Esophageal capsule endoscopy vs. EGD for the evaluation of portal hypertension: a French prospective multicenter comparative study.

OBJECTIVES: Esophagogastroduodenoscopy (EGD) is the standard method for the diagnosis of esophago-gastric varices. The aim of this prospective multicenter study was to evaluate the PillCam esophageal capsule endoscopy (ECE) for this indication. METHODS: Patients presenting with cirrhotic or noncirrhotic portal hypertension underwent ECEfollowed by EGD at the time of diagnosis. Capsule recordings were blindly read by two endoscopists. RESULTS: A total of 120 patients (72 males, mean age: 58 years; mean Child-Pugh score: 7.2) were included. Esophageal varices were detected in 74 patients. No adverse event was observed after either EGD or ECE. Seven (6%) patients were unable to swallow the capsule. The mean recording time was 204 s (range 1-876). Sensitivity, specificity, negative predictive value, and positive predictive value of ECE for the detection of esophageal varices were 77%, 86%, 69%, and 90%, respectively. Sensitivity, specificity, negative and positive predictive values of ECE for the indication of primary prophylaxis (esophageal varices > or = grade 2 and/or red signs) were 77, 88, 90, and 75%, respectively, and 85% of the patients were adequately classified for the indication (or not) of prophylaxis. Interobserver concordance for ECE readings was 79.4% for the diagnosis of varices, 66.4% for the grading of varices, and 89.7% for the indication of prophylaxis. CONCLUSIONS: This large multicenter study confirms the safety and acceptable accuracy of ECE for the evaluation of esophageal varices. ECE might be proposed as an alternative to EGD for the screening of portal hypertension, especially in patients unable or unwilling to undergo EGD.

Intravenous immunoglobulin replacement prevents severe and lower respiratory tract infections, but not upper respiratory tract and non-respiratory infections in common variable immune deficiency.

BACKGROUND: Although the dose of 400 mg/kg body weight intravenous immunoglobulins (IVIG) every 3-4 weeks is now standard for treating patients with common variable immune deficiency, studies demonstrating its long-term benefits over low 200 mg/kg dose and its effects on infectious subsets (upper vs lower respiratory vs non-respiratory infections) are rare. METHODS: All patients from a single center with the diagnosis of common variable immune deficiency and whose clinical chart was available during three successive therapeutic periods [a pre-IVIG replacement period, a low-dose (200 mg/kg every 3 weeks) and a standard-dose replacement period (400 mg/kg every 3 weeks)] were screened retrospectively. RESULTS: Seven patients followed up for a total of 116 patient-years over the three defined periods of observation were recruited. When compared with low-dose therapy, standard-dose intravenous immunoglobulin therapy raised trough IgG levels from 4.3 to 6.5 g/l and significantly decreased the overall frequency of infections, with marked effects on lower respiratory tract and severe infection number. In contrast, non-respiratory and upper respiratory infections were, in comparison, resistant to therapy. CONCLUSIONS: Overall, these data support the use of standard-dose 400 mg/kg intravenous immunoglobulin therapy, despite the high cost, to raise trough IgG levels to 5-7 g/l, but underlines that some categories of infectious events (non-respiratory, upper respiratory) may need parallel surgical or pharmacological approaches to be optimally prevented or treated.

Anal carcinoma: prognostic value of endorectal ultrasound (ERUS). Results of a prospective multicenter study.

BACKGROUND AND STUDY AIMS: The classification of anal carcinoma is based on the clinical examination and the estimation of the tumor height (Union Internationale Contre le Cancer (UICC) 1987 Classification). This classification has a direct therapeutic application since tumors which are designated T1 and T2 are generally treated by radiotherapy whereas T3, T4 or N+ lesions are treated by concomitant radiation and chemotherapy. The aim of this prospective multicenter study was to evaluate endorectal ultrasound (ERUS) and to define an ERUS-based classification. PATIENTS AND METHODS: Between January 1994 and May 1997, 146 patients (42 men and 104 women; mean age, 63) from eight different centers were studied prospectively. The ERUS classification incorporates disease of the anal canal and the perirectal lymph nodes, thus: usT1 describes involvement of the mucosa and submucosa with sparing of the internal sphincter; usT2, involvement of the internal sphincter with sparing of the external sphincter; usT3, involvement of the external sphincter; usT4, involvement of a pelvic organ; N0 describes no suspicious perirectal lymph nodes, and N+, perirectal lymph nodes fulfilling endosonographic criteria for malignancy (e.g. round, hypoechoic). Tumors classified as UICC T1-T2 (<4cm) N0 were treated by radiotherapy alone, whereas lesions with a UICC classification of T2 (> 4 cm), T3-T4, N0-N1-2-3 received combined radiochemotherapy. RESULTS: Data concerning the treatment and follow-up were available for 115/146 patients (78.7%). We compared the prognostic importance of the two classification schemes for treatment response and the rate of local relapse (chi-squared test). A significantly greater proportion of T1-T2N0 lesions classified by ERUS had a complete response to treatment than those classified by conventional UICC staging (94.5% vs. 80%, respectively; P = 0.008). The ERUS T and N stage were significant predictors of relapse (P=0.001 and P=0.03, respectively) whereas the corresponding clinical (UICC) stages were not (P = 0.4 and P = 0.5, respectively). Using a Cox model, usT stage was the only significant predictive factor for patient survival. CONCLUSION: This muticenter prospective study demonstrated the superiority of ERUS-based staging over traditional clinical staging in the prediction of important outcomes such as local tumor recurrence and patient survival.

Relationship between the prescriber's instructions and compliance with antibiotherapy in outpatients treated for an acute infectious disease.

Antibiotics are frequently prescribed in everyday practice for the management of acute microbial infections. The present study was designed to assess the relationship between the prescriber's instructions and the patient's adherence to a prescribed schedule of twice-daily doses of antibiotic for at least 5 days to treat an infectious disease. The trial was conducted by ten practicing physicians on ambulatory patients. Compliance with the antibiotic regimen was evaluated using a microelectronic device, the Medication Event Monitoring System (MEMS). Seventy patients were prescribed an antibiotic in twice-daily doses for 5 to 14 days (mean = 8). Data were available for analysis from 68 of them, aged 18 to 84 years (mean = 44). The "taking compliance" for the whole story group, which corresponded to the ratio of the number of times the bottle was opened and the total number of doses prescribed during the monitoring period, was nearly perfect at 99.6%. However, only 32.6% of the medications was taken within 1 hour before or after the 12-hour interval expected to be optimal for a twice-daily regimen. It therefore seems highly desirable that physicians give more detailed recommendations to their patients regarding the drug regimens they prescribe.

[Influence of HIV infection on hepatitis B virus infection in homosexual patients]. / Influence de l'infection à VIH sur l'infection par le virus de l'hépatite B chez les patients homosexuels.

Clinical expression and outcome of hepatis B virus infections associated with human immunodeficiency virus infection (without AIDS) were studied in 17 homosexuals during 23 months. In an attempt to distinguish the respective impacts of homosexuality from that of human immuno-deficiency virus, patient were compared with a population of homosexual males infected by hepatitis B virus alone. The ratio of biochemical evidence of liver cell necrosis (ALAT)/viral replication (DNAp) was significatively decreased (p less than 0.01), despite evidence of severe histological damage in some cases. Two-thirds of patients with HBV replication tolerated HBV infection at the end of follow-up. This tolerance was significatively more common than in homosexuals infected by HBV alone (p less than 0.01), and did not appear to be related to decreased T4 cell count but seemed to correlate with the existence of the AIDS related complex.