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Background and Aim: Obstructive jaundice caused by distal biliary obstruction can present in up to 70 % of patients with localized cancer of the head of the pancreas. The aim of this study was to report our experience in using self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline resectable carcinoma of the pancreatic head. Methods: We performed a retrospective study evaluating patients from two tertiary referral centers. Two-hundred and forty-one patients with resectable and borderline resectable pancreatic carcinoma underwent ERCP with metal biliary stent placement between September 2006 and August 2011. We assessed the effectiveness of SEMS to adequately decompress the biliary tree, procedural success, patient survival, stent patency, and stent-related complications. Results: Two-hundred and forty-one patients were evaluated [123 male, mean age (±SD) 67.4 ± 9.8 years; resectable 174, borderline resectable 67]. Patients with borderline-resectable cancer underwent neoadjuvant therapy and restaging before possible curative surgery. Successful placement of a metal biliary stent was achieved in all patients and improved jaundice. Patients were followed for mean duration of 6.3 months. The overall survival was 49 % at 27 months. Fourteen (5.8 %) patients experienced stent occlusion; the mean time to stent occlusion was 6.6 (range 1-20) months. Immediate complications included: post-ERCP pancreatitis ( n = 14), stent migration ( n = 3), and duodenal perforation ( n = 3). Long-term complications included stent migration ( n = 9) and hepatic abscess ( n = 1). A total of 144/174 patients deemed to have resectable cancer at time of diagnosis underwent curative surgery. Due to disease progression or the discovery of metastasis after neoadjuvant therapy, only 22/67 patients with borderline-resectable cancer underwent curative surgery. Conclusions: SEMS should be considered for patients with obstructive jaundice and resectable or borderline resectable pancreatic cancer, especially if surgery is not planned immediately as a result of preoperative chemoradiation. These stents appear to be safe and effective. [ABSTRACT FROM AUTHOR]

The article discusses a study to evaluate the efficacy of nurse-assisted propofol sedation (NAPS) in patients with amyotrophic lateral sclerosis (ALS) undergoing percutaneous endoscopic gastrostomy (PEG). The study concluded that PEG placement can be safely performed in patients with ALS using NAPS with bilevel positive airway pressure (BiPAP). The use of NAPS was also found to result in fewer desaturation events as compared with standard conscious sedation.

Background: Most patients with locally advanced esophageal cancer requiring neoadjuvant therapy have significant dysphagia. Objective: To report our experience in using a fully covered self-expandable metal stent (FCSEMS) to treat malignant dysphagia and for maintenance of nutritional support during neoadjuvant therapy. Design: Retrospective study. Setting: Two tertiary-care referral centers. Patients: This study involved 55 patients with locally advanced esophageal cancer (50 adenocarcinoma, 5 squamous cell carcinoma). Forty-three patients were men, and the mean age was 65.8 years. Intervention: EUS followed by FCSEMS placement. Main Outcome Measurements: Procedural success, dysphagia scores, patient weights, stent migration, and stent-related complications. Results: All stents were successfully placed. Tumors were located in the middle esophagus (n = 10) and distal esophagus (n = 45). The mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively; P < .001). Patients maintained their weights at 1 month follow-up when compared with baseline (153 and 149 pounds, respectively; P = .58). Immediate complications included chest discomfort in 13 patients; 2 patients required stent removal because of intractable pain. One patient had stent removal because of significant acid reflux. Stent migration occurred at some point in 17 of 55 patients (31%). There was a delayed perforation in 1 patient. Because of disease progression or the discovery of metastasis after neoadjuvant therapy, only 8 of 55 patients underwent curative surgery. Limitations: Retrospective study. Conclusion: Placement of FCSEMSs in patients with locally advanced esophageal cancer significantly improves dysphagia and allows for oral nutrition during neoadjuvant therapy. FCSEMSs appear to be effective for palliating dysphagia. Migration was not associated with injury or harm to the patient and usually represented a positive response to neoadjuvant therapy. Few patients undergoing stenting in this situation ultimately undergo surgery because of disease progression or poor operative candidacy. [Copyright &y& Elsevier]

Objective: To evaluate the therapeutic effects of filiform needles with traditional acupuncture techniques under the guidance of acupotomology principles in the treatment of stenosing flexor tenosynovitis (trigger finger). Methods: The acupotomology principles were realized through traditional acupuncture manipulation techniques with regular filiform needles to recover the dynamic homeostasis of flexor sheath. Fifty-four digits in 46 patients diagnosed with narrowing flexor tenosynovitis were rendered acupuncture treatments once a week. A therapeutic session consists of 4 treatments. Twenty to 30 minutes of traditional acupuncture manipulation were performed in each treatment. The maneuvers aimed to relax and activate joints, reconnect Qi and Blood, unblock stagnation, and relieve pain in the wake of dissociating soft tissue adhesion in the involved digits. Results: Among the 54 digits treated, 28 digits were completely recovered, 16 significantly effective, 7 essentially effective, and 3 without effect. The total effectiveness of the clinical observation was 94.44%. Conclusion: Acupuncture performed with filiform needles and traditional techniques in view of acupotomology principles is effective in treating stenosing flexor tenosynovitis. This promising approach of acupuncture practice calls for large-scaled clinical trials. [ABSTRACT FROM AUTHOR]

Background: The overwhelming majority of reported duodenal and colonic SEMS placements in the literature have used the 0.035″ guidewire almost to the exclusion of guidewires of other diameters.Aims: The purpose of this study was to compare technical and clinical outcomes in patients undergoing duodenal or colonic SEMS placement with 0.025″ or 0.035″ guidewires.Methods: This was a retrospective study to compare technical and clinical outcomes and complications of patients receiving duodenal or colonic SEMS placement with a 0.035″ guidewire to those undergoing placement with a 0.025″ guidewire.Results: A total of 34 duodenal and 30 colonic stent placement procedures were performed in 59 patients. Technical success was achieved in all duodenal stent placement procedures. The difference in mean GOOSS score increase after stent placement was not statistically significant between the 0.035″ and 0.025″ guidewire groups (P = 0.49). Complications were not statistically significantly different between the two groups undergoing gastroduodenal stenting. Technical and clinical success was achieved in all colonic stent placement procedures. There were no statistically significant differences in complication rates between the two groups undergoing colonic stenting. Procedure times were not significantly different using either wire type.Conclusions: Our study shows that both 0.035″ and 0.025″ guidewires were equally effective with regards to technical success, clinical success, and with regards to the development of complications. [ABSTRACT FROM AUTHOR]

Dysphagia is a common problem and an indication for upper endoscopy. There is no data on the frequency of the different endoscopic findings and whether they change according to demographics or by single versus repeat endoscopy. To determine the prevalence of endoscopic findings in patients with dysphagia and whether findings differ in regard to age, gender, ethnicity, and repeat procedure. This was a retrospective study using a national endoscopic database (CORI). A total of 30,377 patients underwent esophagogastroduodenoscopy (EGD) for dysphagia of which 4,202 patients were repeat endoscopies. Overall frequency of endoscopic findings was determined by gender, age, ethnicity, and single vs. repeat procedures. Esophageal stricture was the most common finding followed by normal, esophagitis/ulcer (EU), Schatzki ring (SR), esophageal food impaction (EFI), and suspected malignancy. Males were more likely to undergo repeat endoscopies and more likely to have stricture, EU, EFI, and suspected malignancy ( P = 0.001). Patients 60 years or older had a higher prevalence of stricture, EU, SR, and suspected malignancy ( P < 0.0001). Esophageal stricture was most common in white non-Hispanic patients compared to other ethnic groups. In patients undergoing repeat EGD, stricture, SR, EFI, and suspected malignancy were more common ( P < 0.0001). The prevalence of endoscopic findings differs significantly by gender, age, and repeat procedure. The most common findings in descending order were stricture, normal, EU, SR, EFI, and suspected malignancy. For patients undergoing a repeat procedure, normal and EU were less common and all other abnormal findings were significantly more common. [ABSTRACT FROM AUTHOR]

Background: Feeding device replacement is often required for long-term maintenance after initial percutaneous endoscopic gastrostomy or jejunostomy placement. Although there are several case reports on serious complications of gastrostomy device replacement, there are few reports of an overall analysis of the complications associated with feeding device replacement. Objective: To evaluate the frequency and variety of complications of transcutaneous replacement of feeding devices. Design: A retrospective study. Setting: Single center: Nishimino Kosei Hospital. Patients: This study involved 363 consecutive patients undergoing a total of 1265 percutaneous gastrostomy or jejunostomy device replacements from March 2000 to September 2010. Intervention: A new replacement device was inserted through the ostomy tract by using an obturator after traction removal of the previous device. Endoscopic treatments were performed in the cases of fistula disruption or hemorrhage. Main Outcome Measurements: Complications and their outcomes. Results: Gastrostomy and jejunostomy devices were replaced 1126 and 139 times, respectively. There were 16 complications (1.3% of total replacements) consisting of 10 cases of fistula disruption caused by misplacement of replacement devices into the peritoneal cavity, 4 cases of hemorrhage, and 1 case each of colocutaneous fistula and device breakage. Anticoagulation or antiplatelet medications were continued in all 4 hemorrhage cases but in only 27 of 347 (7.7%) complication-free cases (P < .0001). There were no replacement-related adverse events that required surgical repair. Limitations: A single center, retrospective analysis. Conclusion: Fistula disruption and hemorrhage were the most common complications associated with device replacement. In patients on anticoagulants, caution is necessary to avoid hemorrhage after replacement. It is also important to verify that the replaced device is located in the GI tract lumen before feeding. [Copyright &y& Elsevier]

High blood pressure is commonly seen in medical settings. According to statistics, 26.4% of adults worldwide had high blood pressure in 2000, and the total hypertensive population is estimated to reach 1.56 billion by 2025. Recognized by the World Health Organization (WHO), acupuncture is a therapy suitable for treating early essential hypertension in addition to conventional medication. Clinically, the utility of acupuncture for hypertension remains controversial in light of researches and trials. Due to the demand in practice and the significance of the health issue, this article discusses an exploration of the effectiveness and consistency of acupuncture in lowering blood pressure and its clinical potential by a narrow literature review. In spite of the disparities of improvements and statistic significance, research articles showed both sham and real acupuncture, including point Quchi LI-11, demonstrated a potential of lowering blood pressure. Accordingly, the effect of Quchi LI-11 in lowering blood pressure and other underlying mechanisms of acupuncture deserve further investigation. Because of the complexity of TCM diagnosis and the disunity of treatment plans in clinicians, the author concluded that more conscientious clinical trials built on various trial modes and proven physiologic rationales are desired to explicate acupuncture's efficacy in terms of Western medicine. The perspective of the clinical utility of acupuncture in treating hypertension, particularly in combination with antihypertensive agents, deserves more research as well. [ABSTRACT FROM AUTHOR]

Background: Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids.Objective: To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone.Design: Prospective randomized controlled trial.Setting: Academic medical center.Participants: Adults (18-80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with >or=15 eosinophils/hpf.Interventions: Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks.Main Outcome Measurements: Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study.Results: About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70).Limitations: Small sample size, unexpectedly high drop-out rate.Conclusions: Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE. [ABSTRACT FROM AUTHOR]

Background: Initial assessment of dyspepsia often includes noninvasive testing for Helicobacter pylori infection. Commercially available tests vary widely in cost and accuracy. Although there is extensive literature on the cost-effectiveness of H. pylori treatment, there is little information comparing the cost-effectiveness of various currently used, noninvasive testing strategies. Methods: A Markov simulation was used to calculate cost per symptom-free year and cost per correct diagnosis. Uncertainty in outcomes was estimated using probabilistic sensitivity analysis. Results: Under the baseline assumptions, cost per symptom-free year was $122 for empiric proton pump inhibitor (PPI) trial, and costs for the noninvasive test strategies ranged from $123 (stool antigen) to $129 (IgG/IgA combined serology). Confidence intervals had significant overlap. Conclusions: Under our assumptions for how testing for H. pylori infection is employed in United States medical practice, the available noninvasive tests all have similar cost-effectiveness between one another as well as with empiric PPI trial. [ABSTRACT FROM AUTHOR]

Background: Exercise-triggered asthma (ETA) develops when physical activity triggers asthma symptoms during or directly after exercise. In patients prone to symptoms of supra-esophageal reflux, exercise may trigger gastroesophageal reflux (GER), resulting in such symptoms.Aims: To determine the prevalence of abnormal pH in patients with ETA and to determine whether acid suppression improves symptoms in ETA patients.Methods: We performed a randomized double-blind trial of rabeprazole versus placebo in the treatment of patients with ETA. Patients underwent treadmill protocol to determine their VO(2 max). Next, pH testing was initiated while undergoing a 30-min treadmill program exercising them at 65% of their VO(2 max). They were subsequently randomized to rabeprazole or placebo for 10 weeks. At the end of 10 weeks, exercise testing was repeated.Results: A total of 31 patients completed the study (20 asthmatics, 11 non-asthmatics). Twenty-two out of 30 (73%) subjects had abnormal pH studies. For all subjects, rabeprazole improved symptoms more than placebo (P = 0.03). The association was stronger in the pH-positive group (P = 0.009).Conclusion: Acid reflux is common in ETA patients. Many patients with exercise-related respiratory symptoms are misdiagnosed as chronic asthmatics. Exercise-related symptoms improve with the use of acid suppression. This study suggests that ETA patients may benefit from acid suppression. [ABSTRACT FROM AUTHOR]

The presence of bilateral arm tremor is a key diagnostic feature of essential tremor (ET). We analyzed the presence of unilateral arm tremor in familial ET cohort of 133 autosomal dominant ET kindreds with 412 affected individuals. Inclusion criteria in patients with unilateral arm postural and/or kinetic tremor required the duration of tremor for at least 5 years, without hypokinetic-rigid syndrome, dystonic posturing, or history of sudden onset of tremor. Only subjects with at least one living first degree relative who met diagnostic criteria for definite ET were included. Eighteen subjects met the inclusion criteria and five had postural tremor only, while the majority (13/18) had a combination of postural and kinetic tremor. Our data shows that unilateral tremor associated with ET is relatively rare and can be identified in 4.4% patients in a cohort of familial ET. © 2008 Movement Disorder Society [ABSTRACT FROM AUTHOR]

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