Review article: cardiac adverse effects of gastrointestinal prokinetics

Gastrointestinal prokinetics, such as metoclopramide, cisapride and levosulpiride, are widely used for the management of functional gut disorders. Recently, several studies have shown that cisapride (a partial 5-HT4 receptor agonist) can induce dose-dependent cardiac adverse effects, including lengthening of the electrocardiographic QT interval, syncopal episodes and ventricular dysrhythmias. Until recently, it was not clear whether these effects were dependent on 5-HT4 receptor activation or related to peculiar characteristics in the molecular structure of single agents within the benzamide class. Experimental evidence now favours the second hypothesis: cisapride possesses Class III antiarrhythmic properties and prolongs the action potential duration through blockade of distinct voltage-dependent K+ channels, thus delaying cardiac repolarization and prolonging the QT interval. Patients at risk of cardiac adverse effects are children, subjects with idiopathic, congenital or acquired long QT syndrome and, in particular, those receiving concomitant medication with Class III antiarrhythmic agents, some H1-receptor antagonists (e.g. terfenadine), or drugs such as azole antifungals (e.g. ketoconazole, itraconazole, miconazole and fluconazole) and macrolide antibacterials (e.g. erythromycin, clarithrod-mycin and troleandomycin), which can inhibit cisapride metabolism by interfering with the CYP3A4 isoenzyme.     

Debris-Filled Duodenal Diverticulum and Lemmel’s Syndrome

Digestive Diseases and Sciences - We report a case of a 73-year-old woman affected by Lemmel’s syndrome, a rare type of obstructive jaundice caused by a periampullary duodenal diverticulum....     

Improving opportunities for effective management of gastro-oesophageal reflux disease

The recent introduction of proton pump inhibitors has extraordinarily improved the therapeutic approach to gastro-oesophageal reflux disease. The concept of decreasing gastric acid secretion and increasing the pH in the lower oesophagus has been demonstrated to be therapeutically effective and the higher the level of pH achieved, the better the results. In spite of the evident efficacy of these molecules, there are still many patients who will continue to have symptoms despite medical treatment. Proton pump inhibitors suppress gastric acidity, but this effect shows a remarkable interindividual variation depending on different reasons. Thus, it is still possible to optimise medical therapy for gastro-oesophageal reflux disease. Esomeprazole, the S-isomer of omeprazole, has an advantageous metabolism and this particular feature translates into superior clinical efficacy. Clinical trials for initial and long-term treatment across the gastro-oesophageal reflux disease spectrum, have clearly demonstrated the superiority of esomeprazole over omeprazole, even if tolerability and safety are very similar.     

Comparison between a built-in "dual side" chest imaging device and a standard "single side" CR

An integrated readout computed radiography system (Fuji XU-D1) incorporating dual-side imaging plates (ST-55BD) was analyzed in terms of modulation transfer function (MTF), noise power spectrum (NPS), and detective quantum efficiency (DQE) for standard beam qualities RQA 9 and RQA 5. NPS and DQE were assessed using a detector entrance air kerma consistent with clinical practice for chest radiography. Similar investigation was performed on a standard reader (Fuji FCR 5000) using single-side imaging plates (ST-VI). Negligible differences were found between the MTFs of the two imaging systems for RQA 9, whereas for RQA 5 the single-side system exhibited slightly superior MTF. Regarding noise response, the dual-side system turned out to be better performing for both beam qualities over a wide range of frequencies. For RQA 9, at 8 microGy, the DQE of the dual-side system was moderately higher over the whole frequency range, whereas for RQA 5, at 10 microGy, significant improvement was found at low- and midrange frequencies. As an example, at 1 cycle/mm, the following improvements in the DQE of the dual-side system were observed: +22% (RQA 9, at 8 microGy), +50% (RQA 9, at 30 microGy), and +45% (RQA 5, at 10 microGy).     

Optimizing acitretin use in patients with plaque psoriasis

Acitretin is one of the systemic agents used for the treatment of psoriasis. Because different acitretin dosages resulted therapeutically successful, there is no general agreement on the optimal dose regimen. To report acitretin efficacy and safety in a real‐life setting, wherein patient‐tailored dose regimen is usually prescribed, a retrospective analysis evaluating charts of all plaque‐type psoriasis patients treated with acitretin from the clinic database was performed. PASI score improvement, as well as PASI 50, 75, 90, and 100 responses were assessed throughout the observational period. Overall, 52% PASI score reduction and a satisfactory safety profile were detected. PASI 50, 75, 90, and 100 response was achieved by 53%, 48%, 28%, and 14%, respectively. Treatment consisted on a mean daily acitretin dose of 25.01 mg. The initial dose was increased (51.2% of cases) or decreased (48.8%) prescribing a mean daily dose of 29.8 mg and 20.02 mg, respectively. This study proposed a dose regimen customized on clinical response and patient's needs, to optimized acitretin benefit.     

Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation

Background Neoadjuvant therapies have significantly improved local control and survival of patients with rectal cancer. Nevertheless, although a complete pathologic response can be achieved in 30% of cases, a transabdominal surgical resection is always required. This study aimed, for the first time, to test in the literature the feasibility of local excision combined with transanal endoscopic microsurgery (TEM) as a surgical option for patients treated with neoadjuvant chemoradiation. Methods Between July 1997 and December 2002, 30 patients with rectal cancer affected by an extraperitoneal tumor entered a protocol consisting of neoadjuvant chemoradiation followed by surgery. The surgical treatment, consisting of open surgery, local excision, or TEM, was planned according to the patient’s clinical response after chemoradiation and distance from the anal verge. Results A significant clinical downstaging was observed in eight patients. Five of these patients underwent TEM, and three had local excision. Consequently, open surgery was performed for 22 patients. Histology showed six cases of complete pathologic response: three in the open surgery group and three in the transanal excision group. After a mean follow-up period of 47 months, the disease-free survival rate was 77% in the open surgery group and 100% in TEM or local excision group. Conclusions The findings suggest the complementary feasibility of TEM and local excision after neoadjuvant chemoradiation. However, randomized trials are needed to confirm the oncologic safety of this approach.