Prevalence of gastro-esophageal reflux disease in patients with difficult to control asthma and effect of proton pump inhibitor therapy on asthma symptoms, reflux symptoms, pulmonary function and requirement for asthma medications.

BACKGROUND: The hypothesis that GER can trigger or exacerbate asthma is supported by several clinical trials that have shown amelioration in asthma symptoms and/or an improvement in pulmonary function after antireflux therapy. AIMS: To investigate the prevalence of GER in patients with difficult to control asthma and to determine the effect of omeprazole on asthma symptoms, reflux symptoms, pulmonary function and on the requirement of asthma medications. MATERIALS AND METHODS: Patients with difficult to control asthma were recruited into the study. All patients underwent esophageal manometry and 24 hour esophageal pH monitoring. Pulmonary function tests were done before and after treatment. The severity of asthma and reflux was assessed by a 1 week pulmonary symptom score(PSS) and reflux symptom score(RSS) respectively before and after treatment. Those who had an abnormal pH study (pH <4 in the distal esophagus for >5% of the time) underwent anti-GER treatment with lifestyle changes, and a proton pump inhibitor (omeprazole 40 mg, bid) for 3 months. Asthma medications were added or deleted based on severity of asthma. RESULTS: Out of 250 asthmatic patients screened, forty patients fulfilled the inclusion criteria. Twenty eight of 40 patients(70%) were diagnosed to have GERD. Of the patients 28 with GER, 8 patients(28.5%) had no reflux symptoms. On 24 hr pH metry, the percentage time pH <4.0 was 10.81 ± 4.72 and 1.11 ± 1.21; Deemester score was 37.65 ± 14.54 and 4.89 ± 6.39 (p-value is 0.0001) in GERD and non-GERD patients respectively.In GERD group, post treatment reflux symptom score(RSS) improved from 22.39 ± 14.99 to 1.04 ± 1.07, pulmonary symptom score(PSS) improved from 27.14 ± 7.49 to 13.82 ± 4.21 and night time asthma symptom score(NASS) improved from 6.71 ± 1.80 to 3.04 ± 1.23 (p-value <0.0001). After treatment, FEV1 and PEFR increased from 1.38 ± 0.57 and 4.14 ± 1.97 to 1.47 ± 0.54 and 5.56 ± 1.72, respectively (p-value 0.00114). CONCLUSIONS: PPI therapy improves nocturnal asthma symptoms, daytime asthma symptoms, pulmonary function and decreases requirement of asthma medications in these patients.

Novel predictors for immediate puncture site bleed during endoscopic glue injection for gastric varices without using lipiodol.

Endoscopic obturation of gastric varices using tissue adhesive glues like cyanoacrylate is an accepted modality for the treatment of gastric varices. This study was undertaken to determine whether it was possible to predict immediate puncture site bleed on withdrawal of needle catheter during endoscopic glue injection without lipiodol. We prospectively analyzed 100 consecutive patients with cirrhosis who underwent glue injection. Glue injection was successful in all the patients. Immediate puncture site bleed was observed in only four cases and all of them correlated with negative catheter pull sign and positive red catheter sign. Catheter pull sign and red catheter sign were excellent predictors of immediate puncture site bleed during endoscopic glue injection and should be routinely tested.

Nutritional status and prognosis in cirrhotic patients.

BACKGROUND AND AIMS: Malnutrition is commonly associated with chronic liver disease. The presence of protein-calorie malnutrition has been shown to be associated with increased short- and long-term mortality in patients with acute and chronic liver disease. We undertook this study to assess the prognostic value of nutritional status in predicting survival in cirrhotic patients. The aim of our study was to determine whether assessment of nutritional status using the RFH-SGA score adds significantly to CP (Child-Pugh) and MELD scores in predicting patient prognosis and survival in cirrhotic patients. METHODS: Diagnosed cases of cirrhosis were enrolled and their nutritional assessment was done using the RFH-SGA score. All patients were followed up for a period of 6 months. The mortality rates in the various groups were compared with respect to their nutritional status. Multivariate analysis was used to determine the factors associated with mortality. RESULTS: A total of 73 cirrhotic patients were taken up for this study. Of these, 23 patients (31.5%) were well nourished, 21 (28.8%) had mild to moderate malnourishment and 29 (39.7%) were severely malnourished. Multivariate analyses of various parameters identified poor nutritional status, increased CP grade, increased creatinine, lower sodium levels and longer prothrombin time as being independently associated with poorer survival. CONCLUSIONS: RFH-SGA is a simple and inexpensive tool for assessing the nutritional status in cirrhotic patients and can reliably predict their disease prognosis and survival.

Effectiveness of voice therapy in reflux-related voice disorders.

Gastroesophageal reflux (GER) with laryngopharyngeal reflux plays a significant role in voice disorders. A significant proportion of patients attending ear, nose, and throat clinics with voice disorders may have gastroesophageal reflux disease (GERD). There is no controlled study of the effect of voice therapy on GERD. We assessed the effect of voice therapy in patients with dysphonia and GERD. Thirty-two patients with dysphonia and GERD underwent indirect laryngoscopy and voice analysis. Esophageal and laryngeal symptoms were assessed using the reflux symptom index (RSI). At endoscopy, esophagitis was graded according to Los Angeles classification. Patients were randomized to receive either voice therapy and omeprazole (20 mg bid) (n=16, mean [SD] age 36.1 [9.6] y; 5 men; Gp A) or omeprazole alone (n=16, age 31.8 [11.7] y; 9 men; Gp B). During voice analysis, jitter, shimmer, harmonic-to-noise ratio (HNR) and normalized noise energy (NNE) were assessed using the Dr. Speech software (version 4 1998; Tigers DRS, Inc). Hoarseness and breathiness of voice were assessed using a perceptual rating scale of 0-3. Parameters were reassessed after 6 weeks, and analyzed using parametric or nonparametric tests as applicable. In Group A, 9 patients had Grade A, 3 had Grade B, and 1 had Grade C esophagitis; 3 had normal study. In Group B, 8 patients had Grade A, 2 had Grade B esophagitis, and 6 had normal study. Baseline findings: median RSI scores were comparable (Group A 20.0 [range 14-27], Group B 19.0 [15-24]). Median rating was 2.0 for hoarseness and breathiness for both groups. Values in Groups A and B for jitter 0.5 (0.6) versus 0.5 (0.8), shimmer 3.1 (2.5) versus 2.8 (2.0), HNR 23.0 (5.6) versus 23.1 (4.2), and NNE -7.3 (3.2) versus -7.2 (3.4) were similar. Post-therapy values for Groups A and B: RSI scores were 9.0 (5-13; P<0.01 as compared with baseline) and 13.0 (10-17; P<0.01), respectively. Ratings for hoarseness and breathiness were 0.5 (P<0.01) and 1.0 (P<0.01) and 2.0. Values for jitter were 0.2 (0.0; P=0.02) versus 0.4 (0.7), shimmer 1.3 (0.7; P<0.01) versus 2.3 (1.2), HNR 26.7 (2.3; P<0.01) versus 23.7 (3.2), and NNE -12.3 (3.0, P<0.01) versus -9.2 (3.4; P<0.01). Improvement in the voice therapy group was significantly better than in patients who received omeprazole alone. Dysphonia is a significant problem in GER. Treatment for GER improves dysphonia, but in addition, voice therapy enhances the improvement.

Outcome of acute liver failure due to acute hepatitis E in pregnant women.

INTRODUCTION: Acute liver failure due to acute hepatitis E carries a high mortality. METHODS: Clinical and laboratory parameters of 42 pregnant women (median age 25.5 years) with acute liver failure due to acute hepatitis E were retrospectively analyzed. RESULTS: 22 women delivered, whereas pregnancy continued in 20 women. The maternal mortality in these two groups was similar (9/22 [41%] versus 14/20 [70%], p=0.056). However, in patients with grade I, II or III hepatic encephalopathy, delivery of fetus was associated with reduced mortality in those who delivered as against those who continued pregnancy (5/16 (31%) vs. 13/20 (65%), p=0.046). On multivariate analysis, higher grade of encephalopathy at admission was associated with risk of death (p=0.005). CONCLUSION: Mortality in pregnant women with acute liver failure with acute hepatitis E is high, especially in patients who present with higher grades of encephalopathy.

Spontaneous esophageal perforation in a patient with achalasia cardia and rheumatoid arthritis.

Perforation of stasis ulcers in achalasia cardia has not been reported in literature. We report a 45-year-old lady with achalasia and rheumatoid arthritis who developed perforation and esophago-mediastinal sinus at the site of stasis ulcers. She succumbed to respiratory infection after resection of the sinus tract, Heller's cardiomyotomy, cervical esophagostomy and feeding jejunostomy.

Scope and limitation of organocuprates, and copper or nickel catalyst-modified Grignard reagents for installation of an alkyl group onto cis-4-cyclopentene-1,3-diol monoacetate.

Alkylation of the title compound 1 was investigated with two types of reagents. One is a copper reagent derived from R(T)MgX (X = Cl, Br) and CuX (X = CN, I) and the other is R(T)MgX in the presence of a copper or a nickel catalyst. First, butylation was studied with BuCu(CN)(MgX), Bu(2)Cu(CN)(MgX)(2), BuMgX/CuCN (10 mol %), BuCu (derived from BuMgCl and CuI), and BuMgCl/CuI (10 mol %) in THF or Et(2)O. We found that trans 1,4-isomer 2a and/or trans 1,2-isomer 3a were produced exclusively with these reagents and that the stoichiometry of BuMgX/CuX and the choice of solvent were critical to attain high regioselectivity and efficient yield. Reaction with Bu(2)Cu(CN)(MgCl)(2) and BuMgCl/CuX (X = CN, I; 10 mol %) both in THF produced 2a with 93-94% regioselectivity in 87-92% yields. On the other hand, BuCu(CN)(MgX) in THF, Bu(2)Cu(CN)(MgX)(2) in Et(2)O, and BuMgX/CuCN (10 mol %) in Et(2)O furnished 3a in good yields with >90% selectively, irrespective of X of BuMgX. In the nickel-catalyzed butylation of 1 with BuMgCl, NiCl(2)(dppp) among NiCl(2)(tpp)(2), NiCl(2)(dppf), and NiCl(2)(dppp) furnished the best result to produce 2a. The CuCN-based protocol was then applied to other alkyl Grignard reagents, which include Me, Et, (CH(2))(3)Ph, c-C(6)H(11), (CH(2))(6)OMOM, (CH(2))(9)CH=CH(2), and CH(2)Ph as the alkyl group (R(T)). In addition, the Mitsunobu inversion of 2a and 3a afforded the corresponding cis isomers stereoselectively with AcOH as an acid at -78 degrees C in toluene for 2a and with 4-(NO(2))C(6)H(4)COOH in THF at r.t. for 3a. No racemization during the alkylation was confirmed by the reaction using (1R,3S)-1 (>99% ee) to produce (1S,4S)-2a and (1S,2S)-3a, respectively.

Egg and miracidium of Hirudinella ventricosa (Trematoda: Hirudinellidae).

It is reported for the first time that Hirudinella ventricosa releases eggs in strings, each string containing active spermatozoa and numerous oval, thick-shelled, translucent eggs measuring 40-42 x 28-30 microns. Each egg contained a fully developed miracidium with an anterior crown of spines.