SUMMARYAim: To assess the efficacy of the 8-week therapy with esomeprazole 40 mg vs. pantoprazole 40 mg for healing erosive oesophagitis (EE) as part of a management study. Methods: Patients had a history of gastro-oesophageal reflux disease symptoms ( ‡6 months) and had suffered heartburn on at least 4 of the 7 days preceding enrolment. Endoscopies were performed to grade EE severity using the Los Angeles (LA) classification system at baseline, 4 and 8 weeks (if unhealed at 4 weeks). Heartburn severity was recorded by patients on diary cards. The primary end point was healing of EE by week 8 of treatment.Results: Of 3170 patients randomized, the intentto-treat population consisted of 3151 patients (63% male, mean age: 50.6 years, 27% Helicobacter pyloripositive). Esomeprazole 40 mg healed a significantly greater proportion of EE patients than pantoprazole 40 mg at both 4 weeks (life table estimates: esomeprazole 81%, pantoprazole 75%, P < 0.001) and 8 weeks (life table estimates: esomeprazole 96%, pantoprazole 92%, P < 0.001). The median time to reach sustained heartburn resolution was 6 days in patients receiving esomeprazole and 8 days with pantoprazole (P < 0.001). Conclusion: Esomeprazole 40 mg is more effective than pantoprazole 40 mg for healing EE and providing resolution of associated heartburn.

Metastatic breast cancer involving the hepatobiliary tract or ascites secondary to peritoneal carcinomatosis has been well described. Luminal gastrointestinal tract involvement is less common and recognition of the range of possible presentations is important for early and accurate diagnosis and treatment. We report 6 patients with a variety of presentations of metastatic breast cancer of the luminal gastrointestinal tract. These include oropharyngeal and esophageal involvement presenting as dysphagia with one case of pseudoachalasia, a linitis plastica-like picture with gastric narrowing and thickened folds, small bowel obstruction and multiple strictures mimicking Crohn's disease, and a colonic neoplasm presenting with obstruction. Lobular carcinoma, representing only 10% of breast cancers is more likely to metastasize to the gastrointestinal tract. These patients presented with gastrointestinal manifestations after an average of 9.5 years and as long as 20 years from initial diagnosis of breast cancer. Given the increased survival of breast cancer patients with current therapeutic regimes, more unusual presentations of metastatic disease, including involvement of the gastrointestinal tract can be anticipated.

The coordination of swallowing and respiration, as measured by nasal airflow, and the effect of changes in the volume of the swallow bolus (0-20 ml) were investigated in 12 normal subjects. Both nonbolus and bolus swallows were usually preceded and followed by expiratory airflow. Swallows followed by inspiratory airflow accounted for 20% of nonbolus swallows but decreased further in frequency in the presence of a bolus. Swallowing was associated with an apneic period lasting 1.90 +/- 0.26 s for nonbolus swallows. Based on the apneic period response to bolus volume, the subjects were divided into two groups. The apneic period decreased by 60% in seven of the subjects regardless of bolus volume. The remaining five subjects gradually increased swallow apnea as bolus volume was increased. At larger bolus volumes, the latter group also exhibited an earlier onset of the swallow apnea and an increase in the number of swallows preceded by inspiration. The duration of the swallow-associated respiratory cycle was similarly prolonged by an increase in bolus volume in both groups. The results indicate that the respiratory pattern associated with swallowing is modulated by the volume of the swallow bolus. Within the normal population, at least two different patterns of response to bolus volume are identified.

Respiration and swallowing were recorded simultaneously by inductance plethysmography, submental electromyography, and a throat microphone in 10 normal subjects during eating and drinking tasks that included single boluses of varying volume (5-20 ml) and consistency presented with a syringe and cup, a 200-ml drink taken with and without the use of a straw, and a sandwich meal. Swallows were associated with a brief swallow apnea (SA) lasting approximately 1 s. Swallow effects on the duration or tidal volume of the preswallow, postswallow and swallow-associated breathing cycles varied depending on bolus characteristics and presentation. Expiration before and after the SA was the preferred pattern with all drinking and eating tasks. Inspiration followed SA in < 5% of single-bolus swallows, but this pattern increased significantly with a 200-ml drink administered by cup or by straw and during a sandwich meal (23.8 +/- 5.2, 27.0 +/- 2.6, and 16.3 +/- 2.7%, respectively. Hence, the swallow-associated breathing pattern seen with single-bolus swallows may not reflect that associated with regular eating and drinking behavior. This finding implies that the risk of aspiration may be reduced by teaching patients prone to aspiration to simplify the complex behavior of eating and drinking to a series of single-bolus swallows.