Obstructive jaundice secondary to benign hepatic cyst

A case of hepatic cyst causing obstructive jaundice is presented. Following percutaneous aspiration of the cyst, the jaundice was relieved. Modern interventional radiologic techniques can provide prompt diagnosis and treatment, thus avoiding major surgery and prolonged hospitalization.     

Comprehension and awareness of symptoms in women with dyspepsia

BACKGROUND: Overlapping symptoms of gastro-oesophageal reflux disease and dyspepsia are a problem for physicians and patients. AIM: This study explored comprehension of dyspepsia symptoms and associated medical terminology among women with symptoms of dyspepsia. METHODS: The US women aged > or = 18 years with dyspepsia (defined by Rome II criteria) were recruited in two phases, via direct mail, the Internet, clinical investigators and/or gastroenterologists. In phase I, subjects took part in an hour-long telephonic interview comprising open-ended questions relating to symptom frequency/duration, triggers/patterns and severity. During phase II, subjects took part in a 45-min telephonic interview, which explored their understanding of dyspepsia symptoms and their predominant or most bothersome symptom. RESULTS: Subjects with 'pure' dyspepsia (without overlapping symptoms of gastro-oesophageal reflux disease or irritable bowel syndrome) were sought, but of 777 subjects screened, most were excluded because of gastrointestinal comorbidities (irritable bowel syndrome, gastro-oesophageal reflux disease). Only 85 (11%) subjects had 'pure' dyspepsia of whom 11 withdrew. Of the 74 subjects interviewed, 70% were unfamiliar with the term 'dyspepsia'. Subjects reported several symptoms, including bloating (65%), gas (50%), nausea (41%) and discomfort (36%). Most subjects could distinguish between symptom bothersomeness and severity, and between pain and discomfort. Terms such as 'satisfactory relief', 'central upper abdominal discomfort', 'early satiety' and 'postmeal fullness' were often misunderstood. CONCLUSIONS: Subjects with 'pure' dyspepsia are rare, because of comorbidities. Dyspepsia-related terminology is often misunderstood by subjects.     

Effect of cholesterol on the release of amphotericin B from PEG-phospholipid micelles

Micelles formed from PEG-DSPE solubilize high levels of the poorly water-soluble antifungal amphotericin B (AmB). AmB release from PEG-DSPE micelles is slow in buffer but remarkably rapid in the presence of bovine serum albumin (BSA). Sequential changes in the absorbance spectrum of AmB in PEG-DSPE micelles point to a rapid dissociation of incorporated drug in the presence of BSA. In this context, we have studied micelles formed from PEG-DSPE which coincorporate cholesterol (PEG-DSPE|cholesterol). (1)H NMR measurements point to a lower mobility of lipid in PEG-DSPE|cholesterol micelles compared to PEG-DSPE micelles. The absorbance spectrum of AmB incorporated in PEG-DSPE|cholesterol micelles is distinct from that in PEG-DSPE micelles, which may point to differences in the drug-micelle interaction. AmB release from PEG-DSPE|cholesterol micelles is slow in buffer and in the presence of BSA. The absorption spectrum of AmB in PEG-DSPE|cholesterol micelles remained unchanged in BSA, further supporting stable incorporation and the slow release from the carrier.     

Clinical trial design in adult reflux disease: a methodological workshop

Background  The development of well-tolerated acid suppressant drugs has stimulated substantial growth in the number of trials assessing therapy options for gastro-oesophageal reflux disease (GERD).
Aim  To develop consensus statements to inform clinical trial design in adult patients with GERD.
Methods  Draft statements were developed employing a systematic literature review. A modified Delphi process including three rounds of voting was used to reach consensus. Between voting, statements were revised based on feedback from the Working Group and additional literature reviews. The final vote was at a face-to-face meeting that included discussion time. Voting was conducted using a six-point scale.
Results  At the last vote, 93% of the final 102 statements achieved consensus (defined a priori as being supported by ≥75% of the votes). The Working Group strongly supported the development of validated patient-reported outcome instruments. Symptom assessments carried out by the investigator were considered unacceptable. There was agreement that exclusion from clinical trials should be minimized to improve generalizability, that prospective evaluation ideally requires electronic timed/dated methods and that endoscopists should be blinded to patient symptom status.
Conclusions  Implementation of the consensus statements will improve the quality and comparability of trials, and make them compatible with regulatory requirements.     

Review article: Helicobacter pylori and reflux disease

The falling prevalence of Helicobacter pylori infection and related diseases (peptic ulcer disease, gastric cancer) in developed countries has been paralleled by an increased recognition of gastro-oesophageal reflux and its complications. These epidemiological data do not support a role for H. pylori in the pathogenesis of reflux disease, but suggest a negative association with the increasing incidence of oesophageal diseases. This has led some investigators to propose a 'protective' role of H. pylori infection against the development of oesophageal diseases. In these patients, pre-existing lower oesophageal sphincter dysfunction, susceptibility to reflux, unmasking of latent reflux and the patterns and severity of gastritis are probably important factors contributing to the development of oesophageal diseases. The most likely mechanism by which H. pylori infection may protect against reflux is by decreasing the potency of the gastric refluxate in patients with corpus-predominant gastritis. The prevalence of H. pylori infection in patients with reflux disease is probably no greater than that in those without reflux, and there are conflicting data indicating that reflux symptoms or erosive oesophagitis develop after H. pylori eradication. It is also unclear whether H. pylori augments the antisecretory effects of proton pump inhibitors or accelerates the development of atrophic gastritis.     

Prospective randomized controlled trial of an injectable esophageal prosthesis versus a sham procedure for endoscopic treatment of gastroesophageal reflux disease

Background

This study aimed to assess whether endoscopic implantation of an injectable esophageal prosthesis, the Gatekeeper Reflux Repair System (GK), is a safe and effective therapy for controlling gastroesophageal reflux disease (GERD).

Methods

A prospective, randomized, sham-controlled, single-blinded, international multicenter study planned final enrollment of 204 patients in three groups: up to 60 lead-in, 96 GK, and 48 sham patients. The sham patients were allowed to cross over to the GK treatment arm or exit the study at 6 months. The primary end points were (1) reduction in serious device- and procedure-related adverse device effects compared with a surgical composite complication rate and (2) reduction in heartburn symptoms 6 months after the GK procedure compared with the sham procedure. The secondary end point was improved esophageal pH (total time pH was <4) 6 months after the GK procedure compared with baseline.

Results

A planned interim analysis was performed after 143 patients were enrolled (25 lead-in, 75 GK, and 43 sham patients), and the GK study was terminated early due to lack of compelling efficacy data. Four reported serious adverse events had occurred (2 perforations, 1 pulmonary infiltrate related to a perforation, and 1 severe chest pain) at termination of the study with no mortality or long-term sequelae. Heartburn symptoms had improved significantly at 6 months compared with baseline in the GK group (p < 0.0001) and the sham group (p < 0.0001), but no significant between-group difference in improvement was observed (p = 0.146). Esophageal acid exposure had improved significantly at 6 months compared with baseline in the GK group (p = 0.021) and the sham group (p = 0.003), but no significant between-group difference in improvement was observed (p = 0.27).

Conclusions

The GK procedure was associated with some serious but infrequent complications. No statistically significant difference in outcomes was observed between the treatment and control groups at 6 months compared with baseline.     

Exploring the oral bacterial flora: current status and future directions

Oral Diseases (2010) 16 , 136–145 Objective: The oral cavity forms an indispensable part of the human microbiome, for its unique and diverse microflora distributed within various niches. While majority of these organisms exhibit commensalism, shifts in bacterial community dynamics cause pathological changes within oral cavity and distant sites. The aim of this review was to appraise the current and emerging methods of detecting bacteria of the oral cavity paying particular attention to the cultivation independent methods. Design: Literature pertaining to cultivation based and cultivation independent methods of oral bacterial identification was reviewed. Methods: The specific advantages and disadvantages of cultivation based, microscopic, immunological and metagenomic identification methods were appraised. Results: Because of their fastidious and exacting growth requirements, cultivation based studies grossly underestimate the extent of bacterial diversity in these polymicrobial infections. Culture independent methods deemed more sensitive in identifying difficult to culture and novel bacterial species. Conclusion: Apart from characterizing potentially novel bacterial species, the nucleic acid sequence data analyzed using various bioinformatics protocols have revealed that there are in excess of 700 bacterial species inhabiting the mouth. Moreover, the latest pyrosequencing based methods have further broadened the extent of bacterial diversity in oral niches.     

Approach to gastroesophageal reflux disease in primary care: Putting the Montreal definition into practice

OBJECTIVE

To apply the recently published Montreal definition of gastroesophageal reflux disease (GERD) in primary care.

SOURCES OF INFORMATION

The Montreal definition of GERD was developed by an international consensus group of experts in GERD and primary care physicians using rigorous evidence-based methods along with modern consensus development techniques and a patient-centred approach.

MAIN MESSAGE

Gastroesophageal reflux disease can be diagnosed in primary care based on symptoms alone without additional diagnostic testing. Symptoms reach a threshold where they constitute disease when they are troublesome (cause difficulty) to patients. In addition to the cardinal symptoms of heartburn and regurgitation, people with GERD can also have sleep disturbances, chest pains, or respiratory symptoms. Monitoring patients’ response to proton pump inhibitor therapy can confirm the success of management. Treatment for symptoms of GERD can also heal underlying reflux esophagitis if it is present.

CONCLUSION

Primary care physicians can diagnose and manage GERD confidently in most patients by investigating and treating troublesome symptoms without the need for additional investigations or referral to specialists.