Esophageal achalasia and pregnancy: own observations in 43 patients and a review of the literature

Introduction

Little is known concerning the interaction of achalasia and pregnancy and about an optimal time and type for treatment. Achalatic women of our collective of patients with at least one pregnancy in their history resulting in confinement or miscarriage were invited for a structured interview.

Materials and methods

43 of 109 female patients were included. Questionnaire contained questions on symptoms, type of symptoms, whether patients could link a specific event with outbreak of disease. Date of primary diagnosis and individual therapies were double checked against our documentation as well as duration of complaints and kind of therapy. Patients were asked about their obstetric history, whether and how symptoms had changed, and during which pregnancy week symptoms have occurred. Temporal correlation of the diagnosis of achalasia and pregnancy was investigated.

Results

There was no relationship between pregnancy and onset of achalasia. Risk of subfertility, undernourishment, premature birth, or miscarriage does not seem to be increased in achalasia. Health condition often worsened significantly during pregnancy, mainly in the first trimester and particularly in the untreated patients.

Conclusions

It is advisable to clarify the diagnosis if symptoms suspicious of an achalasia are present before a planned pregnancy. In case of manifest achalasia, surgical treatment should be performed before pregnancy and the improvement in the state of health should be anticipated, as, otherwise, a considerable deterioration of the symptoms during pregnancy may occur. Scientific impact of our observations is very limited and prospective clinical trials are required.

     

Zinc and Spinal Cord Injury: A Review

Abstract

Everything that is living needs zinc. Because of its multiple cellular functions, many symptoms and signs have been associated with zinc deficiency in humans including poor wound healing, rashes, diarrhea, decreased sexual function, and growth retardation. These problems are usually caused by other factors and indiscriminate use of zinc supplements is associated with some risk. Because inaccurate diagnosis can prevent alternative appropriate therapy and evidence is lacking that zinc supplementation beyond normal levels is generally beneficial, zinc status should be assayed prior to its administration; serum-zinc levels are the easiest method obtainable. A normal value is strong evidence against zinc deficiency (unless zinc replenishment has just been initiated); a single depressed value, however, may reflect the body’s response to stress and not true zinc deficiency. A single low value in an acutely stressed patient should be interpreted with caution and repeated in several days. Symptoms and signs caused by zinc deficiency usually respond to zinc supplementation.     

Respiratory effects of spinal immobillzatlon

Objective. To evaluate the effect of whole-body spinal immobilization on respiration. Methods. This was a randomized, crossover laboratory study with 39 human volunteer subjects (20 males; 19 females) ranging in age from 7 to 85 years. Respiratory function was measured three times: at baseline (seated or lying), immobilized with a Philadelphia collar on a hard wooden backboard, and on a Scandinavian vacuum mattress with a vacuum collar. The comfort levels of each of the two methods were assessed on a forced Likert scale. Results. Both immobilization methods restricted respiration, 15% on the average. The effects were similar under the two immobilization conditions, although the FEV, was lower on the vacuum mattress. Respiratory restriction was more pronounced at the extremes of age. The vacuum mattress was significantly more comfortable. Conclusion. This study confirmed the previously reported respiratory restriction caused by spinal immobilization. Vacuum mattresses are more comfortable than wooden backboards.     

A Systematic Review and Network Meta-Analysis to Evaluate the Comparative Efficacy of Interventions for Unfit Patients with Chronic Lymphocytic Leukemia

Introduction

Rituximab plus fludarabine and cyclophosphamide (RFC) is the standard of care for fit patients with untreated chronic lymphocytic leukemia (CLL); however, its use is limited in ‘unfit’ (co-morbid and/or full-dose F-ineligible) patients due to its toxicity profile. We conducted a systematic review and Bayesian network meta-analysis (NMA) to determine the relative efficacy of commercially available interventions for the first-line treatment of unfit CLL patients.

Methods

For inclusion in the NMA, studies had to be linked via common treatment comparators, report progression-free survival (PFS), and/or overall survival (OS), and meet at least one of the five inclusion criteria: median cumulative illness score >6, median creatinine clearance ≤70 mL/min, existing co-morbidities, median age ≥70 years, and no full-dose F in the comparator arm. A manual review, validated by external experts, of all studies that met at least one of these criteria was also performed to confirm that they evaluated first-line therapeutic options for unfit patients with CLL.

Results

In unfit patients, the main NMA (five studies for PFS and four for OS) demonstrated clear preference in terms of PFS for obinutuzumab + chlorambucil (G-Clb) versus rituximab + chlorambucil (R-Clb), ofatumumab + chlorambucil (O-Clb), fludarabine and chlorambucil (median hazard ratios [HRs] 0.43, 0.33, 0.20, and 0.19, respectively), and a trend for better efficacy versus rituximab + bendamustine (R-Benda) and RFC-Lite (median HR 0.81 and 0.88, respectively). OS results were generally consistent with PFS data, (median HR 0.48, 0.53, and 0.81, respectively) for G-Clb versus Clb, O-Clb, and R-Clb 0.35 and 0.81 versus F and R-Benda, respectively); however, the OS findings were associated with higher uncertainty. Treatment ranking reflected improved PFS and OS with G-Clb over other treatment strategies (median rank of one for both endpoints).

Conclusion

G-Clb is likely to show superior efficacy to other treatment options selected in our NMA for unfit treatment-naïve patients with CLL.

Funding

F. Hoffmann-La Roche Ltd.

     

Trimethoprim-sulfamethoxazole, pseudomembranous colitis, and spinal cord injury

Antibiotic-associated colitis (pseudomembranous colitis) developed in four patients with spinal cord injury and taking oral trimethoprim-sulfamethoxazole. One hundred forty-eight (59%) of 251 patients with spinal cord injury who were evaluated had received this drug. Two of the four patients with pseudomembranous colitis did not promptly respond to therapy, and all four suffered significant further immobilization because of the disease. Pseudomembranous colitis readily occurs in at least certain population groups receiving trimethoprim-sulfamethoxazole.