Hemodynamic effects of a combination of octreotide and terlipressin in patients with viral hepatitis related cirrhosis

BACKGROUND

Terlipressin or octreotide given alone has been used as the first-line pharmacological treatment for acute variceal bleeding. In portal hypertensive animals, pre-infusion of octreotide followed by the addition of terlipressin has an additive or complementary effect on splanchnic hemodynamics. The current study was aimed at evaluating such a combination treatment in patients with cirrhosis and portal hypertension.

METHODS

Patients were randomly assigned to receive either a placebo (n = 11) or an intravenous infusion of octreotide 100 microg/h after an initial bolus of 100 microg (n = 13). Thereafter, each patient received an intravenous injection of terlipressin 2 mg. Hemodynamic values were measured basally, 30 min after octreotide or placebo, and 60 min after terlipressin.

RESULTS

Placebo administration did not affect any of the hemodynamic values. Terlipressin administration resulted in expected changes in hepatic venous pressure gradient, hepatic blood flow and systemic hemodynamics. In contrast, octreotide administration significantly decreased hepatic blood flow but did not affect other hemodynamic values. After terlipressin administration, significant hemodynamic changes were observed that were similar to the hemodynamic changes with terlipressin alone. The magnitude of changes in hepatic venous pressure gradient, cardiac index and systemic vascular resistance were no different between the two groups of patients. The heart rate was significantly lower in patients receiving octreotide plus terlipressin than those receiving terlipressin alone.

CONCLUSION

The current study showed that a combination of octreotide and terlipressin did not exert an additive effect in reducing hepatic venous pressure gradient in patients with cirrhosis. In addition, the systemic hemodynamic changes were comparable between the two groups.

Characteristics of community-acquired methicillin-resistant Staphylococcus aureus in infants and children without known risk factors

This retrospective study sought to determine the characteristics of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in patients younger than 18 years without known risk factors who were treated at a teaching hospital in central Taiwan. Epidemiological and clinical data were collected from medical charts. Possible risk factors included hospitalization within the past 6 months, transfer from other hospitals or nursing homes, and having underlying illness. A total of 173 isolates of community-acquired S. aureus were analyzed. Seventeen (9.8%) of these 173 isolates were methicillin-resistant S. aureus collected from patients without risk factors, 31 (17.9%) were methicillin-resistant S. aureus from patients with risk factors, and the other 125 (72.3%) were methicillin-susceptible S. aureus. Most isolates of community-acquired methicillin-resistant S. aureus collected from patients without risk factors (14/17, 82.4%) were obtained from the infected wounds of skin or soft tissues. Only 4 (23.5%) in 17 patients with isolates resistant to methicillin were prescribed antimicrobial therapy with glycopeptides. Nevertheless, all patients recovered without any long-term sequelae. These results highlight the fact that community-acquired methicillin-resistant S. aureus infections occur frequently in Taiwan among patients who have no established risk factors for this infection.

Modulation of calcium balance in tilapia larvae (Oreochromis mossambicus) acclimated to low-calcium environments

This study examined how developing fish larvae regulate their Ca2+ balance for acclimation to low ambient Ca2+. Calcium balance in newly hatched larvae was examined individually. Developing larvae not only increased Ca2+ influx but also decreased Ca2+ efflux when they were acclimated to low-Ca2+ environments. After acclimation for 8 days, the influx and efflux of the low-Ca2+ (0.02 mM) group were about 106% and 43%, respectively, compared to those of the high-Ca2+ (1.0 mM) group. Sensitivity and response to low-Ca2+ environments are age-dependent. Upon acute exposure to low Ca2+. newly hatched (H0) larvae increased both Ca2+ influx (from 24% to 67% of high-Ca2+) and net uptake (from 5% to 69%) within 64 h, while 3-day-posthatching (H3) larvae managed to reach the levels of the control within 38 h. Declining Ca2+ efflux in H3 larvae occurred 14 h after exposure, much faster than those in H0 larvae (38 h). It is suggested that modulation of Ca2+-balance mechanisms in developing larvae is dependent upon the levels of Ca2+ in the larval body.

DDR2 receptor promotes MMP-2-mediated proliferation and invasion by hepatic stellate cells

Type I collagen provokes activation of hepatic stellate cells during liver injury through mechanisms that have been unclear. Here, we tested the role of the discoidin domain tyrosine kinase receptor 2 (DDR2), which signals in response to type I collagen, in this pathway. DDR2 mRNA and protein are induced in stellate cells activated by primary culture or in vivo during liver injury. The receptor becomes tyrosine phosphorylated in response to either endogenous or exogenous type I collagen, whereas its expression is downregulated during cellular quiescence induced by growth on Matrigel. We developed stellate cell lines stably overexpressing either wild-type DDR2, a constitutively active chimeric DDR2 receptor (Fc-DDR2), a truncated receptor expressing the extracellular domain, or a kinase-dead DDR2 Cells overexpressing DDR2 showed enhanced proliferation and invasion through Matrigel, activities that were directly related to increased expression of active matrix metalloproteinase 2 (MMP-2). These data show that DDR2 is induced during stellate cell activation and implicate the phosphorylated receptor as a mediator of MMP-2 release and growth stimulation in response to type I collagen. Moreover, type I collagen-dependent upregulation of DDR2 expression establishes a positive feedback loop in activated stellate cells, leading to further proliferation and enhanced invasive activity.

Synthesis, antiplatelet and vasorelaxing effects of monooxygenated flavones and flavonoxypropanolamines

A series of flavones and flavonoxypropanolamines were synthesized and tested in-vitro for their ability to inhibit aggregation of washed rabbit platelets and human platelet-rich plasma (PRP), and for vasoconstriction of rat thoracic aorta. The various substituted positions of the hydroxyl group in flavone ring B and the various oxypropanolamine side chains substituted at position C-2' of flavone modified the antiplatelet effects. All the compounds tested in human PRP showed significant inhibition of secondary aggregation induced by adrenaline (epinephrine), suggesting that the antiplatelet effect of these compounds is mainly due to an inhibitory effect on thromboxane formation. Compounds 11 and 12 also had potent vasorelaxant effects in rat thoracic aorta. Phenylephrine- and high-K+-induced 45Ca2+ influx in aorta were both inhibited by the selected compound 11. This result indicates that the inhibitory effect of 11 on the contractile response caused by high-K+ medium and noradrenaline (norepinephrine) in rat thoracic aorta is mainly due to inhibition of Ca2+ influx through both voltage-dependent and receptor-operated Ca2+ channels.

Risk factors of wheeze and allergy after lower respiratory tract infections during early childhood

Lower respiratory tract infections (LRIs) during early childhood can lead to bronchial hyperreactivity or recurrent obstructive bronchitis. The role of LRIs in the pathogenesis of allergic diseases such as allergic rhinoconjunctivitis, atopic eczema, and bronchial asthma is less clear. The aim of this retrospective study was to determine the incidence of subsequent wheezing and atopy, and the known risk factors for allergic sensitization in 74 children hospitalized for acute LRIs of various etiologies from January 1994 through December 1994. Results showed that there are no differences in outcomes between patients with respiratory syncytial virus LRI, Chlamydia pneumoniae LRI, and LRIs caused by other agents. Although lower respiratory tract illnesses, especially those caused by respiratory syncytial virus during infancy, were associated with an increased risk of subsequent wheezing during early childhood, wheezing tended to disappear with increasing age in many children. This study also found recurrent episodes of wheezing during the first 5 years of life, and symptoms suggestive of allergic rhinoconjunctivitis were the only factors predictive of subsequent diagnosis of asthma for children who had LRIs during early childhood. In conclusion, this study suggests that prevention of recurrent wheezing LRIs and good control of allergic rhinoconjunctivitis is critical for preventing subsequent development of bronchial asthma.

A community-based caries control program for pre-school children using topical fluorides: 18-month results

Dental caries in Chinese pre-school children is common, and restorative treatment is not readily available. This prospective controlled clinical trial investigated the effectiveness of topical fluoride applications in arresting dentin caries. We divided 375 children (aged 3-5 yrs) with carious upper anterior teeth into five groups. Children in the first and second groups received annual applications of silver diamine fluoride solution (44,800 ppm F). NaF varnish (22,600 ppm F) was applied every three months onto the lesions of children in the third and fourth groups. For children in the first and third groups, soft carious tissues were removed prior to fluoride application. The fifth group was the control. We followed 341 children for 18 months. The mean numbers of new caries surfaces in the five groups were 0.4, 0.4, 0.8, 0.6, and 1.2, respectively (p = 0.001). The respective mean numbers of arrested carious tooth surfaces were 2.8, 3.0, 1.7, 1.5, and 1.0 (p < 0.001).

DDR2 receptor promotes MMP-2-mediated proliferation and invasion by hepatic stellate cells

Type I collagen provokes activation of hepatic stellate cells during liver injury through mechanisms that have been unclear. Here, we tested the role of the discoidin domain tyrosine kinase receptor 2 (DDR2), which signals in response to type I collagen, in this pathway. DDR2 mRNA and protein are induced in stellate cells activated by primary culture or in vivo during liver injury. The receptor becomes tyrosine phosphorylated in response to either endogenous or exogenous type I collagen, whereas its expression is downregulated during cellular quiescence induced by growth on Matrigel. We developed stellate cell lines stably overexpressing either wild-type DDR2, a constitutively active chimeric DDR2 receptor (Fc-DDR2), a truncated receptor expressing the extracellular domain, or a kinase-dead DDR2 Cells overexpressing DDR2 showed enhanced proliferation and invasion through Matrigel, activities that were directly related to increased expression of active matrix metalloproteinase 2 (MMP-2). These data show that DDR2 is induced during stellate cell activation and implicate the phosphorylated receptor as a mediator of MMP-2 release and growth stimulation in response to type I collagen. Moreover, type I collagen-dependent upregulation of DDR2 expression establishes a positive feedback loop in activated stellate cells, leading to further proliferation and enhanced invasive activity.

Risk factors associated with infantile spasms: a hospital-based case-control study in Taiwan

We investigated the risk factors associated with infantile spasms (IS) by a hospital-based case-control study in Taiwan. Twenty-five patients with IS were recruited from one medical center (National Taiwan University Hospital) between 1990 and 1997. Based on a close-structured questionnaire, standardized interviews were carried out to obtain information on risk factors associated with IS. Two comparison groups are used, including a total of 106 subjects in the Disease Control group, and 139 subjects in the Normal Control group. Unconditional logistic regression is used to calculate odds ratios (OR) and 95% confidence interval (CI). Univariate analysis revealed gestational age, congenital cerebral anomalies, tuberous sclerosis (TS), asphyxia, febrile seizure, and developmental delay (before onset of spasm) were at increased risk of IS. After adjustment of multiple risk factors through unconditional logistic regression, significant risk factors for IS include congenital cerebral anomalies, TS, asphyxia, postterm, and developmental delay were highly associated with IS. The risk factors of IS may closely relate to underlying neurological abnormalities. Our results are consistent with the previous findings.

Use factor analysis to identify difficulties in implementing a case payment reimbursement system in Taiwan

BACKGROUND

Taiwan's National Health Insurance Program (NHIP) began on March 1, 1995. The major purpose of National Health Insurance is to remove financial barriers to care and enhance accessibility to comprehensive health care for all citizens in Taiwan. However, due to the rapid rise in medical expenses and unanticipated accumulation of overdue premiums, the program went into debt in 1999. In response to this financial crisis, the Bureau of National Health Insurance proposed to change hospital financing from a cost-based to a case-based reimbursement system. The major purpose of this study is to identify the difficulties in implementing a case payment reimbursement system in Taiwan.

METHODS

This study was conducted in four stages: structured interviewing, questionnaire development and testing, surveying, and data analysis. In this study, the sampling surgeons were selected based on availability from 7 teaching hospitals and 10 regional hospitals.

RESULTS

The results of factor analysis indicated that a five-factor structure has emerged in the use of the newly developed survey administered to 372 surgeons in Taiwan. These five factors accounted for approximately 97% of the overall variance. The alpha coefficient for this 22-item scale was 0.914. The researchers concluded that these five factors are considered evidence of adequate internal consistency for use in measuring difficulty in the implementation of case payment.

CONCLUSIONS

These five factors were named as follows: perceived barriers to compliance, perceived barriers to quality assurance, perceived financial pressure, perceived threats to physicians' autonomy, and inadequate allowance for patient severity. Policy recommendations including annual revision of coding system, physician education, and hospital specialization were also made to address the perceived difficulties identified in this study.

Matrilysin cleavage of corneal collagen type XVIII NC1 domain and generation of a 28-kDa fragment

PURPOSE

To localize endostatin and collagen type XVIII in human corneas and to characterize the enzymatic action of matrix metalloproteinases (MMPs) in the cleavage of collagen type XVIII and generation of endostatin in the cornea.

METHODS

Anti-endostatin and anti-hinge antibodies were generated using peptide fragments corresponding to the endostatin region and the adjacent nonendostatin hinge region of collagen XVIII noncollagenous (NC)1 domain, respectively. Confocal immunostaining was performed to localize collagen XVIII in human corneas. SV40-immortalized corneal epithelial cells were immunoprecipitated and incubated with active MMP-1, -2, -3, -7, or -9, and Western blot analysis was performed to study collagen XVIII cleavage. Incubation with MMP-7 was performed at various concentrations (0, 2, 4, and 6 microg/ml) and time intervals (0, 1, 5, and 12 hours). Purified recombinant NC1 fragment of collagen XVIII was also digested with MMP-7, and the cleavage product was sequenced.

RESULTS

Collagen XVIII was immunolocalized to the human corneal epithelium, epithelial basement membrane, and Descemet membrane. Western blot analysis demonstrated a 180- to 200-kDa band corresponding to collagen XVIII. MMP-7 (but not MMP-1, -2, -3, and -9) cleaved corneal epithelium-derived collagen XVIII to generate a 28-kDa endostatin-spanning fragment in a time- and concentration-dependent fashion. MMP-7 cleaved purified recombinant 34-kDa NC1 fragment of collagen XVIII in the hinge region to generate a 28-kDa fragment.

CONCLUSIONS

Collagen XVIII is present in human cornea. MMP-7 cleaves the collagen XVIII NC1 domain to generate a 28-kDa fragment in the cornea.

Oral health and dental care in modern-day China

The purpose of this paper is to present salient background information on the oral care situation and organization in China and to review epidemiological literature that has been published on adults in Chinese dental journals during the last 20 years as a context for understanding ongoing oral health research activities in China. Searches were conducted through Medline as well as Chinese language catalogues and around 30 Chinese dental journals. Most oral health surveys on adults were conducted after 1970 mainly on residents living in big cities, which are also the location of major medical universities. Surveys conducted among farmers were uncommon. Dental caries and periodontal disease were the major dental diseases studied. Only a few surveys on people's oral health knowledge, attitudes and behavior were conducted. Papers concerning dental treatment needs and utilization of dental services among adults were scarce. Sample size was usually not a major problem in these surveys but the sampling methods and diagnostic criteria used were often poorly defined. Mean DMFT scores between 2 and 6 were reported in the 35-44-year-olds and between 9 and 16 in the elderly younger than 75 years. Calculus and gingivitis were reported to be common in adult Chinese; the proportion of subjects with shallow and deep periodontal pockets was not high. Complete edentulousness in the 60-69-year-olds was usually reported to be less than 10%. About 14% of the 35-44-year-olds and 19% of the 65-74-year-olds did not brush their teeth daily.

Renal biopsy in pregnancies complicated by undetermined renal disease

BACKGROUND

The aim of this retrospective study was to verify the role of renal biopsy in pregnancies complicated by renal dysfunction.

METHODS

A series of 15 percutaneous renal biopsies performed in 15 pregnant women with renal disease presenting during pregnancy over the past 10 years (1990-1999) were reviewed.

RESULTS

All the patients underwent renal biopsy before 30 weeks of gestation. The indications for renal biopsy were renal dysfunction of unknown cause or symptomatic nephrotic syndrome (NS). Patients with toxemia were excluded. Eight women had lupus nephritis, including five with diffuse crescenteric changes and three with a mesangial proliferative pattern. Three had chronic glomerulonephritis (CGN), two had mesangial proliferative glomerulonephritis and one each had diabetic nephrosclerosis and endocapillary proliferative glomerulonephritis. There were no significant complications except in one patient who experienced gross hematuria. Early induction of labor was recommended for the four patients with diabetic nephrosclerosis or CGM. The other 11 patients received intravenous pulse methylprednisolone or high dose oral prednisolone therapy. The responses to steroid therapy in these 11 patients were as follows: five achieved complete remission of NS, three achieved incomplete remission, and three achieved partial remission. After 2 years' follow-up, seven mothers achieved complete remission, three had died, three developed chronic renal failure (CRF), and two progressed to end stage renal failure (ESRF) requiring chronic hemodialysis. Fourteen of the 15 pregnancies resulted in live births and the other child was stillborn.

CONCLUSIONS

Renal biopsy performed during pregnancy is not contraindicated. The results of histopathological studies are extremely useful in counseling regarding continuation or termination of pregnancy, potential maternal and fetal outcome, and recommending specific therapeutic modalities.

Herpes zoster during varicella

A 4-year-old boy had varicella infection. Two days later vesicular lesions clustered within the left 10th thoracic dermatome. Varicella-zoster virus IgM antibody in serum was positive. He was diagnosed with varicella infection combined with herpes zoster. This is the first case report in the medical literature.

Effects of intravenous lidocaine overdose on cardiac electrical activity and blood pressure in the horse

This study aimed to identify blood serum lidocaine concentrations in the horse which resulted in clinical signs of intoxication, and to document the effects of toxic levels on the cardiovascular and cardiopulmonary systems. Nineteen clinically normal mature horses of mixed breed, age and sex were observed. Lidocaine administration was initiated in each subject with an i.v. loading dose of 1.5 mg/kg bwt and followed by continuous infusion of 0.3 mg/kg bwt/min until clinical signs of intoxication were observed. Intoxication was defined as the development of skeletal muscle tremors. Prior to administration of lidocaine, blood samples for lidocaine analysis, heart rate, mean arterial blood pressure, systolic blood pressure, diastolic blood pressure, respiratory rate and electrocardiographic (ECG) data were collected. After recording baseline data, repeat data were collected at 5 min intervals until signs of intoxication were observed. The range of serum lidocaine concentrations at which the clinical signs of intoxication were observed was 1.85-4.53 microg/ml (mean +/- s.d. 3.24 +/- 0.74 microg/ml). Statistically significant changes in P wave duration, P-R interval, R-R interval and Q-T interval were observed in comparison to control values, as a result of lidocaine administration. These changes in ECG values did not fall outside published normal values and were not clinically significant. Heart rate, blood pressures and respiratory rates were unchanged from control values. This study establishes toxic serum lidocaine levels in the horse, and demonstrates that there were no clinically significant cardiovascular effects with serum lidocaine concentrations less than those required to produce signs of toxicity.

The alkaloids of Artabotrys uncinatus

A novel type of alpha,beta-butenolide alkaloid, uncinine (1), two novel oxoaporphines, artabonatine C (2) and artabonatine D (3), a new oxazoloaporphine, artabonatine E (4), and a new 7,7'-bisdehydroaporphine, artabonatine F (5), along with 25 known alkaloids, were isolated from Artabotrys uncinatus. The structures of 1-5 were determined using NMR and mass spectral data. Atherospermidine and squamolone exhibited cytotoxicity against hepatocarcinoma cancer cell lines (Hep G(2) and 2,2,15), and the activity of some of the alkaloids in an antithrombin assay is also discussed.

Endogenous nitric oxide inhibits neutrophil adherence to lung epithelial cells to modulate interleukin-8 release

To investigate the effect of neutrophil adherence to epithelial cells on the release of interleukin 8 (IL-8), we measured neutrophil adherence in the presence or absence of IFN-gamma+TNF-alpha+IL-1beta (cytomix) stimulation on cultured A549 epithelial cells. The extent of neutrophil adherence to A549 epithelial cells was measured and the concomitant production of IL-8 and nitrite were assayed. The roles of adhesion molecules and nitrite in modulation of neutrophil adherence were examined by pretreatment with oversaturating ICAM-1 blocking antibody and L-NAME (1 mM), respectively. There was a time-dependent spontaneous and cytomix-induced release of IL-8 from epithelial cells, as well as a time-dependent increase in the magnitude of neutrophil adherence to epithelial cells. Stimulation of epithelial cells with cytomix induced a further increase in neutrophil adherence. Pretreatment with oversaturated ICAM-1 monoclonal antibody inhibited neutrophil adherence with or without cytomix stimulation. The inhibition of neutrophil adherence to epithelial cells with ICAM-1 monoclonal antibody or a semipermeable membrane downregulated the release of IL-8 with or without cytomix stimulation. Stimulation with cytomix decreased nitrite production. Both neutrophil adherence and L-NAME pretreatment significantly inhibited the production of nitrite. The inhibition of neutrophil adherence to epithelial cells with ICAM-1 monoclonal antibody or a semipermeable membrane upregulated nitrite production. Pretreatment with L-NAME failed to modify the spontaneous release of IL-8, but significantly enhanced the response to adherence and cytomix. In conclusion, endogenous nitric oxide may play a role in preventing neutrophil adherence to lung epithelial cells, thus modulating concomitant IL-8 release.

Bacteremia after endoscopic injection of N-butyl-2-cyanoacrylate for gastric variceal bleeding

BACKGROUND

Cyanoacrylate may form a barrier that prevents bacterial invasion when used in tissue. Because cyanoacrylate polymerizes within seconds on contact with aqueous media, it is used worldwide to arrest gastric variceal bleeding. The aim of this study was to determine the frequency of bacteremia after endoscopic cyanoacrylate injection for gastric variceal bleeding.

METHODS

Patients with cirrhosis who underwent endoscopic cyanoacrylate injection for gastric variceal bleeding were included. Patients with cirrhosis who underwent upper endoscopy for nonvariceal upper GI bleeding were recruited as controls. Patients with infection before endoscopy were excluded. Blood was cultured in both groups. Injection needles and endoscope accessory channels were cultured in the cyanoacrylate injection group.

RESULTS

More patients injected with cyanoacrylate had positive blood cultures in comparison with the control group (15/47 vs. 1/47, p < 0.0001). In the cyanoacrylate injection group, the volume of blood transfused and Child-Pugh score were factors associated with the occurrence of bacteremia. Most episodes of bacteremia were transient, except for 1 patient who died of sepsis. Most of the microorganisms cultured from blood samples were identical to those cultured from injection needles (65%) and accessory channels (90%).

CONCLUSIONS

Endoscopic cyanoacrylate injection for gastric varices does not limit the spread of bacteria. The endoscope accessory channel was the major source of bacteria. Most episodes of bacteremia were transient and uneventful.

Adaptive vasodilatory response after octreotide treatment

Despite the suppression of glucagon release, an adaptive response aimed at maintaining vasodilatation after octreotide treatment may exist in portal hypertension. The present study was undertaken to evaluate the possible interaction between endothelium and non-endothelium-derived vasodilators after 1-wk octreotide administration in cirrhotic rats. Rats were allocated to receive either vehicle or octreotide (30 or 100 microg/kg every 12 h subcutaneously). Hemodynamic values, plasma glucagon levels, endothelium-related vasodilatory activities, and aortic endothelial nitric oxide synthase (eNOS) expression were determined after treatment. Octreotide administration decreased plasma glucagon and increased serum 6-keto-PGF(1 alpha) and NOx levels without affecting the hemodynamic values. In cirrhotic rats receiving octreotide, there was a blunt response to either L-NAME or indomethacin administration alone, but this blunt pressor response disappeared after simultaneous administration of the two drugs. Additionally, an increased aortic eNOS expression was observed in cirrhotic rats receiving 1-wk octreotide. It is concluded that 1-wk octreotide treatment did not correct the hemodynamic derangement in cirrhotic rats. The enhanced endothelium-related vasodilatory activity was noted after octreotide treatment that overcame the octreotide-induced hemodynamic effects in portal hypertension.

Peppermint oil improves the manometric findings in diffuse esophageal spasm

BACKGROUND

Diffuse esophageal spasm (DES) is an uncommon condition that results in simultaneous esophageal contractions. Current medical treatment of DES is frequently unsatisfactory. We hypothesized that, as a smooth muscle relaxant, peppermint oil may improve the manometric findings in DES.

STUDY

Eight consecutive patients with chest pain or dysphagia and who were found to have DES were enrolled during their diagnostic esophageal manometry. An eight-channel perfusion manometry system was used. Lower esophageal sphincter pressure and contractions of the esophageal body after 10 wet swallows were assessed before and 10 minutes after the ingestion of a solution containing five drops of peppermint oil in 10 mL of water. Each swallow was assessed for duration (seconds), amplitude (mm Hg), and proportion of simultaneous and multiphasic esophageal contractions.

RESULTS

Lower esophageal sphincter pressures and contractile pressures and durations in both the upper and lower esophagus were no different before and after the peppermint oil. Peppermint oil completely eliminated simultaneous esophageal contractions in all patients (p < 0.01). The number of multiphasic, spontaneous, and missed contractions also improved. Because normal esophageal contractions are characteristically uniform in appearance, variability of esophageal contractions was compared before and after treatment. The variability of amplitude improved from 33.4 +/- 36.7 to 24.9 +/- 11.0 mm Hg (p < 0.05) after the peppermint oil. The variability for duration improved from 2.02 +/- 1.80 to 1.36 +/- 0.72 seconds (p < 0.01). Two of the eight patients had chest pain that resolved after the peppermint oil.

CONCLUSIONS

This data demonstrates that peppermint oil improves the manometric features of DES.

Feasibility and potential benefit of maintenance endoscopic variceal ligation in patients with unresectable hepatocellular carcinoma and acute esophageal variceal hemorrhage: a controlled trial

BACKGROUND

Patients with unresectable hepatoma and acute esophageal variceal bleeding have extremely high rates of recurrent bleeding and mortality. This controlled study evaluates the feasibility and potential benefit of maintenance endoscopic variceal ligation in these patients.

METHODS

Patients with unresectable hepatoma and acute esophageal variceal bleeding underwent emergent endoscopic variceal ligation. After hemostasis, patients were randomized to undergo maintenance or esophageal variceal ligation (EVL) as necessary (demand ligation).

RESULTS

Fifty-four patients underwent maintenance EVL and 55 demanded EVL. One or more subsequent EVL session could be performed in only 30 patients (55.6%) in the maintenance group (actual maintenance ligation). Logistic regression analysis found that hepatic function determines the feasibility of maintenance ligation (Child-Pugh's A+B vs. C, OR 23.00: 95% CI [5.26, 100.66]). The survival and recurrent bleeding rates were similar in both groups. A subgroup analysis of patients with Child-Pugh's A and B hepatic reserve in both the maintenance EVL group (n = 24) and demand EVL group (n = 25) was performed to assess the potential benefit of maintenance ligation. Maintenance ligation reduced the rate of recurrent bleeding compared with demand ligation (p = 0.043). Cox regression showed that portal vein thrombosis and tumors in both hepatic lobes were also factors together with EVL that determined recurrence of bleeding. Survival was similar in both groups.

CONCLUSIONS

Maintenance ligation is feasible in patients with unresectable hepatoma and variceal hemorrhage if they have a good hepatic reserve. Maintenance ligation might lower the rate of recurrent bleeding in this subgroup of patients.

Hemodynamic effects of Salvia miltiorrhiza on cirrhotic rats

Salvia miltiorrhiza (Sm) administration has been shown to reduce hepatic fibrosis in rats. We investigated the hemodynamic effects of Sm on bile duct ligated (BDL) rats. Hemodynamic, histological, and vascular contractile studies were conducted in rats 4 weeks after bile duct ligation. An aqueous extract of Sm (0.2 g twice per day) or vehicle was administered for 4 weeks to BDL rats. Sm treatment in BDL rats significantly reduced histological grades of fibrosis and ameliorated the portal hypertensive state (including portal venous pressure, superior mesenteric artery blood flow, cardiac index, and total peripheral resistance) as compared with vehicle treatment. Moreover, Sm treatment enhanced the vascular sensitivity of mesenteric arteries to phenylephrine in BDL rats. Sm treatment had no effect on plasma biochemical profiles of either BDL or normal rats. Our results suggest that 4-week Sm treatment ameliorates the portal hypertensive state in BDL rats.

Synthesis of novel acetal thia-cage compounds

The synthesis of novel acetal thia-cage compounds has been accomplished by the direct substitution for the oxygen atom by the sulfur atom in the reaction of the acetal groups of oxa-cages with Lawesson reagent (LR). Reaction of the tetraoxa-cage compound 2 with LR in dichloromethane at 25 degrees C sequentially gave the monothia-, dithia-, trithia-, and tetrathia-cage compounds 3, 6, 7, and 9. The reaction mechanism for the conversion from oxa-cages into thia-cages was proposed. The diacetal trioxa-cages 18-20 and 24-26 were also transformed into the thia-cages 21-23 and 27-29, respectively. Reaction of the trioxa-cages 34 and 35 with LR under the same reaction conditions gave the thia-cages 36 and 37 with the carbonyl group intact. Treatment of the pentaoxa[5]peristylane 40 with LR in chloroform under supersonic shaking at refluxing temperature gave the monothia[5]peristylane 41 and the dithia[5]peristylane 42. Attempts to synthesize the thia[5]peristylanes from the tetraoxa-cage 51 and the transformation from the parent (unsubstituted) pentaoxa[5]peristylane 46 to the thia-cages have been made. Reaction of the pentaoxa[5]-peristylane 40 with P(2)S(5) in refluxing toluene gave 41, 42, and a rearrangement product 47. The synthesis of new heterocyclic cage compounds 59 and 60, which contain oxygen, nitrogen, and sulfur atoms in the same molecule, was also accomplished.