Eosinophilic Esophagitis: Clinical Pearls for Primary Care Providers and Gastroenterologists

Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated esophageal disorder. Given its increasing incidence, it is now a leading cause of dysphagia and food impaction in the United States. Eosinophilic esophagitis is most common in adult White men and has a high concurrence rate with other atopic conditions like allergic rhinitis, bronchial asthma, and eczema. The initial presentation includes symptoms of esophageal dysfunction, classically solid-food dysphagia. Without treatment, inflammation can progress to fibrosis with the formation of strictures, leading to complications such as food impaction. It is a clinicopathologic disease requiring compatible clinical symptoms and histologic evidence of eosinophil-predominant inflammation of the esophageal epithelium with more than 15 eosinophils per high-power field. The mainstay of management includes the 3 d's (diet, drugs, dilation): dietary modifications to eliminate trigger food groups; medications including proton pump inhibitors, swallowed topical glucocorticoids, and dupilumab; and esophageal dilation to manage strictures. Various elimination diets have been found to be effective, including 1-food, 2-food, 4-food, and 6-food elimination diets. Dupilumab, a humanized monoclonal antibody that regulates interleukin 4 and 13 signaling pathways, has shown promising results in clinical trials and was approved by the Food and Drug Administration in 2022 for use in EoE. Symptom alleviation, although important, is not the sole end point of treatment in EoE as persistent inflammation, even in the absence of symptoms, can lead to esophageal fibrosis and stricture formation over time. The chronic nature and high recurrence rates of EoE warrant maintenance therapy in patients with EoE after initial remission is achieved.

Localized Photodynamic Therapy Using a Chlorin e6-Embedded Silicone-Covered Self-Expandable Metallic Stent as a Palliative Treatment for Malignant Esophageal Strictures

Localized photodynamic therapy (PDT) uses a polymeric-photosensitizer (PS)-embedded, covered self-expandable metallic stent (SEMS). PDT is minimally invasive and a noteworthy potential alternative for treating esophageal strictures, where surgery is not a viable option. However, preclinical evidence is insufficient, and optimized irradiation energy dose ranges for localized PDT are unclear. Herein, we validated the irradiation energy doses of the SEMS (embedded in a PS using chlorin e6 [Ce6] and covered in silicone) and PDT-induced tissue changes in a rat esophagus. Cytotoxicity and phototoxicity in the Ce6-embedded SEMS piece with laser irradiation were significantly higher than that of the silicone-covered SEMS with or without laser and the Ce6-embedded silicone-covered SEMS without laser groups (all p < 0.001). Moreover, surface morphology, atomic changes, and homogeneous coverage of the Ce6-embedded silicone-covered membrane were confirmed. The ablation range of the porcine liver was proportionally increased with the irradiation dose (all p < 0.001). The ablation region was identified at different irradiation energy doses of 50, 100, 200, and 400 J/cm2. The in vivo study in the rat esophagus comprised a control group and 100, 200, and 400 J/cm2 energy-dose groups. Finally, histology and immunohistochemistry (TUNEL and Ki67) confirmed that the optimized Ce6-embedded silicone-covered SEMS with selected irradiation energy doses (200 and 400 J/cm2) effectively damaged the esophageal tissue without ductal perforation. The polymeric PS-embedded silicone-covered SEMS can be easily placed via a minimally invasive approach and represents a promising new approach for the palliative treatment of malignant esophageal strictures.

Impact of coronary CT angiography in selection of treatment modalities and subsequent cardiovascular events in Thai patients with stable CAD

BACKGROUND

Coronary computed tomography angiography (CCTA) enables improved diagnosis of subclinical, coronary artery disease (CAD). This retrospective cohort study investigated the association between different treatment modalities guided by CCTA and the prevention of major adverse cardiovascular events (MACEs) in patients with stable CAD.

METHODS

From 2005 to 2013, a total of 9338 patients, including both asymptomatic individuals with risk factors and symptomatic patients with suspected CAD, who underwent CCTA were analyzed. The patients were categorized into one of three groups based on results of CCTA: obstructive CAD (≥ 50% stenosis in at least one vessel), non-obstructive CAD (1-49% stenosis in at least one vessel), and no observed CAD (0% stenosis). They were subsequently followed up to assess the treatment they received and the occurrence of MACEs (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or late revascularization).

RESULTS

During an average follow-up period of 9.9 ± 2.4 years, patients with obstructive CAD had the highest incidence of MACEs (19.8%), followed by those with non-obstructive CAD and no coronary artery stenosis (10.3 and 5.5%, respectively). After adjusting for confounding variables, it was found that patients treated with statins alone were the least likely to develop MACEs in all three groups, compared to those receiving no treatment, with hazard ratios (95% CI) of 0.43 (0.32, 0.58), 0.47 (0.34, 0.64), and 0.46 (0.31, 0.69), respectively. In patients with obstructive CAD, treatment with a combination of statin and aspirin, or early revascularization was associated with a lower likelihood of experiencing MACEs compared to no treatment with hazard ratios of 0.43 (0.33, 0.58) and 0.64 (0.43, 0.97), respectively.

CONCLUSION

CCTA offers useful guidance for the treatment of patients with stable CAD and shows potential for prevention of CV events. However, the full validation of a given strategy utilizing CCTA will require a prospective longitudinal study, utilizing a randomized clinical trial design.

Banxia Baizhu Tianma Tang decoction and modified Taohong Siwu combined with Western medicine to treat a patient with severe stenosis of the middle cerebral artery: A case report

RATIONALE

Intracranial artery stenosis is an important cause of ischemic stroke, and MCA is one of the most common vessels causing intracranial artery stenosis. At present, there are 3 main treatments for MCA stenosis: medical drug therapy, surgery, and endovascular interventional therapy.

PATIENT CONCERNS

We report a patient with severe middle cerebral artery stenosis, including his imaging and clinical manifestations.

DIAGNOSIS

Severe stenosis of middle cerebral artery.

INTERVENTIONS

Banxia Baizhu Tianma decoction combined with Taohong Siwu decoction combined with western medicine.

OUTCOMES

The stenosis of M1 segment of middle cerebral artery was significantly improved, the stenosis rate was reduced from 70% to 30%, and the clinical symptoms of the patients basically disappeared.

LESSONS

Banxia Baizhu Tianma decoction combined with Taohong Siwu plus subtraction combined with western medicine is effective in the treatment of middle cerebral artery stenosis.

Does the clopidogrel CYP2C19 genotype assay predict postprocedure stenosis in cerebral aneurysms treated with a flow diverter?

OBJECTIVE

Flow diverters have emerged as a popular modality for treating cerebral aneurysms but require dual antiplatelet therapy (DAPT) after placement. Clopidogrel is a common choice but is a prodrug that some patients may not convert into an active metabolite. The CYP2C19 genotype assay is used to predict activation speed; however, limited data exist showcasing whether this genotype accurately predicts postprocedure complications after flow diversion treatment of cerebral aneurysms. Therefore, the authors sought to characterize whether CYP2C19 genotype correlated with the development of postprocedure intimal hyperplasia (stenosis) after flow diverter placement.

METHODS

Medical records were reviewed for patients who underwent flow diverter treatment of cerebral aneurysm at a single academic institution between January 1, 2012, and May 31, 2020. Patient demographics and comorbidities were reviewed alongside CYP2C19 genotype assay, DAPT regimen, and postprocedure angiogram data. Stenosis was defined based on review of angiogram data by two independent physicians.

RESULTS

In this review of 120 unique cerebral aneurysms, 102 received DAPT with clopidogrel and 18 received DAPT with an alternative agent. Stenosis was present on 3-month follow-up angiogram for 35/102 (34.3%) aneurysms receiving DAPT with clopidogrel and in 11/18 (61.1%) aneurysms receiving an alternative DAPT regimen (p = 0.031). The CYP2C19 genotype did not correlate with postprocedure stenosis (p = 0.35).

CONCLUSIONS

Clopidogrel was a significantly more effective DAPT agent for preventing stenosis when compared to nonclopidogrel DAPT regimens. The clopidogrel CYP2C19 genotype did not predict postprocedure stenosis in this cohort of 120 cerebral aneurysms treated with a flow diverter.

Serial Changes in Intestinal Stenotic Stiffness in Patients with Crohn's Disease Treated with Biologics: A Pilot Study Using Ultrasound Shear Wave Elastography

BACKGROUND/AIMS

Intestinal strictures represent an important serious complication of Crohn's disease. Shear wave elastography is a promising noninvasive ultrasound technique for assessing tissue stiffness. This study aimed to evaluate stiffness in the areas of intestinal stricture in patients with Crohn's disease using shear wave elastography and the changes in stiffness after biologics.

MATERIALS AND METHODS

We enrolled 21 Crohn's disease patients having intestinal stricture. The patients consisted of 3 groups, which were the infliximab naïve (n = 6) group, the ustekinumab naïve (n = 8), and the bio-switch from infliximab to ustekinumab (n = 7) group. Bowell wall thickness was examined by ultrasound sonography, and the stiffness of Crohn's disease stricture lesions was evaluated using Shear wave speed before and 1 year after anti-tumor necrosis factor-alpha antibody infliximab, anti-interleukin 12/23 antibody ustekinumab, and bio-switch from infliximab to ustekinumab.

RESULTS

Bowell wall thickness was significantly improved after infliximab, ustekinumab, and the bio-switch. However, shear wave speed indices only in the ustekinumab group significantly decreased after treatment (P = .028), but not in the other group.

CONCLUSIONS

Shear wave elastography might be a useful method to evaluate stiffness in the areas of intestinal stricture in patients with Crohn's disease treated with biologics. However, a prospective randomized study evaluating the development of obstruction after biological treatment is needed to validate the study findings.

Role of systemic immunosuppression on subglottic stenosis in granulomatosis with polyangiitis: Analysis of a single-centre cohort

PURPOSE

Subglottic stenosis (SGS) is a potentially life-threatening manifestation of granulomatosis with polyangiitis (GPA). Endoscopic dilation is effective, but relapses are frequent and the benefit of systemic immunosuppression in this setting is still controversial. We aimed to investigate the role of immunosuppressive treatment on SGS relapse risk.

METHODS

This is a retrospective observational study based on review of medical charts among our cohort of patients with GPA.

RESULTS

Twenty-one patients with SGS-GPA were identified, with a prevalence of 20% among our entire GPA cohort (n = 105). Compared to patients without SGS, patients with SGS-GPA had an earlier disease onset (mean age 30.2 vs. 47.3 years, p<0.001), and lower BVAS (mean 10.5 vs 13.5; p = 0.018). Five patients didn't receive systemic immunosuppression for SGS and they all (100%) relapsed after the first procedure, while among medical treatment group relapse rate was 44% (p = 0.045). When single treatment regimens are considered, rituximab (RTX) and cyclophosphamide (CYC) yielded a protective role towards the need of subsequent dilation procedure after the first if compared with absence of medical treatment. Patients with SGS and generalized disease, who initially received either a RTX- or a CYC-based induction treatment, and higher cumulative doses of glucocorticoids, showed a delayed median time to SGS relapse (36 vs. 12 months, p = 0.024).

CONCLUSIONS

Subglottic stenosis is highly prevalent in patients with GPA and may define a milder systemic disease subset occurring more frequently in younger patients. Systemic immunosuppression provides benefit in preventing recurrence of SGS in GPA patients and regimens based on cyclophosphamide or rituximab might have a non-redundant role in this setting.

Sirolimus-eluting airway stent reduces profibrotic Th17 cells and inhibits laryngotracheal stenosis

Laryngotracheal stenosis (LTS) is pathologic fibrotic narrowing of the larynx and trachea characterized by hypermetabolic fibroblasts and CD4+ T cell-mediated inflammation. However, the role of CD4+ T cells in promoting LTS fibrosis is unknown. The mTOR signaling pathways have been shown to regulate the T cell phenotype. Here we investigated the influence of mTOR signaling in CD4+ T cells on LTS pathogenesis. In this study, human LTS specimens revealed a higher population of CD4+ T cells expressing the activated isoform of mTOR. In a murine LTS model, targeting mTOR with systemic sirolimus and a sirolimus-eluting airway stent reduced fibrosis and Th17 cells. Selective deletion of mTOR in CD4+ cells reduced Th17 cells and attenuated fibrosis, demonstrating CD4+ T cells' pathologic role in LTS. Multispectral immunofluorescence of human LTS revealed increased Th17 cells. In vitro, Th17 cells increased collagen-1 production by LTS fibroblasts, which was prevented with sirolimus pretreatment of Th17 cells. Collectively, mTOR signaling drove pathologic CD4+ T cell phenotypes in LTS, and targeting mTOR with sirolimus was effective at treating LTS through inhibition of profibrotic Th17 cells. Finally, sirolimus may be delivered locally with a drug-eluting stent, transforming clinical therapy for LTS.

Major intracranial arterial stenosis influence association between baseline blood pressure and clinical outcomes after thrombolysis in ischemic stroke patients

BACKGROUND

This study aimed to investigate the relationship between baseline blood pressure (BP) and clinical outcomes after thrombolysis for acute ischemic stroke (AIS) in different intracranial arterial stenosis subgroups.

METHODS

AIS patients from multicenter with intravenous thrombolysis were retrospectively enrolled from January 2013 to December 2021. We categorized participants into severe (≥ 70%) and nonsevere (< 70%) stenosis of major intracranial arteries subgroups. The primary outcome was unfavorable functional outcome defined as 3-month modified Rankin Scale (mRS) ≥2. The association coefficients between baseline BP and functional outcomes were estimated in general linear regression model. The interactive effect was tested to determine the influence of intracranial arterial stenosis on the association between BP and clinical outcomes.

RESULTS

A total of 329 patients were included. Severe subgroup was detected in 151 patients with average age of 70.5. Association between baseline diastolic BP (DBP) and unfavorable functional outcome in intracranial artery stenosis subgroups was significantly different (p for interaction < .05). In nonsevere subgroup, higher baseline DBP was associated with higher risk of unfavorable outcome (OR 1.11, 95% CI 1.03 to 1.20, p = .009) compared with severe subgroup (OR 1.02, 95% CI 0.97 to 1.08, p = .341). Besides, intracranial artery stenosis also modified association between baseline systolic BP (SBP) and 3-month death (p for interaction < .05). In severe subgroup, higher baseline SBP was associated with decreased 3-month death risk (OR 0.88, 95% CI 0.78 to 1, p = .044) compared with nonsevere subgroup (OR 1, 95% CI 0.93 to 1.07, p = .908).

CONCLUSIONS

The major intracranial artery state modulates association between baseline BP and 3-month clinical outcomes after intravenous thrombolysis.

Determinants of 1-Year Unfavorable Outcomes of Intravenous Alteplase Thrombolysis for Acute Ischemic Stroke

OBJECTIVE

Intravenous thrombolytic therapy has become the standard of treatment for eligible patients with ischemic stroke. However, outcomes after receiving intravenous thrombolytic therapy vary widely. This study aims to investigate determinants of 1-year clinical outcomes of intravenous thrombolytic therapy for patients with acute ischemic stroke.

METHODS

In a prospective, observational study, patients with acute ischemic stroke treated with intravenous thrombolysis were consecutively included, and clinical information and laboratory data were collected. The patients were followed up for 12 months after onset, and the 1-year clinical outcome was evaluated using modified Rankin Scale scores. A score ≥ 3 was defined as unfavorable functional outcome. Univariate and multivariate logistic regressions were used to assess the determinants of the 1-year clinical outcomes of intravenous thrombolysis for acute ischemic stroke.

RESULTS

A total of 222 patients with intravenous thrombolysis were enrolled, and we identified 58 patients (26.1%) had unfavorable functional outcomes. Multivariate logistic regression analysis revealed that mean platelet volume-to-lymphocyte ratio (MPVLR) (odds ratio [OR] = 1.114, 95% confidence interval [CI]: 1.024-1.211, P = .012), atrial fibrillation (OR =  2.553, 95% CI: 1.086-6.002, P = .032), symptomatic stenosis occlusion (OR =  2.547, 95% CI: 1.269-5.110, P = .009), and baseline National Institutes of Health Stroke Scale (NIHSS) score (OR = 1.141, 95% CI: 1.074-1.212, P < .001) were independent predictors of unfavorable functional outcomes at 1 year.

CONCLUSIONS

In patients receiving intravenous thrombolysis, we found that MPVLR, atrial fibrillation, symptomatic stenosis occlusion, and baseline NIHSS score were significant predictors of unfavorable functional outcomes at 1 year.

Rescue stenting after the failure of intravenous thrombolysis and bridging thrombolysis: an initial Vietnamese report

OBJECTIVE

Intravenous (IV) recombinant tissue plasminogen activator is the standard of care for patients with acute ischemic stroke (AIS) who present to the hospital within 4.5 hours of symptom onset. However, IV thrombolysis, even bridging thrombolysis (combining intravenous thrombolysis and mechanical thrombectomy) has limited efficacy among patients who had occlusive lesions associated with high-grade arterial stenosis requiring revascularization to improve neurological deficits. We evaluated whether rescue stenting results in good outcomes among patients after the failure of intravenous thrombolysis and bridging thrombolysis.

PATIENTS AND METHODS

We retrospectively analyzed patients with AIS who underwent rescue stenting for large vessel occlusion with severe atherosclerotic stenosis between May 2020 and August 2022 at Can Tho S.I.S General Hospital. Primary outcomes included the incidence of hemorrhagic transformation and the rate of good outcomes (modified Rankin Scale < 3) at 3-month follow-up.

RESULTS

We identified 13 patients who received rescue stenting after the failure of IV alteplase and bridging thrombolysis, but only 11 patients met the inclusion criteria. All patients experienced successful recanalization, and 1 (9.1%) patient experienced new infarcts. Of these 11 patients, 10 (90.9%) had good outcomes 3 months after rescue stenting. Additionally, a loading dose of dual antiplatelet therapy (DAPT) applied concurrently with IV alteplase improved the recanalization rate for large target arteries but had no significant effect on the incidence of symptomatic intracranial hemorrhage.

CONCLUSIONS

Rescue stenting appears to represent an additional therapeutic option in cases that fail to resolve with IV alteplase, which may improve clinical outcomes.

[The effective analysis of refractory esophageal stricture after endoscopic mucosal dissection of early esophageal cancer treated by endoscopic radiotomy combined with local injection of triamcinolone acetonide]

Refractor esophageal stenosis after endoscopic submucosal dissection of early esophageal carcinoma is a difficult clinical problem. To verify the effect of endoscopic radial incision combined local triamcinolone injection to treat refractory esophageal stenosis, we retrospectively analyzed 7 patients diagnosed with refractory esophageal stricture after endoscopic mucosal dissection of early esophageal cancer in this study, of whom 4 male and 3 female patients, aged 50-76 years, with the mean age of 63 years. We performed the endoscopic radial incision in the thickness point of the scar stricture and injected the triamcinolone locally. The results showed it was safe and effective. The follow-up showed no esophageal stenosis occured and no adverse reaction such as hemorrhage, perforation, tumor-recurrence and triamcinolone-allergy occured.

Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial

Importance

Prior randomized trials have generally shown harm or no benefit of stenting added to medical therapy for patients with symptomatic severe intracranial atherosclerotic stenosis, but it remains uncertain as to whether refined patient selection and more experienced surgeons might result in improved outcomes.

Objective

To compare stenting plus medical therapy vs medical therapy alone in patients with symptomatic severe intracranial atherosclerotic stenosis.

Design, Setting, and Participants

Multicenter, open-label, randomized, outcome assessor-blinded trial conducted at 8 centers in China. A total of 380 patients with transient ischemic attack or nondisabling, nonperforator (defined as nonbrainstem or non-basal ganglia end artery) territory ischemic stroke attributed to severe intracranial stenosis (70%-99%) and beyond a duration of 3 weeks from the latest ischemic symptom onset were recruited between March 5, 2014, and November 10, 2016, and followed up for 3 years (final follow-up: November 10, 2019).

Interventions

Medical therapy plus stenting (n = 176) or medical therapy alone (n = 182). Medical therapy included dual-antiplatelet therapy for 90 days (single antiplatelet therapy thereafter) and stroke risk factor control.

Main Outcomes and Measures

The primary outcome was a composite of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. There were 5 secondary outcomes, including stroke in the qualifying artery territory at 2 years and 3 years as well as mortality at 3 years.

Results

Among 380 patients who were randomized, 358 were confirmed eligible (mean age, 56.3 years; 263 male [73.5%]) and 343 (95.8%) completed the trial. For the stenting plus medical therapy group vs medical therapy alone, no significant difference was found for the primary outcome of risk of stroke or death (8.0% [14/176] vs 7.2% [13/181]; difference, 0.4% [95% CI, -5.0% to 5.9%]; hazard ratio, 1.10 [95% CI, 0.52-2.35]; P = .82). Of the 5 prespecified secondary end points, none showed a significant difference including stroke in the qualifying artery territory at 2 years (9.9% [17/171] vs 9.0% [16/178]; difference, 0.7% [95% CI, -5.4% to 6.7%]; hazard ratio, 1.10 [95% CI, 0.56-2.16]; P = .80) and 3 years (11.3% [19/168] vs 11.2% [19/170]; difference, -0.2% [95% CI, -7.0% to 6.5%]; hazard ratio, 1.00 [95% CI, 0.53-1.90]; P > .99). Mortality at 3 years was 4.4% (7/160) in the stenting plus medical therapy group vs 1.3% (2/159) in the medical therapy alone group (difference, 3.2% [95% CI, -0.5% to 6.9%]; hazard ratio, 3.75 [95% CI, 0.77-18.13]; P = .08).

Conclusions and Relevance

Among patients with transient ischemic attack or ischemic stroke due to symptomatic severe intracranial atherosclerotic stenosis, the addition of percutaneous transluminal angioplasty and stenting to medical therapy, compared with medical therapy alone, resulted in no significant difference in the risk of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. The findings do not support the addition of percutaneous transluminal angioplasty and stenting to medical therapy for the treatment of patients with symptomatic severe intracranial atherosclerotic stenosis.

Trial Registration

ClinicalTrials.gov Identifier: NCT01763320.

Intralesional steroid injection after endoluminal esophageal stricture dilatation in a cat

Background:

Benign esophageal strictures arise from various etiologies, mostly severe esophagitis. Although endoscopic balloon dilation is still the first-line therapy, refractory or recurrent strictures do occur and remain a challenge to the endoluminal treatment. The aim of this report was to communicate a recurrent esophageal stricture resolution in a cat treated with balloon dilatation and steroid injections in Ciudad de Buenos Aires, Argentina.

Case Description:

A 1-year-old spayed mix-breed female cat was consulted to the Veterinary Endoscopy Service for recurring regurgitation after two previous esophageal dilations. The cat had received doxycycline for Mycoplasma spp. infection and 20 days after the treatment consulted for dysphagia and regurgitation. Upper esophagogastroscopy (UGE) was performed with an Olympus CV-160 8.7 mm diameter endoscope; an annular 7 mm stricture was observed 3 cm caudal to the cranial esophagus sphincter. Three balloon dilatations procedures were performed with a Boston Scientific Controlled Radial Expansion (CRE) balloon 8–10–12 mm of 1 minute each. Because of ongoing clinical signs, another UGE was performed 15 days from the first procedure: a 3 mm stricture was encountered, balloon dilatation was repeated with 6–10–12 mm diameter, and a four-quadrant triamcinolone was injected in the submucosa. Clinically, the cat could eat with no alterations until day 20, where it started with mild dysphagia. Another UGE was performed, and the known stricture conserved a 11 mm diameter and balloon dilatation 12–15–16.5 mm with triamcinolone injection was repeated 30 days after the previous procedure. The cat could eat kibbles with no clinical signs in an 11-month follow-up.

Conclusion:

The alternative to triamcinolone injection after balloon dilatation presented in this clinical report was successful and it could be a therapeutic option for recurrent esophageal strictures in cats as it is in human medicine.

Intensive drug therapy versus standard drug therapy for symptomatic intestinal Crohn's disease strictures (STRIDENT): an open-label, single-centre, randomised controlled trial

BACKGROUND

Strictures are the most common structural complication of Crohn's disease. Surgery and endoscopic balloon dilation are the main treatments; drug therapy has been considered contraindicated. Given that most strictures have an inflammatory component, we aimed to find out whether strictures are responsive to drug treatment and whether intensive drug therapy is more effective than standard drug therapy.

METHODS

This open-label, single-centre, randomised controlled trial was performed in one specialist inflammatory bowel disease centre in Australia. Patients aged 18 years or older with Crohn's disease were included. Eligible patients had a de novo or postoperative anastomotic intestinal stricture on MRI or ileocolonoscopy, symptoms consistent with chronic or subacute intestinal obstruction (postprandial abdominal pain in the presence of a confirmed stricture), and evidence of active intestinal inflammation. Patients were randomly assigned (2:1) to receive intensive high-dose adalimumab (160 mg adalimumab once per week for 4 weeks followed by 40 mg every 2 weeks, with escalation of dose at 4 months and 8 months if assessment of disease activity indicated active inflammation) plus thiopurine (initial dose of azathioprine 2·5 mg/kg or mercaptopurine 1·5 mg/kg, with dose adjustment based on thiopurine metabolite testing) or standard adalimumab monotherapy (160 mg at week 0, 80 mg at week 2, then 40 mg every 2 weeks) using stratified fixed block randomisation. Stratification factors were stricture dilation at study baseline colonoscopy and current biologic drug use. The primary endpoint was improvement (decrease) in the 14-day obstructive symptom score at 12 months by one or more points compared with baseline. This trial is registered with ClinicalTrials.gov, NCT03220841, and is completed.

FINDINGS

Between Sept 10, 2017, and Sept 6, 2019, 123 patients were screened and 77 randomly assigned to intensive adalimumab plus thiopurine treatment (n=52) or standard adalimumab treatment (n=25). At 12 months, improvement in obstructive symptom score was noted in 41 (79%) of 52 patients in the intensive treatment group and 16 (64%) of 25 in the standard treatment group (odds ratio [OR] 2·10 [95% CI 0·73-6·01]; p=0·17). Treatment failure occurred in five (10%) patients in the intensive treatment group versus seven (28%) in the standard treatment group (OR 0·27 [95% CI 0·08-0·97]; p=0·045); four patients in each group required stricture surgery (0·44 [0·10-1·92]; p=0·27). Crohn's Disease Activity Index was less than 150 in 36 (69%) patients in the intensive treatment group versus 15 (60%) in the standard treatment group (1·50 [0·56-4·05]; p=0·42). MRI at 12 months showed improvement using the stricture MaRIA score (≥25%) in 31 (61%) of 51 versus seven (28%) of 25 patients (3·99 [1·41-11·26]; p=0·0091). MRI complete stricture resolution was seen in ten (20%) versus four (16%) patients (1·28 [0·36 to 4·57]; p=0·70). Intestinal ultrasound at 12 months showed improvement (>25%) in bowel wall thickness in 22 (51%) of 43 versus seven (33%) of 21 patients (2·10 [0·71 to 6·21]; p=0·18). Faecal calprotectin normalised in 32 (62%) versus 11 (44%) patients (2·04 [0·77-5·36]; p=0·15). Normalisation of CRP was seen in 32 (62%) versus 11 (44%) patients (2·04 [0·77-5·36]; p=0·15). Eight (15%) patients in the intensive treatment group and four (16%) in the standard treatment group reported serious adverse events. No deaths occurred during the study.

INTERPRETATION

Crohn's disease strictures are responsive to drug treatment. Most patients had improved symptoms and stricture morphology. Treat-to-target therapy intensification resulted in less treatment failure, a reduction in stricture-associated inflammation, and greater improvement in stricture morphology, although these differences were not significantly different from standard therapy.

FUNDING

Australian National Health and Medical Research Council, Gastroenterological Society of Australia Ferring IBD Clinician Establishment Award, Australasian Gastro Intestinal Research Foundation, AbbVie, and the Spotlight Foundation.

Ghrelin inhibited pressure overload-induced cardiac hypertrophy by promoting autophagy via CaMKK/AMPK signaling pathway

Ghrelin, a novel gut hormone, has been shown to exert protective effects on cardiac dysfunction and remodeling. However, the underlying mechanisms of its protective effects remain unclear. Here, we investigated the effects of ghrelin on cardiac hypertrophy and explored the mechanisms involved. Ghrelin (30 μg.kg^-1. day^-1) was systemically administered to rats with cardiac hypertrophy induced by abdominal aortic constriction (AAC) by a mini-osmotic pump the next day after surgery continuously for 4 weeks. The AAC treated rats without ghrelin infusion showed decreased ghrelin content and expression of its receptors in the hearts. Exogenous ghrelin greatly attenuated cardiac hypertrophy as shown by heart weight to tibial length (HW/TL), hemodynamics, echocardiography, histological analyses, and expression of hypertrophic markers induced by AAC. This corresponded with decreased cardiac fibrosis and inflammation in the hearts of AAC rats treated with ghrelin. Moreover, ghrelin significantly increased the myocardial expression of autophagy markers, which was further confirmed in cultured cardiomyocytes. Concurrently, cardiomyocyte apoptosis in vivo and in vitro was ameliorated by ghrelin, which was reversed by inhibition of autophagy. The enhancement of autophagy and inhibition of apoptosis by ghrelin were eliminated on pretreatment with compound C, an AMP-activated protein kinase (AMPK) inhibitor. Furthermore, inhibition of Ca²⁺/Calmodulin-dependent protein kinase kinase (CaMKK), an upstream kinase of AMPK, made ghrelin fail to activate AMPK and simultaneously reversed ghrelin's promotion of autophagy. In conclusion, ghrelin could exert its cardioprotective effects on cardiac hypertrophy by promoting autophagy, possibly via CaMKK/AMPK signaling pathway.

Thymus algeriensis and Thymus fontanesii exert neuroprotective effect against chronic constriction injury-induced neuropathic pain in rats

We have previously demonstrated that the Thymus algeriensis and Thymus fontanesii extracts have powerful anti-inflammatory, antipyretic, and analgesic effects against acute pain models. We profiled their chemical composition and found many phenolic acids, flavonoids, and phenolic diterpenes. In this work, we investigated their antioxidant properties on HaCaT cells exposed to UVA-induced oxidative stress and examined their effects against chronic neuropathic pain and the underlying mechanisms. Through a rat chronic constriction injury (CCI) model, we induced chronic neuropathic pain by placing 4 loose ligatures around the right sciatic nerve for 14 days. Thermal and mechanical hyperalgesia in addition to cold and dynamic allodynia were tested on the day before surgery and on the 7th and 14th post-surgery days. Key markers of the nitrosative and oxidative stresses, in addition to markers of inflammation, were measured at day 14 post surgery. Histopathological examination and immunostaining of both synaptophysin and caspase-3 of sciatic nerve and brain stem were also performed. Results of this study showed that T. algeriensis extract suppresses UVA oxidative stress in HaCaT cells via activation of the Nrf-2 pathway. Both extracts attenuated hyperalgesia and allodynia at 7- and 14-days post-surgery with more prominent effects at day 14 of surgery. Their protective effects against neuropathic pain were mediated by inhibiting NOX-1, iNOS, by increasing the enzyme activity of catalase, and inhibition of inflammatory mediators, NF-κB, TNF-α, lipoxygenase, COX-2 enzymes, and PGE2. Furthermore, they improved deleterious structural changes of the brainstem and sciatic nerve. They also attenuated the increased caspase-3 and synaptophysin. The data indicate that both extracts have neuroprotective effects against chronic constriction injury-induced neuropathic pain. The observed protective effects are partially mediated through attenuation of oxidative and nitrosative stress and suppression of both neuroinflammation and neuronal apoptosis, suggesting substantial activities of both extracts in amelioration of painful peripheral neuropathy.

Synthesis and evaluation of resveratrol derivatives as fetal hemoglobin inducers

Resveratrol (RVT) derivatives (10a-i) were designed, synthesized, and evaluated for their potential as gamma-globin inducers in treating Sickle Cell Disease (SCD) symptoms. All compounds were able to release NO at different levels ranging from 0 to 26.3%, while RVT did not demonstrate this effect. In vivo, the antinociceptive effect was characterized using an acetic acid-induced abdominal contortion model. All compounds exhibited different levels of protection, ranging from 5.9 to 37.3%; the compound 10a was the most potent among the series. At concentrations between 3.13 and 12.5 µM, the derivative 10a resulted in a reduction of 41.1-64.3% in the TNF-α levels in the supernatants of macrophages that were previously LPS-stimulated. This inhibitory effect was higher than that of RVT used as the control. In addition, the compound 10a and RVT induced double the production of the gamma-globin chains (γG + γA), compared to the vehicle, using CD34+ cells. Compound 10a also did not induce membrane perturbation and it was not mutagenic in the in vivo assay. Thus, compound 10a emerged as a new prototype of the gamma-globin-inducer group with additional analgesic and anti-inflammatory activities and proving to be a useful alternative to treat SCD symptoms.

Systematic review: medical therapy for fibrostenosing Crohn's disease

BACKGROUND

Medical therapy and/or endoscopic balloon dilation with intralesional therapies are options for the treatment of small bowel fibrostenotic Crohn's disease (CD).

AIM

To perform a systematic review summarising evidence for efficacy of systemic and endoscopic intralesional medical therapy in established small bowel strictures in adult CD patients.

METHODS

A systematic search of MEDLINE, EMBASE, CENTRAL and Scopus was conducted. Primary outcomes were rates of surgical resection and repeat endoscopic dilation. Pooled event rates from random effects models across studies with 95% confidence intervals were reported.

RESULTS

Ten studies describing systemic medical therapy and eight studies of intralesional injection were included. One randomised controlled trial each for systemic therapy and intrastricture injection were identified. Only observational studies were found for systemic biologic therapies, which exclusively included tumour necrosis factor (TNF) antagonists, while intralesional therapies all involved corticosteroids except for one study that evaluated infliximab. Pooled event rates for surgical resection after systemic and intralesional therapy were 28.3% (95% CI: 18.2%-41.3%) and 18.5% (95% CI: 8.3%-36.2%), respectively over a median follow-up of 23 months (range 5.5-105.8), and 21.8 months (range 5-47). Risk of repeat endoscopic balloon dilation in those with intralesional therapy was 58.3% (95% CI: 36.6%-77.3%) over a median follow-up of 21.8 months (range 5-47).

CONCLUSIONS

There are no favoured therapies for patients with stricturing small bowel CD. Data are lacking for ustekinumab and vedolizumab. No endoscopic intralesional medications provided a clear benefit for prevention of repeat EBD or surgery.

Comparative Effectiveness of Different Interventions of Perivascular Hyaluronidase

BACKGROUND

Soft-tissue necrosis caused by vascular compromise is a frequent and troublesome complication of hyaluronic acid filler injection. Hyaluronidase has been proposed as a treatment for this condition. This study aimed to determine the effective dose and administration interval of hyaluronidase injection in a skin necrosis animal model.

METHODS

New Zealand rabbits were used to simulate the hyaluronic acid-associated vascular occlusion model. Hyaluronic acid filler (0.1 ml) was injected into the central auricular artery to create an occlusion. Three rabbit auricular flaps were injected with 500 IU of hyaluronidase once (group A) and three flaps each were injected at 15-minute intervals with 250 IU of hyaluronidase twice (group B), 125 IU of hyaluronidase four times (group C), 100 IU of hyaluronidase five times (group D), and 75 IU of hyaluronidase seven times (group E), all at 24 hours after occlusion. No intervention was administered after occlusion in the control group. Flap fluorescence angiography was performed immediately after hyaluronidase injection and on postoperative days 2, 4, and 7. Flap necrotic areas were analyzed.

RESULTS

All control and experimental flaps demonstrated total occlusion after hyaluronic acid injection. The average total survival rate (positive area/total area ×100 percent) of control flaps was 37.61 percent. For experimental groups, the average total survival rates were 74.83 percent, 81.49 percent, 88.26 percent, 56.48 percent, and 60.69 percent in groups A through E, respectively.

CONCLUSION

A better prognosis can be obtained by administering repeated doses rather than a single high dose of hyaluronidase.

Elevated Neutrophil and Presence of Intracranial Artery Stenosis Increase the Risk of Recurrent Stroke

Background and Purpose- The association of neutrophil and intracranial artery stenosis (ICAS) with the prognosis of stroke is uncertain. This study evaluated the relationship between neutrophil levels with and without ICAS and the prognosis of patients with minor stroke or transient ischemic attack. Methods- Data from the CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events) was reviewed. Patients were divided into 4 groups according to the dichotomy of neutrophil counts and status of ICAS. The primary outcome was a new stroke (ischemic or hemorrhagic), and secondary outcomes included a new composite vascular event (stroke, myocardial infarction, or cardiovascular death) and ischemic stroke. Safety outcome was any hemorrhage at 90 days. The association between neutrophil counts with and without ICAS and risk of any outcome was analyzed by Cox regression models. Results- Of 1034 patients included in this subgroup analysis, 91 had recurrent strokes. Compared with the lower neutrophil levels without ICAS, higher neutrophil levels with ICAS significantly increased the risk of stroke recurrence (adjusted hazard ratio, 2.26; 95% CI, 1.19-4.31; P=0.01) and composite outcome (adjusted hazard ratio, 1.98; 95% CI, 1.06-3.67; P=0.03). However, there was no safety issue. Conclusions- Concomitant presence of higher neutrophil levels and ICAS was associated with the increased risk of stroke recurrence, and combined adverse outcome events in patients already had minor ischemic stroke or high-risk transient ischemic attack. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00979589.

Epigallocatechin-3 gallate prevents pressure overload-induced heart failure by up-regulating SERCA2a via histone acetylation modification in mice

Heart failure is a common, costly, and potentially fatal condition. The cardiac sarcoplasmic reticulum Ca-ATPase (SERCA2a) plays a critical role in the regulation of cardiac function. Previously, low SERCA2a expression was revealed in mice with heart failure. Epigallocatechin-3-gallate (EGCG) can function as an epigenetic regulator and has been reported to enhance cardiac function. However, the underlying epigenetic regulatory mechanism is still unclear. In this study, we investigated whether EGCG can up-regulate SERCA2a via histone acetylation and play role in preventing heart failure. For this, we generated a mouse model of heart failure by performing a minimally invasive transverse aortic constriction (TAC) operation and used this to test the effects of EGCG. The TAC+EGCG group showed nearly normal cardiac function compared to that in the SHAM group. The expression of SERCA2a was decreased at both the mRNA and protein levels in the TAC group but was enhanced in the TAC+EGCG group. Levels of AcH3 and AcH3K9 were determined to decrease near the promoter region of Atp2a2 (the gene encoding SERCA-2a) in the TAC group, but were elevated in the TAC+EGCG group. Meanwhile, HDAC1 activity and binding near the Atp2a2 promoter were increased in the TAC group but decreased with EGCG addition. Further, binding levels of GATA4 and Mef2c near the Atp2a2 promoter region were reduced in TAC hearts, which might have been caused by histone hypoacetylation; this was reversed by EGCG. Together, upregulation of SERCA2a via the modification of histone acetylation plays a role in EGCG-mediated prevention of pressure overload-induced heart failure, and this might represent a novel pharmacological target for the treatment of heart failure.

Drug Coated Balloon Angioplasty in Failing AV Fistulas: A Randomized Controlled Trial

BACKGROUND

Restenosis remains a problem in hemodialysis access interventions. Paclitaxel-coated balloons have shown promise in reducing access-related restenosis in small trials. The primary hypotheses for our multicenter trial were superior effectiveness at 180 days and noninferior safety at 30 days of a drug-coated balloon compared with conventional angioplasty for treatment of dysfunctional arteriovenous fistulas.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This randomized trial enrolled 285 patients with dysfunctional arteriovenous fistulas at 23 centers. Grafts, central venous stenoses, thrombosed fistulas, and immature fistulas were excluded. All patients received angioplasty of the lesion responsible for access dysfunction. After successful angioplasty (≤30% residual stenosis), lesions were treated with either a paclitaxel-coated balloon or an uncoated control balloon of similar design to the drug-coated balloon. Access function during follow-up was determined per centers' usual protocols; reintervention was clinically driven. The primary efficacy outcome assessment was done at 6 months, and the safety assessment was done within 30 days of the procedure. Prespecified secondary end points included assessment of postintervention target lesion primary patency and access circuit primary patency at 6 months.

RESULTS

The 180-day end point was not met with target lesion primary patency (71%±4% for the drug-coated balloon and 63%±4% for control; P=0.06), representing a difference of 8%±6% (95% confidence interval, -3% to 20%). Access circuit primary patency did not differ between groups. Interventions to maintain target lesion patency were fewer for the drug-coated balloon at 6 months (0.31 versus 0.44 per patient; P=0.03). The primary safety noninferiority end point was met and did not differ between groups (P=0.002).

CONCLUSIONS

Paclitaxel-coated balloon-assisted angioplasty did not meet the primary effectiveness end point at 180 days compared with conventional angioplasty. Both arms showed equivalent safety (ClinicalTrials.gov number NCT02440022).

Bronchoscopic local steroid spray to prevent bronchial tuberculosis-induced cicatricial bronchial stenosis: A case series

RATONALE

Cicatricial bronchial stenosis or obstruction occurring in the healing process of endobronchial tuberculosis (ET) is a problematic complication of tuberculous airway lesions. Prevention by internal medical treatment is desired.

PATIENT CONCERNS

This case series describes four patients who diagnosed ET with Type IIIb (protruding ulcer-type) based on Arai's classification of bronchoscopic findings of bronchial tuberculosis.

DIAGNOSES

Endobronchial tuberculosis.

INTERVENTIONS

A local steroid spray was applied bronchoscopically to active protruding ulcer-type lesions (which are likely to cause cicatricial stenosis) that extended in the transverse direction and occupied one-half or more of the circumference on bronchoscopy.

OUTCOMES

Cicatricial stenosis was prevented in two of four patients. Treatment was discontinued in athird patient because tolerance could not be achieved, although the patient's condition had improved. In the fourth patient, treatment was switched to systemic steroid administration because of a problem with tolerance and the broad range of the lesion; however, stenosis remained.

LESSONS

Local steroid spray-applied bronchoscopically to bronchial tuberculosis lesions in the ulcer formation and granulation periods may help prevent stenosis.

Drug effect of atorvastatin on middle cerebral atherosclerotic stenosis and high resolution NMR diagnosis

Atherosclerosis (AS) is a chronic inflammatory reaction with the pathological changes in the lipid deposition of arterial intima. The disorder of blood lipid metabolism is the main factor of the occurrence and development of AS, and the inflammatory reaction and autoimmune reaction also run through the development of AS. In this study, we compared the efficacy and safety of atorvastatin, simvastatin, pravastatin and rosuvastatin in the treatment of AS. At the same time, we used high resolution magnetic resonance imaging (MRI) to assess the changes in plaque area in the middle cerebral artery and the patch area before and after drug treatment. After 6 months of treatment, the number of intima-media thickness (IMT), plaque and plaque in each group were significantly lower than that before the same group. The results showed that statin treatment of AS could significantly reduce the level of blood lipids, but rosuvastatin and atorvastatin had better effects on anti inflammation and maintaining plaque stability and the drug safety was good.

Haloperidol Decreases Hyperalgesia and Allodynia Induced by Chronic Constriction Injury

Neuropathic pain has proven to be a difficult condition to treat, so investigational therapy has been sought that may prove useful, such as the use of sigma-1 antagonists. Haloperidol (HAL) is a compound that shows a high affinity with these receptors, acting as an antagonist. Therefore, the objective of this study was to demonstrate its effect in an experimental model of neuropathic pain and corroborate its antagonistic action of the sigma-1 receptors under these conditions. BD-1063 was used as a sigma-1 antagonist control, and gabapentin (Gbp) was used as a positive control. The antihyperalgesic and anti-allodynic effects of the drugs were determined after single-dose trials. In every case, the effects increased in a dose-dependent manner. HAL had the same efficacy as both BD-1063 and Gbp. In the analysis of pharmacological potency, in which the ED50 were compared, HAL was the most potent drug of all. The effect of HAL on chronic constriction injury (CCI) rats was reversed by the sigma-1 agonist (PRE-084). HAL reversed the hyperalgesic and allodynic effects of PRE-084 in naïve rats. The dopamine antagonist, (-)-sulpiride, showed no effect in CCl rats. These results suggest that HAL presents an antinociceptive effect via sigma-1 receptor antagonism at the spinal level in the CCl model.

Antihypertensive treatments for spontaneous intracerebral hemorrhage in patients with cerebrovascular stenosis: A randomized clinical trial (ATICHST)

INTRODUCTION

Antihypertensive treatment is associated with clinical outcomes in patients with spontaneous intracerebral hemorrhage (sICH). ADAPT showed that intensive blood pressure lowering (<140 mm Hg) does not reduce peri-hematoma regional cerebral blood flow (rCBF) in patients with sICH. However, the stenosis of main cerebral arteries that has a high presence in patients with sICH is well-known related to the brain ischemia. The effect of intensive BP lowering for sICH in patients with cerebrovascular stenosis is still unknown.

AIM

The aim of this study was to determine the safety and effectiveness of intensive BP lowering for sICH in patients with cerebrovascular stenosis.

METHODS AND ANALYSIS

A pilot trial has been conducted to calculate the sample size and 80 patients of sICH with cerebrovascular stenosis will be involved. The target of systolic blood pressure (SBP) will be maintained at from 120 to 140 mm Hg or from 140 to 180 mm Hg for 7 days. Cerebral ischemia will be assessed at 24 hours after onset by computed tomography (CT) perfusion imaging and the follow-up will be conducted at 30-day and 90-day. The primary outcome is the reduction of peri-hematoma rCBF. The other cerebral perfusion indexes and the rate of ischemic stroke are regarded as other primary outcomes. The secondary outcomes include clinical outcome at 30 days and 90 days, complications, and hospital stays.

DISCUSSION

The ATICHST trial has been signed as a parallel, prospective, randomized, assessor-blinded clinical trial to determine the effects of intensive BP lowering on sICH in patients with cerebrovascular stenosis, the results of which will contribute to guide the management of blood pressure in sICH.

CONCLUSION

The protocol will determine the safety and effectiveness of intensive BP lowering for sICH with cerebrovascular stenosis.

Idiopathic intracranial hypertension in a paediatric population: a retrospective observational study on epidemiology, symptoms and treatment

Idiopathic intracranial hypertension (IIH) is a disorder of unknown origin, which is characterized by elevated intracranial pressure (ICP) without underlying etiological evidence of neurological disease. The purpose of the current study was to evaluate epidemiological features, clinical presentation, diagnostic findings and treatment of sixteen children (7 males and 9 females) with IIH. Medical records of the patients were obtained from the University Paediatric Hospital of Catania, Italy. Clinical features, investigations and treatment approaches were retrieved. The mean age of the sixteen children at onset of symptoms was 9 years (range: 4 to 16 years). Most of the patients were classified as pre-pubertal. Mean BMI was 28.9 kg/m2. In 93.75% of patients headache was the presenting clinical symptom; and in the same percentage papilledema was detected as the accompanied sign during diagnostic flow-chart. The mean lumbar puncture opening pressure (LPOP) was 350 mm H2O. Fifty percent of the cases had normal brain imaging, while 12.5% showed enlarged optic nerve diameter and one patient had an intraocular protrusion of the optic nerve on MRI. Two patients (12.5%) had venous sinus stenosis, and one case showed an abnormal spinal MRI. With regard to therapeutic approaches, 93.75% of the cases were successfully treated with Acetazolamide. None of the patients required surgical procedures, and all neuroimaging findings disappeared after receiving treatment. In the present study we investigated the association of IIH with venous sinus stenosis. We also found ocular ultrasound to be a useful non-invasive alternative method for determining papilledema in paediatric IIH, specifically in an emergency.

Eosinophilic cholecystitis with common bile duct stricture: a rare disease

Although the most common cause of cholecystitis is gallstones, other conditions may present as acute cholecystitis. We describe a case of eosinophilic cholecystitis with common bile duct stricture. A 36-year-old woman initially had generalised abdominal pain and peripheral eosinophilia. Diagnostic laparoscopy showed eosinophilic ascites and necrotic nodules on the posterior abdominal wall. She was treated with anthelminthics on presumption of toxacara infection based on borderline positivity of serological tests. She later presented with acute cholecystitis and had a cholecystectomy and choledocotomy. Day 9 T-tube cholangiogram showed irregular narrowing of the distal common bile duct. The patient's symptoms were improved with steroids and the T-tube was subsequently removed.

The Role of Selective Nerve Root Block in the Treatment of Lumbar Radicular Leg Pain

The objective of this retrospective study was to investigate the clinical effectiveness of nerve root blocks (i.e., periradicular injection of Lidocaine and triamcinolone) for lumbar monoradiculopathy in patients with a mild neurological deficit in National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh from March 2014 to December 2014. We Included 24 patients (32-74 years) with a minor sensory/motor deficit and an unequivocal MRI finding (18 disc herniations, 6 foraminal stenosis) treated with a selective nerve root block. Based on the clinical and imaging findings, surgery (decompression of the nerve root) was justifiable in all cases. Seventeen patients (87%) had rapid (1-4 days) and substantial regression of pain, four required a repeat injection. Sixty percent (60%) of the patients with disc herniation or foraminal stenosis had permanent resolution of pain, so that an operation was avoided over an average of 6 months (2-9 months) follow-up. Nerve root blocks are very effective in the non-operative treatment of minor monoradiculopathy and should be recommended as the initial treatment of choice for this condition.

Co-Administration of Pioglitazone Improves Fluoxetine's Antinociceptive, Neuroprotective, and Antidepressant Effects in Chronic Constriction Injury in Rats

BACKGROUND

Chronic pain may be associated with diabetes mellitus and/or depression. Use of therapies that target both comorbidities is encouraged.

OBJECTIVE

This study was designed to investigate the potential antinociceptive, neuroprotective, and antidepressant effects of combinations of pioglitazone or metformin with fluoxetine in chronic constriction injury (CCI) in rats.

STUDY DESIGN

Experimental trial in rats.

SETTING

University lab in in Saudi Arabia.

METHODS

Two sets of experiments were performed. In each one, 9 groups of rats (n = 8) were used: sham, CCI, and 7 CCI-treated groups. Treatments were given orally starting on day 7 post-surgery as follows (mg/kg/day): fluoxetine (10, 20, and 40), pioglitazone (20), metformin (50), fluoxetine (20) +' pioglitazone, and fluoxetine (20) +' metformin. In the first set, on day 14 post-surgery mechanical allodynia, thermal hyperalgesia, and serum cytokines were measured. Moreover, immunoreactivity of glial fibrillary acidic protein (GFAP, a marker for astrocytic activation) in the spinal cord was assessed and histopathological changes in the ipsilateral sciatic nerve were examined. In the second set, on days 14 and 21 post-surgery the forced swimming test was done.

RESULTS

In the first set, all treatments significantly decreased mechanical allodynia while all treatments except F10 and F20 significantly decreased thermal hyperalgesia compared to the CCI group. The F20+'M group showed the highest decreases, however still significantly lower than those of the sham group. The treatments didn't impair motor function in the rotarod test. All treatments significantly decreased serum levels of tumor necrosis factor- α, interleukin-6, and monocyte chemoattractant protein-1 while increasing the level of interleukin-10. The CCI-induced marked increase of GFAP immunoexpression has been reduced to moderate with fluoxetine (40) and pioglitazone, and to mild with metformin and the combination groups. The CCI-induced changes in sciatic nerve were less in fluoxetine (40), pioglitazone, and metformin groups, and least in the combination groups. In the second set, the immobility duration was significantly reduced by F20, F40, P, F20+'P, and F20+'M compared to the CCI group. The F20+'P group showed the highest decrease, however still significantly lower than that of the sham group. The treatments didn't affect locomotor activity in the open field test.

LIMITATIONS

Measuring the cytokines levels only in blood and not in the spinal cord and sciatic nerve and measuring the outcome measures in the first set of experiments at only one time-point.

CONCLUSIONS

Co-administration of pioglitazone or metformin with low-dose fluoxetine improved mechanical allodynia, thermal hyperalgesia, and neurohistopathological changes while co-administration of pioglitazone, but not metformin, improved the depressive-like behavior in the peripheral nerve injury model of neuropathic pain in rats. Extrapolation of the current results to clinical reality could be beneficial for pain patients with diabetes and/or depression, however this needs further confirmatory studies.

Safety of laronidase delivered into the spinal canal for treatment of cervical stenosis in mucopolysaccharidosis I

Enzyme replacement therapy with laronidase (recombinant human alpha-l-iduronidase) is successfully used to treat patients with mucopolysaccharidosis type I (MPS I). However, the intravenously-administered enzyme is not expected to treat or prevent neurological deterioration. As MPS I patients suffer from spinal cord compression due in part to thickened spinal meninges, we undertook a phase I clinical trial of lumbar intrathecal laronidase in MPS I subjects age 8 years and older with symptomatic (primarily cervical) spinal cord compression. The study faced significant challenges, including a heterogeneous patient population, difficulty recruiting subjects despite an international collaborative effort, and an inability to include a placebo-controlled design due to ethical concerns. Nine serious adverse events occurred in the subjects. All subjects reported improvement in symptomatology and showed improved neurological examinations, but objective outcome measures did not demonstrate change. Despite limitations, we demonstrated the safety of this approach to treating neurological disease due to MPS I.

[Advances in studies on pharmacological action of main chemical constituent of Curcuma Zedoary in preventing in-stent restenosis]

Traditional Chinese medicine Curcuma Zedoary ( E'Zhu) contains essential oil, curcuminoid and other effective constituents, with such pharmacological actions as anti-platelet aggregation, lowing blood lipid, anti-oxidation and anti-inflammation. In recent years, studies have showed that certain extracts and chemical components of E'Zhu could mitigate myocardial cell mitochondria injury and protect vascular endothelium by enhancing heme oxygenase-1 activity, inhibit nuclear factor NF-kappaB, target genes interleukin-associated kinase-1 (IRAK-1), tumor necrosis factor receptor-6 (TRAF-6) and vascular cell adhesion molecule-1 (VCAM-1), reduce inflammatory infiltration, and inhibit growth factor-induced smooth muscle cells (SMCs) proliferation and migration by impacting oxidation of cellular phosphatases. Due to its different functions in vascular endothelial cells and smooth muscle cells, E'Zhu has been applied in drug-eluting stents, with a potential effect in preventing in-stent restenosis and thrombogenesis. In this paper, studies on pharmacological effects and mechanisms of extracts and main chemical constituents from E'Zhu in preventing vascular restenosis were summarized.

[Mitomycin in the complex treatment of strictures of vesicourethral anastomosis after radical prostatectomy]

The study involved 189 patients aged 40 to 80 years, which underwent retropubic radical prostatectomy for localized prostate cancer in the period from 2009 to 2013. 26 (13.8%) patients required repeated surgery due to the deterioration of urination. In primary detection or recurrent nature of the cicatrical process in vesico-urethral anastomosis, in places of dissection by urethrotomic knife (or transurethral resection), surgery was complemented by submucosal injection of mitomycin, previously diluted in saline to a concentration of not more than 0.2 mg/ml. Effectiveness of additional interstitial administration of mitomycin in primary application was 85%. Systemic infusion reactions have not been reported, that allows to consider this method as safe method for prevention of cicatricial complications.

Safety of low-dose aspirin in endovascular treatment for intracranial atherosclerotic stenosis

Objectives

To evaluate the safety of low-dose aspirin plus clopidogrel versus high-dose aspirin plus clopidogrel in prevention of vascular risk within 90 days of duration of dual antiplatelet therapy in patients treated with intracranial endovascular treatment.

Methods

From January 2012 to December 2013, this prospective and observational study enrolled 370 patients with symptomatic intracranial atherosclerotic stenosis of ≥70% with poor collateral undergoing intracranial endovascular treatment. Antiplatelet therapy consists of aspirin, at a low-dose of 100 mg or high-dose of 300 mg daily; clopidogrel, at a dose of 75 mg daily for 5 days before endovascular treatment. The dual antiplatelet therapy continued for 90 days after intervention. The study endpoints include acute thrombosis, subacute thrombosis, stroke or death within 90 days after intervention.

Results

Two hundred and seventy three patients received low-dose aspirin plus clopidogrel and 97 patients received high-dose aspirin plus clopidogrel before intracranial endovascular treatment. Within 90 days after intervention, there were 4 patients (1.5%) with acute thrombosis, 5 patients (1.8%) with subacute thrombosis, 17 patients (6.2%) with stroke, and 2 death (0.7%) in low-dose aspirin group, compared with no patient (0%) with acute thrombosis, 2 patient (2.1%) with subacute thrombosis, 6 patients (6.2%) with stroke, and 2 death (2.1%) in high-dose aspirin group, and there were no significant difference in all study endpoints between two groups.

Conclusion

Low-dose aspirin plus clopidogrel is comparative in safety with high-dose aspirin plus clopidogrel within 90 days of duration of dual antiplatelet therapy in patients treated with intracranial endovascular treatment.

Inhibition of vein graft stenosis with a c-jun targeting DNAzyme in a cationic liposomal formulation containing 1,2-dioleoyl-3-trimethylammonium propane (DOTAP)/1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE)

BACKGROUND/OBJECTIVES

Coronary artery bypass grafting (CABG) is among the most commonly performed heart surgical procedures. Saphenous vein graft failure due to stenosis impedes the longer-term success of CABG. A key cellular event in the process of vein graft stenosis is smooth muscle cell hyperplasia. In this study, we evaluated the effect of a DNAzyme (Dz13) targeting the transcription factor c-Jun in a rabbit model of vein graft stenosis in a cationic liposomal formulation containing 1,2-dioleoyl-3-trimethylammonium propane (DOTAP)/1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE). Dz13 in DOTAP/DOPE has undergone preclinical toxicological testing, and a Phase I clinical trial we recently conducted in basal cell carcinoma cancer patients demonstrates that it is safe and well tolerated after local administration.

METHODS

Effects of Dz13 in a formulation containing DOTAP/DOPE on smooth muscle cell (SMC) growth and c-Jun expression were assessed. Dz13 transfection was determined by cellular uptake of carboxyfluorescein-labeled Dz13. Autologous jugular vein to carotid artery transplantation was performed in New Zealand White rabbits to investigate the effect of the Dz13 in DOTAP/DOPE formulation on intimal hyperplasia.

RESULTS

Dz13/DOTAP/DOPE reduced SMC proliferation and c-Jun protein expression in vitro compared with an impotent form of Dz13 bearing a point mutation in its catalytic domain (Dz13.G>C). The Dz13(500 μg)/DOTAP/DOPE formed lipoplexes that were colloidally stable for up to 1h on ice (0°C) and 30 min at 37°C, allowing sufficient uptake by the veins. Dz13 (500 μg) inhibited neointima formation 28 d after end-to-side transplantation.

CONCLUSIONS

This formulation applied to veins prior to transplantation may potentially be useful in efforts to reduce graft failure.

Spinal involvement in mucopolysaccharidosis IVA (Morquio-Brailsford or Morquio A syndrome): presentation, diagnosis and management

Mucopolysaccharidosis IVA (MPS IVA), also known as Morquio-Brailsford or Morquio A syndrome, is a lysosomal storage disorder caused by a deficiency of the enzyme N-acetyl-galactosamine-6-sulphate sulphatase (GALNS). MPS IVA is multisystemic but manifests primarily as a progressive skeletal dysplasia. Spinal involvement is a major cause of morbidity and mortality in MPS IVA. Early diagnosis and timely treatment of problems involving the spine are critical in preventing or arresting neurological deterioration and loss of function. This review details the spinal manifestations of MPS IVA and describes the tools used to diagnose and monitor spinal involvement. The relative utility of radiography, computed tomography (CT) and magnetic resonance imaging (MRI) for the evaluation of cervical spine instability, stenosis, and cord compression is discussed. Surgical interventions, anaesthetic considerations, and the use of neurophysiological monitoring during procedures performed under general anaesthesia are reviewed. Recommendations for regular radiological imaging and neurologic assessments are presented, and the need for a more standardized approach for evaluating and managing spinal involvement in MPS IVA is addressed.

Assessment of effectiveness of percutaneous adhesiolysis in managing chronic low back pain secondary to lumbar central spinal canal stenosis

BACKGROUND

Chronic persistent low back and lower extremity pain secondary to central spinal stenosis is common and disabling. Lumbar surgical interventions with decompression or fusion are most commonly performed to manage severe spinal stenosis. However, epidural injections are also frequently performed in managing central spinal stenosis. After failure of epidural steroid injections, the next sequential step is percutaneous adhesiolysis and hypertonic saline neurolysis with a targeted delivery. The literature on the effectiveness of percutaneous adhesiolysis in managing central spinal stenosis after failure of epidural injections has not been widely studied.

STUDY DESIGN

A prospective evaluation.

SETTING

An interventional pain management practice, a specialty referral center, a private practice setting in the United States.

OBJECTIVE

To evaluate the effectiveness of percutaneous epidural adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis.

METHODS

Seventy patients were recruited. The initial phase of the study was randomized, double-blind with a comparison of percutaneous adhesiolysis with caudal epidural injections. The 25 patients from the adhesiolysis group continued with follow-up, along with 45 additional patients, leading to a total of 70 patients. All patients received percutaneous adhesiolysis and appropriate placement of the Racz catheter, followed by an injection of 5 mL of 2% preservative-free lidocaine with subsequent monitoring in the recovery room. In the recovery room, each patient also received 6 mL of 10% hypertonic sodium chloride solution, and 6 mg of non-particulate betamethasone, followed by an injection of 1 mL of sodium chloride solution and removal of the catheter.

OUTCOMES ASSESSMENT

Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12, 18 and 24 months post treatment. The primary outcome measure was 50% or more improvement in pain scores and ODI scores.

RESULTS

Overall, a primary outcome or significant pain relief and functional status improvement of 50% or more was seen in 71% of patients at the end of 2 years. The overall number of procedures over a period of 2 years were 5.7 ± 2.73.

LIMITATIONS

The lack of a control group and a prospective design.

CONCLUSIONS

Significant relief and functional status improvement as seen in 71% of the 70 patients with percutaneous adhesiolysis utilizing local anesthetic steroids and hypertonic sodium chloride solution may be an effective management strategy in patients with chronic function limiting low back and lower extremity pain with central spinal stenosis after failure of conservatie management and fluoroscopically directed epidural injections.

[Expression of inducible nitric oxide synthase in restenosis rats and function of Astragalus membranaceus and Angelica sinensis]

OBJECTIVE

To explore the expression of inducible nitric oxide synthase (iNOS) in restenosis rats and function of Astragalus membranaceus and Angelica sinensis.

METHOD

The restenosis model was established by denuding aorta endothelium, rats were randomly divided into control group, model group, A. membranaceus treatment group, A. sinensis treatment group, combined A. membranaceus with A. sinensis treatment group. After intramuscular injection of drugs for 21 dayss, the changes of iNOS in restenosis rats were observed by histomorphology and immunohistochemisty, the effects of A. membranaceus and A. sinensis on iNOS in restenosis rats was also investigated.

RESULT

A small quantity of iNOS were detected in the intima and media of normal aorta, the expression of iNOS was increased on 3 day after denuding aorta endothelium, the expression of iNOS increasd and the color darken along with injury damage and intima thickening. Compared with model group, the expression of iNOS decreasd in A. membranaceus, A. sinensis treated group, A. membranaceus and A. sinensis treated group changed more significantly.

CONCLUSION

iNOS was involved in blood vessel restenosis by denuding aorta endothelium, A. membranaceus, A. sinensis could inhibit intimal proliferation through iNOS.

Effect of a dihydropyridine-type calcium channel blocker on vascular remodeling after experimental balloon angioplasty

OBJECTIVE

Aim of the study was to evaluate the influence of the dihydropyridine derivative BW 9798 on intimal hyperplasia in a carotid artery injury model of New Zealand White rabbits on a high cholesterol diet.

METHODS

In carotid arteries of 50 New Zealand White rabbits atherosclerotic lesions were induced by cholesterol diet and electrostimulation of the artery. In 40 animals the resulting primary lesion was subjected to balloon angioplasty (BA). Three days prior to BA animals received BW 9798 or placebo per os until sacrifice three days or 28 days after BA.

RESULTS

BW 9798 lead to increased cross sectional area by 128.3% and an increased luminal area by 157% after 28 days after BA compared with placebo. However the degree of stenosis did not significantly decrease. The cell count of the different layers of the arteries decreased by 64.5% in the intima and by 62.6% compared with placebo treated animals after BA. Additionally the number of smooth muscle cell (SMC) layers in the neointima was significantly lower in BW 9798 treated animals than in placebo animals (8±3 vs 14±9, p<0.05) although the proliferation was not changed by BW 9798 treatment 3 days after BA.

CONCLUSION

BW 9798 leads to significant changes in vessel wall geometry although the influence on vascular remodeling of this compound is unclear. It can be speculated that the compound affects the homeostasis of extracellular matrix, invasion of inflammatory cells into the vessel wall and the expression of cytokines. However, further investigation needs to clarify the role of BW 9798 on remodelling after BA.

Anti-inflammatory and antinociceptive properties of blueberry extract (Vaccinium corymbosum)

Blueberries are among the edible fruits that are recognized best for their potential health benefits. The crude extract from Vaccinium corymbosum was assessed in anti-inflammatory and antinociceptive models. The crude hydroalcoholic extract was administered orally at doses of 100, 200 or 300 mg kg−1 for all the assays. In the carrageenan test, the crude extract reduced rat paw oedema by 9.8, 28.5 and 65.9%, respectively. For the histamine assay, the reductions of oedema were 70.1, 71.7 and 81.9%, respectively. In the myeloperoxidase (MPO) assay, 300 mg kg−1 crude extract produced a significant inhibition of the MPO activity, at 6 h and 24 h after injection of carrageenan, by 42.8 and 46.2%, respectively. With the granulomatous tissue assay dexamethasone displayed significant activity, whereas the blueberry extract was inactive. For the abdominal constriction test, inhibitions of 49.0, 54.5, 53.5%, respectively, were observed for the crude extract, and 61.4% for indometacin. In the formalin test, the crude extract (200 and 300 mg kg−1) and indometacin inhibited only the second phase by 36.2, 35.3 and 45.8%, respectively. Considering that the crude extract of blueberry displayed antinociceptive and anti-inflammatory activity, its consumption may be helpful for the treatment of inflammatory disorders.

Topical mitomycin-C for the treatment of anal stricture

BACKGROUND

Anal stricture is a well-known and feared consequence of anorectal surgery. Daily dilatations are often prescribed in the immediate postoperative period to avoid stricture of the anus. Nonetheless, stricture may still occur and, particularly in older children, may require multiple dilatations under anesthesia. Topical mitomycin-C has been found to be effective in the treatment of strictures at various anatomical locations. In this article, we review our experience with topical mitomycin-C as an adjunct to anal dilatation for children with anal stricture.

MATERIALS AND METHODS

Cases of children with anal stricture who were treated with a single application of topical mitomycin-C as an adjunct to anal dilatation between 2000 and 2008 were analyzed retrospectively. Anal diameter was measured with Hegar dilators. Cottonoid swabs soaked in mitomycin-C were placed on the anal mucosa for 5 minutes after dilatation. Treatment success was defined by sustained improvement in anal size, decrease in symptoms, parental satisfaction, and need for additional intervention.

RESULTS

Ten children with anal stricture who underwent anal dilatation with application of topical mitomycin-C were identified. All children presented with severe constipation. Average increase in anal size after dilatation under sedation was 5.7 mm (+/-3.2 mm). Average improvement in anal diameter on first clinic visit after mitomycin-C application was 3.7 mm. On follow-up, only 1 child required repeated intervention for stricture after treatment with mitomycin-C. No complications were associated with the use of mitomycin-C.

CONCLUSIONS

All children treated with mitomycin-C showed early improvement in their anal size after dilatation under sedation. A single application of topical mitomycin-C allowed them to retain an increased anal diameter over time and avoid additional dilatations. Furthermore, the application of mitomycin-C in our population was straightforward and safe. Therefore, we advocate its use as an adjunct to anal dilatation under sedation in the treatment of severe anal stricture.

Effects of vardenafil, a phosphodiesterase type-5 inhibitor, on sphincter of Oddi motility in patients with suspected biliary sphincter of Oddi dysfunction

BACKGROUND

The therapeutic approach in patients with sphincter of Oddi (SO) dysfunction (SOD) aims to reduce the resistance to the flow of bile or pancreatic juice. Vardenafil inhibits the activity of phosphodiesterase type 5 (PDE-5), which degrades cyclic guanossine monophosphate (cGMP) and results in relaxation of smooth muscle.

OBJECTIVE

The present study was performed to determine the effects of vardenafil on SO motility in patients with suspected SOD.

DESIGN

Prospective study.

SETTINGS

Single university center.

PATIENTS AND INTERVENTIONS

Twenty consecutive adult patients with suspected SOD were scheduled to undergo ERCP and SO manometry by standard methods. A second recording was performed in the same position 20 minutes after administration of 10 mg vardenafil dissolved in 10 mL saline solution into the duodenum through a conventional catheter. SO pressures and motor function were compared in all patients with suspected SOD before and after administration of vardenafil.

RESULTS

After administration of 10 mg of vardenafil, the mean basal sphincter pressure was reduced from 59.5 to 26.9 mm Hg (P < .001), and the mean phasic amplitude was reduced from 132.2 to 66.2 mm Hg (P < .001). The mean phasic wave frequency was not changed after administration of vardenafil (7.2/min vs 6.6/min, respectively, P = .07). These results did not differ between SOD types. No significant difference in manometric data were detected before and after administration of vardenafil between cholecystectomy and gallbladder in situ groups. Transient headache was observed in 1 patient, and the procedure-related complication was post-ERCP pancreatitis (n = 2 [10%]).

LIMITATIONS

The small sample size and uncontrolled study.

CONCLUSION

Vardenafil inhibits SO motility in patients with suspected SOD and reduces basal SO pressure, without significant adverse effects.

Combination formoterol and inhaled steroid versus beta2-agonist as relief medication for chronic asthma in adults and children

BACKGROUND

Formoterol has a fast onset of action and can therefore be used to relieve symptoms of asthma. A combination inhaler can deliver formoterol with different doses of inhaled corticosteroid; when used as a reliever both drugs will be delivered more frequently when asthma symptoms increase. This has the potential to treat both bronchoconstriction and inflammation in the early stages of exacerbations.

OBJECTIVES

To assess the efficacy and safety of combined inhalers containing both formoterol and an inhaled corticosteroid when used for reliever therapy in adults and children with chronic asthma.

SEARCH STRATEGY

We last searched the Cochrane Airways Group trials register in April 2008.

SELECTION CRITERIA

Randomised trials in adults and children with chronic asthma, where a combination inhaler containing formoterol and inhaled corticosteroid is compared with fast-acting beta2-agonist alone for the relief of asthma symptoms. This should be the only planned difference between the trial arms.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the characteristics and results of each study. Authors or manufacturers were asked to supply unpublished data in relation to primary outcomes.

MAIN RESULTS

Three trials involving 5905 participants were included. In patients with mild asthma who do not need maintenance treatment, no clinically important advantages of budesonide/formoterol as reliever were found in comparison to formoterol as reliever.Two studies enrolled patients with more severe asthma who were not controlled on high doses of inhaled corticosteroids (around 700 mcg/day in adults), and had suffered a clinically important asthma exacerbation in the past year. Hospitalisations related to asthma in the two studies comparing budesonide/formoterol for maintenance and relief with the same dose of budesonide/formoterol for maintenance with terbutaline for relief yielded an odds ratio of 0.68 (95% CI 0.40 to 1.16), which was not a statistically significant reduction. One adult study found a reduction in exacerbations requiring oral corticosteroids compared to terbutaline, odds ratio 0.56 (95% CI 0.42 to 0.74) and the study in children found less serious adverse events with budesonide/formoterol used for maintenance and relief. There was no significant difference in annual growth in children using budesonide/formoterol reliever in comparison to terbutaline.

AUTHORS' CONCLUSIONS

In mild asthma it is not yet known whether patients who use a budesonide/formoterol inhaler for relief of asthma symptoms derive any clinically important benefits. In more severe asthma, one study that enrolled patients who were not controlled on quite high doses of inhaled corticosteroids, and had suffered an exacerbation in the previous year, demonstrated a reduction in the risk of exacerbations that require oral corticosteroids with budesonide/formoterol for maintenance and relief in comparison with budesonide/formoterol for maintenance and terbutaline or formoterol for relief. The incidence of serious adverse events in children was also less using budesonide/formoterol for maintenance and relief in one study, which similarly enrolled children who were not controlled on medium to high doses of inhaled corticosteroids, and compared to terbutaline relief with an explorative maintenance dose of budesonide/formoterol that is not approved for treatment.