Tommasangelo Petitti

Intra‐oesophageal distribution and perception of acid reflux in patients with non‐erosive gastro‐oesophageal reflux disease

Background: The majority of patients with gastro‐oesophageal reflux disease do not present with erosive oesophagitis and make up a heterogeneous group. Patients with non‐erosive gastro‐oesophageal reflux disease are less responsive than patients with oesophagitis to acid‐suppressive therapy.

Dilated intercellular spaces and acid reflux at the distal and proximal oesophagus in patients with non-erosive gastro-oesophageal reflux disease

Background  Acid exposure of proximal oesophagus and dilated intercellular space diameters of oesophageal epithelium are relevant in the perception of gastro‐oesophageal reflux.

Effect of hiatal hernia on proximal oesophageal acid clearance in gastro-oesophageal reflux disease patients

Proximal acid reflux is common in gastro‐oesophageal reflux disease and is a determinant of symptoms. Patients with hiatal hernia complain of more symptoms than those without and are less responsive to proton‐pump inhibitors.

Impedance baseline and reflux perception in responder and non-responder non-erosive reflux disease patients

Abstract Background. It was recently shown that GERD patients have lower impedance baseline (IB) values than healthy controls and, that the esophageal acid exposure time (AET) correlates with IB levels. Goals. To explore the sensitivity of IB measurements in NERD patients, responders and non-responders to PPIs, when compared with pH-impedance (MII-pH) variables, and to evaluate whether this variable could represent a marker of GERD symptoms. Reproducibility and inter-observer agreement of IB measurement were also assessed. Study. MII-pH tracings from 44 NERD responders and 22 non-responders were analysed. Ten healthy volunteers underwent the same protocol. IB values were measured at the distal and proximal esophagus. IB was also analysed in a subgroup of patients and in controls with two methods and by two blinded operators. Results. Mean IB values at the distal esophagus were significantly lower in NERD patients than in controls. IB values did not differ between responders and non-responders. Of the 8 responders with negative AET and symptom association probability (SAP), 3 (37.5%) showed IB values lower than controls. IB values in responders with positive and negative SAP were similar (1832 (1596–2068) Ω vs 1667 (1361–1973) Ω, p: n.s.). No differences were found between the IB values measured with the two methods and the inter-observer agreement was good. Conclusions. IB is a promising and easy to calculate MII-pH variable and appears to increase the sensitivity of MII-pH monitoring. IB values cannot predict PPI response and are not associated with reflux perception in NERD patients.

Increased frequency and enhanced perception of reflux in non-erosive reflux disease patients non-responders to proton pump inhibitors.

BACKGROUND The unsatisfactory response to medical treatment in non-erosive patients is becoming a real challenge for gastroenterologists. Non-responder patients, evaluated under treatment, present symptoms which are related to non-acidic, mixed and proximal reflux episodes. METHODS To elucidate the reflux pattern and mechanisms related to persistence of symptoms despite treatment, oesophageal pH-impedance was performed in 55 non-erosive responder and 24 non-responder patients, studied off therapy. Ten responder and 10 non-responder patients underwent a repeated study during proton pump inhibitor treatment. RESULTS Non-responders were characterised by a higher overall number and larger proportion of symptomatic reflux episodes. Non-responders were also characterised by an enhanced sensitivity to acidic, mixed and proximal refluxes. Weakly acidic reflux accounted for 29% of symptomatic refluxes in non-responders and 34% in responders. Proportions of acidic and weakly acidic reflux episodes were comparable both in responders and non-responders when analysed off and on treatment. CONCLUSIONS An increased overall number of reflux episodes and enhanced sensitivity to reflux are strongly associated with treatment failure. Treatment strategies aimed at decreasing transient lower oesophageal sphincter relaxations, pain modulators or anti-reflux surgery should be considered in non-responders in whom a significant relationship between symptoms and reflux has been confirmed.

Effect of Preoperative Aspirin Replacement With Enoxaparin in Patients Undergoing Primary Isolated On-Pump Coronary Artery Bypass Grafting

Management of preoperative antiplatelet therapy in coronary artery bypass grafting (CABG) is variable among surgeons: guidelines collide with prejudices because replacement of aspirin with low-molecular-weight heparin is still performed because of a presumed minor bleeding risk. This study aims to analyze postoperative bleedings and complications in patients scheduled for elective primary isolated on-pump CABG, depending on preoperative aspirin treatment or its replacement with enoxaparin. In this cohort study, we propensity score matched 200 patients in whom aspirin was stopped at least 5 days before CABG and replaced with enoxaparin and 200 patients who continued aspirin therapy until the day before surgery. Postoperative bleedings and complications were monitored during hospitalization. Among patients who continued aspirin treatment, mean overall bleeding was 701.0 ± 334.6 ml, whereas in the matched enoxaparin group, it was significantly greater (882.6 ± 64.6 ml, p value <0.001); this was associated with reduced postoperative complications, lower values of postoperative C-reactive protein in aspirin takers, and a presumed protective effect for statins. After propensity score adjustment, aspirin treatment carried a protective effect against major postoperative bleeding (odds ratio 0.312, p = 0.001). In conclusion, postoperative bleeding is reduced in patients who continued aspirin, likely due to a reduction in postoperative inflammation. The practice of empirically discontinuing aspirin and replacing it with enoxaparin before CABG should be abandoned. Patients with coronary artery disease referred to CABG should continue antiplatelet medications until the surgical procedure. Those results might be extended to patients under oral anticoagulant therapy requiring CABG.

Long Term Outcome of Cryopreserved Allograft for Aortic Valve Replacement

Objective The most efficient surgical approach to severe aortic valve disease in the young adult is still debated: cryopreserved aortic allograft offers excellent hemodynamic and avoid anticoagulation, but long‐term durability is influenced by structural valve deterioration (SVD). This study aimed to describe long‐term results of aortic allografts and to identify factors influencing long‐term durability. Methods From January 1993 to August 2010, 210 patients underwent aortic allograft replacement via the free‐hand subcoronary implantation technique (N = 55) or root replacement with coronary reimplantation (N = 155). Clinic and echocardiographic follow‐up was updated to April 2016. Results Overall mortality and cardiac mortality occurred in 80 (38.1%) and 64 (30.5%) patients, respectively. Reoperation was required in 69 cases (32.8%), whereas SVD required reoperation in 57 cases (27.1%). No early endocarditis occurred, whereas late endocarditis occurred in 4 patients. The free‐hand technique seems to be associated with improved left ventricular remodeling compared with the root‐replacement technique, and smaller allograft size represents a predictor of reoperation independently on the surgical technique used. In the overall population, there were 44 women of childbearing age, and 37 patients remained pregnant during the follow‐up of the study. No differences were found in the clinical outcomes among women who had children and who did not. Conclusions Cryopreserved allograft is a valid option, especially in complex infective endocarditis and in women of childbearing age. A careful choice of allograft size and implantation technique can reduce the risk of SVD.

Extracapillary proliferation is an independent predictive factor in Immunoglobulin A nephropathy

Oxford classification of Immunoglobulin A Nephropathy (IgAN) identifies four pathological features as predictors of renal outcome (MEST‐score): mesangial proliferation (M); endocapillary proliferation (E); segmental glomerulosclerosis (S); tubular atrophy/interstitial fibrosis (T). In particular extracapillary proliferation (Ex) was not considered as an independent histological variable predicting renal outcome. Recently the VALIGA study provided a validation of the Oxford classification in a large European cohort of IgAN patients and re‐stated that Ex is not associated with a worse renal prognosis. We propose a retrospective study to evaluate the predictive value of the MEST‐score in a multi‐centre, single region group of patients from central Italy and in addition, to investigate Ex as a marker predicting renal outcome.

Prevalence and clinical characteristics of refractoriness to optimal proton pump inhibitor therapy in non-erosive reflux disease

The real size of the gastro‐oesophageal reflux disease (GERD) population not responding to proton pump inhibitor (PPI) therapy has still not been fully elucidated. Causes of PPI refractoriness include incorrect diagnosis and lack of adherence to therapy, in terms of incorrect dosage and timing.