Akambase, Joseph

Summary Topical steroids are commonly used in treatment of eosinophilic esophagitis (EoE), but currently there is lack of data to clarify most effective regimen. We aimed to study the achievement of histologic remission using the same dose of budesonide in two different delivery formulations. Patients with established EoE treated with pharmacy compounded budesonide capsule or budesonide Rincinol gel (both 3 mg twice daily) were studied retrospectively. Those with pre-treatment and post-treatment histologic assessment were included with main endpoint being histologic remission. 103 patients (62 gel, 41 capsule) were included, with higher rate of histologic remission with gel (84 vs. 59%, P=0.004). A subset of patients in both groups had lack of steroid response (<50% drop in eosinophils) (15% for gel, 32% for capsule). Formulation/delivery vehicle of steroid treatments to esophageal mucosa in EoE appears important for treatment efficacy, with budesonide gel having higher likelihood of histologic remission compared to budesonide capsules in our population. A truly steroid refractory group appears likely in our population. Larger, prospective studies may help clarify best regimen of topical steroids in EoE and may work to identify patients likely to benefit from alternative therapies.

The aim of this research is to study the racial differences in the microcirculation of the foot among dark‐skin Africans (DSA – 20 males) and light‐skin Caucasians (LSC – 20 males) using laser doppler flowmetry (LDF). The participants were all males between the ages of 18 to 20. The average values of the microcirculation parameters (PM) in the subjects with high (DSA) and low (LSC) degree of skin pigmentation on the first toe of the foot were [Plantar surface: Blood perfusion – 6.8±0.8 perfusion units (PU), Flux – 1.8±0.4 perfusion units (PU), Fluxmotion index – 1.3±0.19; Dorsal surface: Blood perfusion – 3.3±0.6 perfusion unit (PU), Flux – 1.8±0.4 perfusion units, Fluxmotion index – 0.6±0.1] and [Plantar surface: Blood perfusion – 7.2±0.7 perfusion units (PU), Flux – 1.9±0.2 perfusion units (PU), Fluxmotion index – 1.4±0.16; Dorsal surface: Blood perfusion – 4.7±0.6 perfusion unit (PU), Flux – 1.5±0.1 perfusion units, Fluxmotion index – 1.1±0.1], respectively. Our research reported no significant difference in the microcirculation parameters on the plantar surface of the first toe in both DSA and LSC. This indicates that both groups at the level of the microcirculatory system triggered the same type of regulatory mechanisms. On the dorsal surface of the first toe, where there is significant difference in melanin content, we recorded significant differences in the parameters of microcirculation. Thus, blood perfusion in LSC was 30% higher than in DSA. However, on the dorsal surface of the first toe, flux was 87% higher in those surveyed with less melanin (LSC) than in those surveyed with more melanin (DSA). The average Fluxmotion index on the dorsal surface of the first toe was 45% higher in those with less melanin than in those with more melanin. In conclusion, we can hypothesize that the high content of melanin in the skin shields the probing signal, leading to a decrease in Laser Doppler Flowmetry metrics. Support or Funding Information Research supported by the Department of Human Anatomy at RUDN University, Moscow, Russia Measurement of microcirculation in the foot of a light‐skin Caucasian using Laser Doppler Flowmetry (Lakk‐OP). Figure 1 Measurement of microcirculation in the foot of a dark‐skin African using Laser Doppler Flowmetry (Lakk‐OP). Figure 2

INTRODUCTION: Histologic response rates to steroids for eosinophilic esophagitis (EoE) vary from < 50% to >90% in controlled trials. We have used varied steroid preparations and higher doses than typically used and aimed to study if steroid dose and delivery vehicle might explain the wide variation in response. METHODS: A database of patients with EoE created in our esophageal clinic was reviewed and patients treated with at least an 8 week course of topical steroid therapy and undergoing pre and post-steroid histologic evaluation were included. Histologic remission was defined as eosinophil count < 15/hpf. Symptomatic remission was defined as complete resolution of symptoms and eating an unlimited diet. Endoscopy reports were reviewed. RESULTS: 94 patients were included, 45 on 3 mg budesonide-Rincinol gel twice daily (HBRG), 29 on 3 mg budesonide capsules BID (BC), and 20 on lower doses of BRG (1.5 mg daily to 2 mg BID) (LBRG). 88.5% had dysphagia at time of steroid initiation. Mean eosinophil count before steroids was 58.6/hpf. 38.3% had esophageal dilation just prior to steroids. Average EFERS prior to steroid treatment was 1.8. There were not significant differences between the groups in terms of demographics, initial eosinophil counts, symptoms, visual EoE assessment (EREFS) or dilation rates. Histologic remission rate for HBRG was 82.2% vs 55.1% for all others combined ( P < 0.001), 51.7% for BC ( P = 0.005 vs 3 mg BRG BID), and 60.0% for LBRG ( P = 0.06 vs 3 mg BRG BID). Symptomatic remission was similar between groups, as was change in EREFS and change in eosinophil counts. Non-responders to HBRG had mean decrease in eosinophil count of only 0.3/hpf (vs 53.2/hpf for responders, P < 0.003) and mean change in EREFS of +1.6 (vs −1.1 for responders, P < 0.001). 62.5% of non-responders to HBRG actually had increase in eosinophil count after steroids. Response rate to HBRG at < 5 eos/hpf was 77.8% overall and 94.6% in those achieving remission. CONCLUSION: A higher remission rate achieved with a more viscous steroid preparation compared to other formulations suggests the importance of both dose and esophageal delivery in treatment of EoE. Further, with adequate mucosal delivery and dosing of topical steroids, steroid refractory EoE appears to be uncommon. On the other hand, these results suggest the existence of a small truly steroid refractory group of EoE patients with negligible histologic, symptomatic and endoscopic response to high dose steroids that warrant further investigation.

Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care patients with the diagnosis of depression, current smoking would have a negative impact on clinical outcomes, regardless of treatment type (usual primary care [UC] vs collaborative care management [CCM]). Methods: A retrospective chart review study of 5155 adult primary care patients with depression in a primary care practice in southeast Minnesota was completed. Variables obtained included age, gender, marital status, race, smoking status, initial Patient Health Questionnaire–9 (PHQ-9), and 6-month PHQ-9. Clinical remission (CR) was defined as 6-month PHQ-9 <5. Persistent depressive symptoms (PDS) were defined as PHQ-9 ≥10 at 6 months. Treatment in both CCM and UC were compared. Results: Using intention to treat analysis, depressed smokers treated with CCM were 4.60 times as likely (95% CI 3.24-6.52, P < .001) to reach CR and were significantly less likely to have PDS at 6 months (adjusted odds ratio [AOR] 0.19, 95% CI 0.14-0.25, P < .001) compared with smokers in UC. After a 6-month follow-up, depressed smokers treated with CCM were 1.75 times as likely (95% CI 1.18-2.59, P = .006) to reach CR and were significantly less likely to have PDS (AOR 0.45, 95% CI 0.31-0.64, P < .001) compared with smokers in UC. Conclusions: CCM significantly improved depression outcomes for smokers at 6 months compared with UC. However, in the UC group, smoking outcomes were not statistically different at 6 months for either remission or PDS. Also, nonsmokers in CCM had the best clinical outcomes at 6 months in both achieving clinical remission and reduction of PDS when compared with smokers in UC as the reference group.