Background/AimsHigh-resolution manometry (HRM) with pressure topography is used to subtype achalasia cardia, which has therapeutic implications. The aim of this study was to compare the clinical characteristics, manometric variables and treatment outcomes among the achalasia subtypes based on the HRM findings.MethodsThe patients who underwent HRM at the Asian Institute of Gastroenterology, Hyderabad between January 2008 and January 2009 were enrolled. The patients with achalasia were categorized into 3 subtypes: type I - achalasia with minimum esophageal pressurization, type II - achalasia with esophageal compression and type III - achalasia with spasm. The clinical and manometric variables and treatment outcomes were compared.ResultsEighty-nine out of the 900 patients who underwent HRM were diagnosed as achalasia cardia. Fifty-one patients with a minimum follow-up period of 6 months were included. Types I and II achalasia were diagnosed in 24 patients each and 3 patients were diagnosed as type III achalasia. Dysphagia and regurgitation were the main presenting symptoms in patients with types I and II achalasia. Patients with type III achalasia had high basal lower esophageal sphincter pressure and maximal esophageal pressurization when compared to types I and II. Most patients underwent pneumatic dilatation (type I, 22/24; type II, 20/24; type III, 3/3). Patients with type II had the best response to pneumatic dilatation (18/20, 90.0%) compared to types I (14/22, 63.3%) and III (1/3, 33.3%).ConclusionsThe type II achalasia cardia showed the best response to pneumatic dilatation.

Context:Thyroid hormone use is common in older populations, but the frequency of over-or under-replacement is debated.Objective: We sought to describe the frequency of and factors associated with thyroid hormone over-or under-replacement in a population of older men and women.Design: Participants were 3678 U.S. community dwelling individuals aged 65 yr or older enrolled in the Cardiovascular Health Study who had thyroid function tests in 1989 -1990. Thyroid hormone users (n ϭ 339) were identified and classified into low TSH (Ͻ0.45 mU/liter), euthyroid (0.45-4.5 mU/liter), and high TSH (Ͼ4.5 mU/liter). Results:Of the 339 thyroid hormone users, 41% had a low TSH, 16% had a high TSH, and 43% were in the euthyroid range. In multivariable analyses, lower weight (P Ͻ 0.001) was independently associated with low TSH status. For every 10 kg lower weight, the likelihood of having low TSH increased by 65% ͓odd ratio (OR) 1.65; 95% confidence interval (CI) 1.31-2.07͔. Those with renal insufficiency were less likely to have low TSH levels (P ϭ 0.02). The presence of diabetes was independently associated with having low (OR 3.35; 95% CI 1.46 -7.65) and high TSH levels (OR 2.66; 95% CI 1.14 -6.21). Conclusions:There is a very high prevalence of thyroid function testing abnormalities in older people taking thyroid hormone preparations, particularly in those of low weight or with diabetes. Because of potential adverse cardiovascular and skeletal effects from over-replacement, older people represent a key population for increased TSH monitoring on therapy. those taking thyroid hormone preparations may be high, with levels in the euthyroid range present in only 40 -60% (1, 2). Factors that contribute to the increased risk of over-or under-replacement have not been defined, despite the clinical importance of identifying at-risk patients. We conducted an analysis of individuals taking thyroid hormone preparations who were enrolled in a population-based, longitudinal study of community dwelling individuals aged 65 yr and older. Our goals were to define the prevalence of thyroid function testing abnormalities, and to determine the relationship between sociodemographical factors, comorbidities, pharmacotherapy, and over-or under-replacement in this population.

Background: EUS-guided rendezvous procedure (EUS-RV) can be done by the transhepatic (TH) or the extrahepatic (EH) route. There is no data on the preferred access route when both routes are available. Study aim: To compare the success, complications, and duration of hospitalization for patients undergoing EUS-RV by the TH or the EH route. Patients and methods: Patients with distal common bile duct (CBD) obstruction, who failed selective cannulation, underwent EUS-RV by the TH route through the stomach or the EH route through the duodenum. Results: A total of 35 patients were analysed (17 TH, 18 EH). The mean procedure time was significantly longer for the TH group (34.4 vs. 25.7 min; p ¼ 0.0004). There was no difference in the technical success (94.1 vs. 100%). However, the TH group had a higher incidence of post-procedure pain (44.1 vs. 5.5%; p ¼ 0.017), bile leak (11.7 vs. 0; p ¼ 0.228), and air under diaphragm (11.7 vs. 0; p ¼ 0.228). All bile leaks were small and managed conservatively. Duration of hospitalization was significantly higher for the TH group (2.52 vs. 0.17 days; p ¼ 0.015). Conclusions: EUS-RV has similar success rate by the TH or the EH route. However, the TH route has higher post-procedure pain, longer procedure time, and longer duration of hospitalization. The EH route should be preferred for EUS-RV in patients with distal CBD obstruction when both access routes are technically feasible.

BackgroundPemphigus vulgaris (PV) is an autoimmune bullous disease caused by acantholysis of keratinocytes due to pathogenic desmoglein-3 autoantibodies. Role of vitamin D has been recently implicated in various autoimmune conditions due to its immunomodulatory effects on innate and adaptive immune responses. One of the key mechanisms of the immune regulation by vitamin D is through its anti-inflammatory effects by suppression of Th17 functions. Thus, vitamin D may be involved in pathogenesis of PV. In this study, the serum vitamin D, IL-17 and TGF-β levels in PV patients as well as healthy controls were estimated in order to understand the underlying immune mechanism involved in disease pathogenesis.ResultsThis retrospective study included 30 biopsy proven PV patients’ sera. Ten age matched volunteers without any cutaneous or autoimmune conditions were recruited as healthy control (HC). Serum Vitamin D levels were measured using chemiluminescence, whereas IL-17 and TGF-β levels were determined using ELISA. All patients showed deficient vitamin D levels (11.1 ± 5.8 ng/ml). Moreover, all the PV patients had elevated serum IL-17 levels (210.7 ± 105.3), whereas it was not detectable in any (n = 10) of the healthy controls sera (ELISA sensitivity ≥ 8 pg/ml). The mean serum TGF-β concentration was also lower in patient sera as compared to healthy control, and the TGF-β/IL-17 ratio was drastically reduced in patients (30.30 ± 28), as compared to healthy controls (1363.34 ± 559.52).ConclusionsHypovitaminosis is common in North India, as ascertained by deficient levels in healthy controls, and was also consistently observed in PV patient. These low levels were not related to age or gender. The increased serum IL-17 and dramatic reduction in TGF-β/IL-17 ratio in diseased patients further indicate that dysregulation of the Treg/Th-17 axis of T effector cells may be of significance in pathogenesis of PV. Thus, the study indicates that vitamin D insufficiency may be a predisposing factor in PV, contributing through its role in any of the various adaptive immune mechanisms that regulate T cell functions in vivo. Thus, there is a need to further evaluate the Treg/Th-17 axis, as it may have an important role in disease progression.

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