The faecal colonization with Clostridium difficile was investigated among 343 infants during their first 18 months of life. Rectal swabs were taken at the ages of 6 days, 6 weeks, 6 months, 11 months and 18 months. About 25% of the children were colonized with Clostridium difficile between 6 days and 6 months of age. The colonization rate decreased to 3% at 18 months of age. The rate of strains producing cytotoxin was low in infants less than 6 months of age, but at that age about half of the strains isolated were toxin-producing. Breast-fed children were significantly less often colonized with Clostridium difficile than were bottle-fed infants, both at 6 weeks of age (21% versus 47%, p less than 0.05) and at 6 months of age (19% versus 39%, p less than 0.001). Colonization with Clostridium difficile at 6 months of age was associated with a greater frequency of diarrhoeal disease between 6 and 11 months of age (27% versus 16%, p less than 0.05). This association was even more pronounced when the bacteria persisted at 11 months of age (54%, p less than 0.01). Antibiotic therapy could not be demonstrated to influence colonization with Clostridium difficile at any age.

Radiofrequency (RF) ablation using the HALO(360) system combined with proton pump inhibitor (PPI) therapy is a new treatment for Barrett's esophagus (BE). We assessed the safety and effectiveness of this combination therapy at a community-based, BE referral center. After symptom evaluation, endoscopy and histologic assessment, esophageal motility, pH monitoring on PPI, computed tomography, endoscopic ultrasonography and mucosal resection for nodules, we performed HALO(360) ablation followed by twice daily PPI and 3-monthly surveillance for up to 12 months. If metaplasia or dysplasia were present at follow-up, the patients received a second ablation. Thirteen patients (12 male) were treated, three with high-grade dysplasia, four with low-grade and six with non-dysplastic intestinal metaplasia. The mean baseline BE length was 6 cm (range 2-12); nine patients had an hiatal hernia and two had a prior fundoplication. Esophageal pH < 4.0 for < 4% of time was achieved only in 5/13 patients. A mean of 1.4 ablation sessions were performed, without serious adverse events or strictures. Complete eradication of BE was achieved in 6/13 (46%) patients. The mean endoscopic surface regression was 84% (from a mean length of 6 +/- 1 cm to 1.2 +/- 0.5 cm, P < 0.001). Complete elimination of dysplasia was achieved in 5/7 (71%) patients. Ablation efficacy was better in those patients who had maximal pH control (P < 0.05). HALO(360) ablation of BE with or without dysplasia is safe, well-tolerated and effective in the community setting. Follow-up ablation further reverses residual BE or dysplasia.

Patients with symptoms suggestive of gastroesophageal reflux disease (GERD), such as chest pain, heartburn, regurgitation, and dysphagia, are typically treated initially with a course of proton pump inhibitors (PPIs). The evaluation of patients who have either not responded at all or partially and inadequately responded to such therapy requires a more detailed history and may involve an endoscopy and esophageal biopsies, followed by esophageal manometry, ambulatory esophageal pH monitoring, and gastric emptying scanning. To assess the merits of a multimodality 'structural' and 'functional' assessment of the esophagus in patients who have inadequately controlled GERD symptoms despite using empiric PPI, a retrospective cohort study of patients without any response or with poor symptomatic control to empiric PPI (>2 months duration) who were referred to an Esophageal Studies Unit was conducted. Patients were studied using symptom questionnaires, endoscopy (+ or - for erosive disease, or Barrett's metaplasia) and multilevel esophageal biopsies (eosinophilia, metaplasia), esophageal motility (aperistalsis, dysmotility), 24-hour ambulatory esophageal pH monitoring (+ if % total time pH < 4 > 5%), and gastric emptying scanning (+ if >10% retention at 4 hours and >70% at 2 hours). Over 3 years, 275 patients (147 men and 128 women) aged 16-89 years underwent complete multimodality testing. Forty percent (n= 109) had nonerosive reflux disease (esophagogastroduodenoscopy [EGD]-, biopsy-, pH+); 19.3% (n= 53) had erosive esophagitis (EGD+); 5.5% (n= 15) Barrett's esophagus (EGD+, metaplasia+); 5.5% (n= 15) eosinophilic esophagitis (biopsy+); 2.5% (n= 7) had achalasia and 5.8% (n= 16) other dysmotility (motility+, pH-); 16% (n= 44) had functional heartburn (EGD-, pH-), and 5.8% (n= 16) had gastroparesis (gastric scan+). Cumulative symptom scores for chest pain, heartburn, regurgitation, and dysphagia were similar among the groups (mean range 1.1-1.35 on a 0-3 scale). Multimodality evaluation changed the diagnosis of GERD in 34.5% of cases and led to or guided alternative therapies in 42%. Overlap diagnoses were frequent: 10/15 (67%) of patients with eosinophilic esophagitis, 12/16 (75%) of patients with gastroparesis, and 11/23 (48%) of patients with achalasia or dysmotility had concomitant pathologic acid reflux by pH studies. Patients with persistent GERD symptoms despite empiric PPI therapy benefit from multimodality evaluation that may change the diagnosis and guide therapy in more than one third of such cases. Because symptoms are not specific and overlap diagnoses are frequent and multifaceted, objective evidence-driven therapies should be considered in such patients.