Is pre-operative axillary ultrasound alone sufficient to determine need for axillary dissection in early breast cancer patients?

Pre-operative status of axillary lymph node (ALN) in early breast cancer is usually initially assessed by pre-operative ultrasound, followed by ultrasound-guided needle biopsy (UNB) confirmation. Patients with positive nodal status will undergo axillary lymph node dissection (ALND), while those with negative nodal status will have sentinel lymph node biopsy. ALND is associated with higher morbidity than Sentinel lymph node biopsy. The objective of this study is to determine if axillary ultrasound alone without UNB is predictive enough to assign patients to ALND and to identify ultrasound features that are significantly associated with pathologically positive ALN.383 newly diagnosed primary breast cancer patients between 2012 and 2014, and who had undergone pre-operative axillary ultrasound in University Malaya Medical Centre with a complete histopathology report of the axillary surgery were retrospectively reviewed. ALN was considered positive if it had any of these features: cortical thickening > 3 mm, loss of fatty hilum, hypoechoic solid node, mass-like appearance, round shape and lymph node size > 5 mm. Post-operative histopathological reports were then analyzed for nodal involvement.The overall sensitivity, specificity, and accuracy of pre-operative axillary ultrasound in detecting diseased nodes were 45.5%, 80.7%, and 60.3% respectively. The positive (PPV) and negative predictive values were 76.5% and 51.8%. Round shape, loss of fatty hilum and mass-like appearance had the highest PPVs of 87%, 83% and 81.6% respectively and significant odds ratios (ORs) of 5.22 (95% confidence interval [CI]: 1.52 - 17.86), ORs of 4.77 (95% CI: 2.62 - 8.70) and ORs of 4.26 (95% CI: 2.37 - 7.67) respectively (P-value < .05). Cortical thickness of > 3 mm was identified to have low PPV at 69.1%, ORs of 1.71 (95% CI: 0.86 - 3.41, P = .126).There are features on axillary ultrasound that confer high PPV for axillary involvement i.e. round shape, loss of fatty hilum, and mass-like appearance. In a low resource setting, these features may benefit from ALND without further pre-operative biopsies. However, pre-operative UNB for features with low PPV that is, cortical thickness > 3 mm should be considered to obviate the unnecessary morbidity associated with ALND.     

Is sigmoidoscopy sufficient for evaluating inflammatory status of ulcerative colitis patients?

Background and Aims: An adequate range of colonic observations for precise evaluation of inflammation in ulcerative colitis (UC) patients has not been reported. Methods: Retrospective analysis of 545 colonoscopic examinations of UC patients was carried out. Severity of mucosal inflammation was evaluated using the Mayo score of endoscopic index at each location (rectum, sigmoid colon, descending colon, and the oral side of the splenic flexure) in each patient. The colonic site with maximum inflammation was determined for each patient. Results: Of 545 patients, 319 (59%) had maximum inflammation in the rectum, 79 (14%) in the sigmoid colon, 70 (13%) in the descending colon, and 77 (14%) on the oral side of the splenic flexure. Severe inflammatory activity (Mayo 3) was observed more frequently in patients who had maximum activity in the descending colon or the more proximal portion than those who had this in the rectum or sigmoid colon (42% vs 25%, P < 0.0001). The first‐attack patients were significantly more frequently found in patients with maximum severity in the descending colon or the oral side of splenic flexure than those with maximum severity in the rectum or sigmoid colon (P = 0.016). Moreover, among 134 patients with no inflammation in the rectum and sigmoid colon, 54 (40%) had inflamed mucosa in the descending colon or the more proximal portion. Conclusions: Sigmoidoscopy is not sufficient for evaluating inflammation in UC patients. In particular, colonoscopy is necessary for first‐attack patients and patients who have a discrepancy between rectosigmoid observation and symptoms.     

Is the questionnaire for the assessment of gastroesophageal reflux useful for diabetic patients?

OBJECTIVE: It has been suggested that the questionnaire reported by Carlsson et al. has high sensitivity in diagnosing gastroesophageal reflux disease (GERD) and is considered to be one of the most useful diagnostic tools for GERD. The aim of the present study was to evaluate the ability of the questionnaire to identify gastroesophageal reflux (GER) diagnosed by 24-h pH monitoring in diabetic patients. MATERIAL AND METHODS: Fifty-three patients with type 2 diabetes were enrolled in the present study. GER was monitored by means of an antimony electrode. Patients completed the questionnaires immediately before undergoing pH monitoring. RESULTS: Diabetic patients were found to have few symptoms, and the average score on the questionnaire was extremely low. No significant difference in scores on the questionnaire was observed between patients with and those without GER. CONCLUSIONS: The questionnaire was shown not to be useful for diagnosing GER as a complication in diabetic patients. We, therefore, should not diagnose GER as a complication in diabetes mellitus on the basis of the questionnaire.     

Is acid relevant in the genesis of dyspeptic symptoms associated with nonerosive reflux disease?

[table: see text] A consistent subset of patients with NERD suffers from symptoms centered in the upper part of the abdomen that are more characteristic of functional dyspepsia than reflux disease. The cause of this overlap is still unclear, but acid has been implicated as one of the possible common pathophysiological factors responsible for these two categories of upper gastrointestinal (GI) symptoms. Many physiological investigations and the modest success of proton pump inhibitors in resolving dyspeptic symptoms associated with typical reflux syndrome seem to support the concept that functional dyspepsia and NERD are two separate entities, which need to be treated with different drugs.     

Is standard-echocardiography sufficient for identification of responders?

During recent years cardiac re-synchronization has become an important tool in the treatment of patients with signs and symptoms of heart failure and de-synchronized contraction of the heart. This article describes the pathophysiological basis of de-synchronized contraction due to left bundle branch block and the use of conventional echocardiography to unmask whether the electrical abnormality is accompanied by an asynchronous contraction in the individual patient. The altered contraction in the de-synchronized heart is analysed on different levels: atrioventricular dyssynchrony describes the disturbed mechanical coupling of the ventricles and atria, interventricular dyssynchrony describes the disturbed mechanical coupling of the left and right ventricle, and intraventricular dyssynchrony describes the uncoordinated contraction of the left ventricle. Since tissue Doppler imaging is implemented only in the top level echo machines of the respective manufacturers, this article uses parameters derived from standard echo techniques to analyse the different aspects of dyssynchrony.     

Is ineffective oesophageal motility associated with reflux oesophagitis?

OBJECTIVE: To evaluate the association between ineffective oesophageal motility and reflux oesophagitis controlling for hiatal hernia, hypotensive lower oesophageal sphincter and male sex in patients with gastro-oesophageal reflux disease. METHODS: A total of 387 patients with reflux disease (mean age, 46 years, 42% men) were consecutively selected from a database. All patients underwent upper endoscopy, oesophageal manometry and 24 h oesophageal pH-metry in accordance with a standardized protocol. Reflux disease was confirmed either by endoscopy (oesophagitis grade I-IV according to Savary-Miller) or by pH-metry (increased acid exposure). Hiatal hernia was diagnosed endoscopically, whereas ineffective oesophageal motility and hypotensive lower oesophageal sphincter were characterized during manometry testing. The association between ineffective oesophageal motility and reflux oesophagitis was assessed by logistic regression analysis. RESULTS: A total of 166 patients with oesophagitis (mean age 45 years, 49% men) and 221 without oesophagitis (mean age 46 years, 37% men) were present. Prevalences of ineffective oesophageal motility, hiatal hernia, hypotensive lower oesophageal sphincter and male sex were significantly higher in patients with oesophagitis compared with those without oesophagitis (P<0.05). Ineffective oesophageal motility was independently associated with oesophagitis after multivariate logistic regression analysis (odds ratio=1.68; 95% confidence interval=1.04-2.70). CONCLUSION: Ineffective oesophageal motility is associated with reflux oesophagitis, independently of hiatal hernia, hypotensive lower oesophageal sphincter and male sex.     

Endoluminal gastroplication for treatment of patients with classic gastroesophageal reflux symptoms and borderline 24‐h pH studies

Background: Patients with classic gastroesophageal reflux disease (GERD) symptoms and borderline 24‐h pH studies are not considered to be good candidates for surgical fundoplication. Endoluminal gastroplication (ELGP) is a new endoscopic treatment for patients with GERD. The aim of this study was to evaluate the efficacy of ELGP in these patients. Methods: Patients with heartburn, regurgitation symptoms and a DeMeester score of less than 30 were studied. ELGP involved placement of two or three plications within 2?cm of the gastroesophageal junction. Clinical outcomes measured were heartburn symptom score (HSS), regurgitation frequency score (RFS) and medication use. Results: Twenty‐five patients (11 M, 14 F, mean age of 51 years) had a medication use of 11.5 doses of proton‐pump inhibitors per week prior to ELGP. Average lower esophageal sphincter pressure measured 15?±?8?mmHg, and average DeMeester score was 18?±?8. Nine patients had hiatal hernias and 11 had esophagitis. Twenty‐four patients were available for a mean follow‐up of 12 months. HSS significantly decreased from 48 to 17 (P?P?P?Conclusions: Endoluminal gastroplication provides symptomatic relief for patients with classic GERD symptoms despite medical therapy and borderline 24‐h pH studies.     

Are steroids alone sufficient for the treatment of giant cell arteritis?

Glucocorticosteroids are the cornerstone of treatment of giant cell arteritis. An initial dose of prednisone or its equivalent of at least 40-60mg per day as single or divided dose is usually adequate. Glucocorticosteroids may prevent, but usually do not reverse, visual loss. A treatment course of 1-2 years is often required. Some patients, however, have a more chronic-relapsing course and may require low doses of glucocorticosteroids for several years. Glucocorticosteroid-related adverse events are common. In studies on immunosuppressant agents, methotrexate has been used as a glucocorticosteroid-sparing drug with conflicting results. This drug may, however, be given to patients who need high doses of glucocorticosteroids to control active disease and who have serious side effects. A recent pilot study found that infliximab was efficacious in patients with glucocorticosteroid-resistant giant cell arteritis. However, randomized controlled trials are required to define the role of anti-tumor necrosis factor-alpha agents in the treatment of giant cell arteritis. Finally, low-dose aspirin has been shown in a recent retrospective study to decrease the rate of cranial ischemic complications secondary to giant cell arteritis. It is conceivable that the definition of different patterns of inflammation in giant cell arteritis in the future might facilitate the design of differentiated therapeutic approaches.     

Is the esophageal squamous epithelial barrier function impaired in patients with gastroesophageal reflux disease?

BACKGROUND: A disturbed epithelial barrier function has been promoted as one factor in the pathogenesis of gastroesophageal reflux disease (GERD). We therefore studied the effect of acid perfusion on the transmural potential difference (PD) of the distal esophagus in relation to onset of reflux symptoms. METHODS: PD was assessed during perfusion with saline and with 0.1 M HCl in healthy controls (n = 17) and in GERD patients without (n = 15) or with esophagitis (n = 6) and in remission after a fundoplication (n = 10). Heartburn and other upper GI symptoms were recorded concomitantly. Endoscopy-negative patients were studied before and after omeprazole treatment. RESULTS: HCl perfusion induced more lumennegative peak PD values in patients with active GERD, regardless of the presence or absence of esophagitis, than in healthy controls. After successful therapy, the PD response to acid perfusion equalled that of healthy subjects. Acid perfusion was associated with the onset of heartburn in most patients with active GERD but in none of the healthy subjects, and less frequently after medical and surgical therapy. CONCLUSIONS: The epithelial permeability to hydrogen ions differs between healthy subjects and patients with active GERD. Effective treatment, such as omeprazole or fundoplication, might improve the barrier function.