Esophageal acid clearance during sleep in patients with Barrett's esophagus

Sleep-related gastroesophageal reflux and esophageal acid clearance have been shown to be important components in the pathogenesis of reflux esophageal disease. Previous studies have suggested that patients with more severe esophagitis are distinguished by an accumulation of acid mucosal contact time during sleep. These data would suggest that patients with Barrett's esophagus should have particularly severe impairment of acid clearance, most notable during sleep. To address this issue, 16 asymptomatic healthy volunteers and 13 patients with Barrett's esophagus were studied. Acid clearance was assessed by timing the reestablishment of an esophageal pH of 4 following the infusion of 15 ml 0.1 N HCl. Sleep was poly graphically monitored in order to objectively determine sleep and waking. The results indicated that while patients with Barrett's esophagus had a marked increase in the frequency of spontaneous gastroesophageal reflux during sleep, they unexpectedly demonstrated faster acid clearance times during both waking and sleep. A greater percentage of arousal responses to acid infusion during sleep was noted in the Barrett's group. It is concluded from these results that patients with Barrett's esophagus can adequately clear acid from the distal esophagus but experience considerable acid mucosal contact through repeated episodes of spontaneous reflux during sleep.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Soluble peptide-MHC monomers cause activation of CD8+ T cells through transfer of the peptide to T cell MHC molecules

T cell receptor (TCR)-mediated activation of CD4(+) T cells is known to require multivalent engagement of the TCR by, for example, oligomeric peptide-MHC complexes. In contrast, for CD8(+) T cells, there is evidence for TCR-mediated activation by univalent engagement of the TCR. We have here compared oligomeric and monomeric L(d) and K(b) peptide-MHC complexes and free peptide as stimulators of CD8(+) T cells expressing the 2C TCR. We found that the monomers are indeed effective in activating naive and effector CD8(+) T cells, but through an unexpected mechanism that involves transfer of peptide from soluble monomers to T cell endogenous MHC (K(b)) molecules. The result is that T cells, acting as antigen-presenting cells, are able to activate other naive T cells.     

From the Cover: Ancient DNA and multimethod dating confirm the late arrival of anatomically modern humans in southern China

The expansion of anatomically modern humans (AMHs) from Africa around 65,000 to 45,000 y ago (ca. 65 to 45 ka) led to the establishment of present-day non-African populations. Some paleoanthropologists have argued that fossil discoveries from Huanglong, Zhiren, Luna, and Fuyan caves in southern China indicate one or more prior dispersals, perhaps as early as ca. 120 ka. We investigated the age of the human remains from three of these localities and two additional early AMH sites (Yangjiapo and Sanyou caves, Hubei) by combining ancient DNA (aDNA) analysis with a multimethod geological dating strategy. Although U–Th dating of capping flowstones suggested they lie within the range ca. 168 to 70 ka, analyses of aDNA and direct AMS ¹⁴C dating on human teeth from Fuyan and Yangjiapo caves showed they derive from the Holocene. OSL dating of sediments and AMS ¹⁴C analysis of mammal teeth and charcoal also demonstrated major discrepancies from the flowstone ages; the difference between them being an order of magnitude or more at most of these localities. Our work highlights the surprisingly complex depositional history recorded at these subtropical caves which involved one or more episodes of erosion and redeposition or intrusion as recently as the late Holocene. In light of our findings, the first appearance datum for AMHs in southern China should probably lie within the timeframe set by molecular data of ca. 50 to 45 ka.

The fossil record suggests that Homo sapiens had evolved in Africa by 315,000 y ago (315 ka) (1), spread into West Asia before 177 ka (2), but disappeared and were seemingly replaced by Homo neanderthalensis until ca. 75 to 55 ka (3, 4). A second and final excursion from Africa by so-called anatomically modern humans (AMHs) occurred soon after and broadly coincides with the extinction of the last archaic hominins, ca. 40 to 30 ka (5, 6). This dispersal involved the ancestors of all present-day non-Africans and according to molecular data occurred ca. 65 to 45 ka (7, 8). Additional support for this “late dispersal” theory is provided by the geographical structure of contemporary DNA lineages with all non-Africans closely related to present-day and ancient eastern African populations (9, 10), as well as a clinal pattern of decreasing diversity from Africa to Eurasia, the signature of serial founder effect (10–12). Corroboration has also been provided by the estimated split time between western and eastern Eurasians of ca. 47 to 42 ka as determined by ancient DNA (aDNA) from the 46,880 to 43,210 cal y B.P. (calendar year before present, i.e., before AD1950) Ust’-Ishim femur (western Siberia, Russian Federation) and the 42,000 to 39,000 cal B.P. Tianyuan skeleton (Northeast China) (13–15). Finally, the upper age boundary for this dispersal is set by interbreeding between early AMHs and the Neanderthals estimated to have occurred ca. 65 to 47 ka and the ancestors of New Guineans with the Denisovans ca. 46 ka and again ca. 30 ka (13, 16–19).In contrast, some paleoanthropologists have suggested that AMHs settled mainland East Asia much earlier, within the period of ca. 120 to 70 ka, in accordance with the “early dispersal” theory. This model is based largely upon the dating of isolated human teeth recovered at Huanglong, Luna, and Fuyan caves and a partial mandible from Zhirendong in southern China (20–24). Yet several researchers have raised questions about these and other sites on the basis of uncertainties surrounding the identification of some of them as AMHs, relationships between human remains and dated materials, or limited information available about their depositional context and dating (25–27).Here, we describe the results of an investigation of the arrival time of AMHs in southern China at five apparent early AMH cave localities involving aDNA analyses of human teeth and the dating of flowstones, sediments, fossil remains, and charcoal. The five localities we studied are the following:

• 1)Huanglong cave, located about 25 km from the town of Yunxi, northern Hubei Province (Fig. 1). Excavations by the Hubei Provincial Institute of Cultural Relics and Archaeology during three field seasons from 2004 to 2006 provided a rich mammal record, comprising 91 taxa and representing a Middle to Late Pleistocene Ailuropoda-Stegodon fauna, stone artifacts, and seven AMH teeth dated indirectly with U–Th dating on thin flowstone formations ca. 101 to 81 ka (20).Open in a separate windowFig. 1.(A) Geographical location of Huanglong Cave (1), Luna Cave (2), Fuyan Cave (3), Yangjiapo Cave (4), and Sanyou Cave (5). (B) Human remains from three localities: Yangjiapo Cave (i), Sanyou Cave (ii), and Fuyan Cave (iii). b = buccal, d = distal, l = lingual, m = mesial, and o = occlusal).
• 2)Luna cave, situated in the karst mountains of the southeastern part of the Bubing basin, Guangxi Zhuang Autonomous Region (Fig. 1). A small sample of mammal fossils (Ailuropoda-Stegodon assemblage), stone artifacts, and two AMH teeth were recovered during excavations by the Natural History Museum of Guangxi Autonomous Region in 2004 and 2008. They have since been dated indirectly through U–Th dating of flowstone in the range ca. 127 to 70 ka (21).
• 3)Fuyan cave, located in Daoxian County, Hunan Province (Fig. 1). Excavations from 2011 to 2013 resulted in a large sample of mammal fossils (Ailuropoda-Stegodon faunal group) and 47 AMH teeth but no associated artifacts (22). They have been dated indirectly using U–Th dating of flowstone within the range ca. 120 to 80 ka (22). Two additional (in situ) AMH teeth, stratigraphically associated with the original finds, were recovered by us during field investigations at the site during early 2019.
• 4)Yangjiapo Cave is a large karstic chamber located in Jianshi County (Fig. 1). It was excavated during 2004 by the Hubei Provincial Institute of Cultural Relics and Archeology and yielded 11 AMH teeth found in association with the fragmentary bones of 80 species belonging to an Ailuropoda-Stegodon fauna, implying it should be of similar age to Huanglong, Luna, and Fuyan caves. No stone artifacts or other cultural remains were found.
• 5)Sanyou Cave is a small chamber within a limestone hill at the confluence of the Yangtze River and Xiling Gorge, close to Yichang city, Hubei Province (Fig. 1). A small excavation was undertaken in 1986 by the Yichang Museum and led to the recovery of a possible Late Pleistocene age partial AMH cranial vault (Fig. 1).

     

消胃痞方治疗萎缩性胃炎临床观察

采用消胃痞方治疗慢性萎缩性胃炎６８例，临床总有效率９４．１％；胃镜及病理活检总有效率５４．４％，与西药对照组的４６．６％和２３．３３％比较，Ｐ＜０．０１和Ｐ＜０．０５。而且治疗后血液流变学有明显改善（Ｐ均＜０．０１）。揭示消胃痞方是治疗萎缩性胃炎的有效方剂。     

Transient right bundle branch block following blunt chest trauma

A 38 year old man with previously normal electrocardiograms suffered a direct blow to the chest which resulted in electrocardiographic changes consistent with transient right bundle branch block. Serial enzyme determinations documented a rise in fraction 5 of serum lactic dehydrogenase. Evaluation subsequent to the injury were all within normal limits. An unexplained finding of paradoxical splitting of the pulmonic component of the second heart sound is noted.     

A clinical trial to evaluate the worth of preoperative multimodality therapy in patients with operable carcinoma of the rectum

PURPOSE: National Surgical Adjuvant Breast and Bowel Project Protocol R-03 was designed to determine the worth of preoperative chemotherapy and radiation therapy in the management of operable rectal cancer. METHODS: Thus far, 116 patients of an eventual 900 with primary operable rectal cancer have been randomized to receive multimodality therapy to begin preoperatively (59 patients) or identical therapy beginning after curative surgery (57). All patients received seven cycles of 5-fluorouracil (FU)/leucovorin (LV) chemotherapy. Cycles 1 and 4 through 7 used a high-dose weekly FU regimen. In Cycles 2 and 3, FU and low-dose LV chemotherapy was given during the first and fifth week of radiation therapy (5,040 cGy). The preoperative arm (Group 1) received the first three cycles of chemotherapy and all radiation therapy before surgery. The postoperative arm (Group 2) received all radiation and chemotherapy after surgery. Primary study end points included disease-free survival and survival. Secondary end points included local recurrence, primary tumor response to combination therapy, tumor downstaging, and sphincter preservation. RESULTS: Overall treatment-related toxicity was similar in both groups. Although seven preoperative patients had events after randomization that precluded surgery, eight events occurred during an equivalent follow-up period in the postoperative group. No patient was deemed inoperable because of progressive local disease. Sphincter-saving surgery was intended in 31 percent of Group 1 patients and 33 percent of Group 2 patients at the time of randomization. Such surgery was actually performed in 50 percent of the preoperatively treated patients and 33 percent of the postoperatively treated patients. The use of protective colostomy in patients undergoing sphincter-sparing surgery and the development of perioperative complications in all surgical patients were similar in both groups. There was evidence of tumor downstaging in evaluable patients under-going preoperative therapy, with 8 percent of Group 1 patients having had a pathologic complete response. CONCLUSION: These data do suggest that the preoperative chemotherapy and radiation therapy regimen used are, at least, as safe and tolerable as standard postoperative treatment. There is presently a trend to tumor downstaging and sphincter preservation in the preoperative arm. Whether this arm will have greater or lesser survival and long-term toxicity awaits the completion of this relevant study.Supported by National Cancer Institute Grants U10-CA-12027 and U10-CA-37377 and American Cancer Society Grant R-13.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study

PURPOSE: To examine the relation between follow-up office visits after emergency discharge and the risk of emergency readmissions in patients with asthma or chronic obstructive pulmonary disease (COPD). SUBJECTS AND METHODS: We used population-based data to identify all patients in Alberta, Canada, who had at least one emergency visit for asthma or COPD between April 1, 1996, and March 31, 1997 (N = 25 256). A Cox proportional hazards model was used to estimate the adjusted relative risk (RR) of a repeat visit to an emergency department within 90 days of an initial emergency visit in patients who did or did not have an office follow-up within the first 30 days. RESULTS: There were 7829 patients (31%) who had an office visit during the 30 days after their initial emergency encounter. Follow-up visits were associated with a significant reduction in the 90-day risk of an emergency readmission (RR = 0.79; 95% confidence interval [CI]: 0.73 to 0.86). Sensitivity analyses showed that a follow-up visit was inversely associated with a repeat emergency visit after adjusting for age, sex, area of residence, and income. CONCLUSION: Although these data should be interpreted with caution because of missing information on factors such as quality of care, they suggest that follow-up office visits are effective in reducing early relapses in patients who have been recently treated in emergency departments for asthma or COPD.     

High-dose radioimmunotherapy versus conventional high-dose therapy and autologous hematopoietic stem cell transplantation for relapsed follicular non-Hodgkin lymphoma: a multivariable cohort analysis

We performed a multivariable comparison of 125 consecutive patients with follicular lymphoma (FL) treated at our centers with either high-dose radioimmunotherapy (HD-RIT) using 131I-anti-CD20 (n = 27) or conventional high-dose therapy (C-HDT) (n = 98) and autologous hematopoietic stem cell transplantation. The groups were similar, although more patients treated with HD-RIT had an elevated pretransplantation level of lactate dehydrogenase (41% versus 20%, P =.03) and elevated international prognostic score (41% versus 19%, P =.02). Patients treated with HD-RIT received individualized therapeutic doses of 131I-tositumomab (median, 19.7 GBq [531 mCi]) to deliver 17 to 31 Gy (median, 27 Gy) to critical organs. Patients treated with C-HDT received total body irradiation plus chemotherapy (70%) or chemotherapy alone (30%). Patients treated with HD-RIT experienced improved overall survival (OS) (unadjusted hazard ratio [HR] for death = 0.4 [95% confidence interval (95% CI), 0.2-0.9], P =.02; adjusted HR, 0.3, P =.004) and progression-free survival (PFS) (unadjusted HR =.6 [95% C.I., 0.3-1.0], P =.06; adjusted HR, 0.5, P =.03) versus patients treated with C-HDT. The estimated 5-year OS and PFS were 67% and 48%, respectively, for HD-RIT and 53% and 29%, respectively, for C-HDT. One hundred-day treatment-related mortality was 3.7% in the HD-RIT group and 11% in the C-HDT group. The probability of secondary myelodysplastic syndrome/acute myeloid leukemia (MDS/AML) was estimated to be.076 at 8 years in the HD-RIT group and.086 at 7 years in the C-HDT group. HD-RIT may improve outcomes versus C-HDT in patients with relapsed FL.