Rabeprazole-based 3-day and 7-day triple therapy vs. omeprazole-based 7-day triple therapy for the treatment of Helicobacter pylori infection

BACKGROUND

Rabeprazole is a new proton pump inhibitor with more potent acid suppressive and anti-Helicobacter effects.

AIM

To compare two different regimens of rabeprazole-based triple therapy vs. 7-day omeprazole-based triple therapy for the eradication of Helicobacter pylori infection.

METHOD

Patients with proven H. pylori infection were randomized to receive: (i) 7-day rabeprazole, 10 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily; (ii) 3-day rabeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily; or (iii) 7-day omeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily. Endoscopy (CLO test, histology) was performed before randomization and 6 weeks after drug treatment.

RESULTS

One hundred and seventy-three patients were randomized. H. pylori eradication rates (intention-to-treat, n=173/per protocol, n=167) were 88%/91% for 7-day rabeprazole-based therapy, 72%/72% for 3-day rabeprazole-based therapy and 82%/89% for 7-day omeprazole-based therapy, respectively. The per protocol eradication rate was significantly better in the 7-day rabeprazole-based therapy and 7-day omeprazole-based therapy groups when compared to the 3-day rabeprazole-based therapy group (P=0.01 and P=0.04, respectively). Compliance was excellent and all three regimens were well tolerated.

CONCLUSIONS

The efficacy of seven-day rabeprazole-based triple therapy is similar to 7-day omeprazole-based triple therapy for the eradication of H. pylori infection.

Clinical and endoscopic characteristics of non-Helicobacter pylori, non-NSAID duodenal ulcers: a long-term prospective study

BACKGROUND

The proportion of duodenal ulcers not associated with Helicobacter pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs) is increasing.

AIM

To identify the clinical and endoscopic characteristics of non-H. pylori, non-NSAID duodenal ulcers.

METHODS

Clinical and endoscopic data and H. pylori status were prospectively collected from consecutive patients who underwent upper endoscopy from 1997 to 1999. Patients with duodenal ulcers were identified, and those with non-H. pylori, non-NSAID duodenal ulcers were analysed further.

RESULTS

A total of 11 717 upper endoscopies were performed in 8344 patients. Of these, 1153 (14%) had duodenal ulcers. Of 599 patients with active ulcers and known H. pylori status, 104 (17%) had ulcers not associated with H. pylori or the use of NSAIDs, 393 (66%) had ulcers associated with H. pylori alone, 51 (8.5%) had ulcers associated with the use of NSAIDs alone and 51 (8.5%) had ulcers associated with both. Multivariate logistic regression analysis revealed that the presence of concomitant diseases (odds ratio=15.0; 95% confidence interval, 8.64-25.9; P < 0.001) and the absence of epigastric pain/discomfort (odds ratio=0.52; 95% confidence interval, 0.29-0.91; P=0.022) were independent predictors for non-H. pylori, non-NSAID duodenal ulcers.

CONCLUSIONS

Non-H. pylori, non-NSAID duodenal ulcers exhibit certain distinct clinical and endoscopic characteristics. The presence of concomitant diseases is an important predictive factor.

An evaluation of the PyloriTek test for the diagnosis of Helicobacter pylori infection in Chinese patients before and after eradication therapy

BACKGROUND AND AIM

The PyloriTek Test Kit (a 1-h rapid urease test) was developed for the rapid diagnosis of Helicobacter pylori (H. pylori) during endoscopy. Most studies were performed in Western populations. The aim of this study was to evaluate the PyloriTek test for the diagnosis of H. pylori infection in Chinese population.

METHODS

Eligible patients without prior treatment or who had had recent eradication of H. pylori were recruited. During endoscopy, biopsies were taken from the antrum and corpus for an in-house rapid urease test (RUT), histology and for the PyloriTek test (one antral and one corpus biopsy). Results of the PyloriTek test were compared with the gold standard (RUT and histology).

RESULTS

Analysis of PyloriTek test results from the antrum alone (101 patients before eradication and 52 patients after eradication) showed a sensitivity, specificity, and accuracy of 96.3, 97.9, and 97.0%, respectively, for cases before eradication, and an accuracy of 100% for cases after eradication. The benefit of an additional body biopsy was marginal and only occurred in the pre-eradication group.

CONCLUSION

The PyloriTek test was highly accurate for the diagnosis of H. pylori infection before and after eradication therapy, with a final result available at 1 h, which is unmatched by any invasive test so far. It enhances clinical decision-making by allowing the clinicians or endoscopists to start therapy on the same day of an endoscopy visit. One biopsy from the antrum is highly reliable for this purpose.

Epidermal growth factor and its receptor in chronic active gastritis and gastroduodenal ulcer before and after Helicobacter pylori eradication

BACKGROUND

Helicobacteria pylori infection of gastroduodenal mucosa is strongly associated with gastritis and peptic ulcer disease. The aims of the present study were to compare the gastroduodenal mucosal levels of epidermal growth factor (EGF) and its receptor (EGFR) among H. pylori-negative controls and H. pylori infected patients with chronic active gastritis or gastroduodenal ulcer before and after H. pylori eradication.

METHODS

The protein levels of EGF in mucosal tissues and saliva were determined by a solid-phase enzyme-linked immunosorbent assay (ELISA). Repeat transcription-polymerase chain reaction and the following polymerase chain reaction ELISA were employed to examine the mucosal EGFR mRNA expression.

RESULTS

Mucosal injury and H. pylori infection increased EGF protein levels and EGFR mRNA expression in the antral mucosa. The concentration of EGF in saliva was not affected by mucosal damage or H. pylori infection. Successful H. pylori eradication normalized the EGFR mRNA back to its basal level 6 weeks after treatment. However, after unsuccessful eradication their high levels in the antrum persisted. All patients experienced ulcer healing after drug treatment, regardless of H. pylori eradication.

CONCLUSIONS

Mucosal damage increased the expression of EGF protein and EGFR mRNA in the gastric mucosa. H. pylori could induce the expression of EGFR but not the EGF in the antral mucosa. The expression of EGFR could be a contributing factor for ulcer healing in patients with H. pylori infection.

Twenty-minute 50 mg 13C-urea breath test without test meal for the diagnosis of Helicobacter pylori infection in Chinese

BACKGROUND

We have previously shown that the 75 mg 13C-urea breath test without citrate test meal is highly accurate for the diagnosis of Helicobacter pylori infection in Chinese subjects. A lower dose 50 mg 13C-urea breath test protocol with a sampling time at 20 min has not been validated previously.

AIM

To investigate the accuracy of a 20-min 50 mg 13C-urea breath test protocol in Chinese subjects.

METHODS

Consecutive dyspeptic patients referred for upper endoscopy were recruited. 13C-urea breath test was performed using (a) 75 mg and 50 mg of 13C-urea on two separate days without a test meal, and (b) 50 mg of 13C-urea with 2.4 g citrate as test meal, and compared with the gold standard [rapid urease test (CLO test) and histology]. Baseline, 20-min and 30-min breath samples were collected in all cases.

RESULTS

Two hundred and six patients were tested. The accuracy of the 50 mg 13C-urea breath test (no citrate) at 20 min and 30 min was 98%, comparable to that of the 50 mg 13C-urea breath test with citrate (99.1%) and the 75 mg 13C-urea breath test without citrate (100%).

CONCLUSIONS

A 20-min 50 mg 13C-urea breath test without citrate produced highly accurate results for the diagnosis of Helicobacter pylori infection and is more economical and convenient for the Chinese population.

Three-day lansoprazole quadruple therapy for Helicobacter pylori-positive duodenal ulcers: a randomized controlled study

AIM

To compare the efficacy and tolerability of a 3-day quadruple therapy with a standard 7-day triple therapy in eradicating Helicobacter pylori infection and healing duodenal ulcers.

METHODS

Patients with H. pylori-positive duodenal ulcers were randomized to receive either lansoprazole 30 mg, clarithromycin 500 mg, and metronidazole 400 mg twice daily for 7 days (LCM-7) or lansoprazole 30 mg, clarithromycin 500 mg, metronidazole 400 mg, and bismuth subcitrate 240 mg twice daily for 3 days (LCMB-3). No pre- or post-treatment acid suppression was used. Follow-up endoscopy was performed at week 6.

RESULTS

A total of 118 patients were recruited. Sixty patients in the LCM-7 group and 53 patients in the LCMB-3 group returned for endoscopy. Intention-to-treat eradication rates were 87% and 86% (P=0.94) and per protocol eradication rates were 87% and 94% (P=0.29) in the LCM-7 and LCMB-3 groups, respectively. Per protocol and intention-to-treat ulcer healing rates were 98% and 98% in LCM-7 and 100% and 91% in LCMB-3, respectively. There were no significant differences in efficacy in relation to the initial metronidazole and clarithromycin susceptibility. Significant reduction in the duration of side-effects was found in the LCMB-3 group.

CONCLUSION

The 3-day quadruple therapy is highly effective, better tolerated and can be considered as a first-line therapy in duodenal ulcer management.

An evaluation of invasive and non-invasive tests for the diagnosis of Helicobacter pylori infection in Chinese

BACKGROUND

Different tests are available for diagnosing Helicobacter pylori infection.

AIM

To compare the most commonly used tests either alone or in combination in Chinese patients with respect to routine clinical use or research purpose.

METHODS

A total of 294 consecutive dyspeptic patients without previous H. pylori treatment were recruited. During upper endoscopy, biopsies were taken from the antrum and corpus, for a commercially available CLO-test, an in-house rapid urease test, culture, polymerase chain reaction and histological examination. Patients then received a 13C-urea breath test. The H. pylori status of each patient was determined by a concordance of test results.

RESULTS

For routine clinical use, histology (antral plus corpus biopsies) had an accuracy of 100%, whilst the rapid urease test had an accuracy of 99.7%. The 13C-urea breath test was equally reliable, with an accuracy of 94.5%. Combinations of two tests did not confer additional advantage over the most accurate single test. For research purposes, the accuracy of using the criteria of two positives out of three diagnostic tests was 100% and equivocal results were not found.

CONCLUSION

Histology with or without a rapid urease test was highly accurate for routine clinical use. Alternatively, the 13C-urea breath test was an equally reliable non-invasive test. The two positives out of three tests approach was highly reliable in predicting H. pylori status of untreated Chinese patients in a research setting.

High prevalence of mixed infections by Helicobacter pylori in Hong Kong: metronidazole sensitivity and overall genotype

BACKGROUND

Diversity in metronidazole susceptibility and genotypes of Helicobacter pylori have been reported with varying results in different areas.

AIMS

To investigate the prevalence of multiple strain infection in a symptomatic Chinese population and to determine the metronidazole susceptibility pattern and genotypic characteristics of these infecting strains.

METHODS

Gastric biopsies from antrum, body and cardia were taken during upper endoscopy in symptomatic patients referred to our department. Pooled cultures and single colony isolates were obtained and tested for metronidazole susceptibility and random amplified polymorphic DNA (RAPD) fingerprint patterns.

RESULTS

A total of 461 isolates were successfully cultured from 46 patients. Fifty-seven per cent of subjects had metronidazole-resistant strains. Among them, 77% carried a mixture of sensitive and resistant strains, non-uniformly distributed in the gastric mucosa. Mixed genotypes were found by RAPD typing in 24% of subjects. These did not correlate with the metronidazole susceptibility/resistance pattern.

CONCLUSION

H. pylori infections with mixed metronidazole sensitive/resistant strains and mixed genotypes are common in Hong Kong. This makes it prudent to use bacterial strains from several biopsy sites when testing for traits such as drug resistance or virulence in relation to disease.

One-week ranitidine bismuth citrate-based triple therapy for the eradication of Helicobacter pylori in Hong Kong with high prevalence of metronidazole resistance

AIM

To compare 1-week ranitidine bismuth citrate-based (RBC) triple therapy vs. omeprazole-based (O) triple therapy for the eradication of Helicobacter pylori infection in Hong Kong with high prevalence of metronidazole resistance.

METHODS

Patients with non-ulcer dyspepsia and H. pylori infection were randomized to receive either: (i) RBCCM: ranitidine bismuth citrate (pylorid) 400 mg, clarithromycin 250 mg and metronidazole 400 mg; or (ii) OCM: omeprazole 20 mg, clarithromycin 250 mg and metronidazole 400 mg, each given twice daily for 1 week. Endoscopy (CLO test, histology and culture) and 13C-urea breath test were performed before randomization and 6 weeks after drug treatment.

RESULTS

A total of 180 patients were randomized. H. pylori eradication rates (intention-to-treat, n=180/per protocol, n=166) were 83%/92% for RBCCM and 66%/70% for OCM (P=0.01, intention-to-treat and P=0.001, per protocol, respectively). RBCCM treatment was unaffected by metronidazole susceptibility and achieved a significantly higher eradication rate in metronidazole-resistant cases (89%) than the OCM group (45%, P=0.0064).

CONCLUSION

One-week ranitidine bismuth citrate-based triple therapy is significantly better than omeprazole-based triple therapy for the eradication of H. pylori infection, especially in metronidazole-resistant cases. It is an effective regimen for the eradication of H. pylori infection in regions with a high prevalence of metronidazole resistance.

Rheumatoid arthritis T cells produce Th1 cytokines in response to stimulation with a novel trispecific antibody directed against CD2, CD3, and CD28

Rheumatoid arthritis (RA) T cells respond poorly to conventional mitogens. We have examined the proliferative and cytokine responses of T cells to a synthetic trispecific antibody (Tsab) directed against CD2, CD3, and CD28. In 11 subjects RA T cells proliferated more, and secreted significantly more IL-2, in response to Tsab than did control peripheral blood (PB) cells. Very high levels of IL-2 were produced by 2 patients with aggressive disease. Measurement of intracellular IL-2, IFN-gamma, IL-4, and IL-5 by flow cytometry showed a Th1 pattern of cytokine production in 13 RA and 9 control subjects. We conclude that RA T cells are not irreversibly inactivated, and that spatial arrangement of stimulating molecules may be important in eliciting maximal responses.

Evaluation of a new referral system for the management of dyspepsia in Hong Kong: role of open-access upper endoscopy

BACKGROUND

In the management of dyspepsia, upper endoscopy is an important component. In our locality, patients requiring upper endoscopy are conventionally referred to specialist clinics by family physicians. We have introduced the first open-access upper endoscopy service in Hong Kong, which has allowed family physicians to arrange endoscopy without prior specialist consultation. A study on the outcome of open-access upper endoscopy in contrast with the conventional referral system was conducted.

METHODS

For patients presenting with dyspepsia, family physicians in our region were given the option to arrange upper endoscopy directly with our Medical Endoscopy Unit in addition to the conventional referral to specialist clinics. The results were compared with those from the specialist clinic. A detailed prospective follow up was performed from June to September 1997 to evaluate the outcome and impact of open-access upper endoscopy.

RESULTS

From November 1996 to September 1999, 978 referrals for open-access upper endoscopy were received. The service significantly reduced the waiting time for the procedure by 16 weeks. Open-access upper endoscopy had similar detection rates for peptic ulcers and cancers compared with referrals from specialist clinics. Seventy-five percent of patients did not require further consultation with their family physicians within 2 months after endoscopy. It is a safe and effective procedure in establishing a definitive diagnosis. All family physicians were satisfied with the open-access upper endoscopy service.

CONCLUSIONS

This is the first Asian report on this service. Open-access upper endoscopy reduced waiting time from the patient perspective, decreased subsequent consultations with family physicians and reduced referral to specialist clinics as well as increased patient and doctor satisfaction. Both referral systems for endoscopy were similar in terms of the diagnostic yield.

A case report: persistent acantholytic dermatosis in chronic renal failure

INTRODUCTION

This is the second case of persistent acantholytic dermatosis in a patient with chronic renal failure, seen at the same institution in 2 years.

CLINICAL PICTURE

A 70-year-old Chinese man with end-stage renal failure on continuous ambulatory peritoneal dialysis for 6 months presented with pruritic rashes over the scalp and chest for 3 months. Histologically, the lesions resembled Darier's disease. Differential diagnoses include Darier's disease, Grover's disease and perforating dermatosis in chronic renal failure.

TREATMENT

The patient was treated with anti-histamines, topical steroids and emollients.

OUTCOME

Resolution of pruritus was documented. However, the extensive hyperkeratotic papules remained persistent.

CONCLUSION

A chronic non-remitting course is to be expected for this dermatoses in which the aetiology is unknown.

(13)C-urea breath test without a test meal is highly accurate for the detection of Helicobacter pylori infection in Chinese

BACKGROUND

Conventional (13)C-urea breath testing ((13)C-UBT) includes a test meal to delay gastric emptying, which, theoretically, improves the accuracy of the test. Citric acid has been proposed as the best test meal. However, recent studies have suggested that a test meal may not be necessary.

AIM

To investigate a new (13)C-UBT protocol without a test meal in a Chinese population.

METHODS

Consecutive dyspeptic patients referred for upper endoscopy were recruited. (13)C-UBT was performed on two separate days with or without a test meal (2.4 Gm citric acid) and compared with the 'gold standard' (CLO test and histology).

RESULTS

Two hundred and two patients were tested. Using receiver operating characteristics (ROC) analysis, the optimal delta-value and optimal measurement interval for UBT were 5% and 30 min, respectively, both with or without a test meal. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of (13)C-UBT with citric acid (96.5%, 97.7%, 98.2%, 95.6%, 97.0%) were similar to (13)C-UBT without a test meal (94.7%, 97.7%, 98.2%, 93.5%, 96.0%).

CONCLUSION

This simplified (13)C-UBT protocol without a test meal produced highly accurate and reliable results in the Chinese population.

Treatment of Helicobacter pylori in patients with duodenal ulcer hemorrhage--a long-term randomized, controlled study

OBJECTIVE

Eradication of Helicobacter pylori (H. pylori) in patients with uncomplicated duodenal ulcers prevents long-term recurrence of ulcers. We aimed to study whether treatment of H. pylori prevents the long-term recurrence of duodenal ulcer hemorrhage.

METHODS

Patients with duodenal ulcer bleeding and confirmed H. pylori infection were recruited. A total of 120 patients were randomly assigned to triple therapy (DeNoltab 120 mg, amoxycillin 500 mg, and metronidazole 300 mg four times daily) or DeNoltab 120 mg four times daily alone. No maintenance therapy was given during the follow-up period. The endpoints were the cumulative rates of symptomatic and bleeding duodenal ulcer recurrences.

RESULTS

Of the patients receiving the triple regimen, 85.1% had H. pylori eradicated as compared to 2.0% of patients receiving DeNoltab (p < 0.05). More patients in the DeNoltab group than those in the Triple group had recurrence of ulcer bleeding, but this did not reach statistical significance (12/60 vs 6/60, p = 0.20). Logistic regression analysis on clinical, personal, and endoscopic characteristics identified persistent H. pylori infection as the only independent predictor of recurrence of duodenal ulcer bleeding.

CONCLUSIONS

Treatment of H. pylori alone with the present bismuth-based triple therapy in patients with duodenal ulcer hemorrhage did not result in significant reduction in further bleeding episodes, although a trend was seen for the group that was given triple therapy. On the other hand, posttreatment H. pylori status was found to be an independent predictor of bleeding recurrence.

Predicting the success of external cephalic version with a scoring system. A prospective, two-phase study

OBJECTIVE

To develop a noninvasive and quantifiable scoring system based on clinical parameters to predict the success of external cephalic version (ECV) in women with breech presentation at term.

STUDY DESIGN

This was a prospective, two-phase, clinical study. Phase 1 was to develop a scoring system from 53 versions with singleton pregnancy in breech presentation at term using a standard protocol with fetal monitoring, ultrasound assessment and tocolysis. Phase 2 was to verify this scoring system by application to 88 versions using the same standard protocol as in phase 1.

RESULTS

The success rates for ECV in phases 1 and 2 were 64.2% and 61.4%, respectively, making the overall success rate 62.4%. The results of phase 1 showed that there were significant differences in the following parameters: head palpable, breech unengagement, symphysisfundal height and uterine relaxation. A scoring system based on these four clinical parameters was developed. When applied to 88 versions in the second phase, the likelihood ratio of successful ECV was > 30 if the version score was > or = 3 and < 1.8 if the version score was < or = 2.

CONCLUSION

Using our scoring system, prediction of successful ECV was possible without ultrasound scan or vaginal examination, and counseling could be given once breech presentation was diagnosed.

Incidence of neuropathy in HIV-infected patients on monotherapy versus those on combination therapy with didanosine, stavudine and hydroxyurea

BACKGROUND

Sensory neuropathy is a common adverse effect of the nucleoside analogue anti-retroviral drugs didanosine (ddl) and stauvudine (d4T). These drugs are increasingly being used in combination, and it is not currently known whether the incidence of neuropathy is higher with combination compared to individual drug use. It is also not known if hydroxyurea, used to potentiate the antiviral efficacy of these drugs, may also increase the risk of neuropathy. The purpose of this analysis is to investigate if the combination of ddl and d4T, with or without hydroxyurea, has a higher incidence of neuropathy than a single drug regimen.

METHODS

Data were obtained from patients followed longitudinally by the Johns Hopkins AIDS Services. Incidence rates of development of neuropathy were calculated for each of five regimens: ddl (+/- hydroxyurea), ddl + d4T (+/- hydroxyurea), and d4T. Cox proportional hazard regression was used to compare the relative risk of neuropathy for each regimen adjusting for CD4 cell count, other drugs received, and time on therapy.

RESULTS

A total of 1116 patients received at least one of the five regimens. There were 117 cases of neuropathy. The crude incidence rate of neuropathy ranged from 6.8 cases per 100 person-years for ddl to 28.6 cases per 100 person-years for ddl + d4T + hydroxyurea. Compared with ddl alone, and adjusting for CD4 cell counts and other variables, the relative risk of neuropathy was 1.39 [95% confidence interval (CI): 0.84-2.32] for d4T alone, 2.35 (95% CI: 0.69-8.07) for ddl + hydroxyurea, 3.50 (95% CI: 1.81-6.77) for ddl + d4T, and 7.80 (95% CI: 3.92-15.5) for ddl + d4T + hydroxyurea.

CONCLUSIONS

Based on the data, the risk of neuropathy is additive or even synergistic for ddl + d4T + hydroxyurea compared with ddl or d4T alone. The combination of ddl + d4T also increases the risk of neuropathy but less than when hydroxyurea is included.

Proliferative populations in intestinal metaplasia: evidence of deregulation in Paneth and goblet cells, but not endocrine cells

In the small intestinal mucosa, four principal epithelial cell lineages are found - the Paneth, goblet, enterocytic, and endocrine cell lineages. These cell lineages are terminally differentiated, non-proliferative, and derive from multipotent stem cells near the bases of the crypts of Lieberkühn. Intestinal metaplasia of the stomach is considered to be a premalignant condition. Since proliferative populations in this condition are not well studied, this feature was examined using double-labelling immunohistochemical and histochemical methods; 20 paraffin blocks of small intestinal mucosa and 24 paraffin blocks of intestinal metaplasia of the human stomach were studied. Double-staining was carried out with MIB-1 as a proliferation marker, with Alcian blue for goblet cells, anti-chromogranin A for endocrine cells, and p-dimethylaminobenzaldehyde-nitrite for Paneth cells. Double-labelling showed that numerous Paneth cells and goblet cells in intestinal metaplasia were in the cell cycle, but endocrine cells appeared non-proliferative. Double-labelled Paneth or endocrine cells were not seen in the control small intestinal mucosa but scanty double-labelled goblet cells were observed in normal intestinal mucosa. In intestinal metaplasia of the stomach, there is evidence of cell-cycle deregulation in the goblet and Paneth cell lineages. These observations have considerable implications for the biology and histogenesis of Paneth cells, goblet cells, and endocrine cells, and the nature of intestinal metaplasia in the gastric mucosa.

Antituberculosis drug-related liver dysfunction in chronic hepatitis B infection

Liver toxicity is a common side effect of antituberculosis (anti-TB) drugs. We studied the differences in liver dysfunction observed during anti-TB treatment between hepatitis B virus carriers (HBV) and noncarriers. Three hundred twenty-four patients on anti-TB drugs were recruited and followed up for 1 year. Forty-three patients with HBV and 276 non-HBV patients were included for analysis. Liver function tests and viral markers were monitored monthly. Liver biopsy was requested whenever the alanine transaminase (ALT) was persistently abnormal. Eighty-six HBV carriers who were not given anti-TB drugs were chosen as a second control and evaluated prospectively. The incidence of liver dysfunction was significantly higher in HBV carriers given anti-TB drugs (34.9%) when compared to noncarriers (9.4%, P <.001) and with HBV carriers not given anti-TB drugs (8.1%, P <.001). For patients given anti-TB drugs, HBV carriers who developed liver dysfunction were younger (P =.011) and had more severe liver injury compared with noncarriers (P =.008). By multiple logistic regression analysis, age (P =.002) and hepatitis B infection (P <.001) were the only 2 significant risk factors for hepatotoxicity related to anti-TB therapy.

Epidermal growth factor, epidermal growth factor receptors, intestinal growth, and adaptation

Epidermal growth factor (EGF) is an important constituent of several gastrointestinal secretions. Many studies in both animals and humans have shown EGF to have multiple effects upon gut epithelial cells. These include cytoprotection, stimulatory effects on cell proliferation and migration, induction of gene expression such as mucosal enzymes and trefoil proteins, and inhibitory effects on gastric acid secretion. The main conundrum associated with EGF action is the disparity between experimental studies on its luminal and systemic actions. Opinion is sharply divided as to whether or not EGF has any action when given luminally and on the site of the EGF receptors on gut epithelial cells. Most studies agree that the EGF receptors are located on the basolateral surface, in which case EGF should only be active if surface ulceration has occurred--unless there is translocation across the epithelium. There are several clinical situations in which EGF might be useful in cytoprotection and in stimulating repair and regeneration in the gut. These include necrotizing enterocolitis and mucositis, and it is to be hoped that the solid basis of experimental studies on EGF might stimulate work on this topic.

Undiagnosed breech revisited

OBJECTIVES

To study the incidence of undiagnosed breech and to compare the obstetric outcome with those diagnosed before the onset of labour in a local teaching hospital where external cephalic version at term is routinely offered.

DESIGN

A retrospective casenote analysis.

SETTING

Tsan Yuk Hospital, a teaching hospital in Hong Kong.

PARTICIPANTS

One hundred and thirty-one women with a singleton breech presentation at term, delivered in a local teaching hospital from 1 January 1997 to 31 December 1997. The group of 22 women who had successful external cephalic version performed was included.

RESULTS

Breech presentation was diagnosed at the antenatal clinic in 103 women (79%). In the remaining 28 women (21%), breech presentation was diagnosed for the first time after the onset of labour. Undiagnosed breech presentations were more likely to deliver vaginally (42%) than those diagnosed at the antenatal clinic (11%) (P < 0.001). Vaginal delivery was still more common in the undiagnosed group (46%) than the diagnosed group (26%), even when the group with successful external cephalic version was included (P < 0.05), although the difference became less obvious. The demographic characteristics, birthweight, type of breech and short term neonatal outcomes were comparable between the two groups.

CONCLUSION

It is important to include women who had successful external cephalic version when comparing the obstetric outcome of undiagnosed and diagnosed breeches. Careful assessment for vaginal delivery is still very useful even when breech presentations are first diagnosed after the onset of labour because the infants are even more likely to deliver vaginally with no great excess of neonatal morbidity.

Origins and morphogenesis of colorectal neoplasms

Gastrointestinal stem cells are considered pivotal in colonic carcinogenesis. There is evidence to suggest that early microadenomas in the colon are polyclonal in origin. Adenomas, once initiated, enlarge by the process of crypt fission. It is also the main mechanism by which neoplastic clones spread through the colorectal epithelium. Both concepts are important for our understanding of the early events in colonic carcinogenesis.