Ethephon induced oxidative stress in the olive leaf abscission zone enables development of a selective abscission compound

BACKGROUND

Table olives (Olea europaea L.), despite their widespread production, are still harvested manually. The low efficiency of manual harvesting and the rising costs of labor have reduced the profitability of this crop. A selective abscission treatment, inducing abscission of fruits but not leaves, is crucial for the adoption of mechanical harvesting of table olives. In the present work we studied the anatomical and molecular differences between the three abscission zones (AZs) of olive fruits and leaves.

RESULTS

The fruit abscission zone 3 (FAZ3), located between the fruit and the pedicel, was found to be the active AZ in mature fruits and is sensitive to ethephon, whereas FAZ2, between the pedicel and the rachis, is the flower active AZ as well as functioning as the most ethephon induced fruit AZ. We found anatomical differences between the leaf AZ (LAZ) and the two FAZs. Unlike the FAZs, the LAZ is characterized by small cells with less pectin compared to neighboring cells. In an attempt to differentiate between the fruit and leaf AZs, we examined the effect of treating olive-bearing trees with ethephon, an ethylene-releasing compound, with or without antioxidants, on the detachment force (DF) of fruits and leaves 5 days after the treatment. Ethephon treatment enhanced pectinase activity and reduced DF in all the three olive AZs. A transcriptomic analysis of the three olive AZs after ethephon treatment revealed induction of several genes encoding for hormones (ethylene, auxin and ABA), as well as for several cell wall degrading enzymes. However, up-regulation of cellulase genes was found only in the LAZ. Many genes involved in oxidative stress were induced by the ethephon treatment in the LAZ alone. In addition, we found that reactive oxygen species (ROS) mediated abscission in response to ethephon only in leaves. Thus, adding antioxidants such as ascorbic acid or butyric acid to the ethephon inhibited leaf abscission but enhanced fruit abscission.

CONCLUSION

Our findings suggest that treating olive-bearing trees with a combination of ethephon and antioxidants reduces the detachment force (DF) of fruit without weakening that of the leaves. Hence, this selective abscission treatment may be used in turn to promote mechanized harvest of olives.

Fat halo sign in the bowel wall of patients with Crohn's disease

AIM

To evaluate the prevalence and localization of the deposition of submucosal fat, the "fat halo sign" (FHS), using computed tomography (CT) in the bowel wall of patients with Crohn's Disease, and to assess its relation to the duration of the disease.

MATERIALS AND METHODS

The abdominal CT examinations of 100 consecutive patients were reviewed for the presence of the FHS in the bowel wall. A measurement of less than -10HU was regarded as indicative of fat. CT findings were correlated with the duration of the disease and statistically tested by simple regression analysis. The patients were divided into two groups: group A included 26 patients with a disease duration of less than 1 year and group B included 73 with a longer disease duration. In one patient disease duration was unknown. To test the relationship between disease duration and FHS the cumulative number of FHS positive and negative patients was plotted against disease duration.

RESULTS

The FHS was present in 17 of the 100 patients in 20 bowel segments, mainly in the ileum (10) and the ascending colon (8). The FHS was present in 3.8% in group A and in 21.9% in group B (p<0.0375).

CONCLUSION

The FHS was present in 17% of patients with CD. Its location was mainly in the terminal ileum and ascending colon, typical sites of the disease. Its prevalence was significantly duration dependent.

The feasibility and risk of early colonoscopy in acute diverticulitis: a prospective controlled study

BACKGROUND AND STUDY AIM

Following acute diverticulitis, colonoscopy is advised to rule out malignancy. Commonly, the colonoscopy is postponed to avoid the potential risk of perforation. In a previous pilot, noncontrolled study, we showed that early colonoscopy is feasible in patients with acute diverticulitis. This randomized controlled trial compared early and late colonoscopy in hospitalized patients with acute diverticulitis.

PATIENTS AND METHODS

154 patients diagnosed with acute diverticulitis were hospitalized between January 2004 and June 2006. Of these, 35 patients were excluded because of either free perforation or pericolic air on computed tomography (CT), and another 18 because they had undergone colonoscopy in the previous year. The remaining 101 patients were offered the possibility of participating in the study, with random allocation to either early in-hospital colonoscopy or late colonoscopy, 6 weeks later. Randomization was refused by 15 patients, and 86 were included in the study.

RESULTS

45 patients were randomly allocated for early colonoscopy and 41 for late colonoscopy. Three and 10 did not present for the examination, in the early and late group respectively. The cecum could not be reached in eight and three patients from the early and late groups, respectively. The colonoscopy revealed polyps in five patients, two in the early group and three in the late group. No malignancy was detected. There were no complications in either group.

CONCLUSIONS

Early colonoscopy in acute diverticulitis is feasible and safe in the absence of pericolic air on CT, and has greater compliance. However, no added value is apparent compared with the CT scan currently used.

Risk factors regarding the need for a second operation in patients with Crohn's disease

BACKGROUND/AIMS

The majority of Crohn's disease patients undergo surgery. However, the factors that predict post-operative recurrence remain controversial. The aim of the present study was to shed light on the potential predictors of such recurrence.

METHODS

86 patients who underwent operative procedures for Crohn's disease were retrospectively studied. Recurrence was defined as the need for a second operation. Life table and multivariate analysis were performed to find the predictors of recurrence.

RESULTS

In 26/86 (30%) of the patients, post-operative recurrence was diagnosed within a mean of 42 months of the follow-up. Logistic regression analysis revealed that smoking (OR 3.69, 95% CI 2.06-11.52) and perforating disease (OR 4.09, 95% CI 1.31-12.65) were associated with a risk of recurrence. However, survival analysis showed that only perforating disease was associated with an early post-operative recurrence (log-rank test, p < 0.001). Neither resected surgical specimen characteristics, nor the duration and the location of the disease were found to predict the need for a second operation.

CONCLUSION

The risk for Crohn's disease patients who undergo surgery is related to the presence of perforating disease and smoking, which predict the need for a second operation. The former is associated with an even earlier recurrence.

Hepatitis C at the Israeli National Hemophilia Center

Haemophilia patients who received non-virucidally treated large pool clotting factors before 1987 have a high rate of chronic hepatitis C viral infection (HCV). Some patients are coinfected with HIV. Haemophilia patients and other coagulation disorders were treated at one centre since the beginning of the 1970, and the Israeli National Hemophilia Center (INHC) was officially founded in 1987. To characterize patients with HCV as well as patients with HCV/HIV coinfection at the INHC. Patients with haemophilia and other coagulation disorders positive for HCV antibodies were evaluated between 2001 and 2004. Demographic data, type and severity of coagulation disorder, frequency of coagulation factor usage and treatment with concentrated clotting factors prior to 1987 were recorded. Liver enzymes, viral load, genotype and data supporting advanced liver disease were evaluated. About 179 of 239 haemophilia patients (75%) tested positive for anti-HCV antibodies. Our cohort consisted of 165 patients in whom clinical, biochemical and virological data were available. About 117 patients had active HCV infection with HCV-RNA-positive, and 27 were HCV/HIV coinfected. Twenty-one patients (13%) persistently tested HCV-RNA-negative, hence were considered to clear their HCV infection. There was no former USSR immigrants among HCV/HIV coinfected compared with HCV-infected or HCV-RNA-negative groups (0 vs. 30% and 38%, respectively; P < 0.001). HCV-RNA-negative patients used concentrated coagulation factor less frequently than HCV or HCV/HIV-infected patients (48% vs. 73%; P = 0.023, and 48% vs. 74%; P = 0.043, respectively). The use of concentrated clotting factors before 1987 was significantly more frequent in HCV/HIV than in either HCV-infected or HCV-RNA-negative patients (96% vs. 49% and 48%, respectively; P < 0.001). Compared with HCV/HIV subjects, patients with HCV monoinfection were characterized by a higher proportion of infection with genotype 1 (80% vs. 61%; P = 0.027). The rate of persistently normal liver enzymes in these patients was higher (24% vs. 7%; P = 0.05) than in the HCV/HIV-coinfected patients. Advanced liver disease was significantly more common in patients with HCV/HIV-coinfection than in HCV-monoinfected patients (11% vs. 3%; P = 0.045). The majority of haemophilia patients are infected with HCV. Viral clearance occurred in a minority of these patients. HCV monoinfected and HCV/HIV coinfected differ clinically and prognostically.

Risk factors for mortality in patients undergoing percutaneous endoscopic gastrostomy

BACKGROUND AND STUDY AIMS

Percutaneous endoscopic gastrostomy (PEG) is a method used for feeding patients who are unable to eat. High early mortality rates among hospitalized patients have been reported. The aim of this study was to shed light on the risk factors for early mortality after PEG tube insertion.

PATIENTS AND METHODS

Outpatients from nursing homes and hospitalized patients who underwent PEG between July 1995 and July 2001 were compared. Survival analysis was used to assess mortality after PEG. In a logistic regression analysis, mortality within 30 days among hospitalized patients was chosen as the outcome variable and the predictor variables were demographic characteristics, co-morbid conditions, and indication for PEG.

RESULTS

A total of 502 PEG tubes were inserted in 419 hospitalized and 83 nursing-home patients. The prevalence of co-morbid conditions was similar in the two groups. Both the 30- and 60-day mortality rates were around six times higher in the hospitalized patient group than in the nursing-home patient group (30-day mortality rate 8 % vs. 1.2 %, P = 0.034; 60-day mortality rate 12 % vs. 2.4 %, P = 0.016). Risk factors for 30-day mortality among hospitalized patients were: serum albumin < 3 g/dl (odds ratio 2.82, 95 % CI 1.34 - 5.96), chronic obstructive pulmonary disease (odds ratio 2.79, 95 % CI 1.26 - 6.14), and diabetes mellitus (odds ratio 2.44, 95 % CI 1.20 - 4.97).

CONCLUSIONS

Compared with nursing-home patients, hospitalized patients are at higher risk for early mortality after PEG. The presence of diabetes, chronic obstructive pulmonary disease, and a low serum albumin level each increase the 30-day mortality risk among hospitalized patients threefold.

Inguinal hernia is not a sign of colon cancer: results of a prospective screening trial

BACKGROUND

It has been suggested that patients with an inguinal hernia harbour an increased risk for colorectal cancer.

METHODS

In a prospective clinical trial, we compared the prevalence of colonic neoplasms in 100 cases with inguinal hernia and 100 controls without inguinal hernia. The number, size, histology type, and the location of all colorectal lesions found during a screening flexible sigmoidoscopy were recorded.

RESULTS

Not a single case of colorectal cancer was detected in the patients with inguinal hernia pending surgical repair. In the asymptomatic control subjects, one Dukes A and one Dukes B1 colon cancer were detected. Polypectomy was performed in 15% and 17% of the case and control subjects, respectively. During a 5-year period following the initial screening procedure, none of the case or control subjects was diagnosed with colon cancer.

CONCLUSIONS

The decision for or against performing an endoscopic procedure in a patient with inguinal hernia should be guided by the general principles of screening for colorectal cancer. The mere presence of an inguinal hernia does not automatically increase the risk of colorectal cancer.

There are no reliable symptoms for erosive oesophagitis and Barrett's oesophagus: endoscopic diagnosis is still essential

AIMS

To evaluate the sensitivity and specificity of different symptoms in erosive reflux oesophagitis and Barrett's oesophagus.

METHODS

The presence of reflux symptoms was compared between a case population of 306 patients with endoscopically determined erosive reflux oesophagitis, 235 patients with biopsy-proven Barrett's oesophagus and a control population of 198 subjects without reflux disease.

RESULTS

Heartburn at any time and heartburn at night represented the only two symptoms to be simultaneously sensitive and specific. Symptoms that were induced by various foods, such as fat, tomato, chocolate, citrus or spices, tended to cluster in the same sub-group of patients. Similarly, heartburn induced by exercise, lying down or bending over tended to occur in the same sub-groups. The frequency of symptoms was influenced more by the presence of mucosal erosions than by the presence of Barrett's oesophagus. Reflux symptoms occurred more frequently in the presence rather than the absence of Barrett's oesophagus, and in long segment rather than short segment of Barrett's mucosa.

CONCLUSIONS

Endoscopic inspection of the oesophageal mucosa remains the only certain method by which to reliably diagnose erosive reflux oesophagitis and Barrett's oesophagus.

Gastric surgery is not a risk for Barrett's esophagus or esophageal adenocarcinoma

BACKGROUND & AIMS

The contribution of duodeno-gastroesophageal reflux to the development of Barrett's esophagus has remained an interesting but controversial topic. The present study assessed the risk for Barrett's esophagus after partial gastrectomy.

METHODS

The data of outpatients from a medicine and gastroenterology clinic who underwent upper gastrointestinal endoscopy for any reason were analyzed in a case-control study. A case population of 650 patients with short- segment and 366 patients with long-segment Barrett's esophagus was compared in a multivariate logistic regression to a control population of 3047 subjects without Barrett's esophagus or other types of gastroesophageal reflux disease.

RESULTS

In the case population, 25 (4%) patients with short-segment and 15 (4%) patients with long-segment Barrett's esophagus presented with a history of gastric surgery compared with 162 (5%) patients in the control population, yielding an adjusted odds ratio of 0.89 with a 95% confidence interval of 0.54-1.46 for short-segment and an adjusted odds ratio of 0.71 (0.30-1.72) for long-segment Barrett's esophagus. Similar results were obtained in separate analyses of 64 patients with Billroth-1 gastrectomy, 105 patients with Billroth-2 gastrectomy, and 33 patients with vagotomy and pyloroplasty for both short- and long-segment Barrett's esophagus. Caucasian ethnicity, the presence of hiatus hernia, and alcohol consumption were all associated with elevated risks for Barrett's esophagus.

CONCLUSIONS

Gastric surgery for benign peptic ulcer disease is not a risk factor for either short- or long-segment Barrett's esophagus. This lack of association between gastric surgery and Barrett's esophagus suggests that reflux of bile without acid is not sufficient to damage the esophageal mucosa.

Temporal associations between coughing or wheezing and acid reflux in asthmatics

BACKGROUND AND AIMS

The pulmonary symptoms of patients with lung disease may be ascribed to gastro-oesophageal reflux although a causal relationship between acid reflux and coughing or wheezing has not been proved. Does cough cause reflux or does reflux cause cough? The aim of this study was to evaluate 24 hour oesophageal pH tracings of asthmatics with gastro-oesophageal reflux to determine the temporal association between acid reflux and coughing or wheezing.

METHODS

The oesophageal tracings of 128 asthmatics from the outpatient clinics who underwent oesophagogastroduodenoscopy, oesophageal manometry, and 24 hour oesophageal pH monitoring were analysed. Three possible temporal relationships between the occurrence of acid reflux and the occurrence of coughs or wheezes were evaluated: (1) pulmonary symptoms preceding reflux; (2) reflux preceding pulmonary symptoms; and (3) unrelated occurrence of both events.

RESULTS

Of 128 asthmatics, 53 recorded five or more coughs and 19 recorded three or more wheezes during the 24 hour recording period. Mean acid contact time was similar in asthmatics with and without pulmonary symptoms (12.2 (1.2)% v 10.4 (0.6)%). Of all coughs and wheezes, 46% and 48%, respectively, were associated with acid reflux. For the individual asthmatic, the likelihood of reflux induced coughing increased as the number of coughs increased.

CONCLUSIONS

Half of all coughs and wheezes in asthmatics are associated with acid reflux into the oesophagus. While an occasional coughing episode can lead to reflux, it is rather the reflux episode in the vast majority of instances that leads to cough.

Reflux symptoms are associated with psychiatric disease

AIMS

To evaluate the frequency of reflux symptoms in patients with a diagnosed psychiatric disorder and to assess potential risk factors for symptom occurrence.

METHODS

The presence of reflux symptoms was compared between a case population of 94 psychiatric patients and a control population of 198 non-psychiatric patients.

RESULTS

Heartburn, exercise-induced heartburn, cough and dysphagia were all reported significantly more frequently by subjects with psychiatric disorders than by control subjects. The presence of any psychiatric diagnosis exerted an increased risk for both heartburn (odds ratio, 2.71; 95% confidence interval, 1.01-7.30) and exercise-induced heartburn (3.34; 1.12-9.96). The type of psychiatric disorder, the type of psychotropic medication and the lifestyle did not influence the presence of reflux symptoms.

CONCLUSIONS

Reflux symptoms occur more frequently in patients with than without a diagnosed psychiatric disorder. The reflux symptoms are not associated with any specific type of medication and may reflect a generally reduced threshold for or distorted perception of symptoms.

No association between gallstones and gastroesophageal reflux disease

OBJECTIVES

Gallstones and hiatal hernia reportedly have been linked to similar dietary factors prevalent in western countries, and patients with cholelithiasis or previous cholecystectomy have been reported to have more duodenogastric reflux than healthy controls. Nonetheless, the contribution of duodenogastric reflux to the development of gastroesophageal reflux disease (GERD) remains controversial. The present study was aimed to assess the association between gallstone disease and GERD.

METHODS

Outpatients from general medical clinics who underwent upper GI endoscopy and abdominal ultrasonography were recruited into a case-control study. A case population of 790 patients with various grades of GERD was compared to a control population of 407 patients without GERD. In a multivariate logistic regression, the presence of GERD served as the outcome variable, whereas the presence of gallstones, hiatal hernia, social habits, and demographic characteristics served as predictor variables.

RESULTS

No associations were found between the presence of cholelithiasis or previous cholecystectomy and GERD or between the presence of cholelithiasis or previous cholecystectomy and hiatal hernia. The severity of GERD also remained unaffected by the presence of gallstones. The occurrence of GERD was influenced only by hiatal hernia (odds ratio [OR] = 3.15, 95% CI = 2.44-4.08), alcohol consumption (OR = 1.47, CI = 1.08-1.99), and not by cholelithiasis (OR = 1.02, CI = 0.68-1.51), or cholecystectomy (OR = 0.90, CI = 0.64-1.28). The frequency of GERD among hiatus hernia patients with gallstones (437/592 = 74%) was similar to the frequency of GERD among hiatus hernia patients without gallstones (168/220 = 76%, p = 0.516).

CONCLUSIONS

Neither cholelithiasis nor cholecystectomy poses a risk for the occurrence of GERD or hiatal hernia. Gallstone disease does not seem to influence the integrity of the esophageal mucosa through GERD.

Risk factors of oesophagitis in arthritic patients

BACKGROUND

The risk factors that precipitate the occurrence of oesophageal mucosal injury in patients on continuous nonsteroidal anti-inflammatory drug (NSAID) therapy are unknown.

METHODS

Outpatients who regularly consumed NSAIDs for osteoarthritis were recruited from a rheumatology clinic into a prospective case-control study. All patients answered a structured interview and underwent upper gastrointestinal endoscopy.

RESULTS

Of 450 eligible patients, 195 (43%) consented to be interviewed and undergo upper gastrointestinal endoscopy. Oesophagitis was diagnosed in 41 of these 195 patients (21%). The occurrence of gastric or duodenal ulcer in individual patients did not predict the concomitant damage of the oesophageal mucosa. Young age (odds ratio: 1.79 per decade of life; 95% confidence interval: 1.11-2.86) and hiatus hernia (odds ratio: 3.72; 95% confidence interval: 1.63-8.49) both increased the risk of developing oesophagitis. When questioned, all oesophagitis patients revealed at least one gastrointestinal symptom, heartburn being named most frequently (odds ratio: 4.78; 95% confidence interval: 2.04-11.17). The type of anti-inflammatory medication, the use of alcohol and the use of nicotine were not associated with any significant risk for erosive oesophagitis.

CONCLUSIONS

Patients on chronic NSAID therapy for rheumatological disease suffer frequently from erosive oesophagitis. While the risk may be higher in patients with a pre-existing tendency for gastro-oesophageal reflux, any concomitant history of NSAID-induced peptic ulcer disease does not add to the risk. Erosive oesophagitis should be considered especially in patients on NSAIDs who complain of heartburn.

Is there a link between cervical inlet patch and Barrett's esophagus?

BACKGROUND

Heterotopic gastric-type mucosa occurs as a flat island or islands of red mucosa in the proximal third of the esophagus where it gives rise to the "cervical inlet patch" (CIP). The aim of the present study was to delineate the clinical epidemiology of the CIP, especially its possible relationship to Barrett's esophagus.

METHODS

A case-control study compared 53 case subjects with CIP and 4882 control subjects without CIP. In a multivariate logistic regression, the presence of CIP was chosen as the outcome variable, whereas demographic characteristics, social habits, and presence of other endoscopic diagnoses served as predictor variables.

RESULTS

The prevalence of CIP was 1.1%. Its presence was associated with hiatal hernia (odds ratio 2.26: 95% CI [1.12, 4.56]) gastric ulcer (2.93: 95% CI [1.34, 6.40]) and Barrett's esophagus (4.41: 95% CI [2.31, 8.41]).

CONCLUSIONS

The coincidence of the cervical inlet patch and Barrett's esophagus could suggest a shared embryonic etiology.

The effect of culture results for Helicobacter pylori on the choice of treatment following failure of initial eradication

BACKGROUND

Current treatment for the eradication of Helicobacter pylori in patients with peptic disease is based on the combination of antibiotic and anti-acid regimens. Multiple combinations have been investigated, however no consensus has been reached regarding the optimal duration and medications.

OBJECTIVES

To assess the efficacy of two treatment regimens in patients with peptic ulcer disease and non-ulcer dyspepsia, and to determine the need for gastric mucosal culture in patients failing previous treatment.

METHODS

Ninety patients with established peptic ulcer and NUD (with previously proven ulcer) were randomly assigned to receive either bismuth-subcitrate, amoxycillin and metrnidazole (BAM) or lansoprasole, clarithromycine and metronidazole (LCM) for 7 days. Patients with active peptic disease were treated with ranitidine 300 mg/day for an additional month.

RESULTS

Eradication failed in 8 of the 42 patients in the BAM group and in 2 of the 43 patients in the LCM group, as determined by the 13C urea breath test or rapid urease test (19% vs. 5%, respectively, P = 0.05). Five of these 10 patients were randomly assigned to treatment with lansoprazole, amoxycillin and clarithromycin (LAC) regardless of the culture obtained, and the other 5 patients were assigned to treatment with lansoprazole and two antibacterial agents chosen according to a susceptibility test. Eradication of H. pylori was confirmed by the 13C urea breath test. The same protocol (LAC) was used in all patients in the first group and in four of the five patients in the second group. The culture results did not influence the treatment protocol employed.

CONCLUSIONS

Combination therapy based on proton pump inhibitor and two antibiotics is superior to bismuth-based therapy for one week. Gastric-mucosal culture testing for sensitivity of H. pylori to antibiotics is probably unnecessary before the initiation of therapy for patients with eradication failure.

Walking and chewing reduce postprandial acid reflux

BACKGROUND

Gastro-oesophageal reflux is worse after meals, and antacids are usually consumed after dietary indiscretion.

AIM

To investigate whether walking or gum chewing affect meal-induced gastro-oesophageal reflux.

METHODS

The study population comprised 12 case subjects with gastro-oesophageal reflux disease and 24 healthy controls. Each subject was studied using pH-metry for 5 h on 3 separate days. After baseline recording of pH for 1 h, all subjects were fed a standard breakfast over a 20-min period. On one of the days, oesophageal pH was recorded after the 20-min eating period for an additional 4 h in the sitting position. On another day, postprandial oesophageal pH was recorded for the first hour whilst walking, and for 3 subsequent hours whilst sitting. During a third day, oesophageal pH was recorded for the first postprandial hour whilst gum-chewing, followed by 3 h of sitting.

RESULTS

Food intake promoted gastro-oesophageal reflux in case subjects with GERD as well as in healthy controls, although postprandial reflux was more pronounced amongst the refluxers than amongst the controls. Chewing gum for 1 h after the meal reduced the acid contact time in both groups, with a more profound effect in refluxers than in controls. Whilst the beneficial effect of 1-h of gum-chewing lasted for up to 3 h in both groups, the beneficial effect of 1-h of walking was apparent only in refluxers, only to a mild degree, and only for a short duration.

CONCLUSIONS

Chewing gum after a meal helps to reduce postprandial oesophageal acid exposure.

Risk factors for erosive reflux esophagitis: a case-control study

OBJECTIVES

It is presently not fully understood which risk factors contribute to the occurrence of reflux esophagitis and how such factors might influence the severity of the disease. The aim of this study was to delineate the clinical epidemiology of erosive reflux esophagitis.

METHODS

Outpatients from a medicine and gastroenterology clinic who underwent upper GI endoscopy were recruited into a case-control study. A total of 1,533 patients with and 3,428 patients without endoscopically diagnosed reflux esophagitis were categorized as case and control subjects, respectively. Using multivariate logistic regressions for statistical analysis, the presence of esophageal erosions, ulcers or strictures, served as three separate outcome variables. Demographic characteristics, intake of nonsteroidal anti-inflammatory drugs (NSAIDs), consumption of alcohol and cigarettes, and the presence of hiatus hernia or peptic ulcer served as predictor variables.

RESULTS

Erosive reflux esophagitis tended to occur more frequently in Caucasian male patients. Hiatus hernia was associated with a strong risk for developing esophageal erosions, ulcers, and strictures. Although statistical significance was demonstrated only for esophageal erosions, in all grades of reflux esophagitis alike, gastric and duodenal ulcer exerted a protective influence. Consumption of NSAIDs increased the risk for esophageal ulcers only. Smoking and alcohol were not associated with an increased risk of developing any type of erosive reflux esophagitis.

CONCLUSIONS

The results stress the critical role played by hiatus hernia in all grades of erosive reflux esophagitis. NSAIDs may act through a mechanism of topically induced esophageal injury. Our data also suggest that the presence of either gastric or duodenal ulcer exerts a protective influence against the development of reflux disease.

Cyclosporin for severe ulcerative colitis

BACKGROUND

About one-third of patients with severe ulcerative colitis do not respond to conventional therapy and require urgent colectomy. It was recently shown that cyclosporin is effective in some of these patients.

OBJECTIVES

To review the current experience of six hospitals in central Israel that used cyclosporin in patients with severe ulcerative colitis.

METHODS

The files of all 32 patients treated with cyclosporin for corticosteroid-resistant ulcerative colitis were reviewed. Activity of disease was measured by a clinical activity, index colonoscopy and laboratory tests.

RESULTS

The average duration of treatment with intravenous cyclosporin was 12.7 days (range 9-28) after which the disease activity index dropped from an average of 14.22 to 4.74. The mean time for response was 7.5 days (4-14). Twelve patients (40%) required surgery within 6 months and another 6 patients (18.8%) were operated on after more than 6 months. Twelve patients (37%) maintained remission for at least 6 months and did not require surgery. In one patient treatment was stopped because of non-compliance and one was lost to follow-up. There were numerous side effects, but in only one case with neurotoxicity was treatment withdrawn.

CONCLUSIONS

Cyclosporin is a relatively safe and effective treatment for severe ulcerative colitis. It induced long-term remission in 37% of the patients, and in those who required surgery the treatment resulted in an improved clinical condition before the operation.

[Sensitivity and resistance of Helicobacter pylori to antibiotic treatment]

Resistance to antibiotics is considered the main reason for failure to eradicate Helicobacter pylori (HP). Resistance rates are different in developed and developing countries and are not known for Israel. We studied HP resistance rates in 40 patients who underwent esophagoduodenoscopy for various indications and were found to have gastric HP colonies. Sensitivity was determined by E-test, using clarythromycin, amoxycillin, clindamycin, erythromycin and metronidazole. The resistance rate for metronidazole was up to 67% but that for clindamycin was only 10%. HP was very sensitive to both macrolide antibiotics, erythromycin and clarythromycin.

Preoperative assessment of blood vessel involvement in patients with pancreatic cancer

The major prerequisite for resection of a pancreatic tumor is non-involvement of large blood vessels. Preoperative assessment of blood vessel infiltration may prevent unnecessary surgery. The aim of our study was to investigate the accuracy of endoscopic ultrasonography (EUS) in diagnosis of pancreatic cancer and in preoperative staging. Thirteen patients (7 females, 6 males; mean age 64 years) with a pancreatic tumor, but no evidence of distant metastases, underwent EUS and computerized tomography (CT) in order to assess blood vessel involvement by the tumor. The results were compared with intraoperative findings in 12 patients and with postmortem findings in 1 patient. A tumor was demonstrated by EUS in 12 patients and was confirmed at surgery in all 12 patients. In one patient no tumor was demonstrated by EUS, although a tumor was visible by CT; no tumor was found at surgery. In two patients CT failed to demonstrate a pancreatic tumor that was demonstrated by EUS; at surgery a tumor was detected in both patients. EUS detected blood vessel involvement in seven patients, which was confirmed at surgery in six of them. In the other six patients surgery confirmed the EUS finding of no blood vessel involvement. CT detected blood vessel involvement in two patients only. The overall accuracy of EUS and CT for detecting the tumor was 100% and 77% respectively, and for blood vessel involvement 92% and 61% respectively. In conclusion, EUS is an accurate procedure for preoperative assessment of blood vessel involvement in patients with pancreatic cancer. This procedure may enable the selection of those patients who may benefit from surgery, and should be part of the evaluation of patients with pancreatic cancer who are candidates for curative surgery.

Accuracy of endoscopic ultrasonography for preoperative staging of esophageal malignancy

Surgery for esophageal cancer carries a high mortality rate and a low rate of resectability for cure. Accurate preoperative staging is therefore of utmost importance. Staging is based on computerized tomography (CT), and recently, the use of endoscopic ultrasonography (EUS). We performed EUS and CT on 10 patients with esophageal cancer. Tumors were staged according to the TNM classification. According to the CT results, seven patients had a T3 tumor, one T1-2 and two T0. All patients were diagnosed as T3 by EUS. One patient, who was treated by combined modality treatment with chemotherapy and radiotherapy, converted to T0. Six patients were operated on, and in five, pathological findings were of an invasive tumor. The T stage was predicted correctly in five patients by CT and in all six patients by EUS. N stage was correctly diagnosed in two patients by CT and in five by EUS. It is concluded that EUS is superior to CT for preoperative staging of esophageal tumors. EUS should be undertaken as a routine procedure prior to surgery for esophageal cancer.

The value of menotrophin treatment for unexplained infertility prior to an in-vitro fertilization attempt

This work was undertaken in order to evaluate retrospectively the relative efficacy of ovulation induction by menotrophins and that of in-vitro fertilization and embryo transfer (IVF-ET) in the treatment of unexplained infertility. These two treatments were compared between two groups of patients: 87 couples undergoing 446 cycles of ovulation induction by menotrophins (group A) and 72 couples undergoing 108 cycles of IVF-ET (group B). A total of 30 and 20 pregnancies were achieved in groups A and B for a rate of 34 and 28% per patient, respectively. A similar cumulative pregnancy rate (CPR) was achieved for three cycles of ovulation induction (23%) and one cycle of IVF-ET (22%). The cumulative live birth rate (CLBR) in group A was 22% after three cycles and exceeded that of one IVF-ET cycle (17%). It is concluded that menotrophin treatment in unexplained infertility is highly beneficial and should precede an IVF attempt.