Long-term evaluation of recombinant interferon alpha2b in the treatment of patients with hepatitis B e antigen-negative chronic hepatitis B in Taiwan

The effect of interferon (IFN) on hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB) has not been fully investigated in Chinese patients. We enrolled 58 HBeAg-negative CHB Chinese patients with hepatitis B viremia in Taiwan to evaluate the response to IFN. 30 patients received recombinant IFN 5 million units 3 times weekly for 6-10 months, and 28 patients who refused IFN treatment served as controls. Rates of virological response and biochemical response were higher in the treated group at the end of treatment (57% vs 18%, P = 0.006, and 73% vs 29%, P = 0.002, respectively). Both effects were superior in the treated group at 6 months after IFN withdrawal (virological: 30% vs 7%, P = 0.06; biochemical: 47% vs 7%, P = 0.002). Improvement of liver histological activities with persistently biochemical response was found in 65% of the treated patients. After a mean of 32 months' follow-up, virological response was rarely maintained (17% vs 4%, P = 0.228) but biochemical response was better in the treated group (27% vs 4%, P = 0.039). None of the treated patients but five controls developed severe complications of CHB during the follow-up period. A larger total IFN dosage or a younger age (< or = 40 years) were associated with 'sustained' virological response. Younger age and higher baseline alanine transaminase values (> or = 120 Ul(-1)) were related to 'sustained' biochemical response.

Resection of triple synchronous tumors--gastric adenocarcinoma, gallbladder adenocarcinoma and stromal tumor of the stomach

We herein report a rare case of triple synchronous tumors: gastric adenocarcinoma, gallbladder adenocarcinoma and stromal cell tumor of stomach, which were resected in the same operation. A 72-year-old male patient suffered from poor appetite and epigastric pain that radiated to his back for one month. Upper gastrointestinal endoscopy showed a gastric ulcer measuring 1.5 cm at the prepyloric area, which was proven to be adenocarcinoma by biopsy. A second tumor was found in the gallbladder, measuring 3 cm, by ultrasonography. On computed tomography, a third tumor about 2.5 cm in size was recognized posterior to the gastric high body and anterior to the pancreas. Given the presence of three tumors, he underwent a radical subtotal gastrectomy with Billroth-II gastrojejunostomy and simultaneous cholecystectomy. Pathological findings revealed gastric adenocarcinoma, gallbladder adenocarcinoma and stromal cell tumor of the stomach. The postoperative course was smooth.

Hereditary hemorrhagic telangiectasia: demonstration of portosystemic venous shunts using power Doppler sonography and sonographically guided percutaneous transhepatic portovenography

Hereditary hemorrhagic telangiectasia is a rare autosomal dominant inherited disease associated with vascular abnormalities, which may occur in any organ. Cases of hereditary hemorrhagic telangiectasia accompanied by intrahepatic portosystemic venous shunts, however, have rarely been described. We report a case of hereditary hemorrhagic telangiectasia in which intrahepatic portosystemic shunts were detected using power Doppler sonography and portovenography with percutaneous transhepatic contrast agent injection. On gray-scale sonography, the common hepatic artery was dilated, and dilated tubular structures mimicking dilated biliary tracts were found. Power Doppler sonography demonstrated the continuity of tortuous vascular channels connecting a branch of the right portal vein to a branch of the right hepatic vein. The dilated vascular channels and tributaries of the right hepatic vein showed a monophasic waveform pattern on spectral analysis. Portovenography showed a tangle of vascular structures connecting with a branch of the right hepatic vein.

The clinical features and prognostic factors of hepatocellular carcinoma patients with spinal metastasis

OBJECTIVE

Hepatocellular carcinoma is the most common malignancy in Taiwan, and spinal metastasis is a serious complication in cancer patients. In this study, we aimed to delineate the clinical features, evaluate the radiotherapy response and analyse the prognostic features in hepatocellular carcinoma subjects with spinal metastasis.

METHODS

From 1981 to 1997, 102 patients with spinal metastasis were enrolled, taken from the 5887 documented hepatocellular carcinoma patients treated at Taipei Veterans General Hospital. All the clinical and laboratory data were recorded, including: age; gender; liver biochemistry; tumour characteristics; Child-Pugh's score; performance status; number and location of vertebral metastasis; motor capacity; neurological symptoms and signs; response to radiotherapy of the spinal lesion; and survival. Prognostic factors in hepatocellular carcinoma patients with spinal metastasis were analysed using Cox's regression model.

RESULTS

The most common symptoms in hepatocellular carcinoma patients with spinal metastasis were lower back pain (74.5%), thoracic numbness (52.9%) and lower limb weakness (51.0%). Of the 102 patients, 84 received palliative radiotherapy using 3000 cGy for spinal lesions. Of these 84 patients, 32.1% showed a complete response, 26.2% a partial response and 41.7% a non-response to the radiotherapy. Multivariate Cox's regression analysis revealed that responsive radiotherapy (complete response + partial response) and good performance status (score <or= 2) were significant positive prognostic factors for survival in hepatocellular carcinoma patients with spinal metastasis.

CONCLUSIONS

Responsive radiotherapy can improve a hepatocellular carcinoma patient's quality of life by ameliorating the neurological condition and relieving pain, and can prolong survival in hepatocellular carcinoma patients with spinal metastasis.

Toxic effect of sulfur compounds on anaerobic biogranule

The effects of sulfide, sulfite and sulfate on degradation of volatile fatty acid (VFA) in UASB process have been studied by using serum bottle assay and septage-leachate acclimated biogranules. The relative toxicity of the compounds towards methane production and degradation of total VFA varied as SO(4)(2-) -S>S(2-)>SO(3)(2-) -S and SO(4)(2-) -S>SO(3)(2-) -S>S(2-), respectively. The difference of this order shows the importance of choosing monitoring factor in evaluating the effect of sulfur compounds on a UASB system. For the individual VFA the effects of sulfur compounds depended on the types of VFA. The VFA-degrading activity of anaerobic biogranules was decreased by 50% when 34, 26 and 20mg of S(2-), SO(3)(2-) -S and SO(4)(2-) -S were added to each gram of biomass, respectively. A comparison of the toxicity-resistance between two different anaerobic biogranules that acclimatized with septage-leachate mixture and septage was also made. In the presence of the leachate, the toxicity-resistance of biogranules was not weakened to sulfide and sulfate but was enhanced to sulfite.

Diversity of SHV and TEM beta-lactamases in Klebsiella pneumoniae: gene evolution in Northern Taiwan and two novel beta-lactamases, SHV-25 and SHV-26

A total of 113 blood culture isolates of Klebsiella pneumoniae from 10 hospitals in northern Taiwan were studied for SHV and TEM beta-lactamase production. bla(SHV) was amplified from all isolates by PCR. TEM-type resistance, was found in 32 of the isolates and was of the TEM-1 type in all isolates. SHV-1, -2, -5, -11, and -12 and two novel enzymes were identified. These novel enzymes were designated SHV-25 and SHV-26 and had pIs of 7.5 and 7.6, respectively. Amino acid differences in comparison to the amino acid sequence of bla(SHV-1) were found at positions T18A (ThrACC-->AlaGCC), L35Q (LeuCTA-->GluCAA), and M129V (MetATG-->ValGTG) for SHV-25 and at position A187T (AlaGCC-->ThrACC) for SHV-26. The results of substrate profiles and MIC determinations showed that the novel enzymes did not hydrolyze extended-spectrum cephalosporins, rendering the isolates susceptible to these agents. Inhibition profiles revealed that the 50% inhibitory concentration for SHV-26 was higher than those for SHV-1 and SHV-25, resulting in an intermediate resistance to amoxicillin-clavulanic acid. Forty-nine ribotypes were identified, suggesting that major clonal spread had not occurred in any of the hospitals. According to the amino acid sequence, SHV beta-lactamases in Taiwan may basically be derived through stepwise mutation from SHV-1 or SHV-11 and further subdivided by four routes. The stepwise mutations initiated from SHV-1 or SHV-11 to SHV-2, SHV-5, and SHV-12 comprise the evolutionary change responsible for extended-spectrum beta-lactamase (ESBL) production in Taiwan. The stepwise mutations that lead to a non-ESBL (SHV-25) and the beta-lactamase (SHV-26) with reduced susceptibility to clavulanic acid are possibly derived from SHV-11 and SHV-1, respectively. The results suggest a stepwise evolution of SHV beta-lactamases in Taiwan.

Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study

BACKGROUND/AIMS

Polyps of the gastrointestinal tract are usually removed due to their link to bleeding, obstruction and malignancy. However, complications may occur following polypectomy. The aim of this study was to assess whether submucosal epinephrine injection before polypectomy could reduce the incidence of bleeding and perforation.

METHODOLOGY

Between June 1997 and November 1999, patients with sessile polyps of the gastrointestinal tract found in our endoscopic unit were randomized to receive submucosal epinephrine injection (epinephrine group) or no injection (control group) before polypectomy. In the epinephrine group, epinephrine (1:10,000) was injected surrounding the stalk of the polyp until the mucosa was blanched and bulged. The patients were observed for complications in the following month.

RESULTS

A total of 120 patients with 151 sessile polyps were enrolled in this study. In the epinephrine group, 75 polyps (n = 68) were randomized to receive epinephrine injection before polypectomy. In the control group, 76 polyps (n = 61) underwent polypectomy without epinephrine injection. In both groups, there was no significant difference in clinical features including the sizes of the polyps and their stalks, the location of polyps and the pathological diagnosis. There were a total of nine episodes of post-polypectomy hemorrhage, two in the epinephrine group and seven in the control group (2/75 vs. 7/76) (P = 0.07). One case in the epinephrine group experienced delayed bleeding (4 days later). Immediate hemorrhage occurred less in the epinephrine group than that in the control group (1/75 vs. 7/76, P = 0.03). There was one case of perforation in each group.

CONCLUSIONS

Epinephrine injection prior to polypectomy is effective in preventing immediate bleeding.

Chronic hepatitis C virus infection associated with primary warm-type autoimmune hemolytic anemia

Autoimmune hematologic abnormalities are not well recognized in chronic hepatitis C virus infection. We demonstrate an unusual association between primary autoimmune hemolytic anemia and chronic hepatitis C virus infection. A 69-year-old woman who had a history of hepatitis C virus-related liver cirrhosis was found to have deteriorating anemia with reticulocytosis when admitted to the hospital. Laboratory work revealed both positive direct and indirect Coombs' tests, and warm-type immunoglobulin G against surface antigens of red blood cells. After prednisolone therapy, her anemia improved dramatically. To our knowledge, this is the first reported case of chronic hepatitis C virus infection linked with autoimmune hemolytic anemia in its natural course, not related to prior interferon treatment. Our report suggests that isolated autoimmune hemolytic anemia may be one of the unusual hematologic manifestations of chronic hepatitis C virus infection.

Applied potential tomography in liquid gastric emptying measurement: design, assembling, calibration, and clinical application

The present study aimed to validate the accuracy of a homemade applied potential tomography (APT) apparatus for liquid gastric emptying (GE). Twelve electrodes were placed in a circular array around the subjects. Ten electrodes in a rotated order recorded electrical current delivered from a driving pair of electrodes. Based on tomography, averaged signals of changed resistivity were constructed to display area changes. Six beakers were respectively placed into a saline-filled Perspex tank to measure their cross-sections. True beaker cross-sections are 2.01, 15.9, 18.8, 30.19, 38.48, and 63.61 cm2, respectively, whereas APT generated cross-sections were 7.9 +/- 2.9, 16.7 +/- 3.3, 22.4 +/- 4.9, 28 +/- 4.8, 48.7 +/- 7.6, 67 +/- 6.1 cm2, respectively (r = 0.98, P < 0.001). Twenty-four healthy males ingested 500-ml test solution to assess GE using both APT and scintigraphy. Only 20 (83.3%) subjects had a successful measurement. The APT half emptying time was 15.6 +/- 4.8 min, whereas scintigraphy was 21.9 +/- 6.3 min (r = 0.67, P < 0.01). In conclusion, our APT apparatus is a simple, noninvasive, and inexpensive way to assess liquid GE. Its clinical usefulness is confirmed using both phantom and human models.

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.

Electrogastrographic characteristics in patients of stomach cancer

Using a homemade electrogastrography (EGG) system, we studied the characteristics of myoelectrical rhythm in gastric cancer (GC) patients. Based on a short-term Fourier transform, recorded slow waves could be automatically analyzed to obtain the following parameters: dominant frequency/power, percent of normal rhythm (2.4-3.7 cpm), power ratio, etc. Fifty histologically confirmed GC patients (34 men, 16 women) were enrolled before surgical intervention to measure their fasting and postprandial EGG parameters for 30 min. The cancerous parameters of GC patients were then obtained postoperatively. In addition, 46 healthy subjects were enrolled for comparison. When compared to controls, GC patients had the following characteristics: absence of postprandial increase in dominant frequency (GC: 3.04 +/- 0.47 vs 3.07 +/- 0.44 cpm, NS; controls: 3.02 +/- 0.31 vs 3.21 +/- 0.25 cpm, P < 0.001), marked power response after meal (P < 0.05), and obvious power ratio (4.58 +/- 7.38 vs 2.27 +/- 2.05, P < 0.05). Multivariate analysis indicated that advanced GC was the factor responsible for the obvious dominant power enhancement after meal (P < 0.05). Other demographic, clinical, and cancerous factors did not influence EGG parameters. We conclude that apparent arrhythmia is not encountered in GC patients, although they mainly exhibit obvious postprandial power response. Advanced GC is likely responsible for this power enhancement on EGG recording.

A 3-day anti-Helicobacter pylori therapy is a good alternative for bleeding peptic ulcer patients with Helicobacter pylori infection

BACKGROUND/AIMS

One-week triple therapy has been recommended as a standard regimen for eradicating Helicobacter pylori infection. The emergence of antibiotic-resistant strains, adverse drug effects, poor compliance and high cost of therapy add problems to the management of these patients. In this study, we assessed whether a 3-day triple therapy could be effective in eradicating Helicobacter pylori infection in bleeding peptic ulcer patients.

METHODOLOGY

Peptic ulcer patients with Helicobacter pylori infection were enrolled in this study. Patients enrolled at the outpatient department (group A) received a 7-day oral regimen: bismuth subcitrate colloid 300 mg + amoxicillin 500 mg + metronidazole 250 mg four times per day. Patients who were admitted to the wards due to peptic ulcer bleeding (group B) received a 3-day regimen including omeprazole 40 mg intravenously every 6 hours, amoxicillin 500 mg + metronidazole 250 mg orally four times daily after hemostasis had been achieved. Patients of both groups received omeprazole 20 mg once per day or cimetidine 400 mg twice daily per os for at least-one month after anti-Helicobacter pylori therapy. We followed every patient endoscopically two months after anti-Helicobacter pylori therapy.

RESULTS

From June 1997 to April 1999, a total of 57 patients (30 in group A and 27 in group B) with gastric or duodenal ulcer and Helicobacter pylori infection completed anti-Helicobacter pylori therapy. Two months after anti-Helicobacter pylori therapy, peptic ulcer was found to be healed with a scar in 26 (86.7%) of group A and 23 (85.2%) of group B (P > 0.1). The eradication rates of Helicobacter pylori in the two groups were not significantly different in an intention-to-treat analysis [group A: 78.8% (26/33), 95% CI: 64.9-92.7%; group B: 80% (24/30), 95% CI: 65.7-94.3%, P > 0.1] and in a per protocol analysis [group A: 86.7% (26/30), 95% CI: 74.5-98.9%, group B: 88.9% (24/27), 95% CI: 77.1-100.7%, P > 0.1]. Fewer side effects occurred in group B (3/30) than those in group A (7/33) (P > 0.1).

CONCLUSIONS

In patients with peptic ulcer bleeding a 3-day anti-Helicobacter pylori therapy is a good alternative for eradicating Helicobacter pylori infection.

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.

The pharmacological effect of omeprazole on water gastric emptying: A study based on an impedance measure

The present study was performed to validate the accuracy of a self-designed applied-potential tomograph (APT) in measuring the cross area of a studied object and to assess the effect of omeprazole premedication on water gastric emptying (GE), based on APT. Twelve electrodes were evenly placed in a circular array around the studied subjects. Ten electrodes in a rotated order recorded the electrical current injected into paired electrodes. Based on tomography, averaged signals of changed resistivity were constructed to display the area of interest and GE curve. Six beakers of various diameters were respectively placed into a cylindrical perspex tank which was filled with saline to measure their cross areas via computer-generated diagrams of APT. One hour after either omeprazole (20 mg) or placebo premedication, 15 healthy males were ordered to consume 500 ml of test water to assess emptying for 40 min. Within 3 days, a similar procedure was repeated using the counterpart premedication. The true cross areas of the 6 beakers are 2.01, 15.9, 18.8, 30.19, 38.48 and 63.61 cm(2), whereas those obtained by APT were 7.9 +/- 2.9, 16.7 +/- 3.3, 22.4 +/- 4.9, 28 +/- 4.8, 48.7 +/- 7.6 and 67 +/- 6.1 cm(2), respectively (r = 0.98, p < 0.001). Valid emptying data were obtained in 73.3 and 86.6% of subjects, following placebo and omeprazole, respectively (not significant). The half emptying times were 12.7 +/- 5.1 min for the placebo-treated group and 10.5 +/- 3.6 min for the omeprazole-treated group, respectively (p < 0.05). The areas under the emptying curve were 1,611.5 +/- 357.6 and 1,317.3 +/- 316.7 arbitrary units, respectively (p < 0.01). In conclusion, our APT system is accurate for large-area measurements; acid inhibition before APT measurement does not increase the success rate but enhances water emptying. The interpretation of impedance-obtained GE should consider the acid-inhibitory effect.

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.

Efficacy of cefepime versus ceftazidime in the treatment of adult pneumonia

Effective empiric treatment of pneumonia requires antibiotic coverage against gram-negative and gram-positive pathogens, including drug-resistant isolates. This study evaluated the efficacy of cefepime treatment in 20 patients with community-acquired pneumonia (CAP) and 21 patients with hospital-acquired pneumonia (HAP), and ceftazidime treatment in 20 patients with HAP. The mean age of patients was over 70 years. More than half of the patients had multiple lobe involvement. There was no significant difference in the severity of illness according to the acute physiology, age, chronic health evaluation (APACHE) III score between the HAP-cefepime and HAP-ceftazidime group. The most common bacteria isolated from sputum of patients with CAP were Streptococcus pneumoniae (n = 7), Klebsiella pneumoniae (n = 4), and Pseudomonas aeruginosa (n = 2). In patients with HAP, P. aeruginosa (n = 13), Acinetobacter baumannii (n = 11), Serratia marcescens (n = 6), K. pneumoniae (n = 5), Stenotrophomonas maltophilia (n = 5), Enterobacter cloacae (n = 3), Citrobacter spp. (n = 2), and Escherichia coli (n = 2) were isolated. The cure rates were 95%, 76%, and 60% in the CAP-cefepime group, the HAP-cefepime group, and the HAP-ceftazidime group, respectively. The increased rates of antimicrobial resistance commonly found among isolates causing CAP and HAP indicate that extended-spectrum antimicrobial agents, such as cefepime, would be more appropriate therapeutic agents.

Detection and typing of vancomycin-resistance genes of enterococci from clinical and nosocomial surveillance specimens by multiplex PCR

Ninety-three clinical isolates of vancomycin-resistant enterococci (VRE) collected from nine hospitals in Taiwan were examined for the presence of vanA, vanB, vanC1, or vanC2/vanC3 genes by a multiplex PCR. Forty-seven of these VRE isolates were vanA positive, 1 contained both vanC1 and vanA, 40 harboured vanB, 2 were vanC1, and 3 were identified to be vanC2/vanC3. Twenty-four vanA isolates were sensitive to teicoplanin and thus did not have a typical VanA phenotype. Five isolates with the VanC phenotype harboured vanB. None of the 40 clinically isolated vancomycin-susceptible E. faecium or E. faecalis and the vancomycin-resistant Leuconostoc and Pediococcus isolates were positive for any of the van genes. While performing nosocomial surveillance, VRE were isolated from 47 of 467 rectal swabs by culture. Compared with the conventional culture method, the sensitivity and specificity of the multiplex PCR for detecting and identifying vancomycin-resistance genes in enterococci directly from culture-positive broth were 97.9% and 100%, respectively. The results suggest that genotypic characterization of vancomycin-resistance is necessary for all clinical VRE isolates and that the multiplex PCR assay can be an alternative method for this purpose.

Hepatic encephalopathy in rats with thioacetamide-induced fulminant hepatic failure: role of endotoxin and tumor necrosis factor-alpha

BACKGROUND

Hepatic encephalopathy, a complex neuropsychiatric syndrome secondary to acute liver failure, chronic parenchymal liver disease or portal-systemic shunting, may possibly develop through mediators of endotoxin and tumor necrosis factor-alpha (TNF-alpha). However, there are no published data concerning the relationships between the severity of encephalopathy and the plasma levels of endotoxin and TNF-alpha.

METHODS

Male Sprague-Dawley rats weighing about 300-350 g were used. Fulminant hepatic failure was induced by intraperitoneal injection ofthioacetamide (350 mg/kg/day) for 3 consecutive days. Severity of encephalopathy was assessed by measuring motor counts using an Opto-Varimex animal activity meter. Plasma levels of endotoxin and TNF-alpha were determined by chromogenic Limulus assay and ELISA method, respectively.

RESULTS

Our study revealed that higher plasma levels of endotoxin (> 5.9 pg/ml) and TNF-alpha (> 18.8 pg/ml) were significantly associated with more blunted motor activities in rats with fulminant hepatic failure (p < 0.05). A significant correlation was observed between plasma concentrations of endotoxin and TNF-alpha (r = 0.59, p < 0.001). Plasma levels of endotoxin were weakly correlated with the total movements in an open field (r = -0.34, p = 0.032) and the counts of ambulatory (r = -0.38, p = 0.014) and vertical movements (r = -0.40, p = 0.010). There were no correlations between the motor counts and plasma levels of TNF-alpha (p > 0.05).

CONCLUSIONS

In addition to endotoxin and TNF-alpha, other factors may participate in the pathogenesis of hepatic encephalopathy in rats with thioacetamide-induced fulminant hepatic failure.

Clinical, virological, and pathological significance of hepatic bile duct injuries in Chinese patients with chronic hepatitis C

PURPOSE

Hepatic bile duct injuries are characteristic histological findings in patients with chronic hepatitis C virus (HCV) infection. However, the pathogenesis and clinical significance of this phenomenon remain unclear. The aims of this study were to evaluate the prevalence and clinical significance of hepatic bile duct injuries in Chinese patients with chronic hepatitis C.

METHODS

One hundred and seventeen Chinese patients with chronic hepatitis C were enrolled. Clinical, biochemical, immunological (serum autoantibodies and cryoglobulinemia), histological, and virological data (serum HCV RNA titer and HCV genotype) were compared between patients with and without hepatic bile duct injuries.

RESULTS

Eighty-three (71%) of the 117 patients with chronic hepatitis C had hepatic bile duct injuries. Patients with hepatic bile duct injuries had a significantly higher frequency of HCV genotype 1b; a higher mean serum globulin level; significantly higher mean scores for histological periportal necro-inflammation, portal inflammation, and fibrosis; and more severe portal lymphoid aggregation/follicles when compared with patients without hepatic bile duct injuries (P < 0.05, all). No significant differences in the presence of serum autoantibodies, cryoglobulinemia, mean serum HCV RNA titer, or response to interferon treatment were noted between the two groups. Multivariate logistic regression analysis showed that HCV genotype 1b infection, portal inflammation, and lymphoid aggregation/follicles were significant independent predictors associated with hepatic bile duct injuries.

CONCLUSIONS

The presence of hepatic bile duct injuries in Chinese patients with chronic hepatitis C was significantly correlated with HCV genotype 1b infection, and the patients with these injuries had more severe portal inflammation and formation of lymphoid aggregates/follicles.

A new "sandwich" method of combined endoscopic variceal ligation and sclerotherapy versus ligation alone in the treatment of esophageal variceal bleeding: a randomized trial

BACKGROUND

Variceal ligation is the optimum endoscopic method for treating esophageal variceal bleeding. However, both early and multiple recurrences of esophageal varices frequently follow ligation. The aim of this randomized study was to determine whether a new, combined endoscopic "sandwich" method (i.e., ligation-sclerotherapy-ligation) could achieve better results than ligation alone.

METHODS

Ninety-four patients with cirrhosis and acute or recent esophageal variceal bleeding were randomized to undergo either the "sandwich" method or ligation alone (47 patients in each group).

RESULTS

The sclerosant was retained in the varices for more than 30 minutes in 7 of 8 patients undergoing the "sandwich" method plus radiographic contrast medium. Active bleeding was controlled with this new method (9/9) as efficiently as ligation (12/12). The rate of recurrent bleeding was similar for both methods. Multivariate analysis showed the necessity for the use of antibiotics (odds ratio 3.95: 95% CI [1.60, 9.76]) to be an independent factor for recurrent bleeding. Two patients in the "sandwich" group developed strictures, but the frequency of other complications did not differ between the 2 groups. Kaplan-Meier analysis showed the cumulative probability of variceal recurrence was lower with the "sandwich" method (p = 0.0391). The survival rate and causes of death were similar in both groups.

CONCLUSIONS

The "sandwich" method leads to longer retention of sclerosant in varices. This method is superior to ligation alone in terms of lower variceal recurrence rate and comparable to ligation with respect to hemostasis. However, it is unknown whether the lower recurrence rate of varices will persist long-term.

Duodenal lesions following severe acute pancreatitis: review of 10 years' clinical experience

BACKGROUND/AIMS

Acute pancreatitis may result in many local and contiguous organ complications; though the pancreas is in close proximity to the duodenum anatomically, acute pancreatitis causing duodenal lesions is rarely encountered. Our aim is to retrospectively evaluate the clinical features of the duodenal lesions in patients with severe acute pancreatitis.

METHODOLOGY

During the past 10 years, 1,637 consecutive patients with acute pancreatitis were admitted to Taipei Veterans General Hospital. Total parenteral nutrition was employed in 251 patients with acute pancreatitis, defined as 'severe acute pancreatitis'. They had all received computed tomography during the hospitalization period, and the computed tomography reports were reviewed to find patients with duodenal involvement induced from pancreatitis. We defined those patients having duodenal wall thickening, extrinsic compression of the duodenum, or other obstructive lesions seen on the computed tomography scan as evident duodenal lesion or duodenal involvement.

RESULTS

Nine cases of evident duodenal lesions following severe acute pancreatitis have been documented over a 10-year period in 1 teaching medical center. The lesions were found by image study or during operation. The most frequently involved site was the second portion of the duodenum. Clinically, 1 unique case developed severe duodenal obstruction requiring surgical correction, and 7 cases recovered after supportive therapy. Of the 9, only 1 case died of multiple organ failure.

CONCLUSIONS

In contrast to the colonic lesions caused by acute pancreatitis with a high morbidity and mortality, total parenteral nutrition yields a good prognosis in patients with evident duodenal lesions following severe acute pancreatitis.

Adult intussuscepted Meckel's diverticulum presenting mainly lower gastrointestinal bleeding

Herein, we report on an adult with intussusception of an invaginated Meckel's diverticulum presenting mainly with acute intermittent lower gastrointestinal bleeding, whereas the common symptom of abdominal pain, indicating intussusception, was absent. Colonoscopy revealed a reducible polypoid lesion in the ileocecal area. Computed tomography led to suspicion of an intussusception. Surgical resection revealed a Meckel's diverticulum containing an aberrant pancreas. The unique clinical symptoms and the methods of diagnosis are discussed.

An unusual cutaneous metastasis from hepatocellular carcinoma

Cutaneous metastases from hepatocellular carcinoma are rare. In this report we detail a case of hepatocellular carcinoma with the unusual manifestations of multiple skin metastases. A 49-year-old male, who had received surgical resection of hepatocellular carcinoma one year prior, presented with multiple reddish-blue, firm, painless and nonulcerative cutaneous papules and nodules over the fingers, palms, toes, soles and back. Pathology of the cutaneous nodules showed characteristic hepatocellular carcinoma with trabecular gland formation. These lesions grew very rapidly and developed to cauliflower appearances which had not been described previously in the literature. The patient died of respiratory failure secondary to lung metastasis two months after the first appearance of the skin lesions.

Ranitidine-related Stevens-Johnson syndrome in patients with severe liver diseases: a report of two cases

Ranitidine is widely used and well tolerated. Ranitidine-related skin eruption is rare and usually mild. We presented two patients who developed Stevens-Johnson syndrome after ranitidine therapy. Before therapy, both patients had severe liver disease and jaundice. The first was a case of ketoconazole-induced hepatitis, and the second was a case of hepatitis C-related liver cirrhosis with hepatocellular carcinoma. Ranitidine was the most likely drug responsible for causing Stevens-Johnson syndrome in these two patients.

Hemodynamic effects of a combination of prazosin and terlipressin in patients with viral cirrhosis

OBJECTIVES

Terlipressin reduces portal pressure in cirrhotic patients mainly through intense splanchnic vasoconstriction that decrease portal venous inflow. Hepatic blood flow may also be reduced by terlipressin. Prazosin (an alpha1-adrenoceptor antagonist) has also been proposed to decrease portal pressure in cirrhotic patients possibly through a decrease in the intrahepatic vascular resistance. The current study was aimed to evaluate whether a combination of prazosin and terlipressin exerts more beneficial effects than terlipressin alone.

METHODS

Patients were randomly assigned to receive either a placebo (n = 12) or an oral administration of prazosin 2 mg (n = 12). Thereafter, each patient received an intravenous injection of terlipressin 2 mg. Hemodynamic values were measured basally, 30 min after prazosin or placebo, and 30 min after terlipressin.

RESULTS

Placebo administration did not affect any hemodynamic values. Terlipressin administration, on the other hand, resulted in expected changes on the hepatic venous pressure gradient, hepatic blood flow, and systemic hemodynamics. In contrast, prazosin significantly decreased hepatic venous pressure gradient with an increased hepatic blood flow and intrinsic hepatic clearance. After terlipressin administration, a further decrease in hepatic venous pressure gradient was observed with preservation of hepatic blood flow and intrinsic hepatic clearance. The magnitude of decrease in hepatic venous pressure gradient was more profound in patients receiving prazosin plus terlipressin than in those receiving terlipressin alone. However, the magnitude of changes in systemic hemodynamics was no different between the two groups of patients.

CONCLUSIONS

The current study showed that a combination of prazosin and terlipressin resulted in a more profound reduction of hepatic venous pressure gradient with a preservation of hepatic blood flow and intrinsic hepatic clearance than did terlipressin alone. However, the combined therapy did not modify the systemic hemodynamic effects exerted by terlipressin.

Endothelin-1 induces vasoconstriction on portal-systemic collaterals of portal hypertensive rats

Portal hypertension is associated with increased hepatic and collateral resistance to an increased portal blood flow. Endothelin-1 (ET-1) can induce intrahepatic vasoconstriction and consequently increase portal pressure. It is unknown if ET-1 also modulates portal pressure by a direct vasoconstrictive effect on collaterals. This study investigated the collateral vascular responses to ET-1, the receptors in mediation, and the regulation of ET-1 action by nitric oxide and prostaglandin. The portal-systemic collaterals of partially portal vein-ligated rats were tested by in situ perfusion. The concentration-response curves of collaterals to graded concentrations of ET-1 (10(-10)-10(-7) mol/L) with or without BQ-123 (ET(A) receptor antagonist, 2 x 10(-6) mol/L), BQ-788 (ET(B) receptor antagonist, 10(-7) mol/L) or both were recorded. In addition, the collateral responses to ET-1 with preincubation of n(omega)-nitro-L-arginine (NNA; 100 mol/L), indomethacin (INDO; 10 mol/L), or in combination were performed. ET-1 increased the perfusion pressure of collaterals and its effect was significantly suppressed by BQ-123 alone and BQ-123 plus BQ-788, but not BQ-788 alone (P <.05). Incubation with NNA, INDO, or both significantly enhanced the response of collaterals to ET-1 (P < .05). These results show that ET-1 produces a direct vasoconstrictive effect on the collateral vessels of portal hypertensive rats. This effect is mediated by ET(A,) but not ET(B), receptors. Both nitric oxide and prostaglandin modulate the collateral vascular response to ET-1 and may therefore participate in the development and maintenance of portal hypertension.

Portopulmonary hypertension: distinctive hemodynamic and clinical manifestations

Portopulmonary hypertension is now recognized as one of the pulmonary complications of chronic liver disease. However, previous studies reported that the incidence ranged from 0.25% to 2%, excluding fortuitous coincidence. In this study, we aimed to determine the variant hemodynamic and clinical features of portopulmonary hypertension in an area with a high prevalence of viral cirrhosis. After reviewing the hemodynamic data of 322 patients with portal hypertension admitted to the Taipei Veterans General Hospital between 1987 and 1999, we found 10 with portopulmonary hypertension. The overall incidence was, therefore, 3.1% in all patients with portal hypertension. Most of the patients with portopulmonary hypertension experienced exertional dyspnea. The survival times ranged from 2 to 86 months. In our series, most of the patients who died, died of complications related to cirrhosis and portal hypertension, but not of complications related to pulmonary hypertension. This study suggested that portopulmonary hypertension was not a frequent complication in cirrhotic patients and was not associated with an adverse outcome.

Kidney transplantation in patients with chronic hepatitis B virus infection: is the prognosis worse?

The impact of hepatitis B virus (HBV) infection on the long-term outcome of kidney transplant patients is controversial. A total of 34 chronic hepatitis B surface antigen (HBsAg) carriers among 143 renal allograft recipients were identified in this study (mean follow-up period: 5.6+/-3.3 years; range: 1-13 years). During the follow-up, one HBsAg-positive recipient with preexisting cirrhosis died of liver failure, and seven (21%) others developed serious HBV-related complications (four fulminant hepatitis, two hepatocellular carcinoma, one cirrhosis), and four died. Although HBsAg-positive recipients had a higher rate of liver-related complications and deaths than HBsAg-negative recipients did, there were no significant differences in the long-term graft and patient survival between the two groups. The survival rates, liver-related complications, and deaths in HBsAg-positive allograft recipients and 28 HBsAg-positive uremic patients under dialysis were similar. In conclusion, HBV infection is not a contraindication to kidney transplantation. However, pretransplant candidates should be warned of potentially serious liver-related complications.

Clinical, virologic, and pathologic significance of elevated serum alpha-fetoprotein levels in patients with chronic hepatitis C

Elevated serum alpha-fetoprotein (AFP) in patients with chronic hepatitis C is not uncommonly seen, but the pathogenesis of this phenomenon remains unclear. The aims of this study were to assess the prevalence of elevated serum AFP in patients with chronic hepatitis C and to evaluate the clinical, virologic, and histopathologic significance of this phenomenon. One hundred and fifteen Chinese patients with a histologic diagnosis of chronic hepatitis C were enrolled. None had evidence of hepatocellular carcinoma by image study at enrollment and for at least 2 years' follow-up. Of the 115 patients, 33 (29%) had elevated serum AFP (more than 12 ng/mL). There was a significantly lower mean serum albumin (4.0 +/- 0.1 vs. 4.3 +/- 0.1 gm/dL, p <0.001) and higher mean scores for periportal necroinflammation (3.3 +/- 0.3 vs. 2.3 +/- 0.2, p = 0.007) and fibrosis (2.3 +/- 0.2 vs. 1.1 +/- 0.1, p < 0.001) in patients with elevated serum AFP when compared with patients without elevated serum AFP. Patients with elevated serum AFP had significantly more incidences of genotype 1b infection when compared with patients without elevated serum AFP (77% vs. 51%, p = 0.021). Mean serum hepatitis C virus (HCV) RNA titer showed no significant difference between the two groups. Multivariate logistic regression analysis showed that as serum albumin of less than 4.2 gm/dL, a histology fibrotic score of more than 3, and HCV genotype 1b infection were significantly independent predictors associated with elevated serum AFP. In conclusion, elevated serum AFP levels were significantly correlated with lower serum albumin levels, advanced fibrosis/cirrhosis, and genotype 1b infection in patients with chronic hepatitis C.

Hepatic steatosis in chronic hepatitis C virus infection: prevalence and clinical correlation

BACKGROUND AND AIMS

Hepatic steatosis is a histological characteristic in patients with chronic hepatitis C virus (HCV) infection. The aim of this study was to evaluate the prevalence of hepatic steatosis in Chinese patients with chronic hepatitis C, and to look for possible correlation with various histopathological changes and to look for possible correlation with various clinical and pathologic variables.

METHODS

One hundred and six patients were enrolled, and patients with alcoholism or diabetes mellitus were excluded. Clinical, biochemical and virologic data, including HCV genotype and serum HCV-RNA titer and histological findings, were compared between patients with and without hepatic steatosis.

RESULTS

Fifty-five (52%) of the 106 patients with chronic hepatitis C had hepatic steatosis. Patients with hepatic steatosis had significantly higher mean serum levels of triglyceride and gamma-glutamyl transpeptidase, higher body mass index, and a higher incidence of obesity compared with patients without hepatic steatosis. No significant differences in serum HCV-RNA titer and HCV genotype or the response to interferon therapy were noted between the two groups. Histological analysis showed patients with hepatic steatosis had a significantly higher mean fibrotic score than patients without hepatic steatosis (1.9 +/- 1.2 vs 1.3 +/- 1.0; P = 0.016). There were no significant differences in the severity of necroinflammation, the presence of lymphoid aggregation/follicle or bile duct damage between the two groups. Multivariate logistic regression analysis showed that independent predictors associated with hepatic steatosis were obesity or a histology fibrotic score of > or = 2.

CONCLUSION

It was found that 52% of Chinese patients with chronic hepatitis C had hepatic steatosis. Patients with hepatic steatosis were more frequently obese and had more severe hepatic fibrosis.

Impaired postprandial gastric myoelectrical activity in Chinese patients with nonulcer dyspepsia

Using a homemade electrogastrography (EGG) system, we studied the characteristics of the myoelectrical rhythm in Chinese patients with nonulcer dyspepsia (NUD). Based on short-term Fourier transformation, recorded slow waves could be automatically analyzed to obtain the following parameters: dominant frequency/power, percent of normal frequency (2-4 cpm), power ratio, etc. EGG parameters, Helicobacter pylori status, histological examination of gastric mucosa, and dyspeptic symptoms were recorded in 27 NUD patients. Compared to 32 healthy controls, the Chinese NUD patients had abnormal postprandial EGG parameters including a lower percentage of regular 2-4 cpm slow waves (70.10 +/- 2.97% vs 79.08 +/- 2.95%, P < 0.05), a lower level of increment of dominant power (0.62, +/- 0.91 vs 3.76 +/- 0.58 dB, P < 0.05), lower power ratio (1.42 +/- 0.28 vs 2.79 +/- 0.39, P < 0.05) and a higher instability coefficient (0.36 +/- 0.03 vs 0.26 +/- 0.03, P < 0.05). However, Helicobacter pylori infection and its associated gastritis did not influence any EGG parameters in NUD patients. Six main dyspeptic symptoms and total symptom score had no correlation with any EGG parameters. In conclusion, Chinese NUD patients may have abnormal postprandial stomach myoelectrical activity, but these EGG abnormalities are not a direct result of Helicobacter pylori infection and its related gastritis and do not contribution to the dyspeptic symptoms.

Detrimental effects of nitric oxide inhibition on hepatic encephalopathy in rats with thioacetamide-induced fulminant hepatic failure

Hepatic encephalopathy is a complex neuropsychiatric syndrome seen secondary to acute liver failure, chronic parenchymal liver disease, or portal-systemic anastomosis. Vasodilatation induced by nitric oxide (NO) may be involved in the development of hepatic coma. However, there are no comprehensive data concerning the effects of NO inhibition on the severity of hepatic encephalopathy. Male Sprague-Dawley rats weighing 300-350 g were used. Fulminant hepatic failure was induced by intraperitoneal injection of thioacetamide (TAA, 350 mg kg-1 day-1) for 3 days. Rats were divided into two groups to receive either NG-nitro-L-arginine methyl ester (L-NAME, 20 mg kg-1 day-1 via intragastric gavage) or normal saline (N/S) from 2 days prior to TAA administration for 5 days. Severity of encephalopathy was assessed by counts of motor activity and neurobehaviour test scores. Plasma levels of endotoxin, tumour necrosis factor-alpha and nitrate/nitrite were determined by the chromogenic Limulus assay, enzyme-linked immunosorbent assay and colorimetric assay, respectively. Compared with N/S-treated rats, the mortality rate was significantly higher in rats receiving L-NAME (59% vs. 18%, P < 0.01). Inhibition of NO had detrimental effects on the counts of motor activities (P < 0.05) and neurobehaviour score (P < 0.01). Rats treated with L-NAME had significantly higher plasma levels of endotoxin (26.7 +/- 3.8 pg mL-1) and tumour necrosis factor-alpha (29.4 +/- 6.5 pg mL-1) compared with rats treated with N/S (13.2 +/- 2.7 pg mL-1 and 11.2 +/- 2.6 pg mL-1, respectively, P < 0.01). Plasma levels of endotoxin and tumour necrosis factor-alpha, but not of nitrate/nitrite, were significantly correlated with the severity of hepatic encephalopathy (P < 0.05). Chronic L-NAME administration had detrimental effects on the severity of encephalopathy in TAA-treated rats, suggesting a protective role of NO in the development of fulminant hepatic failure.

Amyloidosis-induced gastrointestinal bleeding in a patient with multiple myeloma

We present a case of multiple myeloma (MM) complicated by recurrent amyloidosis-induced gastrointestinal bleeding. The patient presented with episodes of coffee-ground vomitus or massive hematochezia. No bleeding focus could be identified using endoscopy, a red blood cell scan, or angiography. Finally, a tissue biopsy taken at the irregular mucosa beside protruding vessels in the duodenum confirmed the diagnosis of gastrointestinal amyloidosis. As this case illustrates, the absence of systemic symptoms of amyloidosis and nonspecific endoscopic findings in gastrointestinal amyloidosis may make diagnosis difficult. Therefore, we recommend that a diagnosis of amyloidosis-induced gastrointestinal bleeding should be considered in patients with MM with an obscure hemorrhage.

Inhibition of prostacyclin by indomethacin ameliorates the splanchnic hyposensitivity to glypressin in haemorrhage-transfused common bile duct-ligated rats

Prostacyclin (PGI2) is an important contributor to the mediation of hyporeactivity to vasoconstrictors and the development of hyperdynamic circulation in portal hypertensive states. Inhibition of PGI2 synthesis in haemorrhage-transfused partially portal vein-ligated rats could ameliorate the splanchnic hyposensitivity to glypressin, a long-acting vasopressin analogue. This study investigated whether the hyposensitivity to glypressin also exists in rats with common bile duct ligation (BDL) and whether the inhibition of PGI2 synthesis by indomethacin could potentiate the portal-hypotensive effect of glypressin in bleeding BDL rats. Two series of BDL rats were used. Series 1 investigated the haemodynamic effects of low dose glypressin (0.07 mg kg-1) in BDL rats with or without bleeding by catheterization. In series 2, haemodynamic parameters were measured in stable or bleeding BDL rats that were receiving intravenously high dose glypressin (0.2 mg kg-1) or indomethacin (5 mg kg-1) followed by high dose glypressin. In rats with a hypotensive haemorrhage, 4.5 mL of blood was withdrawn and 50% of the withdrawn blood was reinfused before the administration of glypressin or indomethacin. Splanchnic hyposensitivity to glypressin was demonstrated in haemorrhage-transfused BDL rats receiving high, but not low, doses of glypressin. Indomethacin infusion did not cause significant systemic and portal haemodynamic changes in bleeding BDL rats (P > 0.05). The addition of indomethacin significantly enhanced the portal-hypotensive effects of glypressin (P < 0.05) and potentiated the increases in mean arterial pressure induced by glypressin infusion (P < 0.001) in bleeding BDL rats. Splanchnic hyposensitivity to glypressin observed in haemorrhage-transfused BDL rats could be ameliorated by the addition of indomethacin, suggesting a role of endogenous PGI2 in its pathophysiology.

Comparison of clinical, virologic and pathologic features in patients with acute hepatitis B and C

BACKGROUND AND AIMS

The clinical outcomes of adult-acquired acute infection of hepatitis C virus (HCV) and hepatitis B virus (HBV) are quite different. In order to compare the clinical, biochemical, virologic and pathologic pictures in these two groups of patients, we enrolled 22 adult patients with acute hepatitis C and 16 adult patients with acute hepatitis B, on whom liver biopsies were performed within 3 months of acute onset of the illness.

RESULTS

The results showed that a significantly younger age, a higher ratio of the clinical symptoms of jaundice, nausea, vomiting, and poor appetite, a higher mean serum level of alanine transaminase, aspartate transaminase, and total bilirubin were present in patients with acute hepatitis B patients than in those with acute hepatitis C (P < 0.05). There was a significantly higher degree of periportal inflammation and total necro-inflammatory activity in the acute hepatitis B patients (P = 0.002 and 0.049, respectively). Fifteen (68.2%) of the 22 patients with acute hepatitis C had detectable serum HCV-RNA, but only two (14.3%) of the 14 tested patients with acute hepatitis B had detectable serum HBV-DNA, detected by using the branched DNA signal amplification assay. Eighteen (82%) of the 22 acute hepatitis C patients and none of the 16 acute hepatitis B patients progressed into a chronic hepatitis stage (P < 0.001).

CONCLUSION

The manifestations of mild clinical symptoms, lower mean serum transaminases and bilirubin levels, a lesser degree of histological periportal necroinflammation, and more patients with a high circulatory viral load among the acute hepatitis C patients, may lead to more of that group developing chronicity than patients with acute hepatitis B.

Long-term outcome of kidney transplantation in patients with hepatitis C virus infection

BACKGROUND/AIMS

The impact of HCV (hepatitis C virus) infection on the long-term outcome of kidney transplant patients is controversial.

METHODOLOGY

Eighty-four renal allograft recipients who were seronegative for hepatitis B surface antigen and had been screened for antibody to hepatitis C virus (anti-HCV) were included. The outcome and survival were compared between anti-HCV-positive (n = 30, group 1) and anti-HCV-negative (n = 54, group 2) kidney transplant patients. Group 1 patients were further compared to 52 anti-HCV-positive end-stage renal disease patients (group 3) who were on chronic dialysis.

RESULTS

Group 1 patients had a higher prevalence of chronic hepatitis than group 2 and group 3 patients did (67% vs. 2% and 31%). Liver-related complications and deaths between group 1 and group 2, and group 1 and group 3 patients were not significantly different. The comparisons of the long-term survival between these groups showed no significant differences, despite group 3 patients had a higher overall mortality rate. Cox regression analysis confirmed that age more than 45 years was the only independent factor that affected survival in anti-HCV-positive end-stage renal disease patients with or without kidney transplantation.

CONCLUSIONS

HCV infection is not a contraindication to kidney transplantation. For anti-HCV-positive end stage renal disease patients, survival is better in younger patients, and is not influenced by kidney transplantation or continuing dialysis.

What is the essential role in the normalized rat intestinal transit? Calcium or calcitonin

BACKGROUND/AIMS

Both calcium and calcitonin have been involved in mediating gastrointestinal motility. Using a thyroidectomized rat model the present study tried to determine which one of them was essential for normal small intestinal transit.

METHODOLOGY

Adult Sprague-Dawley male rats simultaneously received thyroidectomy or a sham operation plus a laparotomy for duodenal tubing. After two-week housing, a small intestinal transit study was conducted via geometric center computation of radioactivities of the intestinal segments counted from intraduodenal feeding of radiochromium. Before feeding, these rats were i.p. injected with saline or human calcitonin in the doses of 0.1, 1 and 10 microM/kg, respectively. Another group of Tx rats received i.v. infusion of saline or CaCl2 for 30 min before motility study.

RESULTS

Thyroidectomization effectively delayed transit compared to the sham-operated controls (3.59 +/- 0.15 vs. 2.98 +/- 0.32, P < 0.05). High doses of calcitonin treatment in thyroidectomized rats further inhibited transit (P < 0.01), whereas calcitonin did not restore the suppressed calcium level. Delayed transit in thyroidectomized rats was restored after calcium infusion (2.95 +/- 0.22 vs. 3.78 +/- 0.42, P < 0.05) while their hypocalcemia was already corrected.

CONCLUSIONS

Thyroidectomization disturbs small intestinal transit, while peripheral calcitonin replacement further inhibits transit. Since calcium replacement enables to restore small intestinal transit, it is apparent that calcium rather than calcitonin is essential for normal small intestinal transit.

Real-time display of the stomach slow wave and its parameters in a newly designed electrogastrographic system

We designed a new three-channel electrogastrographic (EGG) system, which was easily operated on the Windows 95 platform and could automatically provide slow wave parameters. The purpose of the present study was to test its reliability and accuracy in clinical recording. The system included a signal acquisition device assembled on a printed circuit board. Recorded myoelectrical signals were filtered, amplified, digitized, and transmitted via this device into a notebook personal computer (PC). Based on the short-term Fourier transform the software could transfer the time domain of the signal into the frequency domain. Real-time displayed slow wave parameters, including dominant frequency/power, percent of normal frequency (2-4 cpm), instability coefficient in frequency/power, and power ratio, were automatically renewed every 64s. Twenty healthy subjects (M/F, 12/8; age, 23-51 years) were enrolled to measure both fast and postprandial myoelectrical activities for each 30-min recording. Our results indicated that meal ingestion significantly increased dominant frequency (3.15+/-0.20 vs 3.23+/-0.23 cpm; P < 0.05) and power (26.1+/-3.8 vs 28.4+/-3.9 dB; P < 0.05). The power ratio of the meal effect was 2.02+/-2.07. Other parameters, including instability coefficient and percent of normal frequency, remained similar despite food ingestion. This newly designed EGG system is acceptable for clinically measuring gastric myoelectrical activity; the real-time display of many EGG parameters is an advantage with this new system.

Outcomes of Aeromonas bacteremia in patients with different types of underlying disease

Over a 6-year period, 42 patients with different underlying diseases developed Aeromonas bacteremia in our hospital. The male to female ratio was 2:1. The vast majority of these patients had underlying diseases, including various types of neoplasm (n = 14), liver cirrhosis (n = 11), biliary tract disorder (n = 10) and other illnesses (n = 7). Community-acquired bacteremia was predominant (33 cases, 79%). Aeromonas hydrophila was the most common species isolated (88%). Monomicrobial bacteremia was more common than polymicrobial bacteremia (64% vs 36%). Monomicrobial bacteremia was associated with neoplasm or liver cirrhosis in 80% of patients. Polymicrobial bacteremia was more common in patients with biliary tract disorder than in patients from other groups (60% vs 40%). Escherichia coli (60%) was the predominant concomitant organism isolated. The major clinical manifestations were fever (74%), jaundice (57%), and abdominal pain (45%). Recognized infection sites included biliary tract, soft tissue involvement, peritoneal involvement, while 50% of patients had no recognized infection site. Eight patients (80%) received cholecystectomy due to gall stone with acute cholecystitis. However, none of the cirrhotic patients with necrotizing fasciitis received surgical treatment. The mortality attributed to Aeromonas bacteremia was 70%. Patients with liver cirrhosis or malignancy had a higher acute mortality (death within 7 days after admission) than the other patients (89% vs 11%). We conclude that Aeromonas bacteremia can cause a rapidly fatal outcome and should be considered an important pathogen for septicemia in patients with liver cirrhosis or neoplasm.

Splanchnic hyposensitivity to glypressin in a haemorrhage/transfused rat model of portal hypertension: role of nitric oxide and bradykinin

Hyposensitivity to vasopressin is a well documented phenomenon in animals with portal hypertension and patients with cirrhosis subject to haemorrhage. Haemorrhage is associated with the endogenous release of bradykinin, which may subsequently stimulate the formation of nitric oxide (NO). The present study investigated the relative contribution of NO synthase (NOS) isoforms and the role of bradykinin in the pathogenesis of splanchnic hyposensitivity to a long-acting vasopressin analogue, glypressin, in rats with portal hypertension induced by partial portal vein ligation (PVL). At 14 days after the operation, systemic and portal haemodynamics were measured in stable or bleeding PVL rats receiving an intravenous infusion of glypressin (0.07 mg/kg). In the treatment groups, N(G)-nitro-L-arginine methyl ester (L-NAME; a non-selective NOS inhibitor), L-canavanine (a specific inhibitor of inducible NOS) or HOE 140 (a bradykinin B(2) receptor antagonist) was administered 45 min before the infusion of glypressin. In rats with a hypotensive haemorrhage, 4.5 ml of blood was withdrawn and 50% of the withdrawn blood was re-infused before the administration of glypressin or various inhibitors. Splanchnic hyposensitivity to glypressin was demonstrated in the haemorrhage/transfused PVL rats. The infusion of L-NAME elevated the mean arterial pressure in the bleeding PVL rats without the modulation of portal pressure. The addition of L-NAME or HOE 140, but not L-canavanine, significantly and similarly potentiated the portal-hypotensive effects of glypressin. It is concluded that constitutive NOS and bradykinin are responsible, at least partly, for the splanchnic hyposensitivity to glypressin observed in the early stages of the haemorrhage/transfused rat model of portal hypertension.

Chronic inhibition of nitric oxide ameliorates splanchnic hyposensitivity to glypressin in a hemorrhage-transfused rat model of portal hypertension

BACKGROUND

Vasopressin given during hemorrhage is less effective than when given during a stable state in experimental portal hypertension or patients with cirrhosis (the so-called hyposensitivity phenomenon). This study investigated whether chronic inhibition of nitric oxide (NO) synthesis by NG-nitro-L-arginine methyl ester (L-NAME), a non-selective NO synthase inhibitor, could potentiate the portal-hypotensive effect of glypressin (a long-acting vasopressin analogue) in portal-hypertensive rats during acute bleeding status.

METHODS

Portal hypertension was induced by partial portal vein ligation (PVL). Rats were divided to receive either L-NAME (approximately 25 mg/kg/day in tap water) or placebo (tap water) treatment orally from 2 days prior to until 14 days after the operation. At the end of treatment, L-NAME-and placebo-treated PVL rats were subdivided into without-bleeding and with-bleeding groups to assess the effects of glypressin (0.07 mg/kg) on systemic and portal hemodynamics. In rats with a hypotensive hemorrhage, 4.5 ml of blood was withdrawn and 50% of the withdrawn blood was reinfused before the administration of glypressin.

RESULTS

As compared with placebo-treated rats, chronic treatment with L-NAME in PVL rats significantly increased mean arterial pressure (P < 0.001) without modulating portal pressure (P > 0.05). In placebo-treated PVL rats, glypressin resulted in a less decrease in portal pressure in rats with bleeding than in those without bleeding (P < 0.05). For PVL rats with bleeding, the portal-hypotensive effect of glypressin was significantly potentiated after chronic L-NAME treatment (P < 0.05).

CONCLUSIONS

Chronic inhibition of NO alleviates the splanchnic hyposensitivity to glypressin observed in bleeding PVL rats, suggesting the pathophysiological role of nitric oxide in mediating this splanchnic hyposensitivity.

Need for vaccination of susceptible food handlers against hepatitis A in Taiwan

BACKGROUND

With the improvement in the socioeconomic situation and general hygiene standards in Taiwan, the prevalence of antibodies to the hepatitis A virus (anti-HAV) in the general population has declined markedly in recent years. To avoid food-borne outbreaks of HAV infection caused by susceptible food handlers in Taiwan, we investigated the seroprevalence of anti-HAV among the target population and also evaluated the immunogenicity and reactogenicity of the inactivated hepatitis A vaccine in this study group.

METHODS

Two hundred and forty-four food handlers employed in four restaurants at Taipei Veterans General Hospital participated in the anti-HAV serologic screening program in July 1997. Of them, 48 susceptible food handlers received three doses of 720 enzyme-linked immunosorbent units of inactivated hepatitis A vaccine at 0, 1 and 6 months.

RESULTS

Of the 244 food handlers who underwent anti-HAV serologic screening, 169 (69.3%) were anti-HAV positive. The seroprevalence of anti-HAV was related to age: 91.5% of food handlers over 30 years of age were positive for anti-HAV but only 22.8% of food handlers younger than 30 were anti-HAV positive. Anti-HAV response was observed in all vaccinees after a booster vaccination at month 6. The response persisted to 1 year. The side-effects of the vaccinations were minimal.

CONCLUSIONS

Susceptible food handlers should receive hepatitis A vaccination. Hepatitis A vaccine is safe and immunogenic in this target population.

Abdominal wall necrosis following transcatheter arterial chemoembolization for hepatocellular carcinoma

A 76-year-old man, who had inoperable hepatocellular carcinoma, had been treated with transcatheter arterial chemoembolization (TACE) 11 times, percutaneous ethanol injection therapy three times and conformal radiotherapy once, all in other hospitals. At this admission, he developed myocutaneous necrosis in the right abdominal wall after TACE, via the collateral of the right internal mammary artery (IMA). Necrosis of the abdominal wall was due to ischemic changes caused by embolization of the distal branches of the IMA, which were aggravated by previous radiation therapy. We advise that embolization of the IMA in patients who have received radiotherapy should be avoided, if possible.

Triple therapy with clarithromycin, omeprazole, and amoxicillin for eradication of Helicobacter pylori in duodenal ulcer patients in Asia and Africa

BACKGROUND

Studies assessing the efficacy of triple therapy containing clarithromycin and amoxicillin for the eradication of Helicobacter pylori infection and healing of duodenal ulcers in Asian and African countries are limited.

AIM

To determine the efficacy and safety of 1-week triple therapy with omeprazole, amoxicillin and clarithromycin for eradicating H. pylori infection in patients with active duodenal ulcer living in Asian and African regions.

METHODS

This was an open-label, multicentre study in 11 centres in Asia and Africa. Patients with endoscopy-proven duodenal ulcer and who were H. pylori-positive were treated with clarithromycin 500 mg, omeprazole 20 mg, and amoxicillin 1000 mg, all given twice daily for 7 days. Upper endoscopy was repeated at week 6 to check for ulcer healing and H. pylori status.

RESULTS

A total of 117 patients were recruited. H. pylori eradication rates were 85% by per protocol analysis and 80% by intention-to-treat analysis. Ulcer healing was found in 94% of subjects (per protocol analysis). Clinical success, measured by change of pre-treatment ulcer symptoms, was strongly supported by complete resolution or improvement in 100% of the evaluable patients (per protocol analysis). Since treatment-related adverse events, when present, were largely mild or moderate, the triple therapy regimen was considered safe.

CONCLUSION

Seven-day triple therapy with omeprazole, amoxicillin, and clarithromycin was efficacious for treating Asian and African patients with duodenal ulcer disease associated with H. pylori infection, and the treatment regimen was well-tolerated.