Showing papers on "Symptomatic relief published in 2003"

Eosinophilic oesophagitis: a novel treatment using Montelukast.

Abstract: Background: Eosinophilic oesophagitis is a rarely diagnosed condition involving eosinophil infiltration of the oesophageal mucosa and creating significant symptoms of dysphagia. Failure to diagnose this disorder relates to reluctance to biopsy an apparently normal oesophagus. This is essential for histological diagnosis. To date, treatment success has been achieved only with corticosteroids. We describe here the use of an eosinophil stabilising agent Montelukast for the symptomatic relief of these patients. Patients and methods: Twelve patients have been identified with this condition in our unit since 1995, after thorough investigation of their dysphagia. We commenced eight of these patients on the leukotriene receptor antagonist Montelukast to symptomatically improve their swallowing while avoiding the use of long term corticosteroids. Results: Many of these patients had been previously misdiagnosed, and therefore inappropriately and unsuccessfully treated for an extensive period prior to referral to our unit. All patients were unresponsive to acid suppression therapy alone but showed improvement in their swallowing on Montelukast. Six of eight reported complete subjective improvement, five patients remaining completely asymptomatic on a maintenance regimen. Conclusions: Eosinophilic oesophagitis is a disease that is often misdiagnosed due to lack of awareness and reluctance of clinicians to biopsy an apparently normal oesophagus in dysphagic patients, and therefore obtain a histological diagnosis. Investigation of these patients adds further evidence to this condition being a separate pathological state from gastro-oesophageal reflux and eosinophilic enteritis. Montelukast has been found to be of significant help in the symptomatic control of these patients while avoiding long term corticosteroids use.

Clinical features and outcome of subacute thyroiditis in an incidence cohort: Olmsted County, Minnesota, study.

Abstract: Subacute thyroiditis (SAT), or granulomatous thyroiditis, is an inflammatory thyroid condition associated with pain and systemic symptoms. Few community studies are available. We studied the 160 patients with SAT in Olmsted County, Minnesota, seen between January 1, 1960, and December 30, 1997. Subjects were identified through the medical diagnostic index of the Rochester Epidemiology Project. The overall age- and sex-adjusted incidence from 1960 through 1997 was 4.9 cases per 100,000/yr. In the most recent 28-yr period (1970-1997), 94 patients were identified. In this group, pain was the presenting symptom in 96%. SAT recurred in 4% of the patients 6-21 yr after the initial episode. Corticosteroid therapy was given to 36%. Early-onset hypothyroidism occurred both in patients receiving corticosteroid therapy (29%) and in those not receiving corticosteroid therapy (37%). At latest follow-up, significantly more patients who had received corticosteroid therapy had a diagnosis of hypothyroidism than the group without corticosteroid therapy (25% vs. 10%, P < 0.05; overall rate of hypothyroidism, 15%). Early transient hypothyroidism is common in SAT. Permanent hypothyroidism is less common, and only 15% of the patients are receiving T(4) therapy after 28 yr of follow-up. Symptomatic relief is achieved with corticosteroid therapy, but such therapy does not prevent early- and late-onset thyroid dysfunction.

The diagnosis and management of recurrent aphthous stomatitis: a consensus approach.

Abstract: Background Recurrent aphthous stomatitis, or RAS, is a common oral disorder of uncertain etiopathogenesis for which symptomatic therapy only is available. This article reviews the current data on the etiopathogenesis, diagnosis and management of RAS in a primary care setting. Methods The authors reviewed publications on Medline from 1995 through 2000, the period since the last major reviews were published. Results RAS may have an immunogenetic background owing to cross-reactivity with Streptococcus sanguis or heat shock protein. Predisposing factors seen in a minority include haematinic (iron, folate or vitamin B12) deficiency, stress, food allergies and HIV infection. While topical corticosteroids remain the mainstay for therapy, a number of other immunomodulatory modalities now are available. Conclusions There is still no conclusive evidence relevant to the etiopathogenesis of RAS, and therefore therapy can attempt only to suppress symptoms rather than to address the basic issues of susceptibility and prevention. Clinical Implications In the majority of patients, symptomatic relief of RAS can be achieved with topical corticosteroids alone, with other immunomodulatory topical agents or by combination therapy.

Peripheral Arterial Disease: Identification and Implications

Abstract: Peripheral arterial disease (PAD) is most commonly a manifestation of systemic atherosclerosis in which the arterial lumen of the lower extremities becomes progressively occluded by atherosclerotic plaque. Patients with PAD are at triple the risk of all-cause mortality and at more than 6 times the risk of death from coronary heart disease as those without the disease, yet PAD is probably the most underdiagnosed and least aggressively managed atherosclerotic disease. In the diagnosis of PAD, a detailed history and physical examination are extremely important, although limited by a lack of consistent sensitivity and specificity. Other office-based noninvasive tests, including the ankle-brachial index, can be easily performed to confirm the diagnosis and help stratify the risk. The ankle-brachial index correlates well with disease severity and functional symptoms and can also be used to assess disease progression and to predict cardiovascular and cerebrovascular mortality. Once diagnosed, risk factor modification, symptomatic relief, and secondary prevention strategies with antiplatelet agents form the core of medical management of PAD.

High tibial valgus osteotomy for medial gonarthrosis: a 10- to 21-year study.

Abstract: This retrospective study reviewed the long-term experience with high tibial osteotomy and determined which factors influence the results. Between 1980 and 1989, 120 closing wedge high tibial osteotomies for varus gonarthrosis were performed in 102 patients. Twenty-nine knees were excluded because the patients died (17 knees), were bedridden (7 knees), or lost to follow-up (5 knees). Thirty of the remaining 91 knees had a conversion to total knee replacement (TKR) after 11 years on average, leaving 61 knees with a high tibial osteotomy available for clinical and radiographic evaluation at an average follow-up of 15 years (range: 10-21 years). Of the 91 knees, excellent/good results were found in 49% and fair/poor in 51%. Anatomical femorotibial angle in the 61 knees at follow-up averaged 4.7 degrees +/- 5 degrees of valgus (range: 3 degrees varus to 23 degrees valgus). Alignment obtained at consolidation changed with varus recurrence at follow-up in 14% of 61 knees and did not correlate with the clinical results. Twelve (19%) knees showed a patella baja (Caton ratio <0.6) at follow-up, which correlated with patients immobilized postoperatively by a cylinder cast (P=.04). A valgus alignment at consolidation between 8 degrees and 15 degrees, good muscle strength, and male gender correlated with better results (P<.05). Survivorship analysis, considering an unsatisfactory result or revision to TKR as the endpoint, was 96% at 5 years, 88% at 7 years, 78% at 10 years, and 57% at 15 years. High tibial osteotomy provides symptomatic relief for approximately 10 years, but is unlikely to provide permanent relief.

Cancer of the heart: epidemiology and management of primary tumors and metastases.

Abstract: Cardiac tumors, benign or malignant, are rare and most are benign. The most common benign tumor is the cardiac myxoma. Malignant cardiac tumors are usually sarcomas. The pericardium can be the site of benign and malignant cardiac tumors, though metastatic tumors occur here far more commonly than do primary tumors. Successful treatment for benign cardiac tumors is usually achieved by surgical resection. Surgery for primary malignant tumors is, however, much less successful as complete resection is usually not possible. Primary cardiac lymphoma may be successfully treated by chemotherapy. Tumors that metastasize to the heart from other organs occur 100- to 1000-fold more commonly than primary cardiac tumors. Metastatic spread to the heart has been identified in approximately one-fifth of all patients who have metastatic cancer with lung carcinoma being the most common primary tumor. Symptoms of cardiac metastases vary, and they depend on the site and extent of the lesions. Treatment varies depending on the pathology of the primary tumor. However, the aim of treatment is usually symptomatic relief. With the advent of AIDS, Kaposi’s sarcoma and high grade B cell lymphomas have also been identified in cardiac tissue. The aim of this article is to review the epidemiology, clinical presentation, pathology and treatment of cardiac tumors.

Effectiveness of Leech Therapy in Osteoarthritis of the Knee: A Randomized, Controlled Trial

Abstract: BACKGROUND Leech therapy was commonly used in traditional medicine for treating localized pain. Clinically significant pain relief after leech therapy for osteoarthritis of the knee has been demonstrated by preliminary data. OBJECTIVE To evaluate the effectiveness of leech therapy for symptomatic relief of osteoarthritis of the knee. DESIGN Randomized, controlled trial. SETTING Outpatient department for integrative medicine of an academic teaching hospital. PATIENTS 51 patients with osteoarthritis of the knee (leech therapy: 24 patients, mean age [+/-SD], 62.5 +/- 10.2 years; topical diclofenac therapy: 27 patients, mean age [+/-SD], 65.5 +/- 6.7 years). INTERVENTION A single treatment with 4 to 6 locally applied leeches (leech therapy group) or a 28-day topical diclofenac regimen (control group). MEASUREMENTS Mean of the pain, function, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index and physical sum score of the Medical Outcomes Study 36-Item Short-Form Health Survey with group comparisons at days 3, 7, 28, and 91. RESULTS The primary end point, pain at day 7, was reduced from a mean (+/-SD) of 53.5 +/- 13.7 to 19.3 +/- 12.2 after leech therapy compared with 51.5 +/- 16.8 to 42.4 +/- 19.7 with topical diclofenac (estimated group difference, -23.9 [95% CI, -32.8 to -15.1]; P < 0.001). Although the difference between group pain scores was no longer significant after day 7, differences for function, stiffness, and total symptoms remained significant in favor of leech therapy until the end of study and for quality of life until day 28. Results were not affected by outcome expectation. CONCLUSIONS Leech therapy helps relieve symptoms in patients with osteoarthritis of the knee. The potential of leech therapy for treating osteoarthritis and the pharmacologic properties of leech saliva remain to be clarified.

Industry forum: Progress in pursuit of therapeutic A2A antagonists The adenosine A2A receptor selective antagonist KW6002: Research and development toward a novel nondopaminergic therapy for Parkinson’s disease

Abstract: Research and development of the adenosine A 2A receptor selective antagonist KW6002 have focused on developing a novel nondopaminergic therapy for Parkinson’s disease (PD). Salient pharmacologic features of KW6002 were investigated in several animal models of PD. In rodent and primate models, KW6002 provides symptomatic relief from parkinsonian motor deficits without provoking dyskinesia or exacerbating existing dyskinesias. The major target neurons of the A 2A receptor antagonist were identified as GABAergic striatopallidal medium spiny neurons. A possible mechanism of A 2A receptor antagonist action in PD has been proposed based on the involvement of striatal and pallidal presynaptic A 2A receptors in the “dual” modulation of GABAergic synaptic transmission. Experiments with dopamine D 2 receptor knockout mice showed that A 2A receptors can function and anti-PD activities of A 2A antagonists can occur independent of the dopaminergic system. Clinical studies of KW6002 in patients with advanced PD with l-dopa–related motor complications yielded promising results with regard to motor symptom relief without motor side effects. The development of KW6002 represents the first time that a concept gleaned from A 2A biologic research has been applied successfully to “proof of concept” clinical studies. The selective A 2A antagonist should provide a novel nondopaminergic approach to PD therapy.

Distinguishing transient osteoporosis of the hip from avascular necrosis.

Abstract: Transient osteoporosis of the hip (TOH) was first described by Curtiss and Kincaid in 19591 as a syndrome of transient demineralization of the hip in the third trimester of pregnancy. In 1968, Lequesne2 first used the term in a published report. This rare cause of acute hip pain is still a relatively unknown clinical entity. Characteristically, this skeletal disorder is a distinct self-limiting condition that presents spontaneously with sudden-onset pain in the hip, gradually resolving within 6–8 months.3,4,5,6 No intervention is needed for this condition, and management essentially involves symptomatic relief and avoiding excessive activity to minimize the risk of a pathologic fracture until the osteoporosis resolves.3 Unlike TOH, avascular necrosis (AVN) is a progressive condition, resulting from an interruption of the tenuous vascular supply to the femoral head. AVN is a more common cause of acute hip pain than TOH, and early surgical intervention may prevent further deformity of the hip joint.7 Although the prognosis and treatment of these 2 conditions differ greatly, in the early stages the radiographic appearance of TOH may be confused with AVN,8 resulting in unnecessary operative intervention with its accompanying risks and consequences. It is, therefore, vital to distinguish TOH from AVN early in its clinical course. Several studies have investigated the best means to differentiate TOH and AVN. Radiographs lack sensitivity for TOH as osteopenia is only evident 4–8 weeks after the onset of symptoms,9 and although bone scans are sensitive, the positive result of homogeneous increased uptake is not specific for TOH.4 To date, the most reliable investigation for this purpose has been magnetic resonance imaging (MRI)10,11 with abnormalities consistent with TOH reported within 48 hours of onset of symptoms.12 TOH is commonly considered in acute hip pain in pregnancy, but its occurrence in middle-aged men is less well recognized, and is actually far more common in young to middle-aged men.3 In this study we describe the clinical features and course of the disease in 10 young adult men with TOH referred to the orthopedic unit at St. Michael's Hospital, Toronto, for operation after a misdiagnosis of AVN. Our aim is to increase awareness of this condition in middle-aged men. In addition, we will attempt to define the clinical and radiologic characteristics that distinguish AVN from TOH to ensure appropriate treatment of these men in the future.

GABA(A) receptor subtype selective cognition enhancers.

Abstract: Currently the treatment of Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI) is largely unrealised, with no preventive or curative therapies. The marketed acetylcholinesterase inhibitors (eg. donepezil, Aricept) are directed toward temporary symptomatic relief from impaired cognition, but have prominent adverse effects with minimal efficacy. In pursuit of novel cognition enhancers, the observation that classical benzodiazepines (BZ, eg. diazepam) are amnesic, coupled with the preservation of GABA(A) receptors in brain areas most affected by AD, highlighted the GABA(A) receptor as a potential therapeutic target. In contrast to the amnesic BZ agonists, the BZ inverse agonists (eg. DMCM) which attenuate GABA(A) receptor function, have been shown to improve performance in animal models of learning and memory. Unfortunately, such non-selective ligands also induce anxiety and convulsions. More recently, novel ligands have been developed (eg. 6,6-dimethyl-3-(2-hydroxyethyl)thio-1-(thiazol-2-yl)-6,7-dihydro-2-benzothiophen-4(5H)-one) that demonstrate binding selectivity and high inverse agonism for the alpha5 GABA(A) receptor subtype, which is preferentially located in the hippocampus, a region of the brain associated with learning and memory. Pre-clinical results are encouraging, since these alpha5 selective inverse agonists enhance memory in animal models, such as spatial learning in the Morris water-maze, but are devoid of the adverse effects associated with activity at other GABA(A) receptor subtypes in other brain regions. If the efficacy and safety profiles of alpha5 inverse agonists in humans prove to be similar to those seen in pre-clinical studies, these compounds would offer significant benefit to AD and MCI patients.

The role of acetylcholinesterase in the pathogenesis of Alzheimer's disease.

Abstract: Treatment of Alzheimer's disease has been dominated by the use of acetylcholinesterase (AChE) inhibitors These drugs compensate for the death of cholinergic neurons and offer symptomatic relief by inhibiting acetylcholine (ACh) turnover and restoring synaptic levels of this neurotransmitter Recently, however, AChE itself has been implicated in the pathogenesis of Alzheimer's disease In particular, it appears that AChE may directly interact with amyloid-beta in a manner that increases the deposition of this peptide into insoluble plaques This new role suggests that properly designed AChE inhibitors might be able to act as disease-modifying agents rather than as mere palliatives Additionally, numerous studies have suggested that cholinergic modulation and other functional consequences of AChE inhibition may affect amyloid precursor protein processing and protect neurons against a variety of insults It therefore seems likely that new AChE inhibitors, which capitalize on all these strengths would be excellent candidates for future Alzheimer's disease therapy

Glucocorticoids in the treatment of early and late RA.

Abstract: A little GC, like a glass of wine, may benefit many people, whereas a high dose of GC, like a bottle of wine, is harmful to all At the 2003 meeting of the American College of Rheumatology (ACR) a debate on the advantages and disadvantages of glucocorticoids (GCs) in the treatment of early and late rheumatoid arthritis (RA) was held, with some authors putting the case for, and others the case against, such treatment (presentations now available online: http://www.rheumatology.org). Some new data emerged, and this paper summarises the arguments and the existing and new data. Hench was awarded the Nobel prize in 1950 for the discovery of GCs and their effect in established RA. However, subsequently disillusionment with GCs set in, caused by the rapid appearance of unacceptable side effects of long term high dose treatment, and loss of efficacy at lower dosing. The dogma became that treatment with systemic GCs caused only temporary symptomatic relief, led to habituation with danger of ever increasing doses necessary to maintain effect, and that chronic treatment universally caused unacceptable side effects. Therefore, such treatment was often only considered as a last resort. An associated idea was that RA was in most cases a benign disease, which, although incurable, caused significant disability in only a minority of cases. The combination of these ideas caused most rheumatologists to limit treatment to traditional schemes that emphasised rest, lifestyle adjustment, non-steroidal anti-inflammatory drugs (NSAIDs), and spa treatment. In unresponsive cases antirheumatic drugs such as intramuscular gold were advised. A paradigm shift was initiated by Wilske and Healey, who argued that the pyramid should be inverted and aggressive treatment should be started early.1 This was based on the appearance of long term outcome studies that recorded the dismal prognosis of many patients when followed up for a …

Nonoperative treatment of adult acquired flat foot with the Arizona brace

Abstract: Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted, custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In today's climate of patient satisfaction directed health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities. At this time, the Arizona AFO brace can be a useful weapon in the orthopedist's armamentarium for treating acquired flat foot deformity.

Anterior gastropexy may reduce the recurrence rate after laparoscopic paraesophageal hernia repair.

Abstract: Background: Although laparoscopic repair of type 3 paraesophageal hernias is safe and results in symptomatic relief, recent data have questioned the anatomic integrity of the laparoscopic approach. The reports document an asymptomatic recurrence rate as high as 42% with radiologic follow-up evaluation for type 3 paraesophageal hernias repaired laparoscopically. This disturbingly high recurrence rate has prompted the addition of an anterior gastropexy to our standard laparoscopic paraesophageal hernia repair. Methods: A prospective series of 28 patients underwent laparoscopic repair of large type 3 hiatal hernias between July 2000 and January 2002 at the Cleveland Clinic Foundation by one surgeon. All the patients underwent reduction of the hernia, sac excision, crural repair, antireflux procedure, and anterior gastropexy. They all had a video esophagram 24 h after surgery, then at 3-, 6-, and 12-month follow-up visits and annually thereafter. Symptomatic outcomes were assessed with a standard questionnaire at each follow-up visit. Results: In this study, 21 women and 7 men with a mean age of 67 years (range, 35–82 years) underwent successful laparoscopic paraesophageal hernia repair. The mean operative time was 146 min (range, 101–186 min), and the average blood loss was 71 ml (range, 10–200 ml). One intraoperative complication occurred: A small esophageal mucosal tear occurred during esophageal dissection and was repaired laparoscopically. At 24 h, upper gastrointestinal examination identified no leaks. At this writing, all the patients have undergone video esophagram at a 3-month follow-up visit. All were asymptomatic and all examinations were normal. Of the 28 patients, 27 have undergone follow-up assessment at 6 months. At this writing, all the patients have undergone video esophagram at 3, 6, and 12 months follow up visits. All were asymptomatic and all examinations were normal. Ten patients have completed 2 year follow up barium swallows with no recurrences. Conclusions: With up to 2 years of follow-up evaluation, the addition of an anterior gastropexy to the laparoscopic repair of type 3 hiatal hernias resulted in no recurrences. These encouraging results necessitate further follow-up evaluation to document the long-term effects of anterior gastropexy in reducing postoperative recurrence after laparoscopic repair of paraesophageal hernias.

Menthol: effects on nasal sensation of airflow and the drive to breathe.

Abstract: Menthol, in lozenges, nasal sprays, vapo-rubs, inhalers, and cough syrups, is widely used as a treatment for rhinitis that is associated with acute upper respiratory tract infection and allergy. Menthol as a plant extract has been used in traditional medicine in Asia for the treatment of respiratory diseases for hundreds of years, but it was only introduced to the West as a medicine at the end of the 19th century. With the recent discovery of a menthol receptor on the sensory nerves that modulate the cool sensation, menthol has graduated from the realms of herbal medicine into the field of molecular pharmacology. This review concerns the physiologic and pharmacologic mechanisms that underlie the widespread use of menthol as a treatment for the relief of nasal congestion associated with rhinitis and its effects on the drive to breathe and symptomatic relief of dyspnea.

Anterior cruciate ligament reconstruction in patients over the age of 50 years: 2- to 8-year follow-up.

Abstract: We present medium-term results in 30 prospectively followed patients aged over 50 years at the time of ACL reconstruction (31 procedures); mean follow-up time was 46 months (range 24–95). Mean Lysholm score improved significantly from 63 pre-operatively to 93 at final review Cincinnati score from 49 to 89. In IKDC score 25 knees (81%) were considered normal or nearly normal and 6 abnormal; there were no severely abnormal results. Mean Tegner activity scores improved from pre-operatively from 3.7 to 5.2 at review. Mean side-to-side difference measured by the KT-1000 at maximal manual pressure was 2.7 mm; two knees had. a measured difference greater than 5 mm. The mean torque ratio for isokinetic flexion strength was 102% and for extension strength 94%. Poor results as determined by the three scoring systems were associated mainly with advanced articular degenerative changes (Outerbridge grade 3 or 4) seen at the time of reconstruction. Despite this all patients reported improvement in stability and overall function of the knee. Degenerative change itself was associated with increased time to surgery from injury. This study demonstrates that the ACL can be reliably reconstructed in patients over the age of 50 years with good symptomatic relief, restoration of function and return to sporting activity.

Is bronchoscopic photodynamic therapy a therapeutic option in lung cancer

Abstract: This study addresses whether photodynamic therapy (PDT) is a valid therapeutic option in lung cancer treatment. A total of 24 articles were reviewed in two categories: advanced (G1) and early (G2) disease. Details considered included the following: 1) number of patients in each series; 2) staging; 3) methodology; 4) mortality; 5) morbidity; 6) survival; 7) relief of symptoms; and 8) concomitant treatments. G1 (636 patients) had severe endobronchial obstructive cancer and PDT was primarily for symptom relief. G2 (517 patients) had early stage cancer and were treated with PDT for curative intent. There was no procedure-related mortality in either group. G1 had a 5–28% incidence of skin sensitivity. Haemoptysis occurred in two series; one fatal, an incidence of 2.2%. Almost all patients had symptomatic relief. Patients with lower disease stage and better performance status had improved survival rates. G2 had a 8–28% incidence of sunburn. Three patients in one series (38 patients) had haemoptysis. Survival after 5 yrs in complete remission/response patients was 70%. This review suggests that bronchoscopic photodynamic therapy has indications in selected lung cancer patients with early or advanced stage disease. However, in the absence of a formal comparative study, no claim can be made of its superiority over other endobronchial therapies.

Percutaneous radiofrequency ablation of hepatic metastases for symptomatic relief of neuroendocrine syndromes.

Abstract: OBJECTIVE. The purpose of this study was to evaluate the efficacy of percutaneous radiofrequency ablation of hepatic neuroendocrine metastases for symptomatic relief of neuroendocrine syndromes.CONCLUSION. Percutaneous radiofrequency ablation, a minimally invasive technique, is an effective and safe way to reduce systemic symptoms in patients with hepatic metastases from neuroendocrine neoplasms.

Does major depression in patients with gastroesophageal reflux disease affect the outcome of laparoscopic antireflux surgery

Abstract: Background: It is known that psychological factors can affect end points of surgical treatment. The current study aimed to evaluate the outcome of laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who experience concomitant major depression in comparison with GERD patients who have no known comorbidity. Methods: Among a sample of more than 550 patients who underwent LARS, a group of 38 GERD patients with concomitant major depression (MD) were included in this study. The patients included 24 women and 14 men, with a mean age of 51 years. A group of 38 control patients (non-MD) matched in terms of age, gender, and esophageal manometry findings was selected from the database for comparison of surgical outcomes between patients with GERD accompanied by concomitant major depression and GERD patients with no known comorbidity. In each group, 23 patients received a Toupet fundoplication and 15 patients underwent a "floppy" Nissen fundoplication. The following factors were evaluated before surgery, 3 months afterward, and 1 year after LARS: symptoms (heartburn, regurgitation, chest pain, bloating, and dysphagia), quality of life (Gastrointestinal Quality of Life Index [GIQLI]), lower esophageal sphincter pressure (LESP), and 24-h pH monitoring (DeMeester score). Results: Before and after surgery, there were no significant differences between the two groups in terms of LESP and DeMeester score. Preoperative GIQLI showed significant differences (p < 0.05) between the two groups (MD group, 71.8 ± 8.6 vs non-MD group, 91.1 ± 9.8), and significant differences (p < 0.01–0.001) between the mean data and that for healthy individuals (122.6 ± 8.5). The GIQLI scores had improved significantly at 3 months and at 1 year after surgery (p < 0.05–0.001) in all the patients (1 year postoperatively: MD group, 99.3 ± 8.6 vs non-MD group, 121.9 ± 9.7). Before surgery, when symptoms were compared between the two groups, significant differences (p < 0.001) were found in the percentage of chest pain (81.6% vs 37.4%) and bloating (92.2% vs 37.4%), showing that these symptoms were more predominant and graded as much more severe among patients with MD. In both groups, all the symptoms but dysphagia showed a significant improvement in severity (p < 0.05–0.0001). A comparison of both groups postoperatively showed that significant differences were still present in chest pain (44.7% vs 2.6%), bloating (68.4% vs 18.4), and dysphagia (50.1% vs 2.6%). A significant difference (p < 0.001) was observed only in patients with major depression and depending on the kind of wrap procedure (Nissen vs Toupet), showing that dysphagia (78.9% vs 21.1%) and chest pain (82.4% vs 17.6%) were much more predominant in patients who underwent "floppy" Nissen fundoplication. Conclusions: Even if they are good surgical candidates from a physiologic point of view, GERD patients with concomitant major depression should be selected carefully. In these patients, LARS can normalize physiologic data, but some patients have demonstrated less symptomatic relief, suffered from postoperative dysphagia, and showed less quality-of-life improvement. Eventually, laparoscopic Toupet fundoplication used with these patients could result in a better subjective outcome.

Long-term results of balloon catheter dilation for benign gastric outlet stenosis.

Abstract: Background and study aims In 1981, the authors introduced balloon catheter dilation for postoperative gastric outlet stenosis and later for peptic, corrosive and postvagotomy gastric outlet stenosis. This retrospective study evaluates the effectiveness, safety and outcome of balloon catheter dilation in these various indications. Patients and methods Between September 1981 and September 2001, 177 balloon catheter dilation procedures were carried out in 72 patients with benign stenoses. Double-lumen or single-lumen balloon catheters with a mean diameter of 18 mm (range 12-25 mm) were used. Endoscopic check-up examinations were carried out 1-3 weeks later, and then after three, six and 12 months, or if symptoms returned. The mean follow-up period for patients who did not undergo surgery was 98 months (range 12-240 months). Results Symptomatic relief was obtained immediately in 80 % and after 3 months or more in 70% of the patients. The mean diameter of the stenoses was 6 mm (2.0-9.5 mm) before dilation and 16 mm (10-20 mm) afterwards. Gastric retention was observed in 49 patients (68%) before dilation and in 19 patients (26.4%) afterward. Sixteen patients had recurrent stenosis 1-18 months after the first dilation. All of the 18 postoperative strictures, 21 (70%) of the 30 peptic stenoses, six (35%) of the 17 patients with corrosive strictures, and five of the six patients with postvagotomy functional stenosis were successfully treated with dilation. Pyloric perforation occurred in two cases, and arterial hemorrhage was observed in one case after dilation. Conclusions Balloon catheter dilation is an important and effective diagnostic and therapeutic method; depending on the causative factor, it can make surgery unnecessary in nearly 70% of patients with benign gastric outlet stenosis.

Botulinum toxin as second-line therapy for chronic anal fissure failing 0.2 percent glyceryl trinitrate.

Abstract: PURPOSE: Glyceryl trinitrate paste is used by many as first-line therapy for chronic anal fissure but heals only approximately 50 to 60 percent of fissures. We use botulinum toxin as second-line therapy after failed glyceryl trinitrate and aimed to evaluate efficacy, side effects, and patient preference. METHODS: A prospective, nonrandomized, open-label study of patients with chronic anal fissure failing a course of glyceryl trinitrate treated with 20 units of botulinum toxin A injected into the internal sphincter was conducted. Symptomatic relief, visual healing of fissures, side effects, and patient preference were assessed at 8-week follow-up. RESULTS: Forty patients underwent botulinum toxin treatment. Twenty-nine patients (73 percent) overall were improved symptomatically and avoided surgery. Seventeen fissures (43 percent) were healed, whereas 23 fissures (57 percent) remained unhealed. Of the unhealed fissures, 5 (12 percent) were asymptomatic, 7 (18 percent) were symptomatically much improved, and 11 (27 percent) were no better symptomatically and came to surgery. Discomfort associated with injection was minimal. Of 34 patients undergoing botulinum toxin injection in the clinic, 24 (71 percent) preferred botulinum toxin, 7 glyceryl trinitrate (20 percent; difference = 51 percent; 95 percent confidence interval = 31–71 percent), and 9 percent were undecided. Transient minor incontinence symptoms were noted in 7 patients (18 percent). CONCLUSIONS: Second-line botulinum toxin injection improves symptoms in approximately three-quarters of patients after failed primary glyceryl trinitrate therapy and at least in the short term avoids surgical sphincterotomy. Botulinum toxin heals approximately one-half of these fissures. Discomfort and side effects were minimal. A policy of first-line glyceryl trinitrate/second-line botulinum toxin will avoid sphincterotomy in 85 to 90 percent. Higher rates of healing may be achieved by giving botulinum toxin as first-line therapy, or addressing the chronic fibrotic nature of the fissure.

Role of self-expandable metal stents in the palliation of malignant duodenal obstruction.

Abstract: Background: Palliative surgical intervention for malignant duodenal obstruction is often associated with a significant morbidity. Endoscopic enteral stenting offers a suitable alternative, that is safe, effective, and less invasive. This study reports our experience with the use of self-expanding metal stents in the palliation of malignant gastric duodenal obstruction. Methods: A retrospective review of all patients who underwent duodenal stenting from November 1998 to February 2001 was performed. All the patients had symptomatic gastric outlet and duodenal obstruction with nausea, vomiting, and decreased oral intake. All of them underwent enteral stenting with self-expandable metal Wallstents 20 or 22 mm in diameter and 6 or 9 cm long. Results: For this study, 33 patients (19 men and 14 women) with a mean age of 62 years (range, 37–81 years) were identified, 32 of whom had successful duodenal stent placement (6 were performed as outpatient surgery). The malignancies were pancreatic 18 (54%), gastric 4 (12%), duodenal 3 (9%), metastatic 6 (18%), and cholangiocarcinoma 2 (6%) disorders. The site of obstruction was pyloric (n = 5; 15%), pyloroduodenal (n = 3; 9%), duodenal bulb (n = 11; 33%), second portion of duodenum (n = 9; 27%), second and third portion of duodenum (n = 3; 9%), C-loop (n = 1; 3%), and anastomotic (n = 1; 3%). A total of 29 patients (91%) had good clinical outcomes, with relief of obstructive symptoms, Two of three patients with no symptomatic relief underwent gastrojejunostomy. One patient refused further treatment. No immediate stent-related complications were noted. During the follow-up period, 20 patients died (none as a result stent-related causes) due to progression of cancer. Median survival was 102 days. Four patients had recurrent obstruction (2 tumor ingrowths, 1 overgrowth, and 1 distally migrated stent) at a mean interval of 82 days. All four had successful restenting without complications. Conclusion: Self-expandable metal stents placed endoscopically provide a safe, less invasive palliative treatment option with good clinical outcome in the management of malignant gastric outlet–duodenal obstruction.

Residual symptoms in depression: can treatment be symptom-specific?

Abstract: Background Most patients with depression continue to have symptoms after treatment. It is well documented that these "residual" symptoms are common and are associated with increases in suboptimal long-term outcomes such as relapse and disability. While it is clear that residual symptoms, as a group, contribute to poor outcomes, individual residual symptoms have received relatively little attention. To some extent, this lack of attention reflects an uncertainty in the field about the relationship of the syndrome of depression to the symptoms by which the syndrome is defined. Method Recognizing that for clinicians and patients symptom relief is the goal of treatment, this article reviews the evidence that a symptomatic approach to individual residual symptoms is both feasible and useful. Evidence was gathered through a MEDLINE review of articles published in English from 1966 to 2002. Multiple keywords relating to symptoms, depression, and treatment were used. Results Many of the agents that psychiatrists use for augmentation of depression treatment, such as psychostimulants and alerting agents, atypical antipsychotics and mood stabilizers, and buspirone and benzodiazepines, have specific symptomatic effects, which raises the question of whether we are augmenting the core antidepressant effect or providing symptomatic relief. Fatigue, anxiety, sexual dysfunction, and sleep disturbances are all symptoms that are commonly leftover after treatment of depression. Some data indicate that treatment of these residual symptoms is efficacious and may affect the long-term outcome of depression. Discussion This discussion of the treatment of residual depressive symptoms raises a variety of research questions that should be addressed. Also implicit in this discussion are theoretical questions on the relationship between symptoms and syndrome.

Clinical pharmacology of etoricoxib: a novel selective COX2 inhibitor.

Abstract: The development of COX2 inhibitors with improved biochemical selectivity (such as etoricoxib and valdecoxib) over that of commercially available coxibs has been driven by the potential advantage of safety using higher coxib doses for increased efficacy. Etoricoxib has been approved in the UK as a once-daily medicine for symptomatic relief in the treatment of osteoarthritis (OA), rheumatoid arthritis (RA) and acute gouty arthritis. It is currently approved with additional indications (i.e., for relief of acute pain associated with dental surgery, for primary dysmenorrhoea and for chronic musculo-skeletal pain, including chronic lower-back pain) in Mexico, Brazil and Peru. Etoricoxib has an in vitro COX1/COX2 IC(50) ratio of 344, the highest of any coxib. The administration of therapeutic doses of etoricoxib to healthy subjects does not affect COX1 activity in circulating platelets and gastric biopsies. The profound inhibition of monocyte COX2 activity at 24 h after dosing, as predicted by a pharmacological half-life of approximately 22 h, supports a once-daily dosing regimen of etoricoxib. In randomised, well-controlled clinical trials, etoricoxib has been shown to have a comparable clinical efficacy with traditional NSAIDs. Combined analysis of efficacy trials with etoricoxib versus non-selective NSAIDs has shown that the drug halves both investigator-reported upper gastrointestinal perforation, ulcers and bleeds (PUBs) and confirmed PUBs, and reduces the need for gastroprotective agents and gastrointestinal comedications by approximately 40%. The risk of lower extremity oedema and hypertension adverse experiences with etoricoxib was low and generally similar to comparator NSAIDs in a combined analysis of eight Phase III studies in OA, RA, chronic low-back pain and surveillance endoscopy. Large, randomised clinical trials have been planned to confirm the renal, gastrointestinal and cardiovascular safety of etoricoxib.

Systematic review and meta-analysis: does gall-bladder ejection fraction on cholecystokinin cholescintigraphy predict outcome after cholecystectomy in suspected functional biliary pain?

Abstract: Summary Background : Patients with suspected functional biliary pain often undergo cholecystectomy if a decreased gall-bladder ejection fraction (GBEF < 35%) is demonstrated by cholecystokinin cholescintigraphy. However, the validity of GBEF in predicting which patients will have symptomatic relief following cholecystectomy is unclear. Aim : To determine whether patients with suspected functional biliary pain with decreased GBEF have a better symptomatic outcome after cholecystectomy than those with normal GBEF. Methods : Systematic review and meta-analysis of the published literature through MEDLINE and EMBASE databases. Results : We included nine studies with a total of 974 patients with suspected functional biliary pain; 362 patients underwent cholecystectomy. Most studies assessed outcome by direct patient interview. Mean ages across the studies ranged from 35 to 47 years; 78% of all patients were female. Mean duration of follow-up after surgery ranged from 1 to 2.5 years. After cholecystectomy, 94% of the patients with reduced GBEF had a positive outcome compared to 85% among those with normal GBEF. The pooled Mantel–Haenszel odds ratio for positive outcome was 1.37 (95% confidence interval 0.56–3.34), P = 0.56. Conclusion : These data do not support the use of GBEF to select patients with suspected functional biliary pain for cholecystectomy. Prospective randomized trials are required if this practice is to be evidence-based.