Randomised controlled trial of temoporfin photodynamic therapy plus chemotherapy in nonresectable biliary carcinoma--PCS Nordic study.

BACKGROUND: Photodynamic therapy (PDT) in combination with stent have shown promising results in the treatment of biliary tract cancer (BTC) in patients not suitable for surgery. Chemotherapy has been shown to improve survival in patients with local advanced and metastatic BTC. MATERIAL AND METHODS: In the current randomized trial the combination of chemotherapy and stent with and without temoporfin (Foscan) photodynamic therapy (PDT), with a primary endpoint on feasibility and safety, has been performed. Ten patients in each group. RESULTS: No serious, acute procedure-related complication related to PDT or the treatment combination was seen. The number of patients with cholangitis was equal in both groups. In the PDT group--arm A--two patients had cutaneous erythema after sun exposition, one of them with a localized blister. No neutropenic infection was seen. Quality of Life (QoL) was similar in both treatment groups. Progression free survival was numerically longer in the PDT group. CONCLUSION: The treatment combination was feasible. There was no serious complication related to PDT or the treatment combination. Number of cholangitis was equal in both groups, two abscesses were observed in the PDT group. Progression free survival was numerically longer in the PDT group.

Interim analysis of long-term intraduodenal levodopa infusion in advanced Parkinson disease.

BACKGROUND: This interim 12-month analysis is a part of an open-label, observational, prospective study on health outcomes and cost impact of levodopa/carbidopa intestinal gel (LCIG, Duodopa) in Parkinson disease (PD). The specific aim was to investigate clinical and health-related quality of life (HRQoL) effects in routine care. METHODS: Unified PD rating scale (UPDRS) was the primary efficacy measurement. PD QoL questionnaire 39 (PDQ-39) assessed HRQoL. Subjects were assessed at baseline, ≥3 months after surgery, and then every 3 months. RESULTS: Twenty-seven treatment-naïve subjects when started with LCIG showed a decrease in UPDRS score that was statistically significant throughout the year: UPDRS total score (mean ± SD), baseline = 52.1 ± 16.1, N = 27, month 0 (first visit; at least 3 months after permanent LCIG) = 43.1 ± 16.7, N = 27, P = 0.003; month 12 = 42.5 ± 22.6, n = 25, P = 0.017. PDQ-39 results also showed a tendency for improvement: PDQ-39 (mean ± SD), baseline = 33.6 ± 10.8, N = 27, month 0 = 27.1 ± 11.8, N = 27, P = 0.001; 12 months = 28.8 ± 12.8, n = 23, P = 0.126. CONCLUSIONS: LCIG provides functional improvement beginning at first visit that is sustained for 12 months.

Percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients with stroke.

BACKGROUND: The use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients admitted for stroke is difficult, varying and needs specific consideration. There is therefore need for more data on this patient group. We examined the indications, survival, tube removal and time with PEG in stroke patients and in other patients with PEG with the aim of providing guidance for the management of enteral nutrition via PEG in stroke patients. METHODS: Retrospective assessment of data from all stroke patients and patients with other diseases (control group) who had received PEG for enteral nutrition during a period of 8.5 years. RESULTS: Eighty-three stroke patients with dysphagia received PEG after unsuccessful use of nasogastric tubes or long-term tube feeding. Early mortality rate was 19% in the stroke group, 26% in the older group (>74 years) and 12% in the younger group (60-74 years). The PEG tubes were later removed due to swallowing recovery in 20% of the older group and in 31% of the younger group. At 90 days, 50%-60% still needed PEG. The stroke patients were older compared to the control group (n = 115); 30-day mortality was similar but more patients recovered the ability to swallow. CONCLUSIONS: Stroke patients are older than other patients who receive PEG; 27% have swallowing recovery and more than 75% have long-term need for PEG. Nasogastric tubes often fail, and the need for early PEG placement (within 2 weeks) must be assessed in appropriate patients. The patient's prognosis, the objective of nutritional treatment, duration of dysphagia, age and comorbidity should all be taken into consideration.

Neuropeptides in the duodenal mucosa of chronic alcoholic heavy drinkers.

Previous studies have shown that patients with chronic alcohol ingestion may show a variety of morphological and functional alterations in the small intestine. In this study, we have focused on the neuroendocrine system in the duodenal mucosa in chronic alcoholics; an area little studied. Twenty-three defined chronic alcoholics admitted to the hospital for detoxification underwent clinical examination, followed by upper gastrointestinal endoscopy and blood tests on average 4 days after the most recent alcohol intake. Biopsy specimens were taken from the distal part of the descending duodenum for both immunohistochemical and routine histological examination. The control group consisted of 25 patients referred for upper endoscopy mainly because of dyspepsia (ulcer, reflux type), but who were otherwise healthy. A normal carbohydrate-deficient transferrin and a history of low alcohol consumption (<40 g/week) were required for inclusion in the control group. The tissue specimens were studied using antisera for the following neuropeptides: cholecystokinin, galanin, gastric inhibitory peptide (GIP), glucagon, motilin, neuropeptide Y, pituitary adenylyl cyclase activating peptide, secretin, serotonin, somatostatin, substance P, vasoactive intestinal polypeptide and protein gene product, as a general marker for neurones and cells of the diffuse neuroendocrine system. The density of nerve fibres was evaluated semi-quantitatively and the number of endocrine cells per unit length of mucosa was counted in sections cut perpendicularly to the mucosal surface. All the different peptidergic nerve fibres in the alcohol group showed higher densities than the corresponding controls. However, this was not a statistically significant difference. A slightly significant increase (P = 0.02) in the numbers of glucagon and GIP cells was seen in the alcohol group. Gastrointestinal symptoms were frequently present (87%) in chronic alcoholics. We suggest that chronic alcohol consumption in man may have a general effect on the peptidergic nerve system and some endocrine cell types in the duodenal mucosa.

[Assessment of the need of 24-hour availability of endoscopy]. / Evaluering av behovet for døgnkontinuerlig endoskopitilbud.

BACKGROUND: Endoscopy is the cornerstone of the diagnosis and treatment of acute conditions in the upper part of the gastrointestinal tract. The need for 24-hour availability of gastroscopy for these conditions has not previously been assessed. MATERIAL AND METHODS: We assessed the need for emergency gastroscopy in cases of acute upper gastrointestinal bleeding and obstruction by foreign bodies. The assessment was made by a gastroenterologist before gastroscopy was performed, and was based on the available clinical data for the period lasting from admission to hospital to the time of examination. RESULTS: A total of 162 patients were referred and examined. About half of them arrived at the hospital outside working hours. Of these, 47% were assessed as being in need of emergency gastroscopy. We therefore found that emergency gastroscopy outside working hours was needed twice a month per 100,000 people. INTERPRETATION: Round-the-clock endoscopy should be available at acute-care hospitals in the same way as other emergency help.

Comparison of naratriptan and sumatriptan in recurrence-prone migraine patients. Naratriptan International Recurrence Study Group.

OBJECTIVE: This randomized, double-blind, crossover study was undertaken to compare the incidence of headache recurrence after treatment with naratriptan or sumatriptan in migraine patients with a history of frequent headache recurrence (recurrence in > or =50% of successfully treated attacks). BACKGROUND: Although the selective 5-hydroxytryptamine, (5-HT1) agonist sumatriptan is effective and well tolerated for acute treatment of migraine in most patients, headache recurrence within 24 hours of initial successful treatment with sumatriptan and other medications has been reported in approximately 35% of patients. The novel 5-HT1 agonist naratriptan possesses pharmacologic and pharmacokinetic characteristics that may address the issue of headache recurrence. METHODS: Men and women aged 18 to 65 years with a > or =1-year history of migraine with or without aura were randomly assigned to treat 1 moderate or severe migraine attack in a nonclinical setting with one 2.5-mg naratriptan tablet and 1 attack with one 100-mg sumatriptan tablet. A pain-free interval of > or =24 hours was required between attacks. At 4 hours, patients not using rescue medication and experiencing headache recurrence could take a second, identical dose of study medication to treat recurrence. No more than 2 tablets of study medication were permitted in any 24-hour period. RESULTS: A total of 253 patients treated > or =1 migrane attack and were included in the safety analysis; the 225 patients who treated both attacks were included in the efficacy analysis. Of the 164 naratriptan-treated and 181 sumatriptan-treated patients experiencing headache relief after > or =1 attack, headache recurrence 4 to 24 hours after treatment was reported by 74 naratriptan-treated patients (45%) and 101 sumatriptan-treated patients (57%; not statistically significant). (One naratriptan- and 3 sumatriptan-treated patients who experienced headache relief did not record recurrence status and were not included in the denominator for the percentage calculation.) In a subset of patients experiencing headache relief after 2 attacks, headache recurrence 4 to 24 hours after initial dosing was reported by 55 naratriptan- and 77 sumatriptan-treated patients (41% and 57%, respectively; P = 0.005). The overall incidence of adverse events was 22% after treatment with naratriptan and 33% after treatment with sumatriptan. This incidence did not increase after use of a second dose of naratriptan (20%) or sumatriptan (31%). CONCLUSION: These data suggest that naratriptan is a long-acting and well-tolerated addition to currently available medications for the treatment of acute migraine.

[Argon plasma coagulation--a new method in therapeutic endoscopy]. / Koagulasjon med argonplasma--en ny metode i terapeutisk endoskopi.

BACKGROUND: By argon plasma coagulation (APC), a current is applied to tissues as ionised gas. Special probes have recently been developed for applying the gas through flexible endoscopes. In the field of therapeutic endoscopy, this method is promising for several diseases in the gastrointestinal tract. MATERIAL AND METHODS: At Ostfold Hospital in Fredrikstad, Norway, 122 treatments in 80 patients were performed during the years 1997-99. RESULTS: The new method was useful for endoscopic treatment of haemorrhages, tumour debulking and tumour ingrowth and overgrowth in oesophageal stents. Abdominal pain was related to insufflation of air and gas. Complications related to the method were not observed. INTERPRETATION: Our experience with this new method was very positive. The method was effective, had a very low complication rate, and the equipment was easy to use. The application of APC in premalignant conditions is discussed.

Gamma-glutamyl transferase, intestinal alkaline phosphatase and beta-hexosaminidase activity in duodenal biopsies from chronic alcoholics.

BACKGROUND/AIMS: Gamma-glutamyl transferase (GGT) and intestinal alkaline phosphatase (IAP) are present in the brush border of mucosal absorptive cells in the small intestine. There are few studies on the effect of alcohol consumption on these enzymes. Increased intestinal GGT in biopsy specimens from the duodenum has been described in chronic alcoholics. In experimental animals alcohol effects varies with duration of exposure and with nutritional factors. METHODOLOGY: IAP, GGT and the lysosomal enzyme beta-hexosaminidase (Hex) were examined in duodenal biopsy specimens from 23 defined chronic alcoholics and 33 non alcoholic controls. The results were correlated to serum GGT, alkaline phosphatase, CDT (Carbohydrate Deficient Transferrin) and the villus index. RESULTS: Both the intestinal GGT (0.52 + 0.05 SEM vs. 0.30 + 0.024 SEM microkat/g protein, p<0.0001) and the IAP (22.11 + 2.49 SEM vs. 12.28 + 1.35 SEM microkat/g protein, p=0.0010) were significantly higher in alcoholics than in controls. There was no correlation between intestinal and serum alkaline phosphatase and GGT activity within the two groups. CONCLUSIONS: Chronic alcohol consumption causes increased intestinal GGT and IAP activity in man. No effect on Hex was seen. The enzyme activity in the small intestine did not correlate to serum enzyme activity or to morphological changes in the small intestine.

[Percutaneous endoscopic gastrostomy for enteral nutrition. An evaluation of 50 patients]. / Perkutan endoskopisk gastrostomi til enteral ernaering En gjennomgang av 50 pasienter.

The increased use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition, combined with the large number of different gastrostomy tubes available, should initiate a discussion about indications and practice. 50 patients who had had a gastrostomy for enteral nutrition performed at the Regional Hospital in Ostfold during the period 1993-96 have been evaluated. The method is safe and should be considered early if enteral nutrition is required. Few and only minor complications have been reported. Most adult patients will do well with a gastrostomy tube, the need for a button is presently being discussed. Users must be given detailed information on the management and use of a gastrostomy for enteral nutrition. An out-patient clinic for these patients--staffed by nurses--has shown good results. Percutaneous endoscopic gastrostomy for enteral nutrition can be used in the home, but the conditions must be well organized.

A comparison between omeprazole-based triple therapy and bismuth-based triple therapy for the treatment of Helicobacter pylori infection: a prospective randomized 1-yr follow-up study.

OBJECTIVES: To compare the efficacy and side effects of standard bismuth triple therapy with those of omeprazole-based triple therapy in patients with Helicobacter pylori infection and duodenal ulcer disease. METHODS: One hundred patients were prospectively recruited and randomized to receive either bismuth subnitrate 75 mg q.i.d., oxytetracycline 500 mg q.i.d., and metronidazole 400 mg b.i.d. (regimen BTM), or omeprazole 20 mg b.i.d., amoxicillin 750 mg b.i.d., and metronidazole 400 mg b.i.d. (regimen OAM), both for 14 days. Upper endoscopy (with antral biopsy specimens for microbiology and antral and corpus biopsy specimens for histology) was performed before treatment, after 2 months, and again 1 yr after treatment. Serum samples for serology (IgG) were taken. Patients with in vitro metronidazole-resistant (M-R) H. pylori strains were excluded. In a nonrandomized study, 41 patients with M-R strains were given either BTM or OAM. RESULTS: According to intention-to-treat analysis, H. pylori cure rates were 91% and 96% with BTM and OAM, respectively (p = 0.45). In the BTM group, the mean total side effect score was higher (p < 0.001), and more severe side effects were reported (32% vs. 4%, p < 0.001). In the nonrandomized group of patients with M-R strains, H. pylori cure rates were 88% and 67% with BTM and OAM, respectively. All of the successfully treated patients were still H. pylori-negative after 1 yr. CONCLUSIONS: Both treatment regimens were highly effective in curing H. pylori infection in patients with metronidazole-sensitive strains. Omeprazole-based triple therapy was tolerated better than standard bismuth-based triple therapy.

Mucosal bacterial growth in the upper gastrointestinal tract in alcoholics (heavy drinkers).

BACKGROUND/AIMS: Mucosal adherent bacterial flora in chronic alcoholics was studied and compared to a control group referred for upper endoscopy, mainly for dyspepsia. METHODS: 22 alcoholics, admitted to hospital for detoxification, were examined using upper gastrointestinal endoscopy. Gastric and duodenal biopsies were taken for tissue pathology, quantitative and qualitative anaerobic and aerobic bacteriological culture and for culture of Helicobacter pylori (antral biopsies). 12 nonalcoholics, admitted for upper endoscopy mainly for dyspepsia, were chosen as a control group. Seven of these had used gastric acid inhibitors. RESULTS: Gastrointestinal symptoms were common among alcoholics: 20/22 (90%) had diarrhea, nausea and/or abdominal pain. There were signs of gastritis by endoscopy in 64% of the alcoholics and in 58% of the controls. Tissue pathology, however, showed active chronic antral gastritis in 27% of the alcoholics and in 42% of the controls. H. pylori were isolated in 7/22 of the alcoholics and in 4/12 of the controls, which corresponds to the mean prevalence for these age groups in Sweden. Significantly more bacteria, dominated by gram-positive aerobic cocci, were present in the gastric biopsies of alcoholics than in those of controls (mean of 2.9 x 10(6)/g material versus 4.4 x 10(5), p < 0.05). There were 2.6 times more bacteria in the duodenal biopsies of alcoholics than in those of the controls (p > 0.05, NS). Bacterial overgrowth (defined as >2 x 10(3) organisms/g material) was found in the stomach in 20/22 (90%) alcoholics and in 6/12 (50%) controls (p < 0.01). CONCLUSION: Alcoholics have an increased frequency of bacterial overgrowth in the upper gastrointestinal tract. This may contribute to the common gastrointestinal symptoms.

Gastroduodenal morphology and related symptoms in chronic alcoholics.

Twenty-four chronic alcoholics admitted to hospital for detoxification after a drinking spree were examined by upper gastrointestinal endoscopy. Biopsy specimens were taken from corpus/fundus, antrum and duodenum for tissue histology (eosin stain). From the duodenum villus index and ultrastructure (scanning electron microscopy, SEM) were also performed. As a control group 12 subjectively healthy non-alcoholics referred to upper gastrointestinal endoscopy mainly for dyspepsia were chosen.Gastrointestinal symptoms were common in alcoholics (88%). Endoscopic and histological gastroduodenitis were not more common in the alcohol group. There was no correlation between gastrointestinal symptoms and endoscopic or histological gastroduodenitis in both groups. In the duodenum, 50% of the alcoholics and 82% in the control group had alterations by scanning electron microscopy. Ten of the 11 alcoholics with an abnormal ultrastructure had diarrhoea. In the control group dyspepsia (ulcus suspect) was correlated to a pathological SEM.

Distribution of alkaline sphingomyelinase activity in human beings and animals. Tissue and species differences.

The alkaline sphingomyelinase (SMase) was first found in rat intestinal brush border. The important roles of this enzyme in digestion of sphingomyelin and in mucosal cell proliferation have been suggested. In the present work, the distribution of the alkaline SMase in the tissues of human beings and animals have been studied. By assaying the enzyme activity in human biopsy samples, we found that the alkaline SMase activity was absent in the stomach, increased in the duodenum, present at high levels in the small intestine, and slightly declined in the colon and rectum. High activities were found similarly in the intestinal contents of the healthy adults and infants. The activities were also found in the intestinal mucosa of rats, normal and germ-free mice, and hamsters with the same distribution pattern as in humans, but not in the intestinal mucosa of guinea pigs. Apart from the intestinal tract, a SMase activity preferring alkaline pH was identified in human and guinea pig bile, but not in the bile of rat, pig, sheep, and cow. No activity was found in either pancreatic tissue or pancreatic juice in all species tested, and none was detected in human urine and milk. In conclusion, alkaline SMase exists predominantly in the digestive system with considerable tissue and species differences.

Helicobacter pylori, active chronic antral gastritis, and gastrointestinal symptoms in alcoholics.

The frequency of Helocobacter pylori (Hp.) infection and active chronic antral gastritis among people with excessive alcohol consumption is not known. A high alcohol intake regularly causes acute gastroduodenitis. In this study, the prevalence of Hp. infection and active chronic antral gastritis in alcoholics compared with nonalcoholic controls was studied. Further, the frequency of gastrointestinal symptoms was registered. Diagnostic methods for Hp. were compared. Twenty-four alcoholics admitted to the hospital for detoxification underwent upper gastrointestinal endoscopy regardless of symptoms. Twelve individuals admitted to upper endoscopy mainly for dyspepsia, with low alcohol consumption and without gross pathology by upper endoscopy, were chosen as controls. Three diagnostic methods for Hp. were used: culture, direct microscopy, and histology. Hp. infection was found in 7 of the 24 alcoholics (29%) according to culture. In controls, 4 of 12 (33%) had a positive Hp. culture. In the alcoholic group, culture was more sensitive than histology. There was a good correlation between the different diagnostic methods in the control group. Histologically active chronic antral gastritis was found in 6 of the alcoholics (25%) and in 5 of the controls (42%). Five of the 7 Hp.-positive alcoholics and all of the Hp.-positive controls had an active chronic antral gastritis. Hp. infection is not more frequent in alcoholics than in controls. In both groups, there was a good correlation between Hp. infection and histologically, active chronic antral gastritis.

[Percutaneous endoscopic gastrostomy. Experiences with the first 10 cases in a medical department]. / Perkutan endoskopisk gastrostomi. Erfaringer fra de ti første i en medisinsk avdeling.

Enteral nutrition has many advantages over parenteral nutrition and is being increasingly used. Percutaneous endoscopic gastrostomy is performed under local anaesthesia by means of a gastroscope inserted for 15-20 minutes. From January 1993 til January 1994 we performed ten percutaneous endoscopic gastrostomies in patients suffering mainly from stroke and dysphagia. The article includes a description of the method and the results. The mean application time for the gastrostomies was 67.9 days (14-238 days). No serious complication was observed, two local wound infections were noted. It is concluded that percutaneous endoscopic gastrostomy is a safe and efficient method for enteral nutrition. The method seems to have few complications, is cheap and is simple to perform.

Surgery for myelopathy in cervical spondylosis: safety measures and preoperative factors related to outcome.

In 85 patients with myelopathy and cervical spondylosis, Queckenstedt's test was used as a guide in deciding upon laminectomy under local anesthesia or anterior surgery under general anesthesia. Laminectomy was carried out in patients with marked block phenomena. The operations were laminectomy (51), anterior surgery (24), and laminectomy plus anterior surgery (10). None of the patients was made worse as a result of the surgical procedure. Improvement in the legs occurred in 73 patients. Block phenomena and arm symptoms were preoperative factors related to improvement in the legs after surgery. Improvement in the arms occurred in 63 of 73 patients who had such symptoms.

Rheumatoid arthritis of the lumbar spine leading to anterior vertebral subluxation and compression of the cauda equina.

A 71-year-old woman with rheumatoid arthritis suffered a spontaneous anterior subluxation of the fourth lumbar vertebra with compression of the cauda equina. The patient was operated upon with a decompressive lumbar laminectomy and a stabilizing posterior interbody fusion of L4 and L5. Histological examination of the unstable L4-L5 motor segment showed that the apophyseal and discovertebral joints had been destroyed by rheumatoid granulation tissue.

Treatment of rheumatoid pachymeningitis involving the entire thoracic region.

A 67-year-old woman developed a spinal cord compression syndrome due to rheumatoid pachymeningitis with a roentgenological block from T2 to T11. The dura was surgically split from T1 to T12 and carefully dissected away from the spinal cord and then left open without grafting. The patient imporved and 3 years after the operation the spinal subarachnoid space and the circulation of cerebrospinal fluid were normal.