- 作者列表："Laserna-Mendieta EJ","Casabona S","Savarino E","Perelló A","Pérez-Martínez I","Guagnozzi D","Barrio J","Guardiola A","Asensio T","de la Riva S","Ruiz-Ponce M","Rodríguez-Oballe JA","Santander C","Arias Á","Lucendo AJ","EUREOS EoE CONNECT research group.
BACKGROUND & AIMS:Topical steroids, proton pump inhibitors (PPIs), and dietary interventions are recommended first- and second-line therapies for eosinophilic esophagitis (EoE). We investigated differences in their effectiveness in a real-world, clinical practice cohort of patients with EoE. METHODS:We collected data on the efficacy of different therapies for EoE (ability to induce clinical and histologic remission) from the multicenter EoE CONNECT database-a database of patients with a confirmed diagnosis of EoE in Europe that began in 2016. We obtained data from 589 patients, treated at 11 centers, on sex, age, time of diagnosis, starting date of any therapy, response to therapy, treatment end dates, alternative treatments, and findings from endoscopy. The baseline endoscopy used for diagnosis of EoE; second endoscopy was performed to evaluate response to first-line therapies. After changes in treatment, generally because lack of efficacy, a last endoscopy was performed. The time elapsed between endoscopies depended on the criteria of attending physicians. Clinical remission was defined by a decrease of more than 50% in dysphagia symptom score; improvement in symptoms by less than 50% from baseline was considered as clinical response. Histologic remission was defined as a peak eosinophil count below 5 eosinophils/hpf. A peak eosinophil count between 5 and 14 eosinophils/hpf was considered histologic response. We identified factors associated with therapy selection and effectiveness using χ2 and multinomial logistic regression analyses RESULTS: PPIs were the first-line treatment for 76.4% of patients, followed by topical steroids (for 10.5%) and elimination diets (for 7.8%). Topical steroids were most effective in inducing clinical and histologic remission or response (in 67.7% of patients), followed by empiric elimination diets (in 52.0%), and PPIs (in 50.2%). Among the 344 patients who switched to a second-line therapy, dietary interventions were selected for 47.1% of patients, followed by PPIs (for 29.1%) and topical steroids (for 18.6%). Clinical and histologic remission or response was achieved by 80.7% of patients treated with topical steroids, 69.2% of patients given PPIs, and 41.7% of patients on empiric elimination diets. Multivariate analyses found the stricturing phenotype of EoE to be associated with selection of topical steroids over PPIs as the first-line therapy; lack of fibrotic features at initial endoscopy was associated with selection of elimination diets over topical steroids as a second-line therapy. The recruiting center was significantly associated with therapy choice; second-line treatment with topical steroids or PPIs were the only variables associated with clinical and histologic remission. CONCLUSIONS:In an analysis of data from a large cohort of patients with EoE in Europe, we found topical steroids to be the most effective at inducing clinical and histologic remission, but PPIs to be the most frequently prescribed. Treatment approaches vary with institution and presence of fibrosis or strictures.
背景与目的: 局部类固醇、质子泵抑制剂 (PPIs) 和饮食干预是嗜酸性粒细胞性食管炎 (EoE) 的一线和二线治疗方法。我们在真实世界的 EoE 患者临床实践队列中研究了其有效性的差异。 方法: 我们收集了不同疗法对 EoE 疗效的数据 (诱导临床和组织学缓解的能力) 来自多中心 EoE CONNECT 数据库-2016年开始的欧洲确诊 EoE 患者数据库。我们从 589 例患者中获得数据，在 11 个中心接受治疗，关于性别，年龄，诊断时间，任何治疗的开始日期，对治疗的反应，治疗结束日期，替代治疗, 内窥镜检查的结果。用于诊断 EoE 的基线内镜检查; 进行第二次内镜检查以评价对一线治疗的反应。治疗改变后，通常由于缺乏疗效，进行了最后一次内镜检查。内镜检查之间的时间取决于主治医生的标准。临床缓解定义为吞咽困难症状评分下降超过 50%; 症状较基线改善不到 50% 被视为临床缓解。组织学缓解定义为嗜酸性粒细胞计数峰值低于 5 个嗜酸性粒细胞/hpf。嗜酸性粒细胞计数峰值在 5-14 个嗜酸性粒细胞/hpf 之间被认为是组织学反应。我们使用 χ 2 和多项 logistic 回归分析确定了与治疗选择和有效性相关的因素。结果: PPIs 是 76.4% 患者的一线治疗，其次是外用类固醇 (10.5%) 和消除饮食 (7.8%)。局部类固醇在诱导临床和组织学缓解或反应方面最有效 (67.7% 的患者)，其次是经验性消除饮食 (52.0%) 和 PPIs (50.2%)。在转换为二线治疗的 344 例患者中，47.1% 的患者选择饮食干预，其次是 PPIs (29.1%) 和局部类固醇 (18.6%)。80.7% 的局部类固醇治疗患者、 69.2% 的给予 ppi 的患者和 41.7% 的经验性消除饮食患者达到临床和组织学缓解或反应。多变量分析发现 EoE 的狭窄表型与选择局部类固醇而不是 PPIs 作为一线治疗相关; 初始内镜检查时缺乏纤维化特征与选择消除饮食而不是局部类固醇作为二线治疗相关。招募中心与治疗选择显著相关; 局部类固醇或 PPIs 二线治疗是与临床和组织学缓解相关的唯一变量。 结论: 在对欧洲大型 EoE 患者队列数据的分析中，我们发现局部类固醇在诱导临床和组织学缓解方面最有效, 但是 PPIs 是最常见的处方。治疗方法因机构和纤维化或狭窄的存在而异。
METHODS:PURPOSE:The purpose of this study was to compare the survival and toxicities in cervical esophageal squamous cell carcinoma (CESCC) treated by concurrent chemoradiothrapy with either three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) techniques. Materials and Methods:A total of 112 consecutive CESCC patients were retrospectively reviewed. 3D-CRT and IMRT groups had been analyzed by propensity score matching method, with sex, age, Karnofsky performance status, induction chemotherapy, and tumor stage well matched. The Kaplan-Meier method and Cox proportional hazards model were used for overall survival (OS) and progression-free survival (PFS). Toxicities were compared between two groups by Fisher exact test. RESULTS:With a median follow-up time of 34.9 months, the 3-year OS (p=0.927) and PFS (p=0.859) rate was 49.6% and 45.8% in 3D-CRT group, compared with 54.4% and 42.8% in IMRT group. The rates of grade ≥ 3 esophagitis, grade ≥ 2 pneumonitis, esophageal stricture, and hemorrhage were comparable between two groups, while the rate of tracheostomy dependence was much higher in IMRT group than 3D-CRT group (14.3% vs.1.8%, p=0.032). Radiotherapy technique (hazard ratio [HR], 0.09; 95% confidence interval [CI], 0.01 to 0.79) and pretreatment hoarseness (HR, 0.12; 95% CI 0.02 to 0.70) were independently prognostic of tracheostomy dependence. CONCLUSION:No survival benefits had been observed while comparing IMRT versus 3D-CRT in CESCC patients. IMRT with fraction dose escalation and pretreatment hoarseness were considered to be associated with a higher risk for tracheostomy dependence. Radiation dose escalation beyond 60 Gy should be taken into account carefully when using IMRT with hypofractionated regimen.
METHODS::The radial force of esophageal stents may not completely change during extraction and therefore, the procedure of stent removal may cause tissue damage. The present study reports the manufacture of 2 novel detachable stents, which were designed to reduce tissue damage through their capacity to be taken or fall apart prior to removal and evaluated the supporting properties of these stents and the extent of local mucosal injury during their removal. The stents were manufactured by braiding, heat-setting, coating and connecting. The properties of the stents were evaluated by determining the following parameters: Expansion point, softening point, stent flexibility, radial compression ratio and radial force. A total of 18 rabbits with induced esophageal stricture were randomly assigned to 3 groups as follows: Detachable stent (DS) group, biodegradable stent (BS) group and control group. The stricture rate, complications, survival, degradation and stent removal were observed over 8 weeks. The stents of the DS and BS groups provided a similar supporting effect. The stricture rate, incidence of complications and survival were also similar between the 2 groups, while significant differences were noted between the DS and control groups and between the BS and control groups. In the BS group, the stents were degraded and moved to the stomach within 7 weeks (2 in 6 weeks and 3 in 7 weeks). The debris was extracted using biopsy forceps. In the DS group, all stents were easy to remove and 2 cases exhibited minor hemorrhage. In conclusion, the 2 types of novel detachable stent provided an equally efficient supporting effect in vitro and in vivo and may reduce the incidence of secondary injury during stent removal.
METHODS:BACKGROUND:Immune imbalance and inflammation have been suggested as key factors of Barrett's esophagus (BE) pathway towards adenocarcinoma. The neutrophil-lymphocyte ratio (NLR) indirectly reflects the relation between innate and adaptive immune systems and has been studied in premalignant conditions as a biomarker for cancer diagnosis. Our aim was to investigate if increasing values of NLR correlated with advancing stages of BE progression to dysplasia and neoplasia. METHODS:We retrospectively analyzed data of patients with biopsies reporting BE between 2013 and 2017 and with a complete blood count within 6 months from the endoscopy, as well as patients with esophageal adenocarcinoma (EAC). NLR was calculated as neutrophil count/lymphocyte count. Cases (n = 113) were classified as non-dysplastic BE (NDBE, n = 72), dysplastic BE (DBE, n = 11) and EAC (n = 30). RESULTS:NLR progressively increased across groups (NDBE, 1.92 ± 0.7; DBE, 2.92 ± 1.1; EAC 4.54 ± 2.9), with a significant correlation between its increasing value and the presence of dysplasia or neoplasia (r = 0.53, p 2.27 was able to diagnose EAC with 80% sensitivity and 71% specificity (area under the curve = 0.8). CONCLUSION:NLR correlates with advancing stages of BE progression, a finding that reinforces the role of immune imbalance in EAC carcinogenesis and suggests a possible use of this marker for risk stratification on surveillance strategies.