Real-Life Efficacy of Tofacitinib in Various Situations in Ulcerative Colitis: A Retrospective Worldwide Multicenter Collaborative Study

BACKGROUND AND AIMS

Tofacitinib (TFB) appears to be effective in the treatment of ulcerative colitis (UC); however, available real-world studies are limited by cohort size. TFB could be an option in the treatment of acute severe ulcerative colitis (ASUC). We aimed to investigate efficacy and safety of TFB in moderate-to-severe colitis and ASUC.

METHODS

This retrospective, international cohort study enrolling UC patients with ≥6-week follow-up period was conducted from February 1 to July 31, 2022. Indications were categorized as ASUC and chronic activity (CA). Baseline demographic and clinical data were obtained. Steroid-free remission (SFR), colectomy, and safety data were analyzed.

RESULTS

A total of 391 UC patients (median age 38 [interquartile range, 28-47] years; follow-up period 26 [interquartile range, 14-52] weeks) were included. A total of 27.1% received TFB in ASUC. SFR rates were 23.7% (ASUC: 26.0%, CA: 22.8%) at week 12 and 41.1% (ASUC: 34.2%, CA: 43.5%) at week 52. The baseline partial Mayo score (odds ratio [OR], 0.850; P = .006) was negatively associated with week 12 SFR, while biologic-naïve patients (OR, 2.078; P = .04) more likely achieved week 52 SFR. The colectomy rate at week 52 was higher in ASUC group (17.6% vs 5.7%; P < .001) and decreased with age (OR, 0.94; P = .013). A total of 67 adverse events were reported, and 17.9% resulted in cessation of TFB. One case of thromboembolic event was reported.

CONCLUSIONS

TFB is effective in both studied indications. TFB treatment resulted in high rates of SFR in the short and long terms. Higher baseline disease activity and previous biological therapies decreased efficacy. No new adverse event signals were found.

Ustekinumab is associated with superior treatment persistence but not with higher remission rates versus vedolizumab in patients with refractory Crohn's disease: results from a multicentre cohort study

BACKGROUND

Treatment with antitumor necrosis factor alpha (anti-TNF-α) is safe and effective as first-line therapy; however, its efficacy is limited due to primary nonresponse (PNR) and secondary loss of response (LOR), resulting in treatment discontinuation in approximately 40%-50% of cases. Vedolizumab (VDZ) and ustekinumab (UST) therapies could be good alternatives in patient with anti-TNF failure; however, no head-to-head randomized comparison of these drugs as second- or third-line treatments has been made.

OBJECTIVES

This study aimed to assess the treatment persistence and comparative effectiveness of UST and VDZ in patients with refractory Crohn's disease (CD).

DESIGN

In this nationwide retrospective study, patients with CD on UST or VDZ maintenance therapy were enrolled. Clinical data at baseline, after induction, and at week 52 were obtained.

METHODS

Clinical and biochemical activities as well as corticosteroid-free remission (SFR) rates were assessed, while concomitant medications, comorbidities, hospitalizations, and surgeries were recorded during the follow-up to detect any predictors.

RESULTS

A total of 161 UST- and 65 VDZ-treated patients completed the follow-up. No significant difference in clinical or biochemical remission rates was observed after induction between the two treatment groups; however, clinical remission rate at week 52 was higher in UST group. UST showed superior drug persistence than VDZ (86.5%, 57.9%, p < 0.0001). The drug type was predictive of clinical SFR at week 52 [p = 0.011, odds ratio (OR) = 2.39 with UST]. Drug failure rates were higher for VDZ than those for UST (PNR rates: 21.54% and 4.97%, respectively, p < 0.001, OR = 8.267, p = 0.001). LOR and escalations were more common during UST treatment (61.5% versus 36.9%, p < 0.001; 64.2% versus 23.1%, p < 0.001). Hospital and surgical admission rates did not differ significantly. Only one adverse event occurred with VDZ at week 20, which led to drug cessation.

CONCLUSIONS

VDZ and UST were safe and effective for treating patients with CD in whom anti-TNF therapy failed. UST showed superior drug persistence than VDZ, but dose escalation was more frequent. Biologicals used in lower treatment lines resulted in better drug persistence.

Management of acute gastrointestinal bleeding. Multidisciplinary guideline proposal

Gastrointestinal bleeding has a profound impact on public health due to its high prevalence and severity. With the elderly population taking more anticoagulants/antiaggregants/non-steroid anti-inflammatory drugs, the digestive bleeding will certainly raise more and more challenges in quantity as well as in severity for the public healthcare system. The emergency medicine specialists and gastroenterologists have a central role in the management of patients presenting with gastrointestinal bleeding. In certain cases, radiologists, invasive radiologists, intensive care specialists and surgeons should also be involved in the decision making process and management of patients. Therefore, Hungarian experts felt the need to elaborate a comprehensive, multidisciplinary, practical local guideline reflecting the frequently arisen aspects based on current international guidelines. This guideline proposal covers topics of basic requirements, initial assessment of patients, risk evaluation, laboratory tests, hemodynamic resuscitation in the case of gastrointestinal bleeding followed by its consecutive steps of diagnosis and therapy sorted by location of the source of the hemorrhage. The authors give practical instructions for unsuccessful hemostasis or rebleeding. Finally, the role of surgery is also summarized in the management of gastrointestinal bleeding. Orv Hetil. 2020; 161(30): 1231-1242.

Perception of a modular 3D print model in undergraduate endodontic education

AIM

To evaluate a modular 3D print training dental model with embedded human teeth and electronic working length determination for undergraduate endodontic education.

METHODOLOGY

Cone-beam volume tomography data of a human skull were transferred into stereolithographic (STL) data, and a customizable modular 3D print model with individually removable sextants and teeth was generated for the use in commercially available phantom heads. Each of sixty-eight students performed a complete root canal treatment on an extracted human tooth. Working lengths were determined with electronic apex locators (EAL) and verified radiographically. Subsequently, an evaluation was carried out with regard to the difficulty of the working steps access cavity preparation, working length determination, root canal preparation/irrigation and canal filling, and these steps were compared to commonly used benchtop models. Additionally, the agreement of electronic and radiographic working length determination was assessed and analysed statistically with the chi-square test.

RESULTS

A total of 68 teeth (20 incisors, 26 premolars and 22 molars) with 127 root canals were treated. In total, 87% of the students considered the modular 3D print model considerably more demanding than the conventional benchtop model. Overall, 96% felt better prepared for the clinical situation, 92% felt markedly reduced stress levels during endodontic practice in the subsequent clinical courses, and 93% of the students suggested the model should be used in future preclinical endodontic training. The preradiographic use of EAL resulted in 85% of the cases having radiographically acceptable working length determination within 0-2 mm from the radiographic apex. Readings more than 2 mm from the apex or beyond were significantly more common in molars than in premolars and incisors (P < 0.05).

CONCLUSIONS

The vast majority of students rated the modular 3D print training model positively despite it being more demanding. They also recommended its use in preclinical teaching and training. The model allowed a more realistic simulation of the clinical situation with a simultaneous use of EALs and led to reduced stress levels in endodontic treatment in the subsequent clinical courses.

Physico-chemical investigation of endodontic sealers exposed to simulated intracanal heat application: epoxy resins and zinc oxide-eugenols

AIM

To gain information in a laboratory setting about the effect of thermal treatment of epoxy resin-based and zinc oxide-eugenol-based sealers.

METHODOLOGY

AH Plus and Pulp Canal Sealer (PCS) were exposed to thermal treatment at 37, 47, 57, 67, 77, 87 and 97 °C for 30 s. According to clinically relevant considerations, intracanal sealer temperature is likely not to exceed 60 °C during warm vertical root canal filling. Heat application is recommended for less than 30 s during continuous wave technique, but might exceed this threshold in complex cases. Furthermore, heat treatment at 97 °C was performed for 60 and 180 s to simulate inappropriate implementation of warm vertical filling techniques. Specimens were heated inside 2-mL plastic tubes in a thermo-controlled water bath until the temperatures were reached and kept at this temperature for the determined period of time. Afterwards, specimens were cooled to body temperature and physical properties (setting time, flow, film thickness according to ISO 6876) were assessed. Chemical properties (Fourier transformed infrared spectroscopy) were assessed after complete setting of the specimens in an incubator at 37 °C and 100% humidity. Statistical analysis of physical properties was performed using Kruskal-Wallis test (P = 0.05).

RESULTS

The setting time of AH Plus and PCS decreased when temperature and duration of heat application increased. Whilst the setting time of AH Plus decreased from 622 min at 20 °C (for 30 s) to 381 min at 97 °C (for 180 s; P < 0.05), heat treatment of PCS at 97 °C for 180 s led to an immediate setting of the material. From 20 °C (for 30 s) to 97 °C (for 30 s), the setting time of PCS decreased from 80.1 to 41.0 h (P < 0.05). Film thickness and flow were not relevantly influenced by thermal treatment except for PCS at 97 °C for 180 s. FT-IR spectroscopy did not reveal any chemical changes of either sealer after thermal treatment.

CONCLUSIONS

Thermal treatment simulating clinically relevant temperature levels and heating times did not lead to any substantial physical or chemical changes at all temperature levels when heating did not exceed 60 s. AH Plus and Pulp Canal Sealer can be considered suitable for warm root filling techniques.

A critical appraisal of studies on cyclic fatigue resistance of engine-driven endodontic instruments

The endodontic literature contains a plethora of studies on static and dynamic cyclic fatigue resistance tests performed on a large array of rotary or reciprocating nickel-titanium endodontic instruments. It was the aim of this review to summarize the currently available evidence to point out the different outcomes from static versus dynamic tests and to assess whether cyclic fatigue tests provide useful data and information for clinical practice. An electronic literature research in the database PubMed was performed using appropriate search terms, and the titles and abstract were screened for relevance. Language was restricted to English. The review reveals marked differences between the results obtained in static and dynamic tests, and also, the results for the same instruments assessed either under static or dynamic experimental conditions are widely inconsistent. Between the lowest and the highest value for one and the same pathfinding instrument was a factor of about 123 when cyclic fatigue was assessed either under static or dynamic experimental conditions. Moreover, standard deviations of up to 30% have been reported. Environmental temperature has a 500% impact on the lifetime of instruments. In conclusion, fatigue resistance tests conducted under room temperature should be regarded as having little meaning and the scientific and clinical benefits of fatigue resistance tests are very limited. These data should be provided by the manufacturer of the instruments.

Patient and general population values for luminal and perianal fistulising Crohn's disease health states

BACKGROUND

In patients with Crohn's disease (CD), luminal disease activity paralleled by perianal fistulas may seriously impair health-related quality of life (HRQoL). Health utility values are not available from patients with CD that reflect the health loss associated with both luminal and perianal CD.

OBJECTIVE

To generate utilities for luminal and concomitant perianal fistulising CD health states directly from patients and from members of the general public.

METHODS

A cross-sectional survey was undertaken enrolling CD patients and a convenience sample of members of the general population. Respondents were asked to evaluate four common CD heath states [severe luminal disease (sCD), mild luminal disease (mCD), severe luminal disease with active perianal fistulas (sPFCD), and mild luminal disease with active perianal fistulas (mPFCD)] by 10-year time trade-off (TTO). In addition, patients assessed their current HRQoL by the TTO method.

RESULTS

Responses of 206 patients (40.8% with perianal fistulas) and 221 members of the general population were analysed. Mean ± SD utilities among patients for sPFCD, sCD, mPFCD and mCD states were 0.69 ± 0.33, 0.73 ± 0.31, 0.80 ± 0.29 and 0.87 ± 0.26. Corresponding values in the general public were: 0.59 ± 0.31, 0.65 ± 0.29, 0.80 ± 0.26 and 0.88 ± 0.25. Patients with active perianal fistulas, previous non-resection surgeries, and higher pain intensity scores valued their current health as worse (p < 0.05).

CONCLUSIONS

TTO is a feasible method to assess HRQoL in patients with perianal fistulising disease, often not captured by health status questionnaires. Utilities from this study are intended to support the optimization of treatment-related decision making in patients with luminal disease paralleled by active perianal fistulas.

Assessment of imatinib as first-line treatment of chronic myeloid leukemia: 10-year survival results of the randomized CML study IV and impact of non-CML determinants

Chronic myeloid leukemia (CML)-study IV was designed to explore whether treatment with imatinib (IM) at 400 mg/day (n=400) could be optimized by doubling the dose (n=420), adding interferon (IFN) (n=430) or cytarabine (n=158) or using IM after IFN-failure (n=128). From July 2002 to March 2012, 1551 newly diagnosed patients in chronic phase were randomized into a 5-arm study. The study was powered to detect a survival difference of 5% at 5 years. After a median observation time of 9.5 years, 10-year overall survival was 82%, 10-year progression-free survival was 80% and 10-year relative survival was 92%. Survival between IM400 mg and any experimental arm was not different. In a multivariate analysis, risk group, major-route chromosomal aberrations, comorbidities, smoking and treatment center (academic vs other) influenced survival significantly, but not any form of treatment optimization. Patients reaching the molecular response milestones at 3, 6 and 12 months had a significant survival advantage. For responders, monotherapy with IM400 mg provides a close to normal life expectancy independent of the time to response. Survival is more determined by patients' and disease factors than by initial treatment selection. Although improvements are also needed for refractory disease, more life-time can currently be gained by carefully addressing non-CML determinants of survival.

[Introduction of a quality index in a Hungarian endoscopy unit]

The quality of endoscopic examinations substantially determines their value. In developed countries, Continuous Quality Management is used to improve it permanently. In Hungary there is no example for measuring quality in the field of gastrointestinal endoscopy.

AIM

The measurement and improvement of quality of endoscopy applying completeness index (cecum intubation rate) during colonoscopy.

PATIENTS AND METHODS

The authors defined base values retrospectively from 841 colonoscopy reports, performed in the last quarter of the year, before starting the project. The next two years (3160 colonoscopy in 2009 and 3167 in 2010) every three months they calculated the cecum intubation rate for each endoscopist.

RESULTS

The cecum intubation rate was 81.6% in the base period. When the authors excluded examinations with poor preparations and those with a previously unknown stenosis that prevented the total colonoscopy, the adjusted cecal intubation rate was 90.9%. In the next 2 years, the cecum intubation rate was 84.2% and 85.7% (p = 0.0394), while adjusted cecum intubation rate proved to be 92.3% and 92.6% (p = 0.381 NS) for the whole endoscopy unit. Of the 14 endoscopists only 6 reached an adjusted cecum intubation rate of 90%, but in the second year of the project 10 of them reached this rate and only one endoscopist remained below 87%. The endoscopists performing more than 100 colonoscopies per year had better adjusted cecum intubation rate (base 91.2%; 92.7% and 93.1% during the 2 project years) compared to those with less than 100 colonoscopies per year (base, 86.7%; project period, 85.5 and 89%).

CONCLUSIONS

The evaluation and publicity of the cecal intubation rate resulted in an improvement of the quality of colonoscopy. The authors also presented that endoscopists performing more than 100 colonoscopies per year have better endoscopic quality.

Phototropic response of the stage I Phycomyces sporangiophore to a pulse of blue light

Positive phototropic curvature of Phycomyces sporangiophores (stage I) induced by a short pulse (10 sec) of blue light has been characterized. The curvature response, measured 40 min after irradiation, increases with increasing fluences up to approximately 10(-4) J.m(-2); it then decreases and becomes nearly 0 at a fluence of approximately 10(-1) J.m(-2). The threshold fluence is found near 10(-7) J.m(-2), indicating over 1000-fold higher sensitivity than the first positive phototropism of grass coleoptiles. Positive curvature of the sporangiophore becomes detectable 5 min after irradiation and increases with time up to approximately 40 min. During the course of this curvature development, overall elongation growth of the sporangiophore is first stimulated and then inhibited. The relationship between the phototropic response and the response in overall elongation growth is discussed, and it is suggested that the primary mechanisms of these responses are distinct.

From protons to OXPHOS supercomplexes and Alzheimer's disease: structure-dynamics-function relationships of energy-transducing membranes

By the elucidation of high-resolution structures the view of the bioenergetic processes has become more precise. But in the face of these fundamental advances, many problems are still unresolved. We have examined a variety of aspects of energy-transducing membranes from large protein complexes down to the level of protons and functional relevant picosecond protein dynamics. Based on the central role of the ATP synthase for supplying the biological fuel ATP, one main emphasis was put on this protein complex from both chloroplast and mitochondria. In particular the stoichiometry of protons required for the synthesis of one ATP molecule and the supramolecular organisation of ATP synthases were examined. Since formation of supercomplexes also concerns other complexes of the respiratory chain, our work was directed to unravel this kind of organisation, e.g. of the OXPHOS supercomplex I(1)III(2)IV(1), in terms of structure and function. Not only the large protein complexes or supercomplexes work as key players for biological energy conversion, but also small components as quinones which facilitate the transfer of electrons and protons. Therefore, their location in the membrane profile was determined by neutron diffraction. Physico-chemical features of the path of protons from the generators of the electrochemical gradient to the ATP synthase, as well as of their interaction with the membrane surface, could be elucidated by time-resolved absorption spectroscopy in combination with optical pH indicators. Diseases such as Alzheimer's dementia (AD) are triggered by perturbation of membranes and bioenergetics as demonstrated by our neutron scattering studies.

Effect of an ibuprofen-releasing foam dressing on wound pain: a real-life RCT

OBJECTIVE

To compare an ibuprofen-releasing foam dressing (Biatain Ibu, ColoplastA/S) with local best practice in the treatment of painful exuding wounds.

METHOD

In this large-scale randomised comparative study, 853 patients were randomised to either ibuprofen-releasing foam (test) dressing (n=467) or local best practice (n=386). Primary endpoint was wound pain relief from day 1-7, assessed by the patients twice daily using a five-point verbal rating scale. Secondary endpoints were reduction in pain intensity from day 0-7 (assessed using an 11-point numeric box scale), quality of life (assessed using the WHO-5 well-being index and effect on health-related activities of daily living) and the incidence of adverse events.

RESULTS

After seven days significantly more patients in the experimental group experienced relief from temporary and persistent pain and a reduction in pain intensity,when compared with patients in the local best practice group (p<0.0001). They also experienced a greater improvement in quality of life. The number of adverse events in both groups was low.

CONCLUSION

The test dressing provided an appropriate wound healing environment, relieved temporary and persistent wound pain, and decreased pain intensity. It was also associated with an improvement in quality of life.

Comparison of Elisa-Based Tyrosine Kinase Assays for Screening EGFR Inhibitors

Receptor tyrosine kinases (PTKs) play key roles in the pathogenesis of numerous human diseases, including cancer, and therefore PTK inhibitors are currently under intense investigation as potential drug candidates. PTK inhibitor screening data are, however, poorly comparable because of the different assay technologies used. Here we report a comparison of ELISA-based assays for screening epidermal growth factor receptor (EGFR) tyrosine kinase (TK) inhibitory compound libraries to study interassay variations. All assays were based on the same protocol, except for the source of EGFR-TK enzymes. In the first protocol, the enzyme was isolated from A431 cells without affinity purification. In the second protocol, commercial EGFR-TK (Sigma) isolated from A431 cells by affinity-purification was employed. In the third protocol, an enzyme preparation obtained from a recombinant (Baculovirus transfected Sf9 cells) expression system was used. All assays employed the synthetic peptide substrate poly-(Glu,Tyr)l:4 and an ELISA-based system to detect phosphorylated tyrosine residues by a monoclonal antibody. We observed significant differences in both the activity of the enzymes and in the EGFR-TK inhibitory effect of our reference compound PD153035. The differences were significant in case of A431 cell lysate compared to affinity purified EGFR-TKs derived from either A431 cells or Baculovirus transfected Sf9 cells, whereas the latter two showed comparable results. Our data suggest that differences in terms of interassay variation are not related to the source of the enzyme but to its purity; changes in the mode of detection can markedly influence the reproducibility of results. In conclusion, normalization of the EGFR activity used for inhibitor screening and standardization of detection methods enable safe comparison of data.

The tyrosine kinase src plays a crucial role in leukemic cell proliferation in AML

10531

Background: Src-family tyrosine kinases are known to be involved in signal transduction pathways of growth factors and cytokines in hematopoetic cells. While the role of other src family members has been studied widely, only few data exist about c-src in leukemia. The actual study was performed to analyze src mutations in leukemic cells and to determine the role of pp60src in leukemic cell proliferation. Methods: AML cell lines and primary samples were analyzed for expression and activation of src by RT-PCR and Western blot analyses. Mutational analyses were performed by sequencing of C-terminal cDNA from 60 AML samples. The effects of src inhibition were studied by src-specific inhibitors PP1 and PP2 or by siRNA transfection. Effetcs of src inhibition were monitored in proliferation assays and analyzes of signalling through Erk1/2 and apoptosis by annexin V staining and DNA laddering. Results: In all 60 patients analyzed expression of c-src mRNA was detected by RT-PCR. Western blot analyses confirmed strong expression of src on the protein level and revealed a robust activation of the protein as determined by tyrosine phosphorylation. Incubation of leukemic cells with PP1 and PP2 caused significant inhibition of proliferation in a dose dependent manner. Similar results were observed after transfection with specific siRNAs. Src inhibition blocked phosphorylation of pp60src, Erk1/2 and induced apoptosis in leukemic cells. Mutational analyses as performed by SSCP/heteroduplex and bi-directionally sequencing revealed wildtype sequence in cell lines and 60 clinical samples. Conclusions: In summary, pp60src is highly expressed and activated in cell lines and clinical samples of human AML. Moreover, phosphorylation of src is essential for leukemic cell proliferation. Underlying mutations in the coding sequence of c-src causing constitutive activation could be excluded. These data suggest that pp60src plays a crucial role in AML and src inhibition by targeted therapy might offer a useful new approach in the treatment of AML.

No significant financial relationships to disclose.

[Risk management--a new aspect of quality assessment in intensive care medicine: first results of an analysis of the DIVI's interdisciplinary quality assessment research group]

Patient security has become one of the major aspects of clinical management in recent years. The crucial point in research was focused on malpractice. In contradiction to the economic process in non medical fields, the analysis of errors during the in-patient treatment time was neglected. Patient risk management can be defined as a structured procedure in a clinical unit with the aim to reduce harmful events. A risk point model was created based on a Delphi process and founded on the DIVI data register. The risk point model was evaluated in clinically working ICU departments participating in the register data base. The results of the risk point evaluation will be integrated in the next data base update. This might be a step to improve the reliability of the register to measure quality assessment in the ICU.

The influence of various automated devices on the shaping ability of Mtwo rotary nickel-titanium instruments

AIM

To compare the shaping ability of Mtwo rotary nickel-titanium instruments in simulated curved canals and in curved canals of extracted teeth when set into permanent rotation with two different torque-limited automated devices.

METHODOLOGY

Root canal instrumentation was performed with two different torque-limited automated devices (Mtwo direct handpiece and Endo IT motor) using Mtwo rotary nickel-titanium instruments up to size 35. Simulated canals: 28 degrees and 35 degrees curved canals in resin blocks (n = 20 canals in each group) were prepared. Pre- and post-instrumentation images were recorded and assessment of canal shape was completed with a computer image analysis program. Extracted teeth: a total of 40 curved root canals were divided into two groups, which were balanced with respect to the angle and the radius of canal curvature. Straightening of the canal curvatures was determined with a computer image analysis program. Incidence of canal aberrations, preparation time, changes of working length and instrument failures were recorded both in simulated and real canals and were analysed using the t-test and a chi-square test.

RESULTS

In simulated canals, instrumentation with Endo IT was significantly faster than with Mtwo direct (P < 0.05). No significant differences between the two devices were noted when all other parameters were assessed (P > 0.05). Only one instrument separated (Mtwo direct) during the enlargement of 28 degrees curved simulated canals. All systems maintained working distance well.

CONCLUSIONS

Both systems respected original root canal curvature well and were safe, indicating that the Mtwo direct handpiece is suitable for preparing curved root canals with the Mtwo instruments.

Multiple giant leiomyomas of the esophagus and stomach

Leiomyomas are rare esophageal disorders, although among the benign esophageal neoplasms, they are the most common. Multiple leiomyomas are distinguished from esophageal leiomyomatosis, an extremely rare condition, which is associated with Alport syndrome, showing deletions and rearrangements of the COL4A5/COL4A6 gene. There are only a few reports of diffuse multilocular lesions. A 19-year-old man presented with upper gastrointestinal bleeding and diffuse abdominal pain. On endoscopy multiple nodules covered with intact mucosa were present, the largest tumor arising from the gastro-esophageal border infiltrating the cardia. Barium swallow demonstrated narrowing of the middle and lower esophagus with the upper third of the stomach filled by the tumor. Thorax and abdominal CT scans revealed infiltration of almost the total aboral esophagus by the tumor with compression of left and right bronchi. The infiltration reached the whole lesser curvature of the stomach. Endosonography showed multiple encapsulated nodules. Due to the extended tumor growth with infiltration of the upper third of the stomach, a total esophago-gastrectomy with reconstruction by colon interposition was performed. On histopathological examination multiple esophageal leiomyomas with infiltration of the proximal third of the stomach was shown. Immunohistochemically the tumor stained positive for desmin and sm-actin and negative for CD34 and c-kit. Genetic analysis ruled out a deletion of the COL4A5/COL4A6 locus on chromosome X that is linked with Alport syndrome-diffuse leiomyomatosis. Extended mutations in the COL4A5 gene, associated with Alport syndrome, to the COL4A6 gene, are required for the development of leiomyomatosis. In young patients with diffuse multinodular infiltration by encapsulated tumors, esophageal leiomyomatosis should be considered. If the proximal third of the stomach is infiltrated by the tumor an extended resection is necessary. Reconstruction procedures include colon interposition.

Tonsillektomie mit Koagulationsschere oder Raspatorium

BACKGROUND

Postoperative bleeding is the major complication in tonsillectomy, and pain the most common side effect. The use of bipolar scissors versus blunt dissection tonsillectomy were compared in this study in order to evaluate postoperative bleeding and pain, as well as operative time.

METHODS

In this case control study, 138 patients with the diagnosis of chronic tonsillitis, mononucleosis or a peritonsillar abscess were divided into two groups. A total of 78 patients were operated using bipolar scissors while 60 patients underwent tonsillectomy by blunt dissection. Operating time, frequency of postoperative bleeding and the postoperative pain score were compared between these two groups.

RESULTS

The average operating time in the bipolar scissor group showed a tendency to be shorter than in the blunt dissection group (mean 4.1 min), although this did not reach a level of statistical significance. No differences were seen in pain scores or in the incidence of postoperative bleeding.

CONCLUSION

The data documented in this study show that tonsillectomy with bipolar scissors might represent a surgical option to reduce surgical time in a larger patient group. Postoperative pain and the incidence of postoperative bleeding did not show any statistical difference between the two surgical techniques.