Long-Term Follow-up of Barrett’s Epithelium: Medical Versus Antireflux Surgical Therapy

Background

Barrett??s esophagus (BE) is the most serious complication of GERD. In BE patients, this observational study compares the effects of antireflux surgery versus antisecretory medical therapy.

Methods

Overall, 89 BE patients (long BE?=?45; short BE?=?44) were considered: 45 patients underwent antireflux surgery and 44 underwent medical therapy. At both initial and follow-up endoscopy, symptoms were assessed using a detailed questionnaire; BE phenotypic changes [intestinal metaplasia (IM) presence/type, Cdx2 expression] were assessed by histology (H&E), histochemistry (HID), and immunohistochemistry. Surgical failures were defined as follows: (1) abnormal 24-h pH monitoring results after surgery, (2) endoscopically evident recurrent esophagitis, and (3) recurrent hiatal hernia or slipped fundoplication on endoscopy or barium swallow.

Results

Reversion of IM was observed in 12/44 SSBE and 0/45 LSBE patients (p?<?0.01). Reversion was more frequently observed after effective antireflux surgery than after medical treatment (p?=?0.04). In patients with no further evidence of IM after therapy, Cdx2 expression was also absent (p?=?0.02). The extent of IM was reduced, and the IM phenotype improved in SSBE patients after surgery.

Conclusions

Patients with short BE (but not those with long BE) may benefit from surgically reducing the esophagus?? exposure to GE reflux; among these patients, successful surgery carries a higher IM reversion rate than medical treatment.     

Efficacy and safety of caspofungin for treatment of invasive aspergillosis in patients refractory to or intolerant of conventional antifungal therapy

BACKGROUND: Invasive aspergillosis (IA) is an important cause of morbidity and mortality among immunocompromised patients. Echinocandins are novel antifungal molecules with in vitro and in vivo activity against Aspergillus species. METHODS: We investigated the efficacy and safety of caspofungin in the treatment of IA. Ninety patients with IA who were refractory to or intolerant of amphotericin B, lipid formulations of amphotericin B, or triazoles were enrolled to receive caspofungin. RESULTS: Efficacy was assessed for 83 patients who had infection consistent with definitions of IA and who received >or=1 dose of study drug. Common underlying conditions included hematologic malignancy (48% of patients), allogeneic blood and marrow transplantation (25% of patients), and solid-organ transplantation (11% of patients). Seventy-one patients (86%) were refractory to and 12 patients (14%) were intolerant of previous therapy. A favorable response to caspofungin therapy was observed in 37 (45%) of 83 patients, including 32 (50%) of 64 with pulmonary aspergillosis and 3 (23%) of 13 with disseminated aspergillosis. Two patients discontinued caspofungin therapy because of drug-related adverse events. Drug-related nephrotoxicity and hepatotoxicity occurred infrequently. CONCLUSION: Caspofungin demonstrated usefulness in the salvage treatment of IA.     

Analysis of the criteria used for the definition of metabolic syndrome in patients with type 2 diabetes mellitus

The aim was to compare in patients with type 2 diabetes mellitus (DM2) the prevalence of the metabolic syndrome according to the World Health Organization (WHO) and the National Cholesterol Education Program (NCEP) definitions, and to analyze the association between them and the complications of DM2. Patients with DM2 (n= 753) were evaluated for ethnics, anthropometrics and laboratory parameters and for the presence of DM2 complications: diabetic nephropathy, coronary artery disease, stroke, diabetic retinopathy and peripheral vascular disease. Insulin resistance was estimated using the HOMA index. Metabolic syndrome was found in 671 (89%) and 657 (87%) patients using the WHO definition and the NCEP definition, respectively. In the total group, there was a moderate agreement between the two definitions (k= 0.54; 95% CI 0.49-0.59), although, it was better for black patients (k= 0.69; 95% CI 0.60-0.78) than white (k= 0.54; 95% CI 0.48-0.6) or mulattos patients (k= 0.26; 95% CI 0.09-0.43). Patients with metabolic syndrome using the NCEP criteria had higher HOMA-IR values compared to those without metabolic syndrome (p= 0.001). This differentiation was not seen using the WHO definition (p= 0.152). The proportion of diabetic complications was similar for both definitions. In conclusion, regarding the risk of diabetic complications both definitions are equivalent. However, there are some ethnic differences in the agreement between the two definitions.     

Hypovitaminosis D in an hospitalized old population of Western Friuli

Objectives Hypovitaminosis D is very common in the elderly in Italy and generally in the world, contributing to bone fractures and muscle weakness. The aim of the study was to evaluate bone metabolism in an old population of patients hospitalized not for musculo-skeletal complaints. Methods The clinical records of 175 patients, 98 female and 77 male, aged >65 years, hospitalized in a Department of Internal Medicine (Sacile, Western Friuli) were retrospectively reviewed. Serum levels of calcium, phosphorous, alkaline phosphatase, parathyroid hormone (PTH) and 25-OH vitamin D were evaluated. Correlations between these parameters were investigate. Results Abnormalities of bone metabolism parameters were frequently founded, particularly hypocalcemia, increased PTH and reduced 25-OH vitamin D. Hypovitaminosis D were detected in 88% of patients, low levels in 30.28% and very low levels in 57.72%. Hypovitaminosis D was related to female sex, old age of patients and high levels of PTH. Conclusions Our data confirm that hypovitaminosis D is very common in elderly population. The study has been performed in an Italian Region where the supplementation of vitamin D in the elderly is not performed, suggesting that a awareness campaign of the doctors could be very useful to prevent bone metabolism abnormalities.     

Autism and esophageal achalasia in childhood: a possible correlation? Report on three cases

Chronic gastrointestinal symptoms are commonly reported in autistic patients. Dysphagia is often present, and it is generally related to behavioral eating disorders. The association between autism and esophageal achalasia has not been described in literature yet. We report our experience with three cases of autistic children we recently treated for esophageal achalasia. In the first case (a 14‐year‐old male), achalasia was diagnosed with barium swallow and esophageal manometry and was successfully treated with three pneumatic endoscopic dilatations (follow‐up: 3 years). In the second case (a 12‐year‐old female), achalasia was diagnosed with barium swallow and esophageal manometry and was treated with Heller myotomy after two unsuccessful pneumatic endoscopic attempts (follow‐up: 3 months). In the last case, a 15‐year‐old male underwent barium swallow and endoscopy that confirmed achalasia. He was treated with Heller myotomy, and he is asymptomatic at a 6‐month follow‐up. To our knowledge, this is the first report of a possible association between autism and esophageal achalasia. Because of the rarity of both diseases, their association in the same patient is unlikely to be casual even if speculation on their common etiology is impossible at present. This finding needs further confirmation, but it is sufficient, in our opinion, to indicate proper evaluation with barium swallow and/or manometry in any autistic children with eating difficulty.