointestinal endoscopy has become the most complementary test for investigation of esophageal diseases. Its accessibility and safety guarantee wide clinical utilization in patients with suspected benign and malignant diseases of the esophagus. Recent technological advances in endoscopic imaging and tissue analysis obtained from the esophagus have been useful to better understand and manage highly relevant diseases such as gastroesophageal reflux disease, eosinophilic esophagitis and esophageal cancer. Using endoscopy to elucidate esophageal disorders in children has been another field of intensive and challenging research. This editorial highlights the latest advances in the endoscopic management of esophageal diseases, and focuses on Barrett’s esophagus, esophageal cancer, eosinophilic esophagitis, as well as esophageal disorders in the pediatric population.

Gastroesophageal reflux disease is inversely related with glycemic control in morbidly obese patients

BACKGROUND

The link between diabetes mellitus and gastroesophageal reflux disease (GERD) is controversial. We assessed the relationship between glycemic control (GC) and GERD in morbidly obese patients.

METHODS

Consecutive patients with morbid obesity (n = 86) underwent manometry, pH-metry, endoscopy, and contrasted X-ray after responding to a GERD questionnaire and dosing fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Patients with poor GC (HbA1c, 6.1-10% and FPG < 140 mg/dl) and those with very poor GC (HbA1c > 10% or FPG > 140 mg/dl) were compared.

RESULTS

There were 63 patients with poor GC and 17 with very poor GC. Compared to patients with very poor GC, patients with poor GC showed higher heartburn scores [8 (0-12) vs. 0 (0-4); P = 0.003]; higher total esophageal acid exposure [5.2% (2.5-10.5%) vs. 2.3% (0.8-7.5%); P = 0.041]; lower distal esophageal amplitude (105 ± 38 vs. 134 ± 63 mmHg; P = 0.019); higher expiratory gastroesophageal pressure gradient (GEPG, 7 ± 3.4 vs. 5.2 ± 3 mmHg; P = 0.050); lower ventilatory gradient (inspiratory-expiratory GEPG, 10.9 ± 3.8 vs. 13.6 ± 4.1 mmHg; P = 0.012); lower waist-to-hip ratio (0.95 vs. 1; P = 0.040); and more hiatal hernia (38% vs. 6%; P = 0.016).

CONCLUSIONS

This study suggests an inverse relation between glycemic control and GERD in morbidly obese patients. This can be partially explained by a lower frequency of hiatal hernia in patients with very poor glycemic control.

Exon 11 mutations, Ki67, and p16(INK4A) as predictors of prognosis in patients with GIST

Prognostic biomarkers for GIST are under investigation. The aim of this study was to assess whether exon 11 mutations, Ki67, and p16(INK4A) are predictors of prognosis in GIST. Consecutive GIST cases (n=84) had their specimens evaluated for exon 11 mutations and expression of Ki67 and p16(INK4A). Surgical cases were categorized according to NIH and Miettinen's classification, and survival was analyzed from hospital database. GISTs were predominately gastric (45%) and with spindle cell morphology (74%). The risk category was very low or low in 28%, intermediate in 23%, and high in 49%. Exon 11 mutation was identified in 29 (48%) out of 60 cases studied. There were 12 point mutations, 10 deletions, 4 duplications, and 3 double mutations. A third of GISTs had either high Ki67 index (>3%) or negativity for p16(INK4A). In multivariate analysis, independent predictors of mortality were Ki67>3% (HR=7.3; P=0.036) and high mitotic index (HR=10.4; P=0.043). There was no association between exon 11 mutations and survival. This study suggests that Ki67>3% is an independent predictor of poor prognosis in patients with GIST. Exon 11 mutations and negativity for p16(INK4A) need further studies to address the prognostic value.

MicroRNA and hepatocellular carcinoma: biology and prognostic significance

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the third most common cause of cancer-related death worldwide. In 90% of cases, HCC arises on a background of cirrhosis which, in turns, results from hepatitis (HBV and HCV) infections, alcohol abuse, metabolic disorders including NASH, and genetic metabolic diseases, autoimmune hepatitis, primary biliary cirrhosis and exposure to environmental carcinogens. The molecular mechanisms underlying HCC development are still only partially known. Despite a high molecular variability, the deregulation of definite oncogenic pathways has been confirmed as a common finding in HCC. Among these, the molecular ways controlling proliferation, apoptosis and migration play a major role. In recent years, a new class of regulatory RNAs, the microRNAs, has been discovered and their deregulated expression has been linked to the molecular pathogenesis of many cancers because of their ability to strongly impact on the expression of crucial messenger RNAs. This review focuses on some of the most relevant evidence concerning the contribution of microRNA aberrant expression to HCC development.

Determination of pH turning point with pH mapping of the gastroesophageal junction: an alternative technique to orientate esophageal pH monitoring

Manometric location of the lower esophageal sphincter (LES) has been mandatory before esophageal pH monitoring, despite costs and discomfort related with esophageal manometry. The aims of the study were: (i) to map the pH of the gastroesophageal junction (GEJ) to determine a pH turning point (PTP) and its relation with LES; and (ii) to test the feasibility of this technique to orientate esophageal pH monitoring. We studied 310 adult patients who underwent esophageal manometry and pH monitoring off acid-suppressive therapy. GEJ pH mapping was carried out by step-pulling the pH sensor from 5 cm below to 5 cm above LES, and a PTP was determined when pH changed from below to above 4, in centimeters from the nostril. Thirty-six patients referred only for pH monitoring were studied with pH sensor placed at 5 cm above the PTP. Out of 310 patients, a PTP was found in 293 (94.5%): inside LES in 86.3%, into the stomach in 8.2% and in the esophageal body in 5.5% of patients. The median distance between PTP and place where pH sensor monitored reflux was 8 cm. Among 36 patients who performed pH monitoring without LES manometry, there was no gastric monitoring during reflux testing. In adult patients investigated off acid suppressive therapy, GEJ pH mapping with reflux monitoring 5 cm above the PTP can be an alternative technique to perform esophageal pH monitoring when LES manometry is not available. Additional studies are needed before the widespread use of GEJ pH mapping in the clinical practice.

Obese patients have stronger peristalsis and increased acid exposure in the esophagus

BACKGROUND

Obesity is a risk factor for GERD and a potential modulator of esophageal motility.

AIM

To assess whether obese patients differ from non-obese patients in terms of esophageal motility and reflux.

METHODS

Patients (n = 332) were categorized in GERD and controls after clinical assessment, esophageal manometry, and pH monitoring. Non-obese (BMI 16-29.9) and obese (BMI 30-68) were compared in regard of distal esophageal amplitude (DEA), LES pressure (LESP), manometric diagnosis, and esophageal acid exposure (EAE).

RESULTS

Obese showed higher DEA in both controls (122 ± 53 vs. 97 ± 36 mmHg, p = 0.041) and GERD patients (109 ± 38 vs. 94 ± 46 mmHg, p < 0.001), higher LESP in GERD patients (20.5 ± 10.6 vs. 18.2 ± 10.6 mmHg, p = 0.049), higher frequency of nutcracker esophagus in controls (30 vs. 0%, p = 0.001), lower frequency of ineffective motility in GERD patients (6 vs. 20%, p = 0.001), and higher EAE in both controls [total EAE: 1.6% (0.7-5.1) vs. 0.9% (0.2-2.4), p = 0.027] and GERD patients [upright EAE: 6.5% (3.8-11.1) vs. 5.2% (1.5-10.6), p = 0.048]. Multiple linear regression showed that BMI was associated either with EAE (p < 0.001), DEA (p = 0.006), or LESP (in men, p = 0.007).

CONCLUSIONS

Obese patients differed from non-obese in terms of esophageal motility and reflux, regardless of the presence of GERD. Obese patients showed stronger peristalsis and increased acid exposure in the esophagus.

Nocturnal gastroesophageal reflux revisited by impedance-pH monitoring

Background/Aims

Impedance-pH monitoring allows detailed characterization of gastroesophageal reflux and esophageal activity associated with reflux. We assessed the characteristics of nocturnal reflux and esophageal activity preceding and following reflux.

Methods

Impedance-pH tracings from 11 healthy subjects and 76 patients with gastroesophageal reflux disease off acid-suppressive therapy were analyzed. Characteristics of nocturnal supine reflux, time distribution and esophageal activity seen on impedance at 2 minute intervals preceding and following reflux were described.

Results

Patients had more nocturnal reflux events than healthy subjects (8 [4-12] vs 2 [1-5], P = 0.002), with lower proportion of weakly acidic reflux (57% [35-78] vs 80% [60-100], P = 0.044). Nocturnal reflux was mainly liquid (80%) and reached the proximal esophagus more often in patients (6% vs 0%, P = 0.047). Acid reflux predominated in the first 2 hours (66%) and weakly acidic reflux in the last 3 hours (70%) of the night. Most nocturnal reflux was preceded by aboral flows and cleared by short lasting volume clearance. In patients, prolonged chemical clearance was associated with less esophageal activity.

Conclusions

Nocturnal weakly acidic reflux is as common as acid reflux in patients with gastroesophageal reflux disease, and predominates later in the night. Impedance-pH can predict prolonged chemical clearance after nocturnal acid reflux.

Outcomes in mice with abdominal angiostrongyliasis treated with enoxaparin

Abdominal angiostrongyliasis (AA) is caused by the nematode Angiostrongylus costaricensis. Parasite-associated thrombosis of mesenteric vessels may lead to intestinal infarction, which might be prevented with anti-thrombotic agents. This study assessed the effect of enoxaparin on survival and pathological findings in Swiss mice with AA. In this experiment, 24 mice were infected with A. costaricensis (10 L3 per animal) followed by treatment with subcutaneous enoxaparin (40 mg/kg/day) or water (sham), starting from 15 days post-infection (dpi) and continued until animal death. Animals were monitored until death or sacrifice at the 50th dpi. Ten mice (42%) were dead after 36 ± 8 dpi. Of these, five (50%) were treated with enoxaparin. Animals treated with enoxaparin and sham did not differ in terms of weight loss (median, 1.3 vs. 4.2 g; P = 0.303) and macroscopical findings. Microscopically, no difference was found in regard to vascular granuloma (median grade, 2 vs. 3; P = 0.293) and presence of either vasculitis (75% vs. 100%; P = 0.217), mesenteric thrombosis (33% vs. 50%; P = 0.680), or bowel necrosis (25% vs. 50%; P = 0.400). Mice dead before the 50th dpi showed more pneumonia (90% vs. 21%; P = 0.002), bowel infarction (40% vs. 0%; P = 0.02), and purulent peritonitis (60% vs. 7%; P = 0.008) compared to survivors. Prophylactic enoxaparin in mice did not prevent tissue damage and mortality related with AA. The lower prevalence of mesenteric thrombosis and bowel infarction regardless of treatment were notorious. Frequent septic complications suggest the need of studies addressing the effect of antibiotics in AA.

Elimination of Angiostrongylus costaricensis larvae in feces from experimentally infected Swiss mice: circadian rhythm and correlation with survival

Angiostrongylus costaricensis is a nematode which harbors mesentery arteries of rodents. In these animals, a circadian rhythm of elimination of first-stage larvae (L1) and a relation between the amount of L1 in feces and survival are unknown. We assessed fecal elimination of A. costaricensis L1 from experimentally infected Swiss mice and tried to correlate L1 elimination with survival. Thirteen Swiss mice were infected by gavage with ten A. costaricensis L3 larvae obtained from Phyllocaulis slugs. Feces were weighed at 7 A.M: . and 7 P.M: . starting from the 24th day post-infection until animal death. Feces sediment was examined in microscope for L1 counting. The mice were dead after a period ranging 19-61 days post-infection. Compared to diurnal samples, both feces' weight (2.3 ± 0.7 vs. 1.8 ± 0.5 g; P < 0.0001) and L1 total count [median 1,950 vs. 1,250; P = 0.015] were higher in feces eliminated at night. No difference was observed between diurnal and nocturnal elimination when counting L1 by gram of feces (725 vs. 650 L1/g; P = 0.821). A significant correlation was observed between survival and total number of L1 in feces (r = 0.84; P = 0.0007). This study suggests that mice experimentally infected with A. costaricensis eliminate more L1 at night due to higher fecal volume at this period. The correlation between number of L1 in feces and survival suggests a phenomenon of tolerance to A. costaricensis infection in mice with longer survival.

Heartburn and regurgitation in pregnancy: the effect of fat ingestion

BACKGROUND

Reflux symptoms are common in pregnancy, but their association with fat ingestion is unclear.

AIM

To investigate an association of dietary fats with heartburn and regurgitation in pregnancy.

METHODS

This is a prospective study in which 89 pregnant women (gestational age 34 +/- 4 weeks) attending a low-risk prenatal outpatient clinic were asked to provide information on the frequency they experienced heartburn and regurgitation. Fat ingestion was estimated by means of a 24-h diet record. Symptomatic patients were compared with those with no reflux symptoms (n = 20).

RESULTS

Heartburn once a week or more often occurred in 56 of the 89 patients (63%). The ingested amount of polyunsaturated fatty acids was higher in patients with heartburn (11.2 +/- 6.4 vs. 7.7 +/- 3.5 mg; P = 0.022) than in controls after adjusting for age, gain weight during pregnancy, ingestion of caffeine and vitamin C, and total energetic intake. The ingestion of monounsaturated fatty acids was higher in patients with heartburn, but with a borderline statistical significance (16.1 +/- 11 vs. 11.8 +/- 6.5 mg; P = 0.061). No association was observed between the consumption of fats and regurgitation.

CONCLUSIONS

This study suggests that heartburn in the third trimester of pregnancy is associated with the ingestion of polyunsaturated fatty acids.

Diagnostic features of real-time contrast-enhanced ultrasound in focal nodular hyperplasia of the liver

PURPOSE

The typical appearance of focal nodular hyperplasia (FNH) in radiological contrast techniques (helical CT or MRI) includes homogeneous enhancement in the arterial phase, but the exact timing for the best visualization of this pattern is unknown. The aim of the present study was to assess the ultrasound pattern of FNH with special attention to real-time contrast-enhanced ultrasonography (CEUS) appearance and specifically to the timing of perfusion patterns.

MATERIALS AND METHODS

72 patients (60 females, 12 males) with a total of 90 FNH nodules with a diameter ranging from 8 to 100 mm (mean +/- SD, 40.6 +/- 21.5 mm) were examined continuously for at least 4 minutes using CnTI and CPS methods (ESAOTE, Genoa, Italy and Acuson-Siemens) after bolus injection of SonoVue (BRACCO, Milan, Italy).

RESULTS

87 of 90 nodules showed the typical coin-like hyperechogenicity in the arterial phase. The remaining three nodules were all in the same patient and were diagnosed as FNH after resection. Contrast started to appear within the lesions after a mean of 15.7 +/- 4.6 seconds (range 7 - 27 s) and reached peak signal intensity, with the greatest differentiation between the lesion and the surrounding parenchyma, at around 22.6 +/- 7.0 seconds (range 14 - 72 s). In the late phase, 65 lesions (72.2 %) became isoechoic (after a mean of 80.8 +/- 85.7 s, range 20 - 300 s), 22 (24.4 %) slightly hyperechoic and 3 (3.3 %) faintly hypoechoic.

CONCLUSION

FNH shows a typical homogeneous hyperechoic pattern during the arterial phase in real-time CEUS which disappears slowly on average but occasionally even as soon as 20 seconds after contrast injection. If the first scans are taken later than 20 seconds after injection (which is still considered to be a full arterial phase), the ultrasound hyperechogenicity may be missed in some cases. Real-time study of these lesions is therefore strongly recommended to avoid possible false-negative results.

Acid and weakly acidic solutions impair mucosal integrity of distal exposed and proximal non-exposed human oesophagus

BACKGROUND

Oesophageal mucosa dilated intercellular spaces (DIS) may be important for symptom perception in non-erosive reflux disease (NERD). Patients with NERD might have DIS even in the proximal oesophagus. We aimed to assess the effect of oesophageal perfusions with acid and weakly acidic solutions on 'exposed' and 'non-exposed' oesophageal mucosa and its relationship to symptoms in healthy subjects.

METHODS

14 healthy volunteers underwent upper gastrointestinal endoscopy with biopsies at 3 and 13 cm proximal to the oesophagogastric junction (OGJ). In following sessions, subjects received 30 min perfusions with neutral, weakly acidic, acidic and acidic-bile acid solutions at 5 cm above the EGJ (separated 4 weeks). Biopsies were taken 20 min after perfusions. Electron microscopy was used to measure DIS. Subjects scored heartburn during perfusions using a visual analogue scale.

RESULTS

(1) Oesophageal perfusion with acid solutions, with or without bile acids, provoked DIS in the 'exposed' oesophageal mucosa; (2) oesophageal perfusion with weakly acidic solutions provoked identical changes to those observed after perfusion with acid solutions; (3) distal oesophageal perfusions not only provoked changes in the 'exposed' but also in the more proximal 'non-exposed' mucosa; and (4) in spite of the presence of perfusion-induced DIS, most healthy subjects did not perceive heartburn during the experiments.

CONCLUSIONS

The human oesophageal mucosa is very sensitive to continuous exposure with acidic and weakly acidic solutions. In spite of the presence of intraluminal acid and DIS, healthy subjects did not experience heartburn, suggesting that NERD patients should have other critical factors underlying their symptoms.

Contribution of standard oesophageal manometry in sliding hiatal hernia: from the gastro-oesophageal pressure gradient to the diagnosis

OBJECTIVE

We tested whether gastro-oesophageal pressure gradient is augmented in sliding hiatal hernia and the yield of oesophageal manometry in diagnosing sliding hiatal hernia.

METHODS

Patients with equivalent body mass index were categorised according to manometry and endoscopy in groups: (1) no sliding hiatal hernia (n=147); (2) sliding hiatal hernia solely at endoscopy (n=46); and (3) sliding hiatal hernia at manometry (n=22). The yield of manometry was assessed taking endoscopy as referential.

RESULTS

Gastro-oesophageal pressure gradient was similar between groups both at inspiration (13.3+/-5.7 mm Hg vs. 13.6+/-5.4 mm Hg vs. 12.6+/-4.4 mm Hg; P=0.874) or expiration (5.1+/-3.8 mm Hg vs. 5.2+/-3.6 mm Hg vs. 5.1+/-3.7 mm Hg; P=0.767). Group 3 patients were older than those of groups 1 and 2 (59+/-10 vs. 42+/-15 vs. 45+/-13 years; P<0.001). Sliding hiatal hernia was larger when characterised by manometry than at endoscopy [4 cm (2.25-4.75) vs. 2 cm (2-3); P<0.001]. Manometry showed sensitivity of 28% (95%CI 19-40%), specificity of 97% (95%CI 93-99%) and positive predictive value of 82% (95%CI 63-92%) in diagnosing sliding hiatal hernia.

CONCLUSIONS

By using manometry in patients with equivalent body mass index, sliding hiatal hernia presence and size are related with age rather than gastro-oesophageal pressure gradient. This technique may be clinically useful when positive for sliding hiatal hernia.