[Nuclear expression of Survivin in glioma and its correlation to prognosis]

BACKGROUND & OBJECTIVE

Survivin, an inhibitor of apoptosis protein, is correlated to aggressive behavior, resistance to chemotherapy and radiotherapy, and prognosis of human cancers. It is expressed in both nuclei and cytoplasm. Recent research revealed that the nuclear expression of survivin is an important prognostic factor of human cancers. This study was to investigate the nuclear expression of Survivin in human glioma, and its correlations to clinicopathologic characteristics and prognosis.

METHODS

The nuclear expression of Survivin in 88 specimens of glioma (33 at grade I-II, and 55 at grade III-IV) was detected by tissue microarray and immunohistochemistry. Its correlations to clinicopathologic characteristics and prognosis were analyzed.

RESULTS

The positive rate of nuclear Survivin was 27.3% in the whole group. It was significantly lower in grade I-II gliomas than in grade III-IV gliomas (12.1% vs. 36.4%, P=0.013). Nuclear expression of Survivin had no correlation to patient's age (P=0.053), sex (P=0.376), Karnofsky performance status (P=0.486), and clinical stage (P=0.359). The 5-year overall survival rate and 3-year disease-freely survival rate were significantly lower in nuclear Survivin-positive group than in nuclear Survivin-negative group (22.7% vs. 47.7%, P=0.005; 13.7% vs. 39.5%, P=0.015). The median survival was slightly lower in high nuclear Survivin expression group than in low nuclear Survivin expression group (14.9 months vs. 20.2 months, P=0.089).

CONCLUSIONS

The nuclear expression of Survivin is related to the pathologic grade of glioma, and might be a negative prognostic factor of glioma.

Primary large B-cell lymphoma of the ampulla of Vater

Primary lymphoma of the ampulla of Vater is rare. The clinico-pathological and interesting endoscopic and radiological features of a patient with this disorder is presented.

Follow-up of bilateral subthalamic deep brain stimulation for Parkinson's disease

PURPOSE

To demonstrate the effects of bilateral subthalamic deep brain stimulation (STN-DBS) in the treatment of Parkinson's disease (PD) after 4-45 months' follow-up.

METHOD

Between 04/01 and 12/04, 46 PD patients were operated on with bilateral STN-DBS. All of them were evaluated with Unified Parkinson's Disease Rating Scale (UPDRS) parts II-V before surgery and 4-45 months after surgery. The amelioration of miscellaneous symptoms and decrease of medication dose, respectively, were compared. Main side effects were observed.

FINDINGS

After surgery, both the score of activities of daily living (ADL) and the UPDRS motor score decreased significantly (p < 0.001). Among the PD symptoms, tremor was improved best. Rigidity, bradykinesia, axial symptoms, facial expression and dyskinesia were all improved, although to a lesser extent, while speech was not improved. Medication dose was decreased significantly (p < 0.001). According to the time of follow-up, 4 groups were classified (4-12 months, 13-24 months. 25-36 months and 37-45 months group). ADL, UPDRS motor score and dyskinesia subscore improvement were compared among these groups. No significant difference existed. No life threatening complications occurred. Main side effects included hypophonia, dyskinesia, confusion, depression.

CONCLUSIONS

Bilateral STN-DBS is a satisfying surgical method for the treatment of advanced PD. It can improve the cardinal PD symptoms up to 45 months. Complications and side effects were rare and usually temporary or reversible.

[Quality of life of 192 disease-freely survival nasopharyngeal carcinoma patients after radiotherapy]

BACKGROUND & OBJECTIVE

With the elevation of survival rate of nasopharyngeal carcinoma (NPC) patients after treatment, their quality of life (QOL) is more and more emphasized. This study was designed to evaluate the QOL of disease-freely survival NPC patients after treatment, and to investigate the factors correlated with their QOL.

METHODS

From Jul. to Aug. 2003, disease-freely survival NPC patients who had been treated from 1999 to 2000 in Cancer Center of Sun Yat-sen University were enrolled. The Chinese SF-36 questionnaire and a checklist consists of 14 items about self-rating symptoms were self-reported by all participants at clinic. Sociodemographic and clinical data of the patients were also collected, and their relationships with SF-36 data and symptoms were analyzed.

RESULTS

A total of 192 patients were enrolled in the study. The median survival time was 3.6 years (ranged 2.4-4.6 years). Xerostomia was the first common symptom, followed by hypoacusis, hypomnesia, dysphagia, and trismus. Univariate analysis showed that gender, age, educational level, monthly income, economic status, religion, and the number of complications had influences on QOL; the patients in earlier T and N stages, irradiated by linear accelerator, with lower total dose and weekly dosage to the nasopharynx and neck, and those who had anterior nasal field radiation reported better QOL. Multiple stepwise regression analysis showed that the number of complications, monthly income, age, and T stage were independent factors affecting total QOL.

CONCLUSIONS

Improving radiotherapy might enhance physical functions of NPC patients. The prevention and control of chronic diseases, the development of economy, and the increase of income may promote NPC patients' QOL.

Validated questionnaire on diagnosis and symptom severity for functional constipation in the Chinese population

BACKGROUND

Functional constipation is a common problem in clinical practice. No validated questionnaire is available in Chinese.

AIM

To develop a validated questionnaire for diagnosis and symptom assessment in functional constipation for the Chinese population.

METHODS

One hundred and eleven patients with constipation and 110 healthy controls were presented with a 24-item constipation questionnaire in the Chinese language. Quality of life in constipation patients was assessed by Short Form-36. Polyethylene glycol was prescribed, for 4 weeks, to 20 patients with newly diagnosed constipation. The questionnaire was administered before and 4 weeks after treatment. Concept, content, construct, discriminant validity and reliability of the questionnaire were assessed.

RESULTS

Six items were selected by logistic regression to account for most of the differences between controls and constipated patients with a good reproducibility and internal consistency. A cut-off score of > or =5 was determined to discriminate between controls and constipated patients with a sensitivity of 91% and a specificity of 91%. The constipation questionnaire correlated negatively with seven domains of the Short Form-36 and discriminated between constipated patients who reported symptomatic improvement during polyethylene glycol treatment.

CONCLUSIONS

The Chinese constipation questionnaire could be used in epidemiological studies to assess the frequency and severity of constipation in patient populations and in interventional studies of constipation.

Hyperbilirubinemia and cholelithiasis in Chinese patients with hemoglobin H disease

Hemoglobin H disease (HbH) is a hemoglobinopathy peculiar to parts of the world with high incidence alpha-thalassemia mutations. Among 90 HbH cases, 50 cases suffered from clinically significant jaundice (bilirubin >30 mmol/l), including 14 with severe jaundice (bilirubin >60 mmol/l). Cholelithiasis was found in 38 cases. The incidence is roughly eight times higher than that in background control population but 50% lower than that in beta-thalassemia. The risk of gallstones was related to higher bilirubin levels but not alpha-globin genotype, sex, ferritin, and hemoglobin levels. Homozygotes or double heterozygotes for Gilbert alleles (17.2%), but not heterozgyotes (42.2%), were found to have a significantly increased risk of gallstones and jaundice. However, common Chinese Gilbert syndrome alleles do not completely explain the variable risks.

[Comparison between PET-CT and MRI in diagnosing nodal metastasis of nasopharyngeal carcinoma]

BACKGROUND & OBJECTIVE

Nodal metastasis pattern of nasopharyngeal carcinoma (NPC) influences treatment planning. This study was to compare the diagnostic value of integrated positron emission tomography-computed tomography (PET-CT) with that of magnetic resonance imaging (MRI) in detecting nodal metastasis of NPC, and explore the regulation of nodal metastasis of NPC.

METHODS

Clinical data of 105 NPC patients, treated in Cancer Center of Sun Yat-sen University from Jun. 2003 to May 2004, were analyzed. All patients underwent PET-CT and MRI. Findings of PET-CT and MRI were evaluated with the results of follow-up. Distribution of metastatic nodes in different nodal groups was assessed.

RESULTS

Among the 105 patients, nodal metastasis patterns shown on PET-CT and MRI were diverse in 35 patients. Thirty cervical nodes were positive on PET-CT, but negative on MRI; 25 of them were later confirmed positive by follow-up. Thirty-seven cervical nodes were negative on PET-CT, but positive on MRI; 21 of them were confirmed negative by follow-up. Based on the results of follow-up, 77 patients (73.3%) had nodal involvement. Level II nodes were the most frequently involved (87.0%). Along the jugular chain, the frequencies of nodal metastases in level III, level IV, supraclavicular fossa, and level VII were 42.9%, 14.3%, 7.8%, and 1.3%, respectively. The frequency of nodal metastases in retropharyngeal nodes was 70.1%. Cervical nodes involvement without retropharyngeal nodes involvement was seen in 23 patients (29.9%).

CONCLUSIONS

The diagnostic accuracy of PET-CT in detecting nodal metastases of NPC is better than that of MRI. The nodal metastases of NPC reveal a decreasing frequency along the jugular chain. Both retropharyngeal and level II nodes are the first-echelon nodes of NPC.

[Changes of visual field and visual evoked potential in nasopharyngeal carcinoma patients after radiotherapy]

BACKGROUND & OBJECTIVE

Radiotherapy is the main treatment for nasopharyngeal carcinoma (NPC). The incidence of radiation-induced complications, especially radiation optic neuropathy (RON), increases along with prolonging survival time of the patients. This study was to investigate RON in NPC patients after irradiation by visual field and visual evoked potential (VEP) tests.

METHODS

A total of 28 NPC patients, who underwent conventional external-beam irradiation, received visual field and VEP tests before irradiation, at the end of irradiation, and 5 years after irradiation.

RESULTS

Thirty-four (60.7%) eyes in 21 patients developed pathological visual field; 15 (44.1%) of these 34 eyes occurred within 10-24 months after irradiation. Of the 34 eyes, 8 showed concentric visual field constriction; 6 showed bitemporal hemianopia; 8 showed local photosensitivity descend; 10 showed central or cecocentral scotoma; 2 showed scotoma enlargement. Forty-four (78.6%) eyes in 26 patients appeared VEP abnormity; 24 (54.5%) of these 44 eyes occurred within 14 months after irradiation. In small, medium, and large elements, VEP latencies were significantly longer within 1 year after irradiation than pre-irradiation (P < 0.001, P < 0.001, and P=0.001); VEP amplitudes were lower within 1 year after irradiation than pre-irradiation without significant difference (P=0.249, P=0.940, and P=0.450). One year after treatment, VEP latency delay maintained in each element (P=0.004, P < 0.001, P < 0.001); VEP amplitudes were decreased (P=0.002, P=0.189, P < 0.001). The incidence of pathologic visual field was significantly lower in patients received irradiation of < or =70 Gy than in patients received irradiation of > 70 Gy (50.0% vs. 77.3%, P=0.041).

CONCLUSIONS

RON correlates to total irradiation dose. Pathologic visual field may indicate the position of RON.

[Prognosis and treatment for 98 patients with carcinoma of nasal cavity]

BACKGROUND & OBJECTIVE

Carcinoma of nasal cavity is a rare disease without standard treatment. This study was designed to evaluate treatment outcome, and prognostic factors of patients with carcinoma of nasal cavity.

METHODS

Records of 98 patients with carcinoma of nasal cavity were reviewed,43 patients received radiotherapy alone, 55 patients received surgery plus radiotherapy. Survival analysis was performed by Kaplan-Meier method,differences between groups were tested by log-rank test,multivariate analysis was carried out by Cox proportional hazard model.

RESULTS

The overall 5-, and 10-year survival rates were 65.3%, and 37.1%. The 5-, and 10-year survival rates of patients with tumor of stage I, II were 87.3%, and 51.1%, those of patients with tumor of stage III, IV were 56.1%, and 32.2% (P=0.02). The patients with squamous cell carcinoma had lower survival rates than those with adenocarcinoma (P< 0.01). There was significant difference in survival rates between patients received radiotherapy alone and patients received radiotherapy plus surgery in advanced lesions (P=0.04) and in squamous cell carcinoma (P< 0.01), but not in early lesions (P=0.41) and in adenocarcinoma (P=0.73). Patients who were initially diagnosed cervical lymph node metastasis had a reduced survival rate compared with node-negative patients (P=0.01). In Cox's regression, clinical stage and node-positive were independent prognostic factors.

CONCLUSIONS

The criteria should be taken into account when choosing treatment method for patients with carcinoma of nasal cavity: radiotherapy plus surgery is preferred for advanced lesions and for squamous cell carcinoma, radiotherapy alone is better for early lesions and for adenocarcinoma. Clinical stage, and node-positive may be independent prognostic factors of patients with carcinoma of nasal cavity.

Impairment of optic path due to radiotherapy for nasopharyngeal carcinoma

PURPOSE

To evaluate the impairment of optic path caused by radiotherapy for nasopharyngeal carcinoma (NPC).

METHODS

Visual evoked potential was used to evaluate the functional impairment of optic path by an 8 MV linear accelerator or 60Co gamma-ray radiotherapy in 63 (23 women and 40 men) patients with nasopharyngeal carcinoma before radiotherapy, at the end of radiotherapy, 6 months and 1, 2 and 3 years after their radiotherapy respectively.

RESULTS

In the female group, the latency of VEP elicited by the three types of elements significantly delayed 2 and 3 years after radiotherapy than that before radiotherapy, at the end of radiotherapy, 6 months and 1 year after radiotherapy; there were no significant difference among VEP amplitudes elicited by the three types of elements before and after radiotherapy. In the male group, the latency of VEP elicited by the medium and the small elements significantly delayed 1 year after radiotherapy than that before radiotherapy and at the end of radiotherapy, the VEP latency elicited by the small elements was significantly prolonged 3 years after radiotherapy compared to that just after radiotherapy, while the VEP amplitude elicited by the large elements was significantly attenuated 1 year after radiotherapy compared to those before and just after radiotherapy.

CONCLUSIONS

In the female group, the significant prolongation of VEP latency happened at the end of radiotherapy and lasted for 3 years, while the VEP amplitude did not change significantly during the 3 years after radiotherapy. It indicates that the sustained impairment by radiation within the female visual nerve system starts at the end of radiotherapy, but the impairment was mild. In the male group, the significant prolongation of VEP latency mostly happened 1 or 2 years after radiotherapy. It was shown that the radiotherapy for nasopharyngeal carcinoma certainly injured the optic path, and there was difference in the impairment between the two sexes.

Genome-wide scan for familial nasopharyngeal carcinoma reveals evidence of linkage to chromosome 4

Nasopharyngeal carcinoma (NPC) occurs with high frequency in Asian populations, especially among people of Cantonese ancestry. In areas with high incidence, NPC clusters in families, which suggests that both geography and genetics may influence disease risk. Although the HLA-Bw46 locus is associated with increased risk of NPC, no predisposing genes have been identified so far. Here we report the results of a genome-wide search carried out in families at high risk of NPC from Guangdong Province, China. Parametric analyses provide evidence of linkage to the D4S405 marker on chromosome 4 with a logarithm of odds for linkage (lod) score of 3.06 and a heterogeneity-adjusted lod (hlod) score of 3.21. Fine mapping with additional markers flanking D4S405 resulted in a lod score of 3.54 and hlod score of 3.67 for the region 4p15.1-q12. Multipoint nonparametric linkage analysis gives lod scores of 3.54 at D4S405 (P = 5.4 x 10(-5)) and 4.2 at D4S3002 (P = 1.1 x 10(-5)), which is positioned 4.5 cM away from D4S405. When Epstein Barr virus antibody titer was included as a covariate, the lod scores reached 4.70 (P = 2.0 x 10(-5)) and 5.36 (P = 4.36 x 10(-6)) for D4S405 and D4S3002, respectively. Our findings provide evidence of a major susceptibility locus for NPC on chromosome 4 in a subset of families.

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.

Expression and clinical significance of antinuclear antibody in hepatitis C virus infection

BACKGROUND

The prevalence of antinuclear antibody (ANA) has been documented in patients with hepatitis C virus (HCV) infection. We attempted to determine the titer and to characterize the patterns and clinical significance of ANA in HCV infection.

STUDY

Forty-eight consecutive patients with positive anti-HCV antibody and positive HCV RNA were included in this study. Sera from patients were tested for ANA and anti-smooth muscle antibody by indirect immunofluorescence. Serum aminotransferase, alkaline phosphatase, alpha-fetoprotein, and cryoglobulin levels also were determined.

RESULTS

Eleven (23%) of 48 HCV-infected patients were positive for ANA. Antinuclear antibody revealed speckled pattern in 10 (91%) of the 11 ANA-positive HCV-infected patients. Twenty (54%) of 37 ANA-negative HCV-infected patients had detectable pattern with equivocal titer (titer <1.5). The ANA pattern was speckled in all 20 patients. Hepatitis C virus-infected patients with positive ANA were older than the HCV-infected patients with negative ANA (62.90 +/- 11.05 years vs. 56.46 +/- 14.94 years, respectively; p < 0.1). Serum levels of aspartate aminotransferase (39.36 +/- 14.98 IU/L vs. 30.70 +/- 23.15 IU/L, p < 0.05), alkaline phosphatase (189.00 +/- 75.63 IU/L vs. 122.41 +/- 40.88 IU/L, p < 0.01), and alpha-fetoprotein (47.72 +/- 80.47 pg/dL vs. 7.00 +/- 8.28 pg/dL, p < 0.01) were higher in ANA-positive HCV-infected patients than in ANA-negative HCV-infected patients, respectively. There were no significant differences in gender, alanine aminotransferase, anti-smooth muscle antibody, or cryoglobulin between the two groups.

CONCLUSIONS

Antinuclear antibody was present in 11 (23%) of 48 patients with HCV infection in our study. Speckled pattern is the major expression pattern of ANA in HCV infection. Antinuclear antibody-positive HCV-infected patients have significantly higher serum aspartate aminotransferase, alkaline phosphatase, and alpha-fetoprotein levels than ANA-negative HCV-infected patients.

Snakebite complicated with Vibrio vulnificus infection

Snakebite may be complicated with bacteria infections, most of which are Gram-negative bacillus. Snakebite complicated with Vibrio vulnificus infection has not been reported previously. Vibrio vulnificus infection is characterized by a necrotizing wound infection similar to the local lesion of severe snakebite. In Vibrio infections, aggressive debridement with the administration of strong antibiotics as early as possible is the only effective treatment. We report a 79-y-o man who suffered from snakebite on the right palm with rapid progression of hemorrhagic bulla, necrotizing fasciitis, compartment syndrome, and septic shock. Vibrio vulnificuswas cultured from necrotic tissue after aggressive debridement and fasciotomy. The patient recovered from antibiotic treatment and several courses of reconstruction surgery. Severe bacteria infection, such as caused by Vibrio vulnificus, should be considered in snakebite cases refractory to antivenin dosage.

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.

Acute myocardial infarction caused by aortic dissection

Clinical presentation of aortic dissection is similar to that of acute myocardial infarction (AMI). Clinical differential diagnoses from lethal chest pain in emergency department include AMI, aortic dissection, pulmonary embolism, tension pneumothorax, etc. Thrombolytic therapy for recanalization of thrombotic occluded coronary artery in AMI must be considered, but it is absolutely contraindicated for aortic dissection. However, AMI secondary to aortic dissection is a rare condition, which might be caused by compression of the coronary arteries by a hematoma or extension of the dissection into the coronary arterial wall. Surgery is the first choice for AMI secondary to aortic dissection caused by extension of dissection into the coronary arterial wall. We present a case of inferior wall AMI caused by type I aortic dissection with presentation of chest pain and hemiparaplegia of right lower limb.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome with acute cortical blindness

The coincidence of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome and cortical blindness is an uncommon but very dramatic event. We describe a case of HELLP syndrome complicating with acute cortical blindness before delivery. A 27 year-old woman, gravida 1, para 0, with normal medical history, was referred to our emergency department at the 33th week of gestation due to headache, vomiting, and blurred vision. The ophthalmologic examination showed intact pupillary light reflexes and normal ophthalmoscopic findings, but no light perception in either eye. Brain computed tomography showed normal findings. HELLP syndrome and preeclampsia was diagnosed based on the findings of hypertension and proteinuria as well as laboratory data. Prompt delivery was performed in order to achieve good maternal and neonatal outcomes.

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.

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.

The effect of aging on nasal mucociliary clearance, beat frequency, and ultrastructure of respiratory cilia

The increased susceptibility of the elderly to lower respiratory tract infection cannot be fully explained. Although mucociliary clearance, which is affected by ciliary beating and ultrastructure, plays a crucial role in the defense of the airways against inhaled microbes, little is known of the effects of aging on these parameters. We studied the nasal mucociliary clearance (NMCC) time, ciliary beat frequency, and ultrastructure of respiratory cilia in a cohort of healthy volunteers (age range 11 to 90 yr). Ciliary beat frequency of ciliated nasal epithelial cells was obtained via an established photometric method, and NMCC time was measured with the saccharine test. There was a correlation of ciliary beat frequency (r = -0.48, p = 0.0001) and NMCC time r = 0.64, p < 0.001) with increasing age. Transmission electron microscopy revealed an increase in the percent of subjects exhibiting microtubular disarrangement and single central microtubules with aging (p = 0.002 and p = 0.005, respectively). Subjects older than 40 yr of age had significantly slower ciliary beat frequency, higher percent of ciliary cross-sections displaying single tubules, and longer NMCC time than their younger counterparts (p < 0.05). These findings may help explain the frequent occurrence of respiratory infection in the elderly.

Efficacy of endoscopic isotonic saline-epinephrine injection for the management of active Mallory-Weiss tears

Therapeutic endoscopy with isotonic saline-epinephrine (ISE) injection is a convenient and widely used procedure for hemostasis in upper gastrointestinal bleeding. We retrospectively evaluated 36 patients (from January 1996 to April 1999) who had been diagnosed with recent or active bleeding due to Mallory-Weiss tears in emergency endoscopic examination. The endoscopic hemostatic method with ISE injection was performed in 15 of 36 patients. The other 21 patients received conservative treatment with hemodynamic support. Patient's clinical data, laboratory data, transfusion requirements, endoscopic findings, and length of hospital stays were evaluated. Initial hemoglobin was significantly lower in the ISE group than the conservative treatment group (9.74 +/- 2.86 g/dL vs. 12.57 +/- 2.80 g/dL, respectively; p < 0.01). Mean transfusion requirements were significantly higher in the ISE group than the conservative treatment group (7.26 +/- 8.78 units vs. 2.85 +/- 6.21 units, respectively; p < 0.1). Patients in the ISE group were supposed to be having a more severe bleeding episode. Most patients achieved initial hemostasis in the ISE group and the conservative treatment group (93% and 95%, respectively). The rebleeding rate was also similar in both groups (1 in 15 in the ISE group and I in 21 in the conservative treatment group). There was no significant difference in length of hospital stay and rebleeding between these two groups (3.47 +/- 1.92 days vs. 2.47 +/- 1.47 days, respectively: p = 0.89). The endoscopic ISE injection is an inexpensive, simple, convenient therapeutic method and it can achieve initial hemostasis for active Mallory-Weiss tears.

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.

(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.