The effect of ciprofloxacin in the prevention of bacterial infection in patients with cirrhosis after upper gastrointestinal bleeding

OBJECTIVES

Cirrhotic patients with upper gastrointestinal bleeding are prone to bacterial infection. The aim of this study was to investigate the efficacy of prophylactic intestinal decontamination with oral ciprofloxacin for the prevention of bacterial infections in cirrhotic patients with upper gastrointestinal bleeding.

METHODS

A total of 120 cirrhotic patients with acute upper gastrointestinal bleeding were enrolled. Sixty patients received ciprofloxacin 500 mg twice daily given orally or through nasogastric tube immediately after upper gastrointestinal endoscopic examination; drug administration continued for 7 days. The remaining 60 patients, who received placebo, served as controls.

RESULTS

The incidence of proven bacterial infection in the ciprofloxacin-treated group was significantly lower than that of placebo group (10% vs 45%, p < 0.001). The incidences of bacteremia, spontaneous bacterial peritonitis, and urinary tract infection in the ciprofloxacin-treated group were significantly lower than those in the placebo group (0% vs 23%, 3.3% vs 13%, and 5% vs 18%, respectively; p < 0.05, respectively). Multivariate logistic regression analysis showed that a lack of prophylactic treatment with ciprofloxacin and severity of cirrhosis were the independent significant predictors for cirrhotic patients with acute gastrointestinal bleeding with infection.

CONCLUSIONS

Prophylactic intestinal decontamination with oral ciprofloxacin is effective in the prevention of bacterial infections in patients with cirrhosis who were suffering from acute upper gastrointestinal hemorrhage.

Vascular hyporeactivity persists despite increased contractility after long-term administration of isosorbide dinitrate in portal hypertensive rats

BACKGROUND/AIMS

Portal hypertension is associated with decreased vascular responsiveness to vasoconstrictors, which may contribute to the hyperdynamics. Isosorbide dinitrate is an effective portal hypotensive drug. The present study aimed to investigate whether chronic administration of isosorbide dinitrate could affect vascular responsiveness in portal hypertensive rats.

METHODS

Portal hypertension was induced by partial portal vein ligation. Sham-operated (Sham) rats served as controls. There were four animal groups for this study: portal vein ligation-isosorbide dinitrate group, portal vein ligation-vehicle (Veh) group, Sham-isosorbide dinitrate group and Sham-Veh group. Isosorbide dinitrate (5 mg x kg(-1) x 12 h(-1) was given by gavage for 8 days starting 1 day before ligation and continuing thereafter. Mesenteric arteries were removed for contractile study after hemodynamic measurement.

RESULTS

Contractile responses to KCI (15-90 mM) and phenylephrine (10(-9)-10(-4) M) were recorded. Both vascular reactivity and sensitivity were significantly reduced in portal vein ligation rats as compared to Sham rats. Chronic isosorbide dinitrate treatment reduced portal venous pressure in portal vein ligation rats. Moreover, the maximal contractile responses to KCl and phenylephrine were significantly enhanced in both portal vein ligation and Sham rats after isosorbide dinitrate treatment, but relative hyporeactivity persisted in portal vein ligation rats. In contrast, a single dose of isosorbide dinitrate did not alter the contractile sensitivity or reactivity to KCl or phenylephrine in either portal vein ligation or Sham rats.

CONCLUSION

Our results show that long-term administration of isosorbide dinitrate enhanced vascular contractility in both portal vein ligation and Sham rats, but relative hyporeactivity persisted in portal vein ligation rats.

Can advanced hemostatic parameters detect disseminated intravascular coagulation more accurately in patients with cirrhosis of the liver?

BACKGROUND

Laboratory diagnosis of disseminated intravascular coagulation (DIC) is difficult in patients with cirrhosis of the liver due to the complicated hemostatic changes of DIC. More recently, newer molecular hemostatic markers have been used to improve the diagnosis of DIC. This study evaluated the ability of the more advanced hemostatic tests to diagnose DIC in patients with cirrhosis of the liver.

METHODS

A series of hemostatic tests and parameters including activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), factor VIII assay, antithrombin (AT) activity, fibrinogen, plasminogen, protamine sulfate test (PST), fibrin (ogen) degradation product (FDP), D-dimer, thrombin-antithrombin complex (TAT) (measured by modified antithrombin, ATM), euglobulin lysis test (ELT) and platelet count were performed in 51 patients with cirrhosis of the liver. A diagnosis of DIC was made according to the following parameters and criteria: a) platelets less than 80 x 10(9)/l; b) PT greater than 1.5, c) APTT greater than 1.3; d) TT greater than 24 sec; e) AT less than 60%; f) ATM greater than 14.7 ng/ml (normal, mean +/- 3 SD); g) fibrinogen less than 1.50 g/l; h) positive PST; i) D-dimer greater than 1.0 microgram/ml; j) FDP greater than 20 micrograms/ml; k) ELT less than 150 min; l) plasminogen less than 50%. DIC was diagnosed if six or more of the above items were present, and at least two of them were item (a) to (h), and at least two were item (g) to (l).

RESULTS

Although eight patients had results that fitted the diagnostic criteria of DIC by using the more advanced tests, only two of them were diagnosed with DIC by conventional testing. The concentration of factor VIII in these eight patients did not markedly decrease.

CONCLUSIONS

New tests are not necessary to improve the diagnosis of DIC in patients with cirrhosis of the liver.

Oxidative stress: an important phenomenon with pathogenetic significance in the progression of acute pancreatitis

BACKGROUND

Reactive oxygen species and related oxidative damage have been implicated in the initiation of acute pancreatitis. Changes in these parameters during disease progression merit further investigation.

AIMS

To evaluate changes and the clinical relevance of superoxide radicals, endogenous antioxidants, and lipid peroxidation during the course of acute pancreatitis.

PATIENTS AND METHODS

Superoxide radicals (measured as lucigenin amplified chemiluminescence), ascorbic acid, dehydroascorbic acid, alpha tocopherol, and lipid peroxidation (measured as thiobarbiturate reactive substances) were analysed in blood samples from 56 healthy subjects, 30 patients with mild acute pancreatitis, and 23 patients with severe acute pancreatitis. The association with grades of disease severity was analysed. Measurements were repeated one and two weeks after onset of pancreatitis.

RESULTS

In the blood from patients with acute pancreatitis, there were increased levels of the superoxide radical as well as lipid peroxides. There was notable depletion of ascorbic acid and an increased fraction of dehydroascorbic acid. Changes in alpha tocopherol were not great except in one case with poor prognosis. Differences between severe and mild acute pancreatitis were significant (p < 0.01). Variable but significant correlations with disease severity scores were found for most of these markers. The normalisation of these indexes postdated clinical recovery one or two weeks after onset of disease.

CONCLUSIONS

Heightened oxidative stress appears early in the course of acute pancreatitis and lasts longer than the clinical manifestations. The dependence of disease severity on the imbalance between oxidants and natural defences suggests that oxidative stress may have a pivotal role in the progression of pancreatitis and may provide a target for treatment.

Weekly etoposide, epirubicin, cisplatin, 5-fluorouracil and leucovorin: an effective chemotherapy in advanced gastric cancer

In order to optimize the therapeutic index of combining etoposide, epirubicin, cisplatin, 5-fluorouracil (5-FU), leucovorin (EEPFL) chemotherapy in the treatment of advanced gastric cancer, a trial of a novel schedule of weekly administration was conducted. Weekly EEPFL treatment consisted of a concomitant boost of etoposide 40 mg m(-2) i.v. over 30 min, epirubicin 10 mg m(-2) i.v. over 5 min to a backbone regimen, weekly PFL chemotherapy with cisplatin 25 mg m(-2), 5-FU 2200 mg m(-2), leucovorin 120 mg m(-2) given simultaneously by 24-h i.v. infusion. Response, survival and toxicity were evaluated. Forty-two patients were studied. Median age was 69 (range 31-84) years. Twenty-six per cent of patients showed complete response and 45% partial response. The overall response rate was 71% (95% confidence interval 58-84%). For a total of 507 weekly EEPFL cycles delivered, the incidence of grade 4 leucopenia was 1% of cycles. One patient died of neutropenia septicaemia. There was no other grade 4 toxicity. Grade 3 and 2 leucopenia occurred in 7% and 14% of cycles. The incidence of grade 3 and 2 mucositis was 1% and 3% of cycles. Grade 3 and 2 diarrhoea occurred in 0.4% and 1.6% of cycles. Overall median survival was 10 months (range 3-41+ months). Weekly EEPFL chemotherapy is an effective regimen with tolerable toxicities in the treatment of advanced gastric cancer. A randomized controlled clinical trial to formally assess the efficacy and benefit of EEPFL chemotherapy is under way.

Effect of long-term octreotide and isosorbide dinitrate on haemodynamics in rats with portal vein stenosis

1. Both octreotide and isosorbide dinitrate have been shown to have portal hypotensive effects in animals with portal hypertension. Moreover, in both animals and humans with portal hypertension, the reduction of portal pressure was enhanced when nitrovasodilators were combined with propranolol or vasopressin. The present study was undertaken to evaluate the effect of long-term administration of octreotide and isosorbide dinitrate on haemodynamics in rats with portal vein stenosis. 2. Portal hypertension was induced by portal vein stenosis. Portal hypertensive rats were allocated into one of four groups (eight rats in each group): vehicle group, octreotide group (100 micrograms/kg via subcutaneous injection every 12 h), isosorbide dinitrate group (5 mg/kg via gastric gavage every 12 h) and combined treatment group. Drug was given for eight consecutive days, starting 1 day before surgery. Haemodynamic values were measured using a radioactive microsphere technique. 3. Long-term octreotide treatment decreased portal pressure and improved the hyperdynamic circulation. In contrast, long-term administration of isosorbide dinitrate reduced portal pressure but did not ameliorate vasodilatation. A combination of octreotide and isosorbide dinitrate improved the hyperdynamic circulation with a reduction of portal pressure. In addition, the mean value of portal pressure after combination treatment was significantly lower than in rats receiving octreotide alone. 4. These results showed that, in rats with portal hypertension, long-term combined administration of octreotide and isosorbide dinitrate improved the hyperdynamic circulation together with a more profound reduction of portal pressure than rats receiving octreotide alone.

Clinical significance of serum auto-antibodies in Chinese patients with chronic hepatitis C: negative role of serum viral titre and genotype

Positive serum anti-nuclear antibody (ANA) and anti-smooth muscle antibody (SMA) have been reported in 10-66% of patients with chronic hepatitis C virus (HCV) infection from Western countries. However, the mechanism involved in this immunological disorder is still unknown. This study was carried out to evaluate the prevalence and clinical significance of positive serum auto-antibodies in Chinese patients with chronic hepatitis C and to assess the role of serum HCV-RNA titre and HCV genotype in the presence of serum auto-antibodies. Serum ANA, SMA and anti-mitochondrial antibody (AMA) were measured in 122 patients with chronic hepatitis C. Clinical, biochemical and virological data (serum HCV-RNA titre and HCV genotype) were compared between patients with and without serum auto-antibodies. Fifty-eight (48%) patients were associated with positive serum auto-antibodies: 42 (34%) positive for ANA, six (5%) positive for SMA, nine (7%) positive for both ANA and SMA and one (1%) positive for AMA. Clinical parameters (age, sex, blood transfusion history), liver biochemical tests, the presence of cryoglobulinaemia or cirrhosis, and the response to interferon treatment were not significantly different between patients with and without positive serum auto-antibodies. Serum HCV-RNA levels and HCV genotypes were also not significantly different between the two groups. Logistic regression analysis showed that none of the previously mentioned parameters were significant predictors to associate with serum auto-antibodies in chronic hepatitis C. We concluded that 48% of Chinese patients with chronic hepatitis C were associated with positive serum auto-antibodies. Hepatitis C virus genotypes and serum HCV-RNA levels were not correlated to the presence of serum auto-antibodies. The clinical significance and actual pathogenesis of this phenomenon remain to be clarified.

Helicobacter pylori colonization does not influence the symptomatic response to prokinetic agents in patients with functional dyspepsia

Functional dyspepsia (FD) is very common, but the pathogenesis of Helicobacter pylori leading to FD is still debated. The aim of this study was first to evaluate the impact of H. pylori colonization on the efficacy of Paspertase (a metoclopramide plus exogenous enzymes regimen for FD patients) and, second, to compare the prevalence of H. pylori infection in FD patients with the general population. Seventy-four consecutive FD patients were enrolled undergoing Paspertase treatment. The symptomatic response was evaluated according to 1-4 scales of six main dyspeptic symptoms (i.e. epigastric pain/discomfort, early satiety, heartburn, nausea/vomiting, abdominal fullness/bloating, and belching). Nine hundred and seventy healthy subjects undergoing a paid physical check-up were included to study the status of H. pylori colonization. The demographic data and basal symptom scores between 43 H. pylori-positive and 31 H. pylori-negative patients were not significantly different. Total and individual symptom scores improved significantly after 4 weeks of Paspertase therapy (P < 0.05), irrespective of H. pylori infection. The prevalences of H. pylori were very similar in FD patients and the general population (58.1 vs 58.0%, NS). In conclusion, these observations suggest that H. pylori colonization is not significant in FD patients of Taiwan while a short-term prokinetic medication is effective for these patients, irrespective of H. pylori status.

The impact of traveling to endemic areas on the spread of hepatitis E virus infection: epidemiological and molecular analyses

Traveling to endemic areas carries a risk of hepatitis E virus (HEV) infection, but no molecular analysis to document sources of infection is available. Eighteen (38%) of 47 patients with acute non-A, non-B, non-C hepatitis were positive for antibody to HEV (anti-HEV), and 9 (50%) of these were also positive for serum HEV RNA by polymerase chain reaction following reverse transcription. Only 1 (5%) of the 21 patients with acute hepatitis A was positive for HEV RNA. Travel to endemic areas (mostly to China; odds ratio, 22.2; 95% confidence interval, 4.7-105.8) and deeper jaundice (odds ratio, 5.2; 95% confidence interval, 1.01-27.2) were the only factors associated with HEV infection in multivariate analysis. The two HEV isolates from two patients who had traveled to China and the HEV isolate from a patient whose travel history was obscure formed a monophyletic group with the isolates from Guangzhou. The HEV isolates from our patients show a homology of 72% to 78% in nucleotide sequence with the Burma, Beijing, India, Pakistan, and Xiangjiang strains; a homology of 81% to 91% with the Guangzhou strains; and a homology of 76% with the Mexico strain. The close relationship between the Taiwan isolates and the Guangzhou strains was further supported by the short Kimura's two-parameter distances among them. In summary, HEV infection does occur in this area. Epidemiological and molecular analyses strongly indicate that most cases of HEV infection originated from travel to HEV-endemic areas.

Quantitative measurement of serum HCV RNA in patients with chronic hepatitis C: comparison between Amplicor HCV monitor system and branched DNA signal amplification assay

Quantitative measurement of serum hepatitis C virus (HCV) RNA is important in predicting and monitoring the therapeutic effects of interferon in treating patients with chronic hepatitis C. We compared two commercial available assays, Roche Amplicor HCV Monitor test kits and Chiron branched DNA signal amplification (bDNA) assay, in quantitative measurement of serum HCV RNA in 74 patients with chronic hepatitis C. The serum HCV RNA of each of these patients was qualitatively positive by conventional reverse transcription-nested polymerase chain reaction. Serum HCV RNA was detected positive by the Amplicor test kits in 63 (85%) patients and by the bDNA assay in 58 (78%) patients (P > 0.05). The quantitative results of HCV RNA detected by both assays showed a good linear correlation (r = 0.56, P < 0.001). Amplicor test kits detected 5 patients with low viremia which were below the detection limit of the bDNA assay (2.0 x 10(5) genome equivalents/ml). However, the mean HCV RNA values detected by the Amplicor test kits was 1.26 log lower than that of the bDNA assay. The Amplicor test kits detected only 5 samples (8%) with a HCV RNA value greater than 5 x 10(6) copies/ml, while the bDNA assay detected 23 samples (40%) with a HCV RNA value greater than 5 x 10(6) genome equivalents/ml (P < 0.01). HCV genotype did not affect the positive rate of HCV RNA measurement detected by both assays. However, a significantly higher mean serum HCV RNA value was noted in HCV genotype 1b as compared with the other genotypes. We concluded that the Roche Amplicor HCV Monitor test kits and the Chiron branched DNA signal amplification assay are equally sensitive in the quantitative measurement of serum HCV RNA in patients with chronic hepatitis C and can be reliably used in measuring HCV viremia clinically.

The relationship of Helicobacter pylori colonization, the serum pepsinogen A level, and gastric resection

The serum levels of pepsinogen A (PGA) were measured in patients who underwent various forms of gastric resection to assess whether Helicobacter pylori (HP) colonization has any influence. Included in this study were 48 patients who underwent subtotal gastrectomy for a peptic ulcer (SGPU), 36 who underwent radical subtotal gastrectomy for gastric carcinoma (SGGC), 16 who underwent truncal vagotomy plus antrectomy (TV + AE), 24 with recurrent ulcer (RU) and 27 who underwent total gastrectomy (TG). The mean serum PGA levels in these five groups and in 40 healthy controls were 49.1 +/- 30.4 ng/ml, 30.0 +/- 14.8 ng/ml, 44.8 +/- 21.7 ng/ml, 66.4 +/- 42.8 ng/ml, 8.7 +/- 3.0 ng/ml, and 94.7 +/- 27.9 ng/ml, respectively. All patients except those with RU showed a diminished PGA level. The HP colonization rates of the patients who underwent partial resection were 45.8%, 22.2%, 50%, and 54.2%, respectively (P < 0.05). Age, gender, smoking, the type of gastroenterostomy, and underlying disease did not exert any influence on the measured PGA levels. However, higher PGA levels were observed in HP-colonized patients who either underwent SGPU or had RU. We conclude that various forms of distal gastrectomy, but not RU, elicit an indistinguishable acid secretory ability while HP colonization is responsible for the higher serum PGA levels in some patients following peptic ulcer surgery.

Chronic administration of octreotide ameliorates portal hypertension and portal hypertensive gastropathy in rats with cirrhosis

1. Portal hypertension and hyperdynamic circulation have been postulated to play a role in the pathogenesis of portal hypertensive gastropathy. Administration of octreotide to portal hypertensive rats has been shown to reduce portal pressure and ameliorate hyperdynamic circulation. 2. This study investigated the effects of chronic administration of octreotide on systemic and portal haemodynamics and the development of portal hypertensive gastropathy in carbon tetrachloride-induced cirrhotic rats. 3. After 12 weeks of carbon tetrachloride induction, cirrhotic rats were randomly assigned to receive either placebo (5% dextrose in water) or octreotide (65 micrograms/kg in 5% dextrose in water) subcutaneously twice daily for 10 days. Haemodynamic studies with a thermodilution technique and gastric morphometric analyses were performed at 10 days after treatment. 4. In cirrhotic rats, octreotide treatment induced a significant increase in systemic vascular resistance (2.7 +/- 0.2 versus 3.4 +/- 0.2 mmHg/ml.min-1.100 g-1, P < 0.05) and decrease in portal pressure (12.5 +/- 1.2 versus 9.9 +/- 0.5 mmHg, P < 0.05) compared with placebo-treated rats. In addition, octreotide treatment significantly reduced the mean cross-sectional area of gastric mucosal vessels (2290 +/- 145 versus 1810 +/- 101 micron 2, P < 0.05). 5. This study shows that chronic octreotide treatment ameliorates the development of portal hypertensive gastropathy in cirrhotic rats. The effect of octreotide on portal hypertensive gastropathy may, at least partly, be due to the alleviation of portal hypertension and hyperdynamic circulation.

Heterobifunctional membranes by plasma induced graft polymerization as an artificial organ for penetration keratoprosthesis

Highly biocompatible polymer membrane was developed for an artificial cornea in this surface modification study. Heterobifunctional silicone rubber membranes (hetero-SR) were prepared by grafting different functional polymers on each side of a silicone rubber membrane (SR). A novel type of bifunctional membrane was developed with the upper-side favoring cell attachment and growth, and the lower-side suppressing cell adhesion. The preparation of heterobifunctional membranes, characterization of polymer membrane surface properties such as ATR-FTIR and ESCA and contact angle, and biological analysis (in vitro and in vivo studies) were investigated in this work. Based on the biological analysis, the heterobifunctional membrane displays promising potential for use as an artificial cornea.

Monoclonal endothelial cell proliferation is present in primary but not secondary pulmonary hypertension

The etiology and pathogenesis of the vascular lesions characterizing primary pulmonary hypertension (PPH), an often fatal pulmonary vascular disease, are largely unknown. Plexiform lesions composed of proliferating endothelial cells occur in between 20 and 80% of the cases of this irreversible pulmonary vascular disease. Recently, technology to assess monoclonality has allowed the distinction between cellular proliferation present in neoplasms from that in reactive nonneoplastic tissue. To determine whether the endothelial cell proliferation in plexiform lesions in PPH is monoclonal or polyclonal, we assessed the methylation pattern of the human androgen receptor gene by PCR (HUMARA) in proliferated endothelial cells in plexiform lesions from female PPH patients (n = 4) compared with secondary pulmonary hypertension (PH) patients (n = 4). In PPH, 17 of 22 lesions (77%) were monoclonal. However, in secondary PH, all 19 lesions examined were polyclonal. Smooth muscle cell hyperplasia in pulmonary vessels (n = 11) in PPH and secondary PH was polyclonal in all but one of the examined vessels. The monoclonal expansion of endothelial cells provides the first marker that allows the distinction between primary and secondary PH. Our data of a frequent monoclonal endothelial cell proliferation in PPH suggests that a somatic genetic alteration similar to that present in neoplastic processes may be responsible for the pathogenesis of PPH.

Pharmacokinetics of a non-narcotic analgesic, DA-5018, in rats

The pharmacokinetics of a non-narcotic analgesic, DA-5018, were compared after single intravenous (i.v.), subcutaneous (s.c.), and oral administrations, and after multiple (seven consecutive days) s.c. administration to rats. After i.v. administration of DA-5018, 1, 2, and 5 mg kg-1, the pharmacokinetic parameters of DA-5018 were independent of the dose ranges studied. After oral administration of DA-5018, absorption of the drug from gastrointestinal (GI) tract was fast, but the extent of absolute bioavailability (F) was low; the values were 23.2, 23.0, and 27.3% for 2, 5, and 10 mg kg-1, respectively. After single s.c. administration of DA-5018, absorption of the drug from the injected site was fast and the extent of absorption was fairly good; the F values were 74.5 and 71.8% for 2 and 5 mg kg-1, respectively. The lower F values after oral administration of DA-5018 to rats could be due to degradation of the drug in rat GI tract and/or considerable first-pass effect. After i.v., oral, and s.c. administration of DA-5018, the drug had a strong affinity to the rat tissues studied as reflected in the greater-than-unity tissue to plasma ratio. After i.v., oral, and s.c. administration of the drug, the biliary and urinary excretion of unchanged DA-5018 were negligible. There was no significant difference in the pharmacokinetics or tissue distribution of DA-5018 between single and multiple s.c. administration of the drug, 5 mg kg-1, to rats, indicating that there could be no tissue accumulation of the drug after multiple s.c. administration of the drug to rats.

Overexpression of cyclin A but not Skp 2 correlates with the tumor relapse of human hepatocellular carcinoma

Cyclin A is an S- and G2-M-phase regulatory protein, and its abnormal expression has been implicated in cellular transformation. This work was undertaken to investigate the frequency of cyclin A overexpression and the correlated clinical outcome in human hepatocellular carcinoma (HCC). Herein, 12 of 31 (39%) patients exhibited cyclin A overexpression in their tumorous tissues, resulting from gene amplification in 6 of 12 patients, (post)transcription in 4 of 12 patients, and (post)translation in 2 of 12 patients. Patients who overexpressed cyclin A had significantly more tumor cells in the S and G2-M phases compared with those expressing a normal cyclin A level (P = 0.007 and 0.039, respectively). Increased levels of Skp 2, a cyclin A-interacting protein, were also found in 17 of 31 (55%) of HCC patients who showed a trend to have more S-phase tumor cells (P = 0.07). By an unpaired Student's t test and a Fisher's exact or chi2 analysis, overexpression of cyclin A had a strong correlation with elevated Skp 2 expression and increased alpha-fetoprotein levels (P = 0.001 and 0.009, respectively), but it was not associated with patients' age, tumor size, cirrhosis, or the positive detection of hepatitis B virus surface antigen. In the disease-free survival analysis, patients whose tumors overexpressed cyclin A had a median disease-free survival of 6 months, whereas patients who lacked cyclin A overexpression exhibited a longer median period of 29 months (P = 0.046). The overall survival analysis revealed the same trend, i.e., cyclin A-overexpressing patients had shorter overall survival periods (median, 12 versus 50 months; P = 0.09). By multivariate analysis, the correlation of cyclin A overexpression with shorter disease-free periods remained significant after adjustment for Skp 2 overexpression and alpha-fetoprotein induction (P = 0.019). These data suggest that overexpression of cyclin A can be an independent prognostic factor for the tumor relapse of human HCC.

The incidentally found leiomyoma that was in a resected stomach and its follow-up

BACKGROUND/AIMS

A prospective study measured the occurrence of leiomyoma in patients receiving various gastric surgeries and the probable characteristics of patients presenting an incidental leiomyoma.

METHODOLOGY

Twenty-eight (3.5%) patients with gastric leiomyoma were encountered among 796 resected stomach specimens within the past two years. Of these patients, 11 exhibiting a submucosal tumor were preoperatively diagnosed with endoscopy, whereas 17 showing leiomyoma were incidentally found during a thorough survey of the resected stomach specimens. Their demographic characteristics were compared.

RESULTS

Occurrence of incidental leiomyoma tended to be more common in patients with gastric cancer than in other lesions (3.2% vs 0.9%, p = 0.0513). Comparing the characteristics of patients showing incidental leiomyoma and pre-operatively diagnosed submucosal tumor, their differences in age, gender, tumor location or number were not significant. However, the former usually exhibited tiny lesions without an overlying necrotic ulcer. Recent endoscopic follow-up did not find any evidence of recurrence.

CONCLUSIONS

Incidental leiomyoma is not rare in resected specimens. Most lesions are tiny without overlying ulcer and gross recurrence looks impossible. Pre-operative diagnosis of this lesion remains difficult since a warning sign of leiomyoma never exists.

Predictive factors for rebleeding in patients with peptic ulcer bleeding after multipolar electrocoagulation: a retrospective analysis

The role of endoscopic therapy for peptic ulcer bleeding is well-documented. Nevertheless, rebleeding occurs in 10% to 30% of patients, and such patients are at high risk for death without early retreatment or definitive surgery. The aim of our study was to predict which patients would rebleed within 1 month after successful multipolar electrocoagulation of 100 patients with active peptic ulcer bleeding (spurting, oozing, or nonbleeding visible vessel). We had achieved initial hemostasis in 97 patients and carried out univariate and multivariate analyses to predict which patients would rebleed. Rebleeding occurred within 1 month in 17 (17.5%) patients. we correlated 20 clinical and endoscopic factors with rebleeding episodes. With univariate analysis, blood transfusion of 500 ml or more at entry (p < 0.0001) and use of cimetidine (p = 0.01) were statistically significant for rebleeding. With multivariate analysis, use of omeprazole was an independent factor for preventing rebleeding (odds ratio, 7.68; 95% confidence interval, 1.642-35.929). We suggest that omeprazole may help to prevent rebleeding in patients who have had hemostasis with multipolar electrocoagulation.

Effect of sucralfate granules in suspension on endoscopic variceal sclerotherapy induced ulcer: analysis of the factors determining ulcer healing

Oesophageal ulcers commonly occur after endoscopic variceal sclerotherapy and usually cause complications and a delay in further sclerotherapy. The aims of this study are to investigate the effect of sucralfate granules in suspension on the treatment of endoscopic variceal sclerotherapy induced ulcer and analyse the factors determining the ulcer healing. Fifty-two patients with oesophageal variceal bleeding received elective endoscopic variceal sclerotherapy. After endoscopically proved oesophageal ulcers, they were randomized to receive either sucralfate granules in suspension (n = 22) or antacid (n = 23). Follow-up endoscopy was performed weekly. Ulcer healing rates were compared between the groups using the log-rank test. Forty-one ulcers receiving sucralfate and 48 ulcers receiving antacid treatment were evaluated. The clinical characteristics of the ulcers were similar in both groups. The ulcers in patients receiving sucralfate healed faster than those receiving antacid (P<0.02). On analysis of factors affecting ulcer healing, ulcers smaller than 1 cm2 (n = 59) appeared to heal faster than those larger than 1 cm2 (n = 30; P= 0.059) and shallow ulcers (n = 46) healed faster than deep ulcers (n = 43; P<0.001). On multifactorial analysis, ulcer depth was the only factor determining ulcer healing. The ulcer healing effects of sucralfate became more prominent when the ulcer was larger than 1.0cm2 (1.7+/-0.6 weeks vs 2.3+/-0.6 weeks, P= 0.011) and deep (1.7+/-0.7 weeks vs 2.5+/-1.0 weeks, P= 0.013) when compared with those receiving antacid. Sucralfate granules in suspension speed the healing of endoscopic variceal sclerotherapy induced ulcer, especially deep and large ulcers.

Severe colonic complications in acute pancreatitis

BACKGROUND

Colonic complications in patients with acute pancreatitis may be very severe and have rarely been analyzed in Chinese patients.

METHODS

We retrospectively evaluated 1,637 patients with acute pancreatitis who were admitted to the Veterans General Hospital-Taipei from January 1986 to December 1995 in order to identify those with severe colonic complications. The clinical, radiologic and pathologic features and surgical findings in these patients are reviewed.

RESULTS

Eight of 1,637 patients with acute pancreatitis had severe colonic complications. Six of them were diagnosed between two and eight weeks after the onset of clinical pancreatitis. All had a Ranson's score of at least 3. Four patients, including one with hematochezia, had a strong positive reaction for occult blood in stool specimens. Computed tomography (CT) revealed necrotizing pancreatitis and colonic wall swelling in all eight patients. Colonic involvement was discovered by CT in two patients prior to surgery, one with colocutancous fistula and the other with colonic perforation. The other six patients were found to have colonic involvement incidentally at the time of laparotomy. All of the colonic involvements were located near the splenic flexure. In addition to necrosectomy, three patients underwent segmental hemicolectomy and the remaining five patients had simple closure of the perforation. Diverting loop ileostomy or colostomy was also carried out in all patients. Three patients (34%) died of overwhelming sepsis superimposed on the subsequent multiple organ failure between 44 and 122 days after the onset of pancreatitis.

CONCLUSIONS

Severe colonic complications of acute pancreatitis are rare. Although preoperative diagnosis is difficult, CT may be helpful to make an early diagnosis. These complications should be suspected in patients with severe acute pancreatitis when acute lower gastrointestinal hemorrhage or positive stool occult blood is found two to eight weeks after the onset of pancreatitis or when CT reveals necrotizing pancreatitis and colonic wall swelling; this will allow early surgical intervention.

Hemodynamic effects of eight-day octreotide and propranolol administration in portal hypertensive rats

Octreotide and propranolol are both effective portal hypotensive drugs in the control or prevention of variceal bleeding. The present study was undertaken to investigate the hemodynamic effects of octreotide and propranolol, alone or in combination, in portal hypertensive rats. Portal hypertension was induced by partial portal vein ligation. Portal hypertensive rats were allocated into one of the four groups: vehicle group (saline, 0.5 ml/day), octreotide group (100 microg/kg/12 hr), propranolol group (30 mg/kg/day), and octreotide (100 microg/kg/12 hr) plus propranolol (30 mg/kg/day) group. Propranolol or saline was administered by gavage, octreotide by subcutaneous injection. Drug was given one day before ligation and continued for eight consecutive days. Systemic as well as splanchnic hemodynamic parameters were measured thereafter. The portal venous pressure, portal tributary blood flow, and cardiac index were significantly reduced by octreotide, propranolol, or octreotide plus propranolol in portal hypertensive rats. Portal territory, systemic, and renal vascular resistances were significantly enhanced, while hepatic arterial blood flow significantly reduced, in the octreotide and octreotide plus propranolol groups as compared to vehicle group. Our results showed that eight-day administration of octreotide, propranolol, or octreotide plus propranolol led to portal hypotensive and antihyperdynamic effects in portal hypertensive rats. Overall, octreotide treatment alone resulted in better antihyperdynamic profiles than propranolol treatment alone. The combination of octreotide and propranolol offered no therapeutic benefits and was slightly less effective than octreotide alone.

Diagnostic value of anti-hepatitis D virus (HDV) antibodies revisited: a study of total and IgM anti-HDV compared with detection of HDV-RNA by polymerase chain reaction

A high serum titre (> or = 1000 or > or = 5000) of total antibody to hepatitis D virus (anti-HDV) and positive for immunoglobulin (Ig)M anti-HDV have been used to represent HDV replication, while reverse transcription-polymerase chain reaction (RT-PCR) is currently the most sensitive assay for detecting HDV viraemia. The aim of the present study was to re-evaluate the correlation of total anti-HDV and IgM anti-HDV with HDV viraemia based on RT-PCR and to assess the clinical significance of these markers in acute and chronic HDV superinfection. Chronic HDV infection was defined as positive HDV-RNA by RT-PCR for more than 6 months, while total anti-HDV titre was defined by serial dilution. Of 178 hepatitis B virus (HBV) carrier patients studied, 119 cases had been anti-HDV positive for more than 6 months. Two-thirds (79/119) were positive for HDV viraemia by RT-PCR. Only half the chronic HDV viraemic patients had a high titre (> or = 1000) of total anti-HDV, and there was only moderate agreement (kappa = 0.41) between total anti-HDV titre/IgM anti-HDV and HDV-RNA and chronic HDV viraemia. Based on cross-sectional and longitudinal follow-up analyses, serum total anti-HDV titres > or = 100 appeared to be an excellent cut-off titre (kappa = 0.91) in differentiating chronic from acute HDV infection among viraemic patients. In summary, IgM and a high titre total of anti-HDV are not good markers of HDV viraemia, but an anti-HDV titre of > or = 100 appears to be an excellent marker for the differentiation of acute from chronic HDV superinfection.

Effects of high dose octreotide on retrograde bile salt-induced pancreatitis in rats

The effects of somatostatin and octreotide (a long acting somatostatin analogue) in acute pancreatitis are inconclusive. This study examined the prophylactic and therapeutic effects of different doses of octreotide on retrograde sodium taurodeoxycholate-induced acute necrotizing pancreatitis in rats. The rats were divided into 4 groups receiving subcutaneous injection of saline, octreotide 10 microg/kg, 20 microg/kg at 0, 8 and 16 h and octreotide 20 microg/kg at 5, 13 and 21 h, separately. The serum levels of amylase and lipase, pancreatic histopathology, mortality and hemodynamics were examined. Octreotide significantly reduced serum levels of amylase and lipase at 12 h and the degree of pancreatic edema, necrosis and hemorrhage at 18-24 h as compared to the control group. Prophylactic octreotide 10 microg/kg significantly decreased the 24-h mortality from 100% to 44.4% (p < 0.05). The 24-h mortality further reduced to 12.5% and 10% with prophylactic and therapeutic octreotide 20 microg/kg, respectively. The decrease of mean arterial pressure at 12 h was significantly lower in octreotide groups than in the control group. We conclude that octreotide improves pancreatic histopathology and survival in acute necrotizing pancreatitis in rats.

Cloning and characterization of cDNAs encoding VH and VL of a monoclonal anti-CEA antibody (CEA 79) cross-reactive with NCA-95 and generation of a single-chain Fv molecule (scFv)

We cloned complementary DNA (cDNA) encoding the variable regions of heavy chain (VH) and of light chain (VL) of a monoclonal anti-carcinoembryonic antigen (CEA) antibody cross-reactive with nonspecific cross-reacting antigen-95 (NCA-95), which had been previously prepared and designated as CEA 79 (gamma 2a, kappa). From these cDNAs, a phagemid expression vector for the CEA79 single chain variable fragment (scFv) was generated. Enzyme-linked immunosorbent assay (ELISA), competitive ELISAs, and Western blotting confirmed that the scFv displayed on the surface of the bacteriophage had retained affinity for CEA and NCA-95. We then determined the nucleotide sequences of the cloned cDNAs for VH and VL. The sequence analysis revealed that VH and VL of the CEA 79 antibody represent new members of the mouse heavy chain subgroup "miscellaneous" and the kappa light chain subgroup "V", respectively.