Meta-analysis: factors predicting post-operative recurrence with placebo therapy in patients with Crohn's disease

Background  The use of placebo in randomized clinical trials (PC-RCTs) is often required to evaluate drug efficacy in maintenance of Crohn's disease (CD).
Aim  To determine pooled estimates of placebo rates of maintaining clinical remission and endoscopic recurrence following surgery for CD and identify factors that influenced placebo outcomes.
Methods  We performed a systematic review and meta-analysis of PC-RCTs evaluating post-operative maintenance therapies for CD identified from MEDLINE from 1966 to 2005.
Results  Twelve studies met our inclusion criteria. The pooled placebo rate of maintaining clinical remission was 56% (95% CI 47–64%; range 34–89%) during a median follow-up of 52 weeks (range 12–156 weeks), but significant heterogeneity existed among the studies ( P  < 0.001). Prior steroid therapy was the only factor found to be associated with maintaining remission ( P  = 0.04). The pooled placebo endoscopic recurrence rate was 58% (95% CI 51–65%; range 36–80%) during a median follow-up of 52 weeks (range 12–156 weeks), with significant heterogeneity noted ( P  = 0.0003). Prior surgery, concomitant small bowel and colonic disease, fistulizing phenotype, or prior immunomodulator therapy influenced endoscopic recurrence ( P  < 0.05).
Conclusion  Placebo rates in PC-RCTs evaluating post-operative clinical and endoscopic recurrence demonstrate significant variability, which is influenced by specific study characteristics.     

Comparison of risk factors and clinical responses to proton pump inhibitors in patients with erosive oesophagitis and non-erosive reflux disease

Background  There has been no report on the response to proton pump inhibitor (PPI) therapy and on-demand or the relapse rate of non-erosive reflux disease (NERD) and erosive oesophagitis in Korea.
Aim  To compare the risk factors, clinical symptoms and PPI responses between patients with erosive oesophagitis and NERD patients.
Methods  A survey was performed prospectively in the erosive oesophagitis (205 patients) and NERD group (200 patients). Clinical symptoms, risk factors and PPI responses were analysed. On-demand therapy and the relapse rate of GERD symptoms were investigated during a one-year follow-up.
Results  BMI ≥ 25 (OR 3.0, 95% CI 1.1–8.3), alcohol use (OR 2.9, 95% CI 1.0–8.3), hiatal hernia (OR 5.0, 95% CI 1.2–20) and triglyceride ≥150 mg/dL (OR 4.0, 95% CI 1.7–10) were more common in the erosive oesophagitis group than in the NERD group by multivariate analysis. The ratio of oesophageal to extra-oesophageal symptoms was higher in the erosive oesophagitis group compared with the NERD group ( P  <   0.001). The PPI response rates at 8 weeks were different ( P  =   0.02); refractory rates were higher in the NERD group (16.7%) compared with the erosive oesophagitis group (6.0%). However, there was no significant difference between the two groups in on-demand therapy or the relapse rate.
Conclusion  These results suggest that the underlying pathogenic mechanisms of erosive oesophagitis and NERD are distinct.     

Efficacy of an intravenous proton pump inhibitor after endoscopic therapy with epinephrine injection for peptic ulcer bleeding in patients with uraemia: a case-control study

Background  Patients with peptic ulcer bleeding and uraemia are prone to re-bleeding.
Aim  To compare the efficacy of an intravenous proton pump inhibitor in treating peptic ulcer bleeding in patients with uraemia and those without uraemia.
Methods  High-risk peptic ulcer bleeding patients received endoscopic therapy with epinephrine (adrenaline) injection plus intravenous omeprazole (40 mg bolus followed by 40 mg infusion every 12 h) for 3 days. Re-bleeding, volume of blood transfusion, hospital stay, need for surgery, and mortality were analysed.
Results  The uraemic group had similar 7-day re-bleeding rate (6/42, 14.29% vs. 6/46, 13.04%, P  =   0.865) to that of non-uraemic patients, but more re-bleeding episodes beyond 7 days (4/42, 9.52% vs. 0/46, 0%, P  =   0.032, OR [95% CI] = 1.105 [1.002–1.219]) and all-cause mortality (4/42 vs. 0/46 P  =   0.032, OR [95% CI] = 1.105 [1.002–1.219]). The uraemic group also had more units of blood transfusion after endoscopic therapy (mean ± s.d. 4.33 ± 3.35 units vs. 2.15 ± 1.65 units, P  <   0.001), longer hospital stay (mean ± s.d. 8.55 ± 8.12 days vs. 4.11 ± 1.60 days, P  <   0.001) and complications during hospitalization (9/42 vs. 0/46, P  =   0.001, OR [95% CI] = 1.273 [1.087–1.490]).
Conclusion  Endoscopic therapy with epinephrine injection plus an intravenous proton pump inhibitor can offer protection against early re-bleeding in uraemic patients with peptic ulcer bleeding, but has a limited role beyond 7 days.     

Meta-analysis: allopurinol in the prevention of postendoscopic retrograde cholangiopancreatography pancreatitis

Background  Several clinical trials evaluating the prophylactic effect of allopurinol on postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis have been published; however, there is no consensus on whether prophylactic allopurinol can reduce the incidence of post-ERCP pancreatitis.
Aim  To compare prophylactic allopurinol with placebo on post-ERCP pancreatitis reduction by performing a meta-analysis in randomized controlled trials.
Methods  Databases including MEDLINE, EMBASE and the Cochrane Library, Science Citation Index were searched to find relevant trials. Two reviewers independently identified relevant randomized controlled trials assessing the effect of prophylactic allopurinol on the incidence of post-ERCP pancreatitis. Outcome measures were the incidence of post-ERCP pancreatitis.
Results  Four trials involving 1730 patients were included. Analysis suggested that post-ERCP pancreatitis rates were not significantly different (allopurinol 8.9%, placebo 9.7%, P  =   0.68), RR 0.86 (95% CI: 0.42, 1.77). Subsequent subgroup analysis confirmed that allopurinol was not statistically superior to placebo in reducing post-ERCP pancreatitis.
Conclusion  Based on current best evidence, prophylactic allopurinol may not be useful for post-ERCP pancreatitis reduction.     

Systematic review and meta-analysis: the clinical and physiological effects of fibre-containing enteral formulae

Background  Enteral nutrition can be associated with gastrointestinal side effects and fibre supplementation has been proposed as a means to normalize bowel function.
Aim  To evaluate systematically the effects of fibre supplementation of enteral feeds in healthy volunteers and patients both in the hospital and community settings.
Methods  Electronic and manual bibliographic searches were conducted. Controlled studies in adults or children, comparing fibre-supplemented vs. fibre-free formulae given as the sole source of nutrition for at least 3 days, were included.
Results  Fifty-one studies (including 43 randomized-controlled trials), enrolling 1762 subjects (1591 patients and 171 healthy volunteers) met the inclusion criteria. Fibre supplementation was generally well tolerated. In the hospital setting, the incidence of diarrhoea was reduced as a result of fibre administration (OR 0.68, 95% CI: 0.48–0.96; 13 randomized-controlled trials). Meta-regression showed a more pronounced effect when the baseline incidence of diarrhoea was high. In both patients and healthy subjects, fibre significantly reduced bowel frequency when baseline frequency was high and increased it when it was low, revealing a significant moderating effect of fibre.
Conclusions  The review indicates that the fibre-supplemented enteral formulae have important physiological effects and clinical benefits. There is a need to use a consistent approach to undertake more studies on this issue in the community setting.     

Systematic review: primary and secondary prevention of gastrointestinal cancers with antioxidant supplements

Background  The evidence on whether antioxidant supplements prevent gastrointestinal cancers is contradictory.
Aim  To assess the beneficial and harmful effects of antioxidant supplements in preventing gastrointestinal cancers.
Methods  Using the Cochrane Collaboration methodology, we reviewed the randomized trials comparing antioxidant supplements with placebo or no intervention on the occurrence of gastrointestinal cancers. We searched electronic databases and reference lists until October, 2007. Our outcome measures were gastrointestinal cancers, overall mortality and adverse events. Outcomes were reported as relative risks (RR) with 95% confidence intervals (CI) based on random-effects and fixed-effect models meta-analyses.
Results  We identified 20 randomized trials (211 818 participants) assessing beta-carotene, vitamin A, vitamin C, vitamin E, and selenium. The trial quality was generally high. The antioxidant supplements were without a significant effect on the occurrence of gastrointestinal cancers (RR 0.94, 95% CI 0.83–1.06, I ²  = 54.0%). The heterogeneity seemed to be explained by bias risk (low-bias risk trials RR 1.04, 95% CI 0.96–1.13 compared to high-bias risk trials RR 0.59, 95% CI 0.43–0.80, test of interaction P  < 0.0005) and type of antioxidant supplement (beta-carotene potentially increasing and selenium potentially decreasing cancer risk). Antioxidant supplements had no significant effect on mortality in a random-effects model meta-analysis (RR 1.02, 95% CI 0.97–1.07, I ²  = 53.5%) but significantly increased mortality in a fixed-effect model meta-analysis (RR 1.04, 95% CI 1.02–1.07).
Conclusions  We could not find evidence that the studied antioxidant supplements prevented gastrointestinal cancers. On the contrary, they seem to increase overall mortality.     

Clinical trial: the impact of cyclooxygenase inhibitors on gastrointestinal recovery after major surgery – a randomized double blind controlled trial of celecoxib or diclofenac vs. placebo

Background  Ileus occurs after abdominal surgery and may be severe. Inhibition of prostaglandin release reduces post-operative ileus in a rat model.
Aim  To determine whether prostaglandin inhibition by cyclooxygenase inhibitors, celecoxib or diclofenac, could enhance gastrointestinal recovery and reduce post-operative ileus in humans.
Methods  Two hundred and ten patients undergoing elective major abdominal surgery were randomized to receive twice daily placebo ( n  = 67), celecoxib (100 mg, n  = 74) or diclofenac (50 mg, n  = 69), preoperatively and continuing for up to 7 days. Primary outcomes were hallmarks of gut recovery. Secondary outcomes were paralytic ileus, pain and complications.
Results  There was no clinically significant difference between the groups for restoration of bowel function. There was a significant reduction in paralytic ileus in the celecoxib-treated group ( n  = 1, 1%) compared with diclofenac ( n  = 7, 10%) and placebo ( n  = 9, 13%); P  = 0.025, RR 0.20, CI 0.01–0.77. Pain scores, analgesia, transfusion requirements and adverse event rates were similar between study groups.
Conclusions  Perioperative low dose celecoxib, but not diclofenac, markedly reduced the development of paralytic ileus following major abdominal surgery, but did not accelerate early recovery of bowel function. This was independent of narcotic use and had no increase in post-operative complications.     

Meta-analysis: zinc supplementation for acute gastroenteritis in children

Background  Uncertainty exists regarding the use of zinc in the treatment of acute gastroenteritis in children living in Europe, where zinc deficiency is rare.
Aim  To review evidence for the effectiveness of zinc in treating acute gastroenteritis in children, with special emphasis on data from developed countries.
Methods  MEDLINE, EMBASE, and the Cochrane Library were searched through November 2007 for randomized controlled trials (RCTs) relevant to acute gastroenteritis in children younger than 5 years of age and zinc; additional references were obtained from the reviewed articles.
Results  Eighteen RCTs (11 180 participants, mainly from developing countries) met the inclusion criteria. Use of zinc was associated with a significant reduction in diarrhoea duration (13 RCTs, 5643 infants, weighted mean difference −0.69 day, 95% CI −0.97 to −0.40) and the risk of diarrhoea lasting longer than 7 days [eight RCTs, n  = 5769, relative risk (RR) 0.71, 95% CI 0.53–0.96]. No significant reduction in stool volume was observed for those receiving zinc compared with placebo (three RCTs, n  = 606, standardized mean difference, −0.38, 95% CI −1.04 to 0.27). Combined data from five RCTs ( n  = 3156) showed that zinc significantly increased the chance of vomiting compared to the control agent (RR 1.2, 95% CI 1.05–1.4).
Conclusions  These data confirm that zinc supplementation can be useful for treating acute gastroenteritis in children, particularly those from developing countries. However, the role of zinc supplements in treating children with acute gastroenteritis in developed countries needs further evaluation.     

Meta-analysis: efficacy of bovine lactoferrin in Helicobacter pylori eradication

Background  Several randomized-controlled trials (RCTs) have sought to determine the efficacy of bovine lactoferrin in Helicobacter pylori eradication with equivocal results.
Aim  To evaluate the effect of bovine lactoferrin supplementation in H. pylori eradication.
Methods  Electronic databases, reviews, bibliographies, abstracts and conference proceedings were searched. Included trials had to be randomized or quasi-randomized and controlled, using bovine lactoferrin in the intervention group, treating Helicobacter -infected subjects and evaluating eradication of H. pylori as an outcome.
Results  The search identified five eligible RCTs (of 169). Data were available for 682 subjects (bovine lactoferrin group- n  = 316; control group- n  = 366). The pooled odds ratio (five studies) for eradication by intention-to-treat analysis was 2.22 (95% CI 1.44–3.44; P  = 0.0003) using the fixed effects model (FEM) and 2.24 (95% CI 1.15–4.35; P  = 0.0003) using the random effects model (REM) (Cochran's Q  = 6.83; P  = 0.145). The pooled risk difference was 0.11 (95% CI 0.05–0.16; P  = 0.0001) by FEM (Cochran's Q  = 6.67; P  = 0.154) and 0.10 (95% CI 0.04–0.17; P  = 0.0023) by REM. There was no significant difference in incidence of adverse effects.
Conclusion  Bovine lactoferrin potentially improves H. pylori eradication rates without any impact on adverse effects, but available evidence is limited and further research is necessary to confirm the findings.     

Acute pancreatitis in inflammatory bowel disease, with special reference to azathioprine-induced pancreatitis

Background  Pancreatitis is a potentially severe condition. Patients with inflammatory bowel disease (IBD) seem to be at increased risk for acute pancreatitis.
Aim  To describe the incidence, main causes and possible predictive factors of acute pancreatitis in inflammatory bowel disease.
Methods  Information was retrospectively extracted from the clinical records of patients followed in the IBD Units of nine hospitals in Madrid ( n  = 5073).
Results  A total of 82 acute pancreatitis episodes were diagnosed (cumulative incidence, 1.6%); 98% of them were mild. Recurrent acute pancreatitis developed in 13% of patients. Most cases of acute pancreatitis (63.4%) were attributed to drug exposure [azathioprine/mercaptopurine (AZA/MP) n  = 46, mesalazine (mesalamine) n  = 6]; 20.7% were idiopathic, and 12.2% were biliary. Incidence of acute pancreatitis in patients treated with AZA/MP was 3.1%. In patients with acute pancreatitis, female gender (OR 3.4 95% CI: 1.3–9.3; P  = 0.012) and Crohn's disease (CD) (OR 5.8 95% CI: 1.6–20.6; P  = 0.007) were risk factors for AZA/MP-associated acute pancreatitis, the latter also when analysed only in patients treated with AZA/MP ( n  = 1477) (OR 5.2 95% CI: 1.8–14; P  = 0.002).
Conclusions  The incidence of acute pancreatitis in our IBD patients (1.6%) is similar to that previously described. Drugs, mainly AZA/MP, are the leading cause. AZA-induced acute pancreatitis is always mild. Patients with CD are at a higher risk for AZA/MP-associated acute pancreatitis. The frequency of idiopathic acute pancreatitis is higher than expected, suggesting that part of these cases could be extraintestinal manifestations of IBD.     

Cycled enteral antibiotics reduce sepsis rates in paediatric patients on long-term parenteral nutrition for intestinal failure

Aliment Pharmacol Ther 2011; 34: 1005–1011

Summary

Background Long‐term parenteral nutrition has transformed the prognosis for children suffering from intestinal failure. However, parenteral nutrition itself is associated with considerable morbidity and mortality including that caused by sepsis. Aim To examine a strategy of cycled enteral antibiotics in reducing the incidence of sepsis in paediatric intestinal failure patients. Methods Retrospective analysis of the incidence of sepsis rates of patients on long‐term parenteral nutrition, at a tertiary paediatric hospital. Patients were separated into those who received cycled enteral antibiotics and a control group. Sepsis rates before and during cycled enteral antibiotics were compared with comparable timeframes between the cycled enteral antibiotics and control groups. Central venous catheter removal rates were also compared. Results Fifteen patients (eight cycled enteral antibiotics, & seven controls) received 9512 parenteral nutrition days, with a total of 132 sepsis episodes. All eight patients of the treatment group demonstrated a decrease in the frequency of episodes of sepsis following the introduction of cycled enteral antibiotics. The cycled enteral antibiotics group had a significant reduction in infection rate during the treatment period (from 2.14 to 1.06 per 100 parenteral nutrition days, P = 0.014: median effect size ?1.04 CI 95%–1.93, ?0.22), whereas the controls had no significant change (1.91 – 2.36 per 100 parenteral nutrition days P = 0.402: median effect size 0.92 CI 95%–1.96, 4.17). The central venous catheter survival rates increased in the cycled enteral antibiotics group from 0.44 central venous catheter removals per 100 parenteral nutrition days to 0.27 central venous catheter removals per 100 parenteral nutrition days, although this was not statistically significant. Conclusions Cycled enteral antibiotics significantly reduced the rate of sepsis in a small group of paediatric intestinal failure patients. Larger well‐designed prospective studies are warranted to further explore this finding.

     

Clinical trial: oral ondansetron for reducing vomiting secondary to acute gastroenteritis in children – a double-blind randomized study

Background  Vomiting as a consequence of gastroenteritis frequently occurs in children. It is still debatable whether vomiting should be treated with antiemetic drugs.
Aim  To investigate potential beneficial effects of ondansetron in treating vomiting during acute gastroenteritis.
Methods  A randomized, double blind, placebo-controlled trial was performed in our emergency departments. Children, aged 5 months to 8 years, were randomized to receive either ondansetron 0.2 mg/kg or placebo at 8h intervals. The primary outcome measure was the frequency of emesis during an 8-h-period after enrolment.
Results  A hundred and nine patients were enrolled; 54 received placebo and 55 received ondansetron. As compared with the children who received placebo, children who received ondansetron were less likely to vomit both during the first 8-h follow-up in the emergency department [relative risk (RR): 0.33, 95% CI: 0.19–0.56, NNT: 2, 95% CI: 1.6–3.5], and during the next 24-h follow-up (RR: 0.15, 95% CI: 0.07–0.33, NNT: 2, 95% CI: 1.3–2.1).
Conclusion  Ondansetron may be an effective and efficient treatment that reduces the incidence of vomiting from gastroenteritis during both the first 8 h and the next 24 h, and is probably a useful adjunct to oral rehydration.     

Systematic review: secondary prevention with band ligation, pharmacotherapy or combination therapy after bleeding from oesophageal varices

Background  Variable methods are available for secondary prevention after oesophageal variceal bleeding (EVB).
Aim  To compare band ligation (BL), pharmacotherapy (PT) and BL+PT for EVB secondary prevention.
Methods  A systematic search of databases, references and meeting abstracts was conducted for randomized trials of BL, PT or BL+PT. The outcomes were mortality, rebleeding and adverse events. A random-effects model was used for meta-analyses.
Results  Twelve trials were included (6 BL vs. PT, 4 BL+PT vs. BL, 2 BL+PT vs. PT). All trials used beta-blockers ± isosorbide mononitrate (ISMN) as PT. Mortality was not significantly different among trials. Rebleeding was not significantly different for BL vs. PT (RR 1.00, 95% CI 0.73–1.37). BL reduced rebleeding compared with PT for trials with mean beta-blocker dose <80 mg/day (RR 0.67, 95% CI 0.49–0.91). There were nonsignificant differences in rebleeding for BL+PT vs. BL (RR 0.57, 95% CI 0.31–1.08) and BL+PT vs. PT (RR 0.76, 95% CI 0.56–1.03). There was no difference in adverse events between BL vs. PT, but was higher with BL+PT vs. BL.
Conclusion  Band ligation and PT alone are comparable for secondary prevention of rebleeding after EVB. Further trials with adequate PT dosing are required to determine the efficacy of combination BL+PT therapy.     

Endoscopic feeding tube placement in patients with cancer: a prospective clinical audit of 2055 procedures in 1866 patients

Background Feeding tube placement in patients with aero‐digestive cancer is challenging because of the distortion and/or obstruction of the upper digestive passage. As a result, many patients may receive intravenous fluids and parenteral nutrition instead of enteral feeds. Aim To audit all the endoscopic feeding tube placements in large sample of patients to determine difficulties, success, reasons for failures and procedure‐related complications. Methods Audit of all consecutive feeding tube placements from January 1996 to December 2003 was conducted. Tubes were placed depending on the site of cancer and anticipated duration of feeding: naso‐gastric tubes, naso‐enteral tubes and percutaneous endoscopic gastrostomy. Nutrition support team evaluated these patients. Technical modifications, difficulties, success and complications encountered during the procedure were recorded. Results Two thousand and fifty‐five attempts were made for feeding tube placements (naso‐gastric tube – 1637, naso‐enteral tube – 177 and percutaneous endoscopic gastrostomy – 241) in 1866 patients. Technical success was achieved in 1969 (96%, 95% CI: 95–97%). Immediate complications occurred in 62 (3%, 95% CI: 2–4%), seven needed hospitalization and one patient died of tumour perforation caused by naso‐gastric tube placement. The technical success and complications rates of the procedures performed by fellows in training were comparable to those performed by attending consultants. Conclusions Enteral feeding tubes can be placed in almost all patients with cancer using endoscopic techniques. Adequate training of the endoscopy fellows and sufficient care by nutrition support team help achieve high success with few complications.     

The effect of a single rectal dose of cisapride on delayed gastric emptying

Background : Cisapride has an established prokinetic effect in patients with delayed gastric emptying. However, rectal administration of the drug might be preferred in patients with either dysphagia or nausea due to gastroparesis.
Aim : To determine the effect of a single rectal dose of cisapride 60 mg on gastric emptying in patients with delayed gastric emptying.
Methods : Thirty-two patients (16 males, 16 females) with demonstrated delayed gastric emptying received a single dose of two suppositories containing either cisapride (2 × 30 mg) or placebo, according to a double-blind randomized crossover design. Three hours after administration of the suppositories, the patients received a radio-labelled test meal and radio-opaque markers for measurement of gastric emptying.
Results : The mean t _½ after cisapride administration (76 min, 95% CI: 68–95) was significantly shorter ( P  = 0.005; n  = 28, per-protocol analysis) than after placebo administration (104 min, 81–126). Four hours after ingestion of the meal significantly fewer radio-opaque markers remained in the stomach after cisapride than after placebo administration ( P  < 0.05). Mild to moderate adverse events, mainly involving the gastrointestinal tract, were reported in 10 patients (31%) after cisapride treatment and in four patients (13%) after placebo (N.S.; n  = 32).
Conclusion : A single suppository dose of cisapride 60 mg significantly accelerates gastric emptying of the solid phase of a meal and of radio-opaque markers in patients with previously demonstrated delayed gastric emptying.     

肠内联合肠外营养的应用对危重症患者的预后影响

目的:研究肠内联合肠外营养(EN+PN)支持在危重症病人中的临床应用效果. 方法:将60例有部分或全部胃肠功能的危重症病例随机分为肠内联合肠外营养(EN+PN)支持组、完全肠内营养(TEN)支持组和完全肠外营养(TPN)支持组,每组20例,对比观察营养支持前1d及营养支持后d7患者的体重指数、肱三头肌皮褶厚度、血清前白蛋白、白蛋白、总蛋白、血红蛋白、免疫球蛋白、淋巴细胞计数,且每天观察并发症情况. 结果:营养指标比较:经EN+PN支持后,血清前白蛋白明显升高(P<0.01),总蛋白、白蛋白、血红蛋白、免疫球蛋白、淋巴细胞计数亦有升高(P<0.05);而TEN和TPN支持后,各指标结果无显著差异.三组对比,EN+PN支持组血清前白蛋白、白蛋白、总蛋白、血红蛋白、免疫球蛋白、淋巴细胞计数均高于EN组和PN组(P<0.05),体重指数,肱三头肌皮褶厚度无显著差异.并发症比较:EN+PN支持组患者并发症的发生率显著低于EN组和PN组(P<0.05).结论:EN+PN支持更符合生理状态,有更好的代谢效应,能改善危重症病例营养状况提高免疫功能,降低并发症发生率,对有部分或全部胃肠功能的危重症病例,应尽量早期采用.     

Epidemiological study of gastro-oesophageal reflux disease: reflux in spouse as a risk factor

Background  Gastro-oesophageal reflux disease (GERD) is a growing health-care problem with variable distribution.
Aim  To assess GERD prevalence and risk factors and their possible correlation with pathophysiology in a population-based study.
Methods  Individuals aged 18–65 years were enrolled through random cluster sampling in Tehran. Previously validated self-administered questionnaires were used.
Results  Of the 2500 questionnaires, 2057 were analysed (mean age: 34.8 ± 13.0 years, 55.1% female). Frequent GERD was seen in 18.2%. Minor symptoms increased prevalence. Female gender (OR: 1.55, 95% CI: 1.01–2.41), BMI >30 kg/m² (OR: 1.79, 95% CI: 1.03–3.12), less education (OR: 1.52, 95% CI: 1.02–2.27), smoking (OR: 1.83, 95% CI: 1.12–2.99), NSAID use (OR: 4.23, 95% CI: 1.66–10.74) and GERD in spouse (OR: 1.82, 95% CI: 1.18–2.82) were associated with frequent GERD on multivariable analysis. GERD in first-degree relatives (OR: 1.73, 95% CI: 1.23–2.43) and asthma (OR: 4.09, 95% CI: 1.27–13.15) correlated with infrequent GERD. Minor symptoms correlated with GERD history in first-degree relatives, coffee consumption and NSAID use. Prevalence in the past 3 months was similar to that in the past 12 months ( P  < 0.05).
Conclusions  Gastro-oesophageal reflux disease is common in Tehran. The association of 'infrequent symptoms' with GERD history in first-degree relatives and 'frequent symptoms' with GERD history in spouse may point to the presence of yet unknown precipitating environmental factors inducing GERD in a genetically susceptible host. Minor GERD symptoms seem to have independent contribution to GERD. Assessing GERD in the past 3 months predicts prevalence in the past year.     

Perfil de uso de los diferentes tipos de nutrición artificial en un hospital de agudos y de crónicos

ObjectiveTo evaluate the use of parenteral, enteral, and mixed nutrition in one acute and one chronic hospital.DesignRetrospective, non-randomised, observational study.Study sitesSouth Seville Health Area: Acute Hospital (H1) and Chronic Hospital (H2) with 447 and 84 beds, respectively.We analysed all episodes of artificial nutrition administered in a 6-month period. Exclusion criteria included: age <18 years, oral supplements, and peripheral nutrition.ResultsArtificial nutrition was used in a total of 568 episodes: 406 were enteral nutrition, 162 were parenteral nutrition, constituting 4.95%, 3.54% and 1,41% of all hospitalisations, respectively. Enteral nutrition was more common at H2 hospital (n = 219, 15.5/100 hospitalisations) and parenteral nutrition was more commonly used at H1 (n = 155, 6.96/100 hospitalisations), with the ICU providing the majority of treatments (43.8%).Mixed nutritional support was used in 68 patients (0.59% of all cases), and was most commonly used in the surgery department (n = 32, P<.001). The most commonly used enteral formula was the special diabetes diet; 41.2% at H1 and 46.6% at H2. Patient mortality with enteral nutrition was 37% at H1, 63% at H2, and was correlated with age (OR = 1.025, 95% CI: 1.006-1.046, P<.05), male sex (OR = 1.612, 95% CI: 1.023-2.540, P<.05), and time in ICU (OR = 49.379, 95% CI: 11.971-203.675, P<.01).ConclusionsEnteral nutrition was more frequently used in both the acute and chronic hospitals. Parenteral nutrition and mixed nutritional support were used almost exclusively at the acute hospital.     

Meta-analysis: nitroglycerin for prevention of post-ERCP pancreatitis

Background  Acute pancreatitis after ERCP is a severe side effect.
Aim  To evaluate the preventive effect of nitroglycerin on post-ERCP pancreatitis by a meta-analysis of randomized clinical studies.
Methods  We searched on Pubmed, Embase, Cochrane Library and all abstracts presented at Digestive Disease Week and United European Gastrointestinal Week from 2004 to 2008. We used the MeSH terms 'pancreatitis' together (AND) with the terms: 'glyceryl trinitrate', 'glyceryl dinitrate', 'isosorbide dinitrate' or 'nitroglycerin'.
Results  Five clinical studies evaluating the incidence of post-ERCP pancreatitis after administration of nitroglycerin were identified. Meta-analysis including all five studies showed a relative risk (RR) of 0.61 (95% CI; 0.44, 0.86) with the number needed to treat (NNT) of 26 (95% CI: 16, 82). Three studies evaluated nitroglycerin administered by a dermal patch reaching together an RR of 0.66 (95% CI; 0.43, 1.01). The use of nitroglycerin is associated with a significantly increased risk of hypotension (RR 2.25) and headache (RR 3.64). No difference in mortality was observed.
Conclusions  Overall, our meta-analysis supports the use of nitroglycerin in the prevention of post-ERCP pancreatitis, but administration of nitroglycerin by the dermal route, which is the preferred route of administration, did not reach statistical significance.