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ABSTRACT: OBJECTIVES: The clinical and economic burden of Clostridium difficile infection (CDI) is significant. Recurrent CDI management has emerged as a major challenge with suboptimal response to standard therapy. Fecal microbiota transplantation (FMT) has been used as a treatment to reconstitute the normal microbial homeostasis and break the cycle of antibiotic agents that may further disrupt the microbiome. Given the lack of randomized-controlled trials (RCTs) and limitations in previous systematic reviews, we aimed to conduct a systematic review with robust methods to determine the efficacy and safety profile of FMT in CDI.METHODS: An electronic search was conducted using MEDLINE (1946-March 2012), EMBASE (1974-March 2012) and Cochrane Central Register of Controlled Trials (2012). The search strategy was not limited by language. Abstract data were excluded and only completed studies that underwent the full, rigorous peer-review process were included. Studies that used FMT via any delivery modality for laboratory or endoscopically proven CDI with clinical resolution as primary outcome were included. A sample size of 10 or more patients was a further criterion. Elements of the Centre for Reviews and Dissemination checklist and the National Institute of Clinical Excellence quality assessment for case series checklist were employed to determine study quality. Eligibility assessment and data extraction were performed by two independent researchers. Both unweighted pooled resolution rates (UPR) and weighted pooled resolution rates (WPR) were calculated with corresponding 95% confidence intervals (CI) for overall studies, as well as predefined subgroups.RESULTS: Eleven studies with a total of 273 CDI patients treated with FMT were identified; no RCTs were found as none have been published. Two-hundred and forty-five out of 273 patients experienced clinical resolution (UPR 89.7%; WPR 89.1% (95% CI 84 to 93%)). There was no statistically significant heterogeneity between studies (Cochran Q test P=0.13, I(2)=33.7%). A priori subgroup analysis suggested that lower gastrointestinal FMT delivery (UPR 91.4%; WPR 91.2% (95% CI 86 to 95%)) led to a trend towards higher clinical resolution rates than the upper gastrointestinal route (UPR 82.3%; WPR 80.6% (95% CI 69-90%)) (proportion difference of WPR was 10.6% (95% CI -0.6 to 22%)). No difference in clinical outcomes was detected between anonymous vs. patient selected donors. There were no reported adverse events associated with FMT and follow-up was variable from weeks to years.CONCLUSIONS: FMT holds considerable promise as a therapy for recurrent CDI but well-designed, RCTs and long-term follow-up registries are still required. These are needed to identify the right patient, efficacy and safety profile of FMT before this approach can be widely advocated.Am J Gastroenterol advance online publication, 19 March 2013; doi:10.1038/ajg.2013.59.
The American Journal of Gastroenterology 03/2013; · 7.28 Impact Factor
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P B Ernst,
L D Erickson,
W M Loo,
K G Scott,
E B Wiznerowicz,
C C Brown,
F J Torres-Velez,
M S Alam,
S G Black,
M McDuffie,
S H Feldman,
J L Wallace,
G W McKnight,
I T Padol, R H Hunt,
K S Tung
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ABSTRACT: SAMP1/YitFcs mice serve as a model of Crohn's disease, and we have used them to assess gastritis. Gastritis was compared in SAMP1/YitFcs, AKR, and C57BL/6 mice by histology, immunohistochemistry, and flow cytometry. Gastric acid secretion was measured in ligated stomachs, while anti-parietal cell antibodies were assayed by immunofluorescence and enzyme-linked immunosorbent spot assay. SAMP1/YitFcs mice display a corpus-dominant, chronic gastritis with multifocal aggregates of mononuclear cells consisting of T and B lymphocytes. Relatively few aggregates were observed elsewhere in the stomach. The infiltrates in the oxyntic mucosa were associated with the loss of parietal cell mass. AKR mice, the founder strain of the SAMP1/YitFcs, also have gastritis, although they do not develop ileitis. Genetic studies using SAMP1/YitFcs-C57BL/6 congenic mice showed that the genetic regions regulating ileitis had comparable effects on gastritis. The majority of the cells in the aggregates expressed the T cell marker CD3 or the B cell marker B220. Adoptive transfer of SAMP1/YitFcs CD4(+) T helper cells, with or without B cells, into immunodeficient recipients induced a pangastritis and duodenitis. SAMP1/YitFcs and AKR mice manifest hypochlorhydria and anti-parietal cell antibodies. These data suggest that common genetic factors controlling gastroenteric disease in SAMP1/YitFcs mice regulate distinct pathogenic mechanisms causing inflammation in separate sites within the digestive tract.
AJP Gastrointestinal and Liver Physiology 09/2011; 302(1):G105-15. · 3.43 Impact Factor
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ABSTRACT: Helicobacter pylori (H. pylori)infection is a well recognized upper gastrointestinal pathogen. Eradication of the infection heals type B chronic active gastritis,
peptic ulcer disease and virtually abolishes ulcer recurrence.1–5Cure of the infection also results in a complete histological regression of gastric MALT lymphoma in 80% of the patients and
prevents recurrence in almost all cases6–8and may prevent metachronous occurrence of gastric adenocarcinoma following endoscopic resection of early gastric cancer.9
07/2011: pages 71-85;
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ABSTRACT: The presence of gastric acid plays a critical role in the mechanisms of NSAIDs/aspirin-associated gastric and duodenal mucosal injury and ulceration. The role of gastric acid and its relationship to NSAIDs/aspirin in mucosal damage, ulcer and ulcer complications continues to be an important concern because of the increasing worldwide use of NSAIDs and aspirin. Acid suppression continues to be an important prevention strategy for NSAID-associated gastric and duodenal ulcer and ulcer complications. While a coxib or an NSAID and PPI in combination are considered to have comparable safety profiles, the evidence from direct comparisons in high-risk patients is limited, and the cardiovascular safety of coxibs and NSAIDs remains a concern especially in patients with a high risk of cardiovascular disease. An evaluation of individual gastrointestinal and cardiovascular risks and benefits, selection of the most appropriate NSAID and dose for each particular patient should always be emphasized. Twice daily PPI is more appropriate to protect a patient who is taking NSAIDs twice daily. PPI co-therapy is still recommended in patients receiving dual antiplatelet treatment, although conflicting results have been reported about adverse drug interactions between PPIs and clopidogrel.
Digestive Diseases 01/2011; 29(5):465-8. · 2.37 Impact Factor
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ABSTRACT: Proton pump inhibitors (PPIs) are effective in gastroesophageal reflux disease (GERD), but their cost effectiveness is unknown. This is usually determined by cost/quality-adjusted life year (QALY) gained, but whether PPI therapy improves QALYs has not been assessed in a randomized trial. The PPI acid suppression symptom (PASS) test is a five-item questionnaire that identifies patients with persistent acid-related symptoms. We evaluated whether a PASS test-based management strategy of changing GERD therapy to esomeprazole in those with continued symptoms on another PPI or H(2) receptor antagonist therapy would be cost effective. We expressed the data in terms of cost per quality-adjusted life months (QALM), as this was a 4-week trial.
This is a multicenter, cluster-randomized, open-label study in primary care physician centers across Canada. Primary care physician centers were randomized to intervention or control arms. Patients on acid-suppressing medication were identified from primary care records and asked to complete the PASS test. PASS test failures at baseline assessment continued current therapy in control practices or switched to esomeprazole 20 or 40 mg daily (the dose was at the clinician's discretion) for 4 weeks in intervention practices. A planned secondary end point was QALM gain, measured using the validated Euroqol (EQ-5D) completed at baseline and 4 weeks. Medication use was also assessed by questionnaire. Canadian unit generic costs were applied to all GERD drugs, except to esomeprazole and lansoprazole, wherein proprietary costs were used (all costs in Canadian $). Data were analyzed using bootstrap sampling.
A total of 1,564 patients were recruited from 134 intervention sites and 92 control sites. Data were evaluable for 808 intervention and 445 control patients. The mean (±standard deviation) QALM at 4 weeks in the intervention group was 0.885±0.164 compared with 0.814±0.179 in the control group, resulting in a mean 0.071 (95% CI=0.091-0.051) QALM gain (P<0.0001). Esomeprazole was cost effective for PASS test failures, with a mean cost of $763 (95% CI=456-1,414) per QALM gain.
Esomeprazole was associated with a statistically significant gain in QALMs and was cost effective in primary care patients with persistent acid-related symptoms identified by the PASS test.
The American Journal of Gastroenterology 11/2010; 105(11):2341-6. · 7.28 Impact Factor
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Richard H Hunt
Gastroenterology clinics of North America 09/2010; 39(3):xv-xvi. · 2.56 Impact Factor
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ABSTRACT: Some studies suggest that eradication of Helicobacter pylori (Hp) might increase the risk of gastroesophageal reflux disease (GERD) in a portion of patients. We aimed to conduct a meta-analysis to investigate this.
A comprehensive, English, multiple-source literature search was performed from 1983 to February 2007. Only randomized controlled trial (RCT) and cohort studies comparing the prevalence of GERD in patients free from GERD at baseline with Hp eradication vs. those with persistent Hp were included. Quality of RCTs and cohorts was assessed by Jadad and New Castle-Ottawa scores, respectively. Meta-analysis of pooled odds ratios (ORs) was performed using Review Manager 4.2.10.
Twelve (7 RCTs and 5 cohorts) of 271 articles were included. In six RCTs using erosive GERD as outcome, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp group was 1.11 (0.81-1.53, P=0.52). In five RCTs using symptomatic outcome, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp was 1.22 (0.89-1.69, P=0.22). In cohort studies, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp was 1.37 (0.89-2.12; P=0.15). Test of heterogeneity was not significant for any analyses. The results were consistent in subgroup and sensitivity analyses, including cohort studies vs. RCTs, high-quality studies vs. low-quality studies, and use of endoscopic vs. symptomatic outcomes except for the subgroup of patients with peptic ulcer disease (PUD) in cohort studies (OR: 2.04 (1.08-3.85); P=0.03).
There is no association between Hp eradication and development of new cases of GERD in the population of dyspeptic patients. However, in cohort studies, there seems to be a twofold higher risk of development of erosive GERD in patients with PUD. The effect in RCTs of patients with PUD did not show a significant difference.
The American Journal of Gastroenterology 05/2010; 105(5):1007-13; quiz 1006, 1014. · 7.28 Impact Factor
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ABSTRACT: The results of clinical trials with proton pump inhibitors (PPIs) are usually based on the Hetzel-Dent (HD), Savary-Miller (SM), or Los Angeles (LA) classifications to describe the severity and assess the healing of erosive oesophagitis. However, it is not known whether these classifications are comparable. The aim of this study was to review systematically the literature to compare the healing rates of erosive oesophagitis with PPIs in clinical trials assessed by the HD, SM, or LA classifications.
A recursive, English language literature search in PubMed and Cochrane databases to December 2006 was performed. Double-blind randomized control trials comparing a PPI with another PPI, an H2-RA or placebo using endoscopic assessment of the healing of oesophagitis by the HD, SM or LA, or their modified classifications at 4 or 8 weeks, were included in the study. The healing rates on treatment with the same PPI(s), and same endoscopic grade(s) were pooled and compared between different classifications using Fisher's exact test or chi2 test where appropriate.
Forty-seven studies from 965 potential citations met inclusion criteria. Seventy-eight PPI arms were identified, with 27 using HD, 29 using SM, and 22 using LA for five marketed PPIs. There was insufficient data for rabeprazole and esomeprazole (week 4 only) to compare because they were evaluated by only one classification. When data from all PPIs were pooled, regardless of baseline oesophagitis grades, the LA healing rate was significantly higher than SM and HD at both 4 and 8 weeks (74, 71, and 68% at 4 weeks and 89, 84, and 83% at 8 weeks, respectively). The distribution of different grades in study population was available only for pantoprazole where it was not significantly different between LA and SM subgroups. When analyzing data for PPI and dose, the LA classification showed a higher healing rate for omeprazole 20 mg/day and pantoprazole 40 mg/day (significant at 8 weeks), whereas healing by SM classification was significantly higher for omeprazole 40 mg/day (no data for LA) and lansoprazole 30 mg/day at 4 and 8 weeks. The healing rate by individual oesophagitis grade was not always available or robust enough for meaningful analysis. However, a difference between classifications remained.
There is a significant, but not always consistent, difference in oesophagitis healing rates with the same PPI(s) reported by the LA, SM, or HD classifications. The possible difference between grading classifications should be considered when interpreting or comparing healing rates for oesophagitis from different studies.
European journal of gastroenterology & hepatology 05/2010; 22(5):583-90. · 1.66 Impact Factor
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ABSTRACT: A multidisciplinary group of 34 experts from 15 countries developed this update and expansion of the recommendations on the management of acute nonvariceal upper gastrointestinal bleeding (UGIB) from 2003.
The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews; randomized, controlled trials; and abstracts up to October 2008. Quality of evidence and strength of recommendations have been rated by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.
Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermocoagulation, alone or with epinephrine injection, are effective methods; epinephrine injection alone is not recommended. Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. Preendoscopy proton-pump inhibitor (PPI) therapy may downstage the lesion; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIB who require a nonsteroidal anti-inflammatory drug, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding. Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days); ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding.
Annals of internal medicine 01/2010; 152(2):101-13. · 16.73 Impact Factor
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ABSTRACT: Cyclooxygenase (COX) inhibitors remain a major class of drugs in rheumatology and their widespread use is expected to continue. The view that a prothrombotic effect explains the increase in myocardial infarction (MI) associated with both COX-2 selective and traditional NSAIDs (tNSAIDs) has been increasingly questioned. We review the evidence that prostanoids direct the immune response away from a Th1 response and that consequently inhibition of prostaglandin synthesis results in augmentation of the Th1 response by limiting prostanoid synthesis. Although the role of prostanoids as mediators of inflammation in the periphery is well understood, the systemic immunomodulatory role of prostanoids shifting the immune response away from a Th1 type is less appreciated. Atherosclerosis is an inflammatory arterial disease driven by a Th1 type immune response. Moreover, the vulnerable phenotype of atheroma is associated with the cellular Th1 immune response in contrast to the stable plaque phenotype associated with a Th2 type response. We propose a class effect of COX-2 selective and tNSAIDs, which results in augmentation of Th1-mediated atherogenesis/ production of pro-atherogenic cytokines associated with detrimental plaque remodeling, instability, rupture and embolization resulting in MI. Understanding of the Th1 mediated immunity, which underlies the cardiovascular, and the non-Th1, which underlies gastrointestinal adverse effects associated with the use of COX inhibitors, should lead to better risk assessment and the development of anti-inflammatory treatments with improved safety. Our explanation also emphasizes the pharmacological effects and consequences of immunomodulation in the inflammation associated with atherosclerosis and other Th1- as well as non-Th1-driven diseases.
Rheumatology (Oxford, England) 09/2009; 49(5):837-43. · 4.24 Impact Factor
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ABSTRACT: Systematic reviews systematically evaluate and summarize current knowledge and have many advantages over narrative reviews. Meta-analyses provide a more reliable and enhanced precision of effect estimate than do individual studies. Systematic reviews are invaluable for defining the methods used in subsequent studies, but, as retrospective research projects, they are subject to bias. Rigorous research methods are essential, and the quality depends on the extent to which scientific review methods are used. Systematic reviews can be misleading, unhelpful, or even harmful when data are inappropriately handled; meta-analyses can be misused when the difference between a patient seen in the clinic and those included in the meta-analysis is not considered. Furthermore, systematic reviews cannot answer all clinically relevant questions, and their conclusions may be difficult to incorporate into practice. They should be reviewed on an ongoing basis. As clinicians, we need proper methodological training to perform good systematic reviews and must ask the appropriate questions before we can properly interpret such a review and apply its conclusions to our patients. This paper aims to assist in the reading of a systematic review.
The American Journal of Gastroenterology 06/2009; 104(5):1086-92. · 7.28 Impact Factor
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ABSTRACT: The majority of distal esophageal adenocarcinomas are believed to arise in patients with Barrett's esophagus (BE). Helicobacter pylori (H. pylori) infection plays an etiological role in gastric carcinogenesis, but any possible role in BE is uncertain. We aimed to explore the possible relationship between H. pylori infection and BE by meta-analysis.
Observational studies comparing the prevalence of H. pylori infection in patients with BE and healthy controls conducted in adult populations and published in all languages were identified through MEDLINE, EMBASE, and Cochrane database searches up to week 5, 2008. H. pylori infection had to be confirmed by histology and/or serology and/or RUT and/or culture. Studies were excluded if no raw data for outcomes of interest were available or controls were patients with disease or duplicate publications. Summary effect size was calculated as odds ratio (OR) and 95% confidence intervals (CIs) by the random-effects model using Review Manager 4.2.8.
Of 519 citations identified, a total of 12 case-control studies compared the prevalence of H. pylori infection in BE (n=550) and controls (9 studies included controls with normal endoscopy and 3 studies used healthy blood donors as control, n=2,979). There was no significant difference in the overall prevalence of H. pylori infection between BE and controls (42.9% vs. 43.9%, OR=0.74, 95% CI 0.40-1.37, P=0.34), but with significant heterogeneity. Subgroup analysis showed that the prevalence of H. pylori infection was significantly lower in BE than in endoscopically normal healthy controls (23.1% vs. 42.7%, OR=0.50, 95% CI 0.27-0.93, P=0.03) with significant heterogeneity observed between studies. The heterogeneity was eliminated by excluding a single Asian outlier study. In contrast, H. pylori infection was significantly increased in BE patients in the three studies using healthy blood donors as "normal controls" (71.2% vs. 48.1%, OR=2.21, 95% CI 1.07-4.55). In BE patients, the prevalence of H. pylori infection was significantly lower in the esophagus than in the stomach (3.3% vs. 24.7%, OR=0.14, 0.03-0.67) in three studies.
H. pylori infection and BE are inversely related when compared with endoscopically normal controls but not blood donor controls. Limited evidence suggests that there is no clear association between H. pylori infection and BE. To determine more accurately the effect size of H. pylori infection in BE, high quality prospective case-control studies with age-matched, endoscopically normal healthy controls are needed.
The American Journal of Gastroenterology 02/2009; 104(2):492-500; quiz 491, 501. · 7.28 Impact Factor
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ABSTRACT: Antisecretory therapies that raise intragastric pH provide the best healing of the esophageal mucosal damage that occurs in gastroesophageal reflux disease. Continuous maintenance therapy is also effective to reduce the likelihood of recurrence of esophagitis and control symptoms in the long term. Proton pump inhibitor (PPI) therapy is an effective approach for healing esophagitis and controlling symptoms. Endoscopic and surgical treatments may provide an option for patients who are refractory to PPIs in whom reflux has been clearly demonstrated. Long-term antireflux medication is often needed after surgical treatment because of persisting or recurrent pathologic reflux and symptoms. An alternative approach to controlling transient lower esophageal sphincter relaxations, such as the GABA-B agonists, deserves further study.
Gastroenterology Clinics of North America 01/2009; 37(4):879-99, ix. · 2.62 Impact Factor
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The American Journal of Gastroenterology 01/2009; 103(12):2969-71. · 7.28 Impact Factor
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ABSTRACT: Acute nonvariceal upper-GI bleeding (NVUGIB) is common, with a high rate of recurrent bleeding and substantial mortality rate. Endoscopic clipping has the theoretical advantage of minimizing tissue injury and is increasingly used.
We conducted a systematic review and meta-analysis to investigate any potential benefits of clipping over other endoscopic techniques for NVUGIB.
Randomized controlled trials (RCT) that compared clipping with other endoscopic hemostatic methods to treat NVUGIB were included. Summary effect size was estimated by odds ratio (OR) with a random-effects model.
Twelve RCTs met inclusion criteria. For peptic ulcer bleeding (PUB), the hemoclip (n = 351 patients) was compared with the heat probe alone, thermal therapy plus injection, and injection alone in 2, 2, and 5 studies, respectively (n = 348 patients). The rate of the initial hemostasis was nonsignificantly increased in the control group compared with the hemoclip group (92% vs 96%, OR 0.58 [95% CI, 0.19-1.75]). The rebleeding rate was nonsignificantly decreased with hemoclips compared with controls (8.5% vs 15.5%, OR 0.56 [95% CI, 0.30-1.05]). Emergency surgery and the mortality rate were not significantly different between the hemoclip and controls. Subgroup analysis conducted in studies that compared hemoclips with injection alone show similar results. Two studies and one study reported outcomes of interest for Dieulafoy's lesions and Mallory-Weiss syndrome, respectively.
RCTs that compared clipping alone with other endoscopic hemostatic techniques for NVUGIB were limited. Current evidence suggests that the hemoclip is not superior to other endoscopic modalities in terms of initial hemostasis, rebleeding rate, emergency surgery, and the mortality rate for treatment of PUB.
Gastrointestinal endoscopy 08/2008; 68(2):339-51. · 6.71 Impact Factor
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ABSTRACT: In the developed world, most patients with gastroesophageal reflux disease (GERD) do not exhibit erosions when examined by standard white light endoscopy. Despite the high prevalence of such non-erosive reflux disease (NERD), relatively little is known of its underlying pathophysiology, hence there is no clear guide to clinical management. To establish areas of agreement or uncertainty in NERD, an international meeting was held in Vevey, Switzerland, in late 2007. The goal was to document current thinking in the areas of clinical presentation, assessment of clinical outcome, pathobiological mechanisms, and define optimal clinical strategies to diagnose and manage NERD. After extensive debates, the modified Delphi technique was utilized to reach a consensus on 85 specific statements. In addition, it was proposed that NERD be defined as 'a subcategory of GERD characterised by troublesome reflux-related symptoms in the absence of esophageal mucosal erosions/breaks at conventional endoscopy and without recent acid suppressive therapy'. Evidence in support of this diagnosis may include responsiveness to acid suppression therapy, abnormal reflux monitoring or the identification of specific novel endoscopic findings. Defining the current state of knowledge in NERD should help improve the elucidation and management of this condition in the future.
Digestion 02/2008; 78 Suppl 1:1-5. · 2.05 Impact Factor
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ABSTRACT: The fundamental abnormality in gastroesophageal reflux disease is exposure of the esophageal epithelium to acidic gastric contents, resulting in histopathologic injury and/or symptoms. With increasing understanding of gastroesophageal reflux disease, non-erosive reflux disease (NERD) is found to account for >50% of cases involving gastroesophageal reflux. There is a good correlation between esophageal acid exposure (EAE) and endoscopic changes. Duration of EAE correlates with severity of erosive esophagitis (EE), and the number of prolonged acid reflux episodes and esophageal exposure to acid and pepsin is increased in more severe reflux. However, there is no convincing evidence to support a significant difference in the acid secretory capacity between patients with NERD or EE. Although acid reflux gives rise to similar symptoms in both NERD and EE patients, the underlying mechanism of acid injury may be different. Dilated intercellular spaces may be responsible for the enhanced perception of proximal acid reflux and dilated intercellular spaces are a feature of NERD patients, irrespective of EAE, and can be considered an objective, structural marker of reflux symptoms. Three different mechanisms have been proposed to explain the occurrence of heartburn in endoscopy-negative patients: esophageal visceral hypersensitivity, sustained esophageal contractions, and abnormal tissue resistance. Impaired esophageal mucosal resistance or increased sensitivity, even to small amounts of acid reflux, plays a key role in the pathophysiology of NERD. Moreover, hyperalgesia may be a predominant mechanism in eliciting symptoms in NERD patients. Increasingly seen are patients with a poor response to acid suppression treatment. Moreover, even double proton pump inhibitor dosing does not completely inhibit gastric acid secretion and relieve all symptoms. Thus, current definitions of acid reflux require review to increase the sensitivity to determine the frequency and implication of short periods of acidity in the esophagus. Analysis such as analysis of the area under the H(+) activity time curve is one alternative approach for evaluating acid secretion. The precise role of acid in NERD needs further clarification.
Digestion 01/2008; 78 Suppl 1:31-41. · 2.05 Impact Factor
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ABSTRACT: Helicobacter pylori (H. pylori) is recognized as a definite carcinogen for gastric cancer. The prevalence of H. pylori infection in patients with gastric cancer varies widely among studies and no meta-analysis on the prevalence of H. pylori infection in early gastric cancer (EGC) has been performed. We aimed to review systematically the relationship between H. pylori infection and EGC, and different types of EGC.
Observational studies reporting raw data on the prevalence of H. pylori infection in EGC and controls, or comparing different types of EGC, conducted in adult populations, and published in the English language were identified through MEDLINE and EMBASE up to June 2006.
Of 87 relevant studies, 19 case-control studies met inclusion criteria. Of these, 15 studies compared EGC (N = 2,722) and non-neoplasm controls (N = 13,976) or advanced gastric cancer (AGC) (N = 1,130), 9 studies compared the intestinal-type (I-EGC) and diffuse-type (D-EGC) of EGC, and 2 studies compared the differentiated-type (DF-EGC) and undifferentiated-type (UDF-EGC) of EGC and were included in the meta-analysis. The prevalence of H. pylori infection was significantly higher in patients with EGC (87.3%) than in non-neoplasm controls (61.4%) (OR 3.38, 95% CI 2.15-5.33, P < 0.00001). However, significant heterogeneity was seen (P < 0.00001). Four large sample (N > or = 100) studies (N = 2,060) may result in the heterogeneity, but the conclusion remained unchanged when sensitivity analysis was made with the other 11 homogeneous small sample studies alone, in which the prevalence of H. pylori infection was significantly higher in EGC (N = 662) than that in controls (N = 5,898) (87.8%vs 68.6%, P < 0.00001), and the odds ratio (OR 3.28, 95% CI 2.34-4.61) was similar to the large sample studies alone (OR 3.40, 95% CI 1.14-10.12). The prevalence of H. pylori infection in EGC was significantly higher than in AGC (6 studies) (OR 2.13, 95% CI 1.75-2.59) and 16-fold higher in patients with DF-EGC than in those with UDF-EGC (OR 16.53, 95% CI 2.64-103.43). No significant difference in the prevalence of H. pylori infection was seen between the patients with I-EGC and D-EGC types (OR 0.75, 95% CI 0.26-2.18).
This study indicates that H. pylori infection is strongly associated with early gastric cancer when compared with non-neoplasm controls or advanced gastric cancer. To determine more accurately the effect size of H. pylori in EGC, age-matched normal controls or adjusting for age in the analysis should be considered in H. pylori-related gastric cancer case-control studies.
The American Journal of Gastroenterology 09/2007; 102(8):1789-98. · 7.28 Impact Factor
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ABSTRACT: To provide family physicians and pharmacists with practical, evidence- and expertise-based guidance on choosing the safest approach to using analgesics to manage patients with musculoskeletal pain.
Health care providers from family practice, rheumatology, gastroenterology, hepatology, internal medicine, and pharmacy participated in an educational needs assessment regarding the management of pain and the safety of commonly used analgesics. Feedback from one-on-one interviews was compiled and distributed to participants who selected key topics. Topics chosen formed the basis for the discussions of this multidisciplinary panel that reviewed data on the safety of analgesics, particularly in regard to comorbidity and concurrent use with other therapies.
Treatment should begin with an effective analgesic with the best safety profile at the lowest dose and escalate to higher doses and different analgesics as required. Acetaminophen is a safe medication that should be considered first-line therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with potential adverse gastrointestinal, renal, hepatic, and cardiovascular effects. Physicians should not prescribe NSAIDs before taking a careful history and doing a physical examination so they have the information they need to weigh the risks (adverse effects and potential drug interactions) and benefits for individual patients.
Taking a complete and accurate history and doing a physical examination are essential for choosing the safest analgesic for a particular patient.
Canadian family physician Medecin de famille canadien 08/2007; 53(7):1177-84. · 1.19 Impact Factor
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Richard H Hunt,
Guido H Tytgat,
Peter Malfertheiner,
Kwong Ming Fock,
Robert C Heading,
Peter H Katelaris,
Denis M McCarthy,
Kenneth E L McColl,
Steven F Moss,
George Sachs,
Stephen J Sontag,
Alan B R Thomson,
Irvin M Modlin
Journal of Clinical Gastroenterology 08/2007; 41(6):539-45. · 3.16 Impact Factor
