Symptomatic and physiologic outcomes after operative treatment for extraesophageal reflux

Background: Pharyngeal pH monitoring has recently been used to identify patients with extraesophageal symptoms induced by gastroesophageal reflux. We employed this method of acid detection to evaluate patients with respiratory symptoms prior to and after laparoscopic Nissen fundoplication to further elucidate the relationship between GERD and respiratory symptoms. Methods: Twenty-one consecutive patients with extraesophageal symptoms thought to be caused by reflux underwent symptomatic and functional evaluation (esophageal manometry and 24-h pH monitoring with a pharyngeal probe) before and after laparoscopic Nissen fundoplication. Episodes of pharyngeal acid exposure were considered abnormal if the pH dropped below 4, occurred simultaneously with esophageal acidification, and occurred outside meal times. Results: All patients had gastroesophageal reflux disease (GERD) and respiratory symptoms; nine of 15 (60%) had evidence of pharyngeal reflux preoperatively. Antireflux procedures resulted in a significant decrease in pharyngeal reflux (7.9 to 1.6 episodes/24h; p <0.05) and esophageal acid exposure (7.5% to 2.1%; p <0.05). In patients with pharyngeal reflux and complete postoperative testing, three (60%) obtained improvement of respiratory symptoms and resolution of pharyngeal reflux. In two patients with recurrent respiratory symptoms after surgery, persistent pharyngeal reflux was detected. Conclusions: Operative treatment of GERD is effective in controlling extraesophageal reflux, measured subjectively and objectively. Evidence of pharyngeal reflux on pH testing helps to identify which patients with respiratory symptoms will benefit from an antireflux procedure.     

Androgenic regulation of growth factor and growth factor receptor expression in the CWR22 model of prostatic adenocarcinoma.

The effects of androgen manipulation on epidermal growth factor (EGF) receptor, p185erbB-2 and transforming growth factor-alpha (TGF-alpha) levels were examined in prostatic adenocarcinoma. Male nude mice were inoculated with the CWR22 androgen-dependent human prostatic tumor or an androgen-independent (CWR22R) derivative. Mice with CWR22 tumors were castrated and subsequently killed at 3, 7, 21, 28 or 42 days post-castration. Other CWR22-bearing mice received s.c. testosterone pellets at 21 days post-castration and were killed 7 days later. EGF receptor, p185erbB-2 and TGF-alpha levels were examined by immuno-histochemistry. Strong EGF receptor and p185erbB-2 immunostaining was detected in CWR22 tumors from intact controls. EGF receptor immunostaining decreased by 65% to 70% at 21 to 42 days post-castration. Testosterone treatment at 21 to 28 days post-castration resulted in a 2-fold increase in EGF receptor immunostaining. p185erbB-2 immunostaining within CWR22 tumors did not decrease following castration and, in fact, was slightly increased at 7 days post-castration. The effects of castration on EGF receptor and p185erbB-2 levels were confirmed by Western blot analysis. Fewer than 10% of CWR22 tumor cells demonstrated strong TGF-alpha immunostaining, and androgen manipulation did not effect TGF-alpha immunostaining. In contrast, 30% of androgen-independent CWR22R tumor cells were strongly immunostained for TGF-alpha. Our findings indicate that EGF receptor levels, but not p185erbB-2 levels, are strongly dependent on testosterone in CWR22 tumors. The co-localization of TGF-alpha and the EGF receptor in CWR22R tumors suggests that these factors may constitute an autocrine pathway that regulates androgen-independent growth.     

MID-TRIMESTER MTP USING ENDOCERVICAL PGE2 GEL AND SERIAL INTRAMUSCULAR CARBOPROST

60 cases of mid-trimester pregnancy were terminated using endocervical PGE₂ gel (for achieving cervical priming) followed by serial intramuscular injections of carboprost. In this prospective study, 56 cases were multiparae with gestational age varying between 15-22 weeks. The induction-abortion-interval was 8.4h ± 0.8h with a success rate of 100%. The incidence of incomplete abortion was 5% and check curettage was performed in 16.6% cases. Gastrointestinal side effects were common. Vomiting occurred in 42% cases and diarrhoea in 50%. Febrile morbidity was seen in 8.3% cases. There were no complications of the procedure. The method was highly acceptable to the patients being non-invasive and allowing ambulation throughout. This method of elective mid-trimester abortion is an effective alternative to the other commonly used methods like extra-amniotic ethacridine lactate or intra-amniotic hypertonic saline instillation.KEY WORDS: Carboprost, Mid-trimester abortion, PGE₂     

Intravenous calcitriol regresses myocardial hypertrophy in hemodialysis patients with secondary hyperparathyroidism

To evaluate the response of circulating intact parathyroid hormone (iPTH) on myocardial hypertrophy in hemodialysis (HD) patients with secondary hyperparathyroidism (SHPT), echocardiographic and neurohormonal assessments were performed over a 15-week period in 15 HD patients with SHPT before and after calcitriol treatment and 10 HD control patients with SHPT not receiving calcitriol therapy. We prospectively studied a group of 15 patients with significantly elevated iPTH levels (iPTH >450 pg/mL) receiving calcitriol (2 microg after dialysis twice weekly). Clinical assessment, medication status, and biochemical and hematological measurements were performed once a month. Throughout the study, calcium carbonate levels were modified to maintain serum phosphate levels at less than 6 mg/dL, but body weight, antihypertensive medication, and ultrafiltration dose remained constant. In patients treated with calcitriol, an adequate reduction of iPTH levels was found (1,112 +/- 694 v 741 +/- 644 pg/mL; P < 0.05) without changes in values of serum ionized calcium (iCa++), phosphate, or hematocrit. Blood pressure (BP), cardiac output (CO), and total peripheral resistance (TPR) did not significantly change. After 15 weeks of treatment with calcitriol, M-mode echocardiograms showed pronounced reductions in interventricular wall thickness (13.9 +/- 3.6 v 12.8 +/- 3.10 mm; P = 0.01), left ventricular posterior wall thickness (12.5 +/- 2.4 v 11.3 +/- 1.8 mm; P < 0.05), and left ventricle mass index (LVMi; 178 +/- 73 v 155 +/- 61 g/m2; P < 0.01). However, in control patients, these changes were not found after the treatment period. In addition, sequential measurements of neurohormonal mediator levels in patients receiving calcitriol showed that plasma renin (18.5 +/- 12.7 v 12.3 +/- 11.0 pg/mL; P = 0.007), angiotensin II (AT II; 79.7 +/- 48.6 v 47.2 +/- 45.7 pg/mL; P = 0.001), and atrial natriuretic peptide (ANP; 16.6 +/- 9.7 v 12.2 +/- 4.4 pg/mL; P = 0.03) levels significantly decreased, whereas antidiuretic hormone (ADH), epinephrine, and norepinephrine levels did not change significantly. The percent change in LVMi associated with calcitriol therapy had a strong correlation with the percent change in iPTH (r = 0.52; P < 0.05) and AT II (r = 0.47; P < 0.05) levels. We conclude that the partial correction of SHPT with intravenous calcitriol causes a regression in myocardial hypertrophy without biochemical or hemodynamic changes, such as heart rate, BP, and TPR. The changes in plasma levels of iPTH and, secondarily, plasma levels of neurohormones (especially AT II) after calcitriol therapy may have a key role in attenuating ventricular hypertrophy in SHPT.     

CHANGES IN THE USE OF EEG FOLLOWING CLINICAL AUDIT

SUMMARY An audit of the clinical use of EEG in mentally handicapped patients was performed over a three-year period. EEG requests seemed inappropriate in more than one-quarter of cases. Changes in clinical practice during the 10 months following presentation of these audit results were examined. There was a marked reduction in EEG requests, which were subsequently used in a more cost-effective and clinically appropriate way. There was also a reduction in the time taken to process requests.     

Incipient ovarian failure associated with raised levels of follicle stimulating hormone and reduced levels of inhibin A in older sheep

In women there is a gradual rise in the basal level of follicle stimulating hormone (FSH) in the years prior to the menopause (pre- menopause) which is thought to be due to a relative lack of ovarian factors reflecting the number of antral follicles present in the ovaries. Experimental animal models for this phenomenon, particularly in mono-ovulatory species, have been lacking due to most animals' relatively short life span. We have available a group of experimental ewes in which the right ovary was removed and the left ovary was autotransplanted to the neck at least 10 years previously, which have been maintained in good health until an age of 12-13 years. Two experiments were conducted with these animals to determine the endocrine and follicular effects of age: a retrospective experiment in the same Finn-Merino ewes (n = 5) when the animals were 6-7 or 12-13 years of age; and a cohort experiment in old (12-13 years, n = 6) and young (2 years, n = 5) ewes of the same breed. In both retrospective and cohort experiments, the concentrations of FSH were significantly higher (P < 0.05) in older animals during the luteal phase when oestradiol secretion was low. This increase in FSH was associated with a decrease in the concentration of inhibin A (P < 0.05) in older animals in both the follicular and luteal stages of the cycle but the concentrations of oestradiol were similar between ages. Although there were significantly fewer antral follicles (P < 0.05) available for development in older ewes during the early luteal phase of the cycle, the ovulation rate was similar to that observed in younger animals (2.0+/-0 vs 2.0+/-4; P > 0.05) but the interval from luteal regression to the onset of the LH surge was longer (P < 0.05) in older animals. In conclusion, the endocrine changes associated with increasing reproductive age in sheep are therefore similar to those observed in women, suggesting that the sheep could be a useful animal model to study the effect of age on human fertility.      

Urinary N-acetyl-beta -D-glucosaminidase and its isoenzymes A & B in workers exposed to cadmium at cadmium plating

Objective  

The present study was carried out to determine the effect of cadmium exposure on Urinary N-acetyl-beta -D-glucosaminidase and its isoenzymes A and B in workers exposed at cadmium plating.     

Complete Regression of Barrett's Esophagus after Roux-en-Y Gastric Bypass

Regression of Barrett's esophagus may occur after effective anti-reflux surgery. Roux-en-Y gastric bypass (RYGBP) is an effective operation to treat morbid obesity. In addition, it provides complete relief of gastroesophageal reflux disease (GERD). Regression of Barrett's has not been reported after RYGBP. We performed a laparoscopic Roux-en-Y gastric bypass on a patient with GERD and Barrett's esophagus. At 1 year after the RYGBP, an upper endoscopy was performed as routine surveillance for the patient's Barrett's esophagus; endoscopic and histologic evaluation demonstrated complete regression of the Barrett's esophagus. The patient lost one-third of her preoperative weight and had resolution of her reflux symptoms. RYGBP limits the amount of acid reflux and completely diverts bile away from the esophagus. This may lead to the regression of Barrett's esophagus.