Epidemiological and prognostic factors involved in upper gastrointestinal bleeding: results of a French prospective multicenter study.

BACKGROUND AND STUDY AIMS: The mortality rate from upper gastrointestinal bleeding (UGIB) remains high, at 5 % - 10 %. The aim of the current study was to describe the epidemiological characteristics, prognostic factors, and actual practice in a cohort of patients with UGIB admitted to French general hospitals. METHODS: From March 2005 to February 2006, a prospective multicenter study was conducted at 53 French hospitals. A total of 3298 patients admitted for UGIB were enrolled consecutively. Patient data were collected up to the date of discharge from hospital. RESULTS: Data were available for 2130 men and 1073 women (mean age 63 ± 18 years), one-third of whom were taking drugs that would increase the risk of UGIB. The two main causes of bleeding were peptic ulcers (38 %) and esophagogastric varices (EGV) or portal hypertensive gastropathy (24.5 %). Mean Rockall score was 5.0 ± 2.3. Endoscopy was performed on 96 % of patients (within 24 hours in 79 %), and 66 % of those with ulcers and 62.5 % of the EGV patients underwent hemostatic therapy when indicated. Rebleeding occurred in 9.9 % of the patients, and 8.3 % died. Independent predictors of rebleeding were: need for transfusion (odds ratio [OR] 19.1; 95 % confidence interval [95 %CI] 10.1 - 35.9); hemoglobin < 10 g/dL (OR: 1.7; 95 %CI 1.1 - 3.3); Rockall score (OR: 1.4 for each 1 point score increase; 95 %CI 1.0 - 1.9), systolic blood pressure < 100 mmHg (OR: 1.9; 95 %CI 1.4 - 2.5), and signs of recent bleeding (OR: 2.4; 95 %CI 1.7 - 3.5). Independent predictors of mortality were: Rockall score (OR: 2.8; 95 %CI 2.0 - 4.0), co-morbidities (OR: 3.6 for each additional co-morbidity; 95 %CI 2.0 - 6.3), and systolic blood pressure < 100 mmHg (OR: 2.1; 95 %CI 1.8 - 2.8). Rockall score, blood pressure and co-morbidities were taken as continuous variables meaning that the OR was 1.4 for every point increase, it was the same for blood pressure. CONCLUSION: UGIB still occurs mainly as a result of peptic ulcers and portal hypertension in France, and causes significant rates of mortality. There is scope for improvement via better prevention (better use of UGIB-facilitating drugs), endoscopic therapy, and management of co-morbidities.

Embryonic development of the larval body wall musculature of Drosophila melanogaster.

The somatic, or body wall, muscles of the larva of Drosophila melanogaster are composed of an elaborate pattern of segmentally repeating fibers that form during embryogenesis. The primordia of these muscles progress from morphologically indistinct mesodermal cells to multinucleate syncytia with unique characteristics that include shape, size, location and attachment to the epidermis. Although relatively little is known about the development of the musculature and the mechanisms by which this elaborate pattern is achieved, recent progress has begun to reveal key players in this process.

Long-term treatment of gastro-oesophageal reflux disease patients with frequent symptomatic relapses using rabeprazole: on-demand treatment compared with continuous treatment.

BACKGROUND: On-demand treatment may be an alternative in the long-term treatment of non-severe gastro-oesophageal reflux disease in patients with frequent symptomatic relapses. AIM: To compare the efficacy of on-demand treatment with rabeprazole 10 mg versus continuous treatment in the long-term treatment of patients with frequent symptomatic relapses of mild to moderate gastro-oesophageal reflux disease. METHODS: This randomized, open-label study enrolled patients diagnosed with non-erosive reflux disease or oesophagitis grade 1 or 2 (Savary-Miller classification) reporting frequent symptomatic relapses (requiring > or =2 courses of antisecretory therapy during the previous year), whose intensity is rated at least moderate (>2 on a 5-point Likert scale). After a 4-week selection phase with rabeprazole 10 mg once daily, patients reporting symptom relief (Likert score < or =2) were randomized to receive either rabeprazole 10 mg continuous treatment or on-demand treatment for 6 months. The main evaluation criterion was the rate of symptom relief (scored on the Likert scale) after 6 months. RESULTS: One hundred and seventy-six patients were enrolled in the 4-week selection phase (men, 53%; mean age, 49 years; non-erosive reflux disease, 36.4%; gastro-oesophageal reflux disease 1, 53.4%; gastro-oesophageal reflux disease 2, 10.2%). Rabeprazole relieved symptoms in 88.6% of patients. Of this group, 152 were randomized to the comparative phase to receive rabeprazole 10 mg continuous treatment (once daily) or on-demand treatment (continuous treatment, n = 81; on-demand treatment, n = 71). At month 6 (end point), the symptom relief rate was slightly higher for patients in the continuous treatment group compared with those in the on-demand treatment group: 86.4% versus 74.6%, respectively. This difference was not statistically significant (P = 0.065). For the overall quality of life score, there was no difference between the continuous treatment and on-demand treatment groups (86.25 and 84.94). Mean daily consumption of rabeprazole was significantly lower in the on-demand treatment group versus the continuous treatment group (0.31 tablets versus 0.96 tablets; P < 0.0001). CONCLUSION: On-demand therapy with rabeprazole 10 mg provides an alternative to continuous therapy in patients with mild to moderate gastro-oesophageal reflux disease suffering from frequent symptomatic relapses.

Internal drainage into an Onlay-Roux-en-Y jejunal loop in isolated pancreatic injury with ductal transection: short-term and long-term follow-up in two pediatric cases.

Two pediatric cases of isolated pancreatic injury treated by internal drainage into an Onlay-Roux-en-Y jejunal loop are reported. The discussion concerns the difficulties of early diagnosis, the importance of endoscopic retrograde cholangiopancreatography (ERCP) in surgery and the reasons for the choice of internal drainage by Onlay-Roux-en-Y jejunal loop in our two cases.

[Endoscopic treatment of severe digestive hemorrhage by hemostatic injection]. / Traitement endoscopique des hémorragies digestives graves par injection hémostatique.

The results of emergency endoscopic treatment of severe non variceal bleeding in the upper and lower gastrointestinal tract by hemostatic injections are reported. Most of the 44 patients were seriously ill and had a high surgical risk. Definitive hemostasis was obtained in 88.6 per cent of cases. Twenty-five patients had active bleeding which was arrested in 84 per cent of cases. There were no serious complications related to the technique. The overall survival rate was 52 per cent. Ten of the 13 deaths were not due to gastrointestinal hemorrhage. The authors advocate this simple, effective and inexpensive method as the initial treatment of ulcerated gastrointestinal bleeding in critically ill patients.

Orally administered omeprazole versus injection therapy in the prevention of rebleeding from peptic ulcer with visible vessel. A multicenter randomized study.

Endoscopic injection therapy significantly reduces the risk of bleeding relapse in patients with digestive hemorrhage due to peptic ulcers associated with a visible vessel. Profound and sustained acid inhibition by proton pump inhibitors may generate optimal conditions for clotting and prevent bleeding relapse. Over a one-year period, 52 patients presenting with digestive hemorrhage, in whom emergency endoscopy showed a peptic ulcer with a non-bleeding visible vessel, were enrolled in a multicenter randomized study comparing oral omeprazole, 40 mg per day (n = 31) vs adrenaline (1:10,000) plus polidocanol (1%) injection associated with oral ranitidine 300 mg per day (n = 21). Rebleeding occurred in 15/52 (29%) patients: 8/31 (26%) in the omeprazole group with 6 major hemorrhages (19%), and in 7/21 (33%) in the injection group with 3 major hemorrhages (14%); the differences were not significant. No difference was observed between omeprazole and injection group in terms of volume of transfused blood (2.03 +/- 1.5 vs 3.1 +/- 0.9 blood units), need for hemostatic surgery (9.6% vs 14.3%), mortality (19.3% vs 14.3%) and mean hospital stay (11.5 days both groups). This study suggests that oral omeprazole, 40 mg per day, has an efficacy comparable to injection therapy in reducing the bleeding relapse from non bleeding peptic ulcers associated with visible vessel.

[Evaluation of the teaching of echo-endoscopy. Application to the assessment of invasiveness of cancer of the esophagus and the cardia]. / Evaluation de l'enseignement de l'écho-endoscopie. Application au Application au bilan d'extension du cancer de l'oesophage et du cardia.

OBJECTIVES: Learning endosonography (EES) is known to be difficult, and the theory must be understood before performing EES routinely. The aim of the study was to evaluate the diagnostic indexes of EES in the staging of cardio-oesophageal cancer after a period of theoretical apprenticeship of EES and a learning period in a centre experienced in EES since 1989. METHODS: Five observers, having never used EES, followed to EES examinations for a 3-6 month period. They then reviewed the standardized records of 29 patients with cardio-oesophageal cancer. They had to evaluate the degree of tumour infiltration within oesophageal wall and the site of metastatic lymph nodes. Results were compared with the diagnosis of 5 experienced senior endoscopists. Interobserver agreement was estimated with kappa statistics and considered excellent for k > or = 0.75, good to moderate if 0.75 > k > or = 0.40, and poor if k < 0.40. RESULTS: Inter-observer agreement was poor for the topographic diagnosis of lymph nodes (kappa index from -0.09 to 0.33), lower to that of the 5 senior observers (0.33 to 0.77). It was satisfactory for degree of tumour infiltration (T1: k = 0.66; T2: k = 0.58; T3: k = 0.56; T4: k = 0.46). The individual sensitivities were weak according to lymph nodes site, but good for presence of lymph nodes (86 to 100%), with a specificity of 40 to 73%. CONCLUSIONS: After theoretical training of EES, agreement and diagnostic performances are good enough to diagnose pathological images (except for T4 tumors), and poor for localizing images in the mediastinum. This emphasizes the difficulties in learning echo-anatomy and gives useful guidelines for training programs in EES.

[Gastroesophageal reflux after percutaneous endoscopic gastrostomy. Scintigraphic study in 51 patients]. / Reflux gastro-oesophagien après gastrostomie percutanée endoscopique. Etude scintigraphique chez 51 malades.

Gastro-oesophageal reflux and pneumonia are complications of enteral feeding. We report our experience of a scintigraphic technique in 51 patients fed by percutaneous endoscopic gastrostomy. The technique was very well tolerated; only one patient (2 percent) had vagal discomfort. A quantitative isotopic study using Tc 99 m labelled enteral infusion demonstrated episodes of reflux in 26 patients (51 percent). The reflux was greater than 6 percent of recording time in 15 patients. All patients with pneumonia had positive scintigraphy. Our study suggests that reflux is frequent after percutaneous endoscopic gastrostomy and constant in patients with pneumonia.

[Severe gastroduodenal ulcer hemorrhage. Treatment with endoscopic injections of an epinephrine solution]. / Hémorragies ulcéreuses gastroduodénales graves. Traitement par injections endoscopiques d'une solution d'épinéphrine.

Eighty-three patients (more than one half of whom were at high surgical risk) presenting with haemorrhages from a gastric or duodenal ulcer were treated with endoscopic injections of an epinephrine-hypertonic saline mixture. The overall rate of definitive haemostasis was 83 p. 100. Depending on the degree of haemorrhagic activity, this rate was 64 p. 100 in pulsatile lesions, 90.5 p. 100 in oozing lesions, 85.7 p. 100 in cases with visible vessels and 81.2 p. 100 when signs of recent bleeding were present. There was no dangerous complication related to the technique. The overall survival rate was 67.5 p. 100 and 20 out of the 26 deaths were due to other causes than haemorrhages. On follow-up, 94.7 p. 100 of the ulcers healed under antisecretory treatment within the usual length of time. This simple, effective and inexpensive technique is suggested as initial treatment of gastric or duodenal haemorrhages in subjects at high surgical risk, especially since the haemorrhage has no influence on the course of the ulcer.

[Percutaneous endoscopic gastrostomy. 174 cases]. / Gastrostomie percutanée endoscopique. Cent soixante quatorze observations.

Nutritional assistance was given by percutaneous endoscopic gastrostomy to 174 patients with neurological diseases (80 cases), tumours of the ear, nose and throat (ENT) region (70 cases) or malnutrition (24 elderly people). These patients had either deglutition disorders with inhalation or severe malnutrition, or could not tolerate a nasogastric tube. The endoscopic catheter (Bioser) was installed by the pull technique under general anaesthesia (26 percent), neuroleptanalgesia (16 percent), premedication (14 percent) or without sedation (44 percent). Installation was possible in 98 percent of the cases. Twenty-nine percent of the patients were treated in an outpatient clinic. The problems encountered (21 percent) were mainly due to blockade of the flange and rupture of the thread. Transoperative accidents, such as dyspnoea, bleeding or cardiac arrest, all without sequelae, were noted in 5 percent of the cases. The catheter remained in situ for a mean period of 3.9 +/- 0.3 months (range: 0.1 to 20 months). The following complications were observed: short-term (15 percent), hyperthermia (5), local infection (6), abscess of the abdominal wall (3), meteorism (9), pneumoperitoneum (1), subocclusion (2); long-term (25 percent), inflammatory reactions (13), leakage (19), catheter displacement (8) and catheter rupture (3). Local infections were more frequent in patients with ENT tumours than in the others. Percutaneous endoscopic gastrostomy is a fast and reliable technique preferable to surgical gastrostomy. Complications are frequent (46 percent) but usually minor (42 percent). Contra-indications must be respected, and the catheter must be introduced with the utmost care.

Effect of hindlimb suspension simulation of microgravity on in vitro immunological responses.

The effects of microgravity on the immune system are largely unknown, but understanding such effects becomes increasingly important as space exploration continues and mission duration increases. Reductions in postflight human T cell reactivity to mitogens is well documented. Similar results have been obtained using a clinostat as an in vitro model of microgravity. In this study, a rat tail suspension model of weightlessness was used to examine in vitro lymphocyte proliferation in response to mitogens. Experiments were designed to uncover potential deficits in events related to proliferation including cell surface protein and IL-2 receptor (IL-2R) expression, interleukin-2 (IL-2) production, and accessory cells. Suspension of rats for 1 week led to a significant depression in [3H]thymidine incorporation by mitogen-stimulated peripheral blood lymphocytes (PBL) but only a small decrease in the proliferation of lymph node lymphocytes and splenocytes. There were no changes in the percentages of cells expressing CD4, CD5, CD8 or immunoglobulin. Moreover, no changes in IL-2 production or IL-2R expression were observed. More esterase-positive macrophages were detected in all lymphatic tissues of suspended rats, but there was no corresponding increase in the percentage of cells bearing the macrophage markers OX41 or OX42. This increase in the number of macrophages may be related to the observed suppression of lymphocyte proliferation. The tissue specificity of the decrease in mitogen activation indicates that there may be a compartmentalized response in the rats tested in the hindlimb suspension model.

Alternative solutions to hCG induction of ovulation in the mare.

Injection of hCG (2000-2500 i.u., i.v.) to mares when a follicle reaches 35 mm induces ovulation between 24 and 48 h. However, repeated injections induce antibodies against hCG. We report attempts to induce ovulation without this inconvenience. We called 'response' an ovulation between 24 and 48 h after treatment. The typical response to hCG was obtained in 73% (N = 145) of treated mares. After immunization against hCG, the response (0%, N = 10) was less than in nonimmunized controls (100%, N = 9). Simultaneous injection of dexamethasone and hCG resulted in induction of ovulation (71%, N = 14). However, simultaneous hCG + dexamethasone resulted in antibody formation similar to that induced by hCG alone, when injected repeatedly every 21 days. Neither GnRH (2 mg i.m.) nor partly purified pig LH (26 mg i.v. or s.c.) induced ovulation consistently (40%, N = 30 and 31%, N = 16). Crude horse gonadotrophin (60 mg i.v. or s.c.) induced ovulation (86%, N = 14). Fertility was not different from control (61%, N = 13 vs 40%, N = 10). Crude horse gonadotrophin also induced ovulation in mares previously immunized against hCG (78%, N = 9): 50 or 25 mg gave satisfactory response (86%, N = 29 and 57%, N = 40). We conclude that crude horse gonadotrophin is a good alternative to hCG for the induction of ovulation in mares.

Colonic investigations in the elderly: colonoscopy or barium enema?

Colonoscopy (CS) is currently considered the best diagnostic procedure for colonic imaging. The objectives of this multicentric study were to assess whether CS or simple contrast barium enema (SCBE) has the best effectiveness and tolerance in the elderly (over 80 years old). Except in cases of emergency, 67 elderly patients from 3 centers were randomized among three diagnostic strategies: CS, SCBE or barium enema+rectosigmoidoscopy (BERS). CSs were generally carried out after polyethylene-glycol (PEG) cleansing, and barium enemas after enema cleansing. The diagnostic effectiveness of the three strategies was not significantly different: a colonic abnormality was found in CS, SCBE, BERS groups in 65, 56 and 71% of the cases, respectively. No other investigation was needed in 61 to 76% of cases, and, on the basis of the exploration, final therapy was modified in less than 22% of cases. Overall cleansing quality was significantly better with barium enema (84.1%) than with CS (57.0%; p < 0.05). This was explained by a poor tolerance to PEG intake, which led to 28.2% of adverse effects, compared with 7.1% after enema preparation (p < 0.05). This resulted in a significantly higher failure rate of complete colonic exploration with CS (48%) than with barium enema (9%; p < 0.001). In conclusion, the effectiveness of the three diagnostic strategies is similar in the elderly. However, due to a better acceptance of the enema preparation, and to a better success rate of complete exploration, SCBE should be preferred to investigate colonic symptoms when the above preparations are used.

The expression of forms of prolactin receptors in splenocytes and thymocytes of neonatal rats: the effect of milk ingestion.

Because prolactin (PRL) plays a role in neonatal immune development, we examined the expression of prolactin receptors (PRL-R) in neonatal lymphoid tissues. We had shown previously that deprivation of milk-borne PRL, days 2-5 in the neonatal rat, leads to enhanced in vitro mitogenesis of thymocytes and splenocytes as well as a change in lymphoid-specific, cell surface antigens (GROVE et al. 1991). In this present study, we asked if neonatal lymphocytes express PRL-R; which forms of PRL-R are expressed (long vs. short form); when these forms are expressed during development; and if milk ingestion plays a role in receptor expression. Two approaches were taken using neonatal rat thymocytes and splenocytes: RNA was analyzed by polymerase chain reaction (PCR) and cells were stained with antibody to PRL-R and analyzed by flow cytometry. In regard to cell surface expression, the percentage of PRL-R positive splenocytes was greater than thymocytes at all ages tested. In the spleen, the percentage of PRL-R positive cells gradually increased to adult levels by day 10; in the thymus the percentage fell to adult levels by the first day after birth. Finally, milk ingestion in the first 7 h decreased the percentage of cells expressing cell surface PRL-R. Tissues from animals deprived of milk during this time expressed PRL-R at the same level as the newborn.