Is analysis of lower esophageal sphincter vector volumes of value in diagnosing gastroesophageal reflux disease?

AIM:With successful surgical treatment of gastroesophageal reflux disease(GERD),there is interest in understanding the anti-reflux barrier and its mechanisms of failure.To date, the potential use of vector volumes to predict the DeMeester score has not been adequately explored. METHODS:627 patients in the referral database received esophageal manometry and ambulatory 24-hour pH monitoring.Study data included LES resting pressure(LESP), overall LES length(OL)and abdominal length(AL),total vector volume(TVV)and intrabdominal vector volume(IVV). RESULTS:In cases where LESP,TVV or IVV were all below normal,there was an 81.4%probability of a positive DeMeester score.In cases where all three were normal, there was an 86.9%probability that the DeMeester score would be negative.Receiver-operating characteristics(ROC) for LESP,TVV and IVV were nearly identical and indicated no useful cut-off values.Logistic regression demonstrated that LESP and IVV had the strongest association with a positive DeMeester score;however,the regression formula was only 76.1%accurate. CONCLUSION:While the indices based on TVV,IVV and LESP are more sensitive and specific,respectively,than any single measurement,the measurement of vector volumes does not add significantly to the diagnosis of GERD.

Biofeedback therapy improves motor function following stroke Meta-analysis of 14 articles from Chinese Medical Institutions

OBJECTIVE： To evaluate feasibility of biofeedback therapy in China Medical Institutions to improve dysfunction following stroke. DATA SOURCE： A computer-based online search of publications was conducted using the Vip and PubMed Databases to identify publications that addressed biofeedback. The search key words included ＂electromyogram＂, ＂biofeedback＂, and ＂stroke＂. In total, 81 articles were retrieved. DATA SELECTION： Studies closely related to biofeedback, or studies with contents recently published in the same study field or in authorized journals, were included. Duplicated articles were excluded. Following full-text retrieval of selected articles, a total of 14 articles were collected, which addressed randomized, controlled trials of biofeedback therapy for dysfunction after stroke. Methodological quality was assessed for randomized, controlled trials using criteria from Cochrane reviewers＇ handbook. Results were analyzed using Revman 4.2 software. MAIN OUTCOME MEASURES： Outcomes and evaluation indices were expressed by odds ratio （OR）, weighted mean difference （WMD）, and 95% confidence interval （95% CO. Potential publication bias was presented using the funnel plot. RESULTS： The study included 14 randomized, controlled trials of 1 147 patients. Following biofeedback therapy, meta-analysis results demonstrated that： （1） The total effective rate was significantly greater in the biofeedback therapy group compared with the control group [OR = 3.46, 95% Cl （2.09, 5.73）, P = 0.62]. （2） Electromyogram changes were better in biofeedback therapy patients compared to the control group [WMD= 22.31, 95% C/（17.19, 27.43）, P〈 0.001]. （3） Motor function was better in biofeedback therapy patients compared with the control group [WMD = 12.43, 95% CI （6.71, 18.16）, P 〈 0.001]. （4） Daily living activities were better in biofeedback therapy patients compared with the control group [WMD= 18.11, 95% C/（15.77, 20.44）, P= 0.36]. （5） Joint range of motion was better in biofeedback therapy patients compared with the control group [WMD = 6.43, 95% Cl （4.44, 8.41）, P = 0.77]. Sensitivity analysis also demonstrated similar results after eliminating articles that described unknown diagnostic criteria and statistical methods. CONCLUSION： Following stroke, biofeedback therapy for dysfunction was shown to result in significant and valid outcomes, increased motor function and electromyogram values, improved joint range of motion, and improved daily living activities.

Clinical effects of electroacupuncture stimulation on treatment of stroke-induced limb spasm

OBJECTIVE： To summarize the development of electroacupuncture stimulation in the treatment of stroke-induced limb spasm, to provide research possibilities or clinical development, and to clarify the mechanism and therapeutic effects of electroacupuncture stimulation. DATA SOURCES： Articles relating to therapeutic effects of electroacupuncture stimulation on treatment of stroke-induced limb spasm, as well as clinical studies （which are not limited to age, sex and race）, were retrieved from the China Journal Fulltext Database from January 2000 to December 2007. The key words were stroke, apoplexy, spasm, and electroacupuncture in Chinese. Other articles were obtained from specific journals or books. STUDY SELECTION： Data were first selected by title and abstract. Clinical and rehabilitative studies relating to the effects of electroacupuncture and acupuncture on the treatment of stroke-induced limb spasm were included. Clinical studies related to the rehabilitative treatment of limb spasm were excluded, unless the effects of electroacupuncture stimulation were recorded. DATA EXTRACTION： A total of 338 references were collected; however, 295 of these were excluded. Therefore, 43 articles were analyzed, comprising 40 in Chinese and 3 in English. DATA SYNTHESIS： At present, acupuncture is widely used at home to treat stroke-induced limb spasm; however, acupuncture at different acupoints might cause different clinical effects. Electroacupuncture, which is characterized by analgesia and relief of spasm, can preclude inflammatory edema, improve blood circulation and blood viscosity, inhibit platelet aggregation and adherence, relieve formation of atheromatous plaque in tunica intima of artery, and resist cerebral anoxia, so as to relieve stroke-induced limb spasm. Meanwhile, electroacupuncture combined with rehabilitation can effectively decrease the degree of spasm and improve motor function. CONCLUSION： Acupuncture and moxibustion therapy are superior in the rehabilitative treatment of stroke-induced limb spasm. Electroacupuncture is a convenient means to stimulate the acupoints. There are various ways to use this method, but it clearly has therapeutic effects, with few side effects. Electroacupuncture can effectively control limb spasms, while improving motor function and living ability.

Postmyotomy dysphagia after laparoscopic surgery for achalasia

AIM: To determine predictive factors for postoperative dysphagia after laparoscopic myotomy for achalasia.METHODS: Logistic regression was used to investigate the possible association between the response (postoperative dysphagia, with two levels: none/mild and moderate/severe)and several plausible predictive factors.RESULTS: Eight patients experienced severe or moderate postoperative dysphagia. The logistic regression revealed that only the severity of preoperative dysphagia (with four levels; mild, moderate, severe, and liquid) was a marginally significant (P=0.0575) predictive factor for postoperative dysphagia.CONCLUSION: The severity of postoperative dysphagia is strongly associated with preoperative dysphagia. Preoperative symptomatology can significantly impact patient outcome.

Role of cell-free network communication in alcohol-associated disorders and liver metastasis

The aberrant use of alcohol is a major factor in cancer progression and metastasis.Contributing mechanisms include the systemic effects of alcohol and the exchange of bioactive molecules between cancerous and non-cancerous cells along the brain-gut-liver axis.Such interplay leads to changes in molecular,cellular,and biological functions resulting in cancer progression.Recent investigations have examined the role of extracellular vesicles(EVs)in cancer mechanisms in addition to their contribution as diagnostic biomarkers.Also,EVs are emerging as novel cell-free mediators in pathophysiological scenarios including alcohol-mediated gut microbiome dysbiosis and the release of nanosized EVs into the circulatory system.Interestingly,EVs in cancer patients are enriched with oncogenes,miRNA,lipids,and glycoproteins whose delivery into the hepatic microenvironment may be enhanced by the detrimental effects of alcohol.Proof-of-concept studies indicate that alcohol-associated liver disease is impacted by the effects of exosomes,including altered immune responses,reprogramming of stromal cells,and remodeling of the extracellular matrix.Moreover,the culmination of alcoholrelated changes in the liver likely contributes to enhanced hepatic metastases and poor outcomes for cancer patients.This review summarizes the numerous aspects of exosome communications between organs with emphasis on the relationship of EVs in alcohol-associated diseases and cancer metastasis.The potential impact of EV cargo and release along a multi-organ axis is highly relevant to the promotion of tumorigenic mechanisms and metastatic disease.It is hypothesized that EVs target recipient tissues to initiate the formation of prometastatic niches and cancer progression.The study of alcohol-associated mechanisms in metastatic cancers is expected to reveal a better understanding of factors involved in the growth of secondary malignancies as well as novel approaches for therapeutic interventions.

Endoscopic therapies of gastroesophageal reflux disease

The high prevalence of gastroesophageal reflux disease （GERD） in Western societies has accelerated the need for new modalities of treatment. Currently, medical and surgical therapies are widely accepted among patients and physicians. New potent antisecretory drugs and the development of minimally invasive surgery for the management of GERD are at present the pivotal and largely accepted approaches to treatment. The minimally invasive treatment revolution, however, has stimulated several new endoscopic techniques for GERD. Up to now, the data is limited and further studies are necessary to compare the advantages and disadvantages of the various endoscopic techniques to medical and laparoscopic management of GERD. New journal articles and abstracts are continuously being published. The Food and Drug Administration has approved 3 modalities, thus gastroenterologists and surgeons are beginning to apply these techniques. Further trials and device refinements will assist clinicians. This article will present an overview of the various techniques that are currently on study. This review will report the efficacy and durability of various endoscopic therapies for gastroesophageal reflux disease （GERD）. The potential for widespread use of these techniques will also be discussed. Articles and abstracts published in English on this topic were retrieved from Pubmed. Due to limited number of studies and remarkable differences between various trials, strict criteria were not used for the pooled data presented, however, an effort was made to avoid bias by including only studies that used off-PPI scoring as baseline and intent to treat.

Meta-analysis of transcranial magnetic stimulation to treat post-stroke dysfunction

OBJECTIVE： To evaluate the effects of transcranial magnetic stimulation （TMS） on post-stroke dysfunction. DATA SOURCES： A computer-based online search of the VIP and PubMed databases was performed to identify TMS studies published between January 1989 and December 2010 using the key words ＂transcranial magnetic stimulation, stroke＂ in Chinese and English. A total of 61 articles were collected. STUDY SELECTION： Repetitive articles were excluded. Articles published recently in the authoritative journals of the same domain were selected. The full-text of selected articles was searched. A total of seven articles were randomized controlled experiments regarding the application of TMS in the treatment of post-stroke dysfunction. The methodology quality of included articles was evaluated according to standards of Cochrane Reviewer＇s Handbook system and analyzed using RevMand4.2 software. MAIN OUTCOME MEASURES： Therapeutic effects and difference evaluation indices were represented by odds ratios, weighted mean difference （WMD） and 95% confidence interval （CO. Potential publication bias was described using a funnel plot. RESULTS： A total of seven randomized, controlled studies were included involving 281 patients. Following TMS treatment, meta-analysis results revealed that scores in the Mini-Mental State Examination were higher in the TMS group compared with the control group [WMD = 3.96, 95% CI （2.44, 5.49）, P = 0.08]; scores in the Hamilton Rating Scale for Depression were significantly lower in the TMS group compared with the control group [WMD = 6.21,95% C （ 7.55, 4.87）, P = 0.92] scores in National Institutes of Health Stroke Scale were lower following TMS treatment compared with the control group [WMD = 0.89, 95% C （ 1.98, 0.19）, P = 0.04]. Performance of patients undergoing TMS treatment was better than the controls in the line bisection test [WMD = 0.78, 95% Cl （ 1.43,-0.12）, P = 0.005] and line cancellation test [WMD = 0.47, 95% CI （ 0.78, 0.15）, P 〈 0.000 01]. Sensitivity analysis produced identical results after eliminating articles with unknown diagnostic standards or statistical methods. CONCLUSION： TMS effectively improved post-stroke dysfunction, manifested by improved cognitive function and memory performance compared with controls.

Cryopreservation of the Trachea Can Reduce Its Antigenicity in Various Species

Background: Cryopreserved tracheal allograft has been used successfully for esophageal replacement in the canine model. The working hypothesis was cryopreservation decreases antigenicity but epithelial desquamation remains. However, cryopreservation of human tracheal samples collected at tracheostomy, resulted in no significant desquamation. The aim of this study was to examine the extent of desquamation of the epithelial layer of cryopreserved animal tracheas and find a reason for decreased antigenicity of cryopreserved canine and pig’s trachea. Methods: 5 cm long tracheal segments were removed from 6 dogs and 125 pigs and stored in liquid nitrogen for 21 days. Cross section samples were taken from the end of the segment, 1 cm from the end and at the middle of the segment. Histological examination was performed using haematoxyllineosin and MHC-II antigen specific antibody staining. Changes in histological structure were analyzed. Results: General histological morphology of samples changed after cryopreservation. The percentage of intact epithelium and the overall intensity of immune-staining increased significantly from the ends to the middle of the segments, but the intensity of immune-staining showed no difference in the remaining epithelial cells. Conclusion: Cryopreservation damages the epithelial cells, but does not influence the cell’s antigenicity or cause desepithelisation. The main effect is a retraction of the epithelial layer from the ends to the midpart and this effect may be protection against organ rejection. Based on our canine and pig results a 5 cm, long tracheal segment seems to be a promising organ for human esophageal replacement.

Avoiding hepatic metastasis naturally: Lessons from the cotton top tamarin(Saguinus oedipus )

Much has been written about hepatic metastasis and animal models abound. In terms of the human experience, progress in treating this final common pathway, a terminal event of many human malignancies has been relatively slow. The current thinking is that primary prevention is best served by early detection of cancer and eradication of early stage cancers by screening. Some cancers spread early in their course and the role of screening may be limited. Until relatively recently there has not been a pathfinder model that makes the evasion of this unfortunate event a reality. This review discusses such an animal model and attempts to relate it to human disease in terms of intervention. Concrete proposals are also offered on how scientists may be able to intervene to prevent this deadly progression of the cancer process.

A diabetic hypertension treatment program for the underserved in rural Dominican Republic

Background: Worldwide, diabetes and hypertension are leading causes of preventable end-organ disease. The prevalence of these diseases in the Dominican Republic is high and the end stage complications common. A treatment program utilizing modern protocols often thought too complex for the rural poor was initiated. Methods: With local government permission, a pilot study utilized Dominican physicians and local healthcare advocates (cooperadores) to obtain medical histories and physical exams as well as to determine healthcare needs specifically for type 2 diabetes and hypertension. A glycosylated hemoglobin (A1c) was used to identify and stratify diabetes patients. Blood pressure parameters per established standards were used to identify patients with hypertension. As indicated, pharmacotherapy was initiated (see treatment protocols), multiple forms of education and awareness building utilized, and a protocol-driven follow-up program maintained under weekly review. Results: In fifteen months, 1405 patients were screened, 229 type 2 diabetes patients, 59 pre-diabetes patients, and 98 hypertension patients were identified and enrolled for education, treatment, and follow-up. Normalization of blood pressure in hypertensives at 6 month follow-up was 78% and reduction of A1c values to <7.0 was 79.8%. Conclusion: Utilizing a best practice approach per internationally agreed-upon parameters has been shown here to be not only relevant but capable of improving outcomes in a developing world setting. A model incorporating standard of care, education, and integration of local resources as established suggests that further study is warranted to evaluate the long-term benefits as well as secondary outcomes of this approach to local populations.

胃内折叠缝合的术式:一项环形折叠式与螺旋折叠式对比

Goals: To determine the long-term efficacy of endoluminal gastroplication (ELGP) and the most effective plication configuration. Background: Endoluminal gast roplication is an intriguing therapy for gastroesophageal reflux disease. We con ducted a retrospective review of a prospective experience of patient cohorts com paring outcomes of the circumferential and helical plication patterns. Study: Tw enty patients underwent ELGP, with 9 receiving the circumferential (Group 1) and 11 the helical pattern (Group 2). Manometry, endoscopy, and 24-hour pH monitor ing were performed at baseline and at 6 months. Symptom scores and medication us age were assessed at baseline, 1, 3, 6, 12, and 18months. Results: Both groups d id not differ significantly from each other with respect to symptom improvement, medication usage, or other variables measured. At 6 months, symptom scores, his tamine-2 receptor antagonist (H2RA), proton pump inhibitor usage,and hernia siz e decreased significantly. No other parameter showed a significant change. At th e 18-month follow-up, symptom scores and H2RA usage decreased significantly. C onclusion: ELGP improves heartburn and regurgitation scores at 18 months. Our st udy suggests that there is no benefit to additional placations when using the he lical pattern.