Ultrasound-guided selective supraclavicular nerve block for postoperative pain control in children receiving Hickman catheter or chemoport insertion: A randomized controlled trial

BACKGROUND

Optimal pain management after insertion of a central venous catheter in children remains unclear.

AIM

This study aimed to evaluate the effects of a selective supraclavicular nerve block on postoperative analgesia in pediatric patients undergoing hickman catheter or chemoport insertion.

METHODS

Fifty patients aged 3-18 years scheduled for elective Hickman or chemoport insertion were randomized into two groups of 25 each: one group received an ultrasound-guided selective supraclavicular nerve block with 0.1 mL/kg of 0.5% ropivacaine (SSCNB group), and the other group did not receive a nerve block (control group). The primary outcome was the postoperative Wong-Baker Faces Pain Rating Scale score measured between 10 and 30 min after surgery. Secondary outcomes included pain scores at 1, 3, and 24 h after the surgery, block-related complications, length of stay in the postanesthesia care unit, postoperative analgesic consumption, and time to first analgesic use 24 h after surgery.

RESULTS

The worst pain score within 30 min in the recovery room was significantly lower in the SSCNB group compared to the control group (6 [5-7] vs. 3 [2-4]; median difference, -3; 95% CI, -4 to -1; p < .001). Pain scores at 1, 3, and 24 h after surgery were also significantly lower in the SSCNB group. The need for both opioid and non-opioid analgesics in the postoperative period was significantly lower in the SSCNB group (36.0% vs. 0%; p = .002 and 44.0% vs. 16.0%; mean difference, -28%; 95% CI, -56 to 0.19; p = .033, respectively), while other secondary outcomes were not significantly different between the two groups.

CONCLUSIONS

Ultrasound-guided SSCNB is an effective method for managing postoperative pain in children undergoing Hickman catheter or chemoport insertion, reducing the need for analgesics within 24 h after surgery.

Validation of the Masimo O3™ regional oximetry device in pediatric patients undergoing cardiac surgery

We assessed the accuracy of Masimo O3™ regional cerebral oxygen saturation (rSO₂) readings by comparing them with reference values and evaluated the relationship between rSO₂ and somatic tissue oxygen saturation (StO₂) in children undergoing cardiac surgery. After anesthesia induction, pediatric sensors were applied to the forehead and foot sole, and rSO₂ and StO₂ values were monitored continuously. Before cardiopulmonary bypass (CPB), F_IO₂ was set to 0.2, 0.5, and 0.8 serially every 15 min. After CPB, F_IO₂ was reversed. The reference values (SavO₂) were calculated by combining arterial (SaO₂) and central venous oxygen saturation (SvO₂) readings from the arterial and central lines, respectively (0.7 [Formula: see text] SvO₂ + 0.3 [Formula: see text] SaO₂). In total, 265 pairs of rSO₂/StO₂ and SavO₂ from 49 patients were analyzed. The bias, standard deviation (SD), standard error (SE), and root mean squared error (RMSE) of rSO₂ were 2.6%, 4.5%, 0.3%, and 4.3%, respectively. The limits of agreement ranged from -6.3% to 11.6%. Trend accuracy analysis yielded a relative mean error of -1.4%, with an SD of 4.3%, SE of 0.2%, and RMSE of 3.9%. According to multiple linear regression analysis, the application of CPB, F_IO₂, Hb level, and tip location of the central venous catheter influenced the bias (all P < 0.05). Furthermore, the correlation between rSO₂ and StO₂ was weak (r = 0.254). rSO₂ readings by the Masimo O3™ device and pediatric sensor had good absolute and trending accuracies with respect to the calculated reference values in children undergoing cardiac surgery. rSO₂ and StO₂ cannot be used interchangeably.Clinical trial registration http://clinicaltrials.gov (number: NCT04208906).

Ultrasound-guided esophageal compression during mask ventilation in small children: a prospective observational study

Background

The use of cricoid compression to prevent insufflation remains controversial, and its use in children is limited. This study aimed to examine the effect of real-time ultrasound-guided esophageal compression on the prevention of gastric insufflation.

Method

This prospective observational study was conducted with fifty children aged < 2 years undergoing general anesthesia. Patients were excluded if they were at an increased risk for gastric regurgitation or pulmonary aspiration. Following anesthetic induction under spontaneous breathing, ultrasound-guided esophageal compression was performed during pressure-controlled face-mask ventilation using a gradual increase in peak inspiratory pressure from 10 to 24 cm H₂O to determine the pressure at which gastric insufflation occurred. The primary outcome was the incidence of gastric insufflation during anesthetic induction with variable peak inspiratory pressure after real-time ultrasound-guided esophageal compression was applied.

Results

Data from a total of 42 patients were analyzed. Gastric insufflation was observed in 2 (4.7%) patients. All patients except one had their esophagus on the left side of the trachea. Applying ultrasound-guided esophageal compression did not affect the percentage of glottic opening scores (P = 0.220).

Conclusions

The use of real-time ultrasound-guided esophageal compression pressure can aid preventing gastric insufflation during face-mask ventilation in children less than 2 years old.

Trial registration

Clinicaltrials.gov identifier: NCT04645043.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01803-5.

Performance time of anesthesiology trainees for cricothyroid membrane identification and characteristics of cricothyroid membrane in pediatric patients using ultrasonography

BACKGROUND

Identifying the cricothyroid membrane is an essential technical skill for front-of-neck access procedures.

AIMS

This study evaluated the usefulness of cricothyroid membrane identification in pediatric patients using ultrasonography by anesthesiology trainees without experience in airway ultrasound and collected anatomical data on the cricothyroid membrane and its surrounding airway structures in children.

METHODS

This prospective observational study included children aged <18 years scheduled to undergo general anesthesia and anesthesiology trainees who identified the cricothyroid membrane in five sequential anesthetized patients using ultrasonography. A pediatric anesthesiologist confirmed the accuracy of the identified cricothyroid membrane and recorded the performance time. The primary aims were the cricothyroid membrane identification success rate and performance time. The secondary aims were the characterization of the cricothyroid membrane and its surrounding structures.

RESULTS

Overall, 150 pediatric patients and 30 anesthesiology trainees were analyzed. The cricothyroid membrane identification success rate using ultrasonography was 100% in all the attempts using a transverse approach. The mean (standard deviation) performance time was 27.2 (18.6) s and 31.0 (23.8) s using the transverse and longitudinal approaches, respectively. The performance time decreased by 3.1 (p = .003, 95% confidence interval [CI] = -5.1--1.0) and 5.2 (p = .007, 95% CI = -8.9--1.4) seconds per increase in number of attempts with the transverse and longitudinal approaches, respectively. The cricothyroid membrane length was mostly correlated with the patients' height (r = .75, p < .001), and the blood vessels surrounding the cricothyroid membrane were observed in 95.9% of the patients.

CONCLUSIONS

Anesthesiology trainees without experience in airway ultrasound successfully identified the cricothyroid membrane in pediatric patients using ultrasonography after a brief training period. Further research is required as the identification of a structure does not predict the success of the actual procedure, particularly if done in an emergency situation.

The effect of dexmedetomidine on neuroprotection in pediatric cardiac surgery patients: study protocol for a prospective randomized controlled trial

Background

Infants undergoing cardiac surgery under cardiopulmonary bypass are vulnerable to postoperative neurodevelopmental delays. Dexmedetomidine has been shown to have protective effects on the heart, kidneys, and brain in animals and adults undergoing cardiac surgery with cardiopulmonary bypass. We hypothesized that dexmedetomidine would have a neuroprotective effect on infants undergoing cardiopulmonary bypass and planned a prospective randomized controlled trial with postoperative neurodevelopment measurements.

Methods

This is a single-center, prospective, double-blinded, randomized controlled trial with 1:1 allocation. A cohort of 160 infants undergoing cardiac surgery with cardiopulmonary bypass will be enrolled. After induction, dexmedetomidine will be infused with a loading dose of 1 μg/kg and a maintenance dose of 0.5 μg/kg/h or the same amount of normal saline will be administered. Upon initiation of cardiopulmonary bypass, an additional dose of dexmedetomidine (0.01 μg/cardiopulmonary priming volume) will be mixed with the cardiopulmonary bypass circuit. The primary outcome will be the proportion of infants who score lower than 85 in any of the cognitive, language, or motor Bayley scales of infant development-III tests 1 year after the surgery. Other feasible outcome measures will include differences in plasma glial fibrillary acidic protein, troponin I, interleukin-6, urinary neutrophil gelatinase-associated lipocalin, and perioperative major adverse events. The results of the Bayley scales of infant development-III test from the study group and the control group will be compared using a chi-squared test under intention-to-treat analysis. A generalized estimating equation will be used to analyze repeated measurements over time.

Discussion

This study will enable us to assess whether the use of dexmedetomidine can alter the early neurodevelopmental outcome in infants undergoing cardiac surgery with cardiopulmonary bypass and also estimate effects of dexmedetomidine on other organs.

Trial registration

ClinicalTrials.gov NCT04484922. Registered on 24 July 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06217-9.

Central venous catheter-related thrombosis in pediatric surgical patients: A prospective observational study

BACKGROUND

Perioperative central venous catheters are required but may be associated with various complications.

AIMS

The purpose of our study was to assess the incidence and perioperative risk factors for catheter-related internal jugular vein thrombosis in pediatric surgical patients.

METHODS

This prospective observational study included children under 6 years of age who were scheduled to undergo central venous catheterization of the right internal jugular vein under general anesthesia. A central venous catheter was inserted under real-time ultrasound guidance. An investigator examined for thrombosis using ultrasonography at predetermined time points. The primary aim was the incidence of catheter-related thrombosis from insertion until the 5th day postoperatively or the removal of the central venous catheter. The secondary aim was the determination of the risk factors for thrombosis.

RESULTS

Eighty patients completed the study. Internal jugular vein thrombi were found in 31 patients (38.8%, 95% CI 28.0-49.4). On multiple logistic regression analyses, the number of insertion attempts was the only influencing factor for catheter-related thrombosis (p < .001). More than two insertion attempts increased the risk of thrombosis (odds ratio 5.6; 95% CI 1.7 - 18.7, p = .004). Anesthesia time (p = .017; mean difference 166.4 min; 95% CI 55.7-277.1), intraoperative red blood cell transfusion (p = .001; median difference 21.1 ml kg^-1 ; 95% CI 6.6-34.4), and intensive care unit stay (p = .001; median difference 100.0 h; 95% CI 48-311) differed between patients with transient thrombosis and those with thrombosis lasting for more than 3 days.

CONCLUSION

Internal jugular vein thrombosis was frequently detected by ultrasound following central venous catheterization in pediatric surgical patients. Multiple insertion attempts may be associated with the incidence of thrombosis. The clinical relevance of thrombi detected via ultrasound surveillance has not been determined.

The Association between Oxidative Stress and Metabolic Syndrome in Adults

BACKGROUND

In this Study, we investigated the effects of lifestyle and metabolic syndrome on free oxygen radical levels in men and women in Korea.

METHODS

A total of 254 adults were included in this study from February 2011 to June 2012 at a health promotion center. Information of the lifestyles and presence of metabolic syndrome factors was obtained. Biochemical markers were measured and free oxygen radicals test (FORT) was performed on the blood.

RESULTS

Of the 254 subjects, 86 (33.9%) had metabolic syndrome, and 187 (73.6%) were men. Between the subjects with and without metabolic syndrome, there was a significant increase in alanine aminotransferase and serum FORT values in the subjects with metabolic syndrome. Multiple linear regression analysis showed that high-sensitivity C-reactive protein (hs-CRP) (P = 0.004), metabolic syndrome (P = 0.037), and female gender (P = 0.030) were independent predictors of serum FORT values. The subjects with high fasting blood sugar level or low high density lipoprotein cholesterol levels showed high serum FORT values.

CONCLUSION

High hs-CRP, the presence of metabolic syndrome, and female gender were associated with the high oxidative stress. High oxidative stress was associated with the presence of metabolic syndrome.

Mitochondrial modulation decreases the bortezomib-resistance in multiple myeloma cells

Multiple myeloma (MM) is an incurable hematological malignancy that causes most patients to eventually relapse and die from their disease. The 20S proteasome inhibitor bortezomib has emerged as an effective drug for MM treatment; however, intrinsic and acquired resistance to bortezomib has already been observed in MM patients. We evaluated the involvement of mitochondria in resistance to bortezomib-induced cell death in two different MM cell lines (bortezomib-resistant KMS20 cells and bortezomib-sensitive KMS28BM cells). Indices of mitochondrial function, including membrane potential, oxygen consumption rate and adenosine-5'-triphosphate and mitochondrial Ca(2+) concentrations, were positively correlated with drug resistance of KMS cell lines. Mitochondrial genes including CYPD, SOD2 and MCU were differentially expressed in KMS cells. Thus, changes in the expression of these genes lead to changes in mitochondrial activity and in bortezomib susceptibility or resistance, and their combined effect contributes to differential sensitivity or resistance of MM cells to bortezomib. In support of this finding, coadministration of bortezomib and 2-methoxyestradiol, a SOD inhibitor, rendered KMS20 cells sensitive to apoptosis. Our results provide new insight into therapeutic modalities for MM patients. Studying mitochondrial activity and specific mitochondrial gene expression in fresh MM specimens might help predict resistance to proapoptotic chemotherapies and inform clinical decision-making.

Transport of organic cationic drugs: effect of ion-pair formation with bile salts on the biliary excretion and pharmacokinetics

More than 40% of clinically used drugs are organic cations (OCs), which are positively charged at a physiologic pH, and recent reports have established that these drugs are substrates of membrane transporters. The transport of OCs via membrane transporters may play important roles in gastrointestinal absorption, distribution to target sites, and biliary and/or renal elimination of various OC drugs. Almost 40 years ago, a molecular weight (Mw) threshold of 200 was reported to exist in rats for monoquaternary ammonium (mono QA) compounds to be substantially (e.g., >10% of iv dose) excreted to bile. It is well known that some OCs interact with appropriate endogenous organic anions in the body (e.g., bile salts) to form lipophilic ion-pair complexes. The ion-pair formation may influence the affinity or binding of OCs to membrane transporters that are relevant to biliary excretion. In that sense, the association of the ion-pair formation with the existence of the Mw threshold appears to be worthy of examination. It assumes the ion-pair formation of high Mw mono QA compounds (i.e., >200) in the presence of bile salts in the liver, followed by accelerated transport of the ion-pair complexes via relevant bile canalicular transporter(s). In this article, therefore, the transport of OC drugs will be reviewed with a special focus on the ion-pair formation hypothesis. Such information will deepen the understanding of the pharmacokinetics of OC drugs as well as the physiological roles of endogenous bile salts in the detoxification or phase II metabolism of high Mw QA drugs.

Assessment of lifestyle effects on the levels of free oxygen radicals in the korean population

Background

As many studies revealed that oxidative stress due to the imbalance of reactive oxygen species (ROS) and antioxidant capacity is related with pathologic processes such as cardiovascular diseases, diabetes, as well as aging and obesity, the relationship between lifestyle and oxidative stress has recently gained much medical attention. However, little information exists on the effects of lifestyle on ROS in Korea. In this study, we investigated the effects of lifestyle on free oxygen radical levels in men and women in Korea.

Methods

A total of 138 adults participated in this study from September 2007 to June 2010 at a health promotion center and department of family medicine. Information on the lifestyle of each participant was obtained by questionnaire. Biochemical markers and a free oxygen radical test (FORT) were also measured.

Results

The average age was 47.28 ± 10.85 years and 79.7% were male. High sensitivity C-reactive protein (hs-CRP; r = 0.418, P = 0.012), triglycerides (r = -0.243, P = 0.008), hemoglobin (r = -0.445, P < 0.001), total protein (r = 0.210, P = 0.036), creatinine (r = -0.294, P = 0.001), fruit intake per day (P = 0.047), and smoking (P = 0.003) were related to the FORT levels in univariate analysis. Multiple linear regression analysis showed that hs-CRP (P = 0.039) was an independent predictor of serum FORT values. This statistical model can explain 78% of the variance in FORT values.

Conclusion

This result suggests that hs-CRP showed a statistically significant positive association with FORT values. Further studies on the relationship between lifestyle and antioxidant capacity as well as ROS seem to be warranted to evaluate the overall effect of oxidative stress.

A case of a giant mucocoele of the appendiceal stump presented with a palpable mass in the right thigh: pre-operative diagnosis based on characteristic multidetector CT findings

The pre-operative diagnosis of a mucocoele of the appendiceal stump (MAS) may be difficult owing to rarity and non-specific clinical presentation. However, a pre-operative diagnosis of a MAS is important to prevent widespread dissemination by inadvertent spillage of mucous contents. We describe a case of a MAS presenting with a palpable mass in the right thigh in which a pre-operative diagnosis was made by characteristic multidetector CT (MDCT) findings.

Comparison of endoscopic ultrasonography and conventional endoscopy for prediction of depth of tumor invasion in early gastric cancer

BACKGROUND AND STUDY AIMS

This study aimed to compare the diagnostic accuracy of endoscopic ultrasonography (EUS) with that of conventional endoscopy for staging depth of invasion (T staging) in early gastric cancer.

PATIENTS AND METHODS

A total of 955 patients with suspected early gastric cancer were prospectively registered. EUS staging was carried out prospectively by a single endoscopist using either miniprobe or radial EUS depending on the endoscopic appearance of the tumor. Conventional endoscopy staging was performed retrospectively by consensus between two endoscopists who were blinded to the EUS staging. Conventional endoscopy staging was conducted on the basis of endoscopic features such as surface nodularity and fold convergence. Patients underwent either surgical (n = 586) or endoscopic resection (n = 369) with curative intent. The staging accuracy of each test was compared with the pathological staging of the resected specimen.

RESULTS

The presence of a T1m tumor was histologically confirmed in 644 cases (67.4 %) and that of a T1sm tumor in 311 cases (32.6 %). The overall accuracy of EUS staging was 67.4 % (644 / 955) and that of conventional endoscopy staging was 73.7 % (704 / 955) ( P < 0.001). The accuracy of miniprobe EUS was significantly higher than that of radial EUS (79.5 % vs. 59.6 %, P < 0.001), but did not differ significantly from that of conventional endoscopy (79.0 %).

CONCLUSIONS

EUS does not substantially impact on pretreatment T staging of patients with early gastric cancer compared with conventional endoscopy. Therefore, EUS may not be necessary routinely, and conventional endoscopy may be sufficient for determining the optimal therapeutic strategy, especially in relation to endoscopic resection for early gastric cancer.

Mutant DLX 3 disrupts odontoblast polarization and dentin formation

Tricho-dento-osseous (TDO) syndrome is an autosomal dominant disorder characterized by abnormalities in the thickness and density of bones and teeth. A 4-bp deletion mutation in the Distal-Less 3 (DLX3) gene is etiologic for most cases of TDO. To investigate the in vivo role of mutant DLX3 (MT-DLX3) on dentin development, we generated transgenic (TG) mice expressing MT-DLX3 driven by a mouse 2.3 Col1A1 promoter. Dentin defects were radiographically evident in all teeth and the size of the nonmineralized pulp was enlarged in TG mice, consistent with clinical characteristics in patients with TDO. High-resolution radiography, microcomputed tomography, and SEM revealed a reduced zone of mineralized dentin with anomalies in the number and organization of dentinal tubules in MT-DLX3 TG mice. Histological and immunohistochemical studies demonstrated that the decreased dentin was accompanied by altered odontoblast cytology that included disruption of odontoblast polarization and reduced numbers of odontoblasts. TUNEL assays indicated enhanced odontoblast apoptosis. Expression levels of the apoptotic marker caspase-3 were increased in odontoblasts in TG mice as well as in odontoblastic-like MDPC-23 cells transfected with MT-DLX3 cDNA. Expression of Runx2, Wnt 10A, and TBC1D19 colocalized with DLX3 expression in odontoblasts, and MT-DLX3 significantly reduced expression of all three genes. TBC1D19 functions in cell polarity and decreased TBC1D19 expression may contribute to the observed disruption of odontoblast polarity and apoptosis. These data indicate that MT-DLX3 acts to disrupt odontoblast cytodifferentiation leading to odontoblast apoptosis, and aberrations of dentin tubule formation and dentin matrix production, resulting in decreased dentin and taurodontism. In summary, this TG model demonstrates that MT-DLX3 has differential effects on matrix production and mineralization in dentin and bone and provides a novel tool for the investigation of odontoblast biology.

Comparison of risk factors and clinical responses to proton pump inhibitors in patients with erosive oesophagitis and non-erosive reflux disease

BACKGROUND

There has been no report on the response to proton pump inhibitor (PPI) therapy and on-demand or the relapse rate of non-erosive reflux disease (NERD) and erosive oesophagitis in Korea.

AIM

To compare the risk factors, clinical symptoms and PPI responses between patients with erosive oesophagitis and NERD patients.

METHODS

A survey was performed prospectively in the erosive oesophagitis (205 patients) and NERD group (200 patients). Clinical symptoms, risk factors and PPI responses were analysed. On-demand therapy and the relapse rate of GERD symptoms were investigated during a one-year follow-up.

RESULTS

BMI > or = 25 (OR 3.0, 95% CI 1.1-8.3), alcohol use (OR 2.9, 95% CI 1.0-8.3), hiatal hernia (OR 5.0, 95% CI 1.2-20) and triglyceride > or =150 mg/dL (OR 4.0, 95% CI 1.7-10) were more common in the erosive oesophagitis group than in the NERD group by multivariate analysis. The ratio of oesophageal to extra-oesophageal symptoms was higher in the erosive oesophagitis group compared with the NERD group (P < 0.001). The PPI response rates at 8 weeks were different (P = 0.02); refractory rates were higher in the NERD group (16.7%) compared with the erosive oesophagitis group (6.0%). However, there was no significant difference between the two groups in on-demand therapy or the relapse rate.

CONCLUSION

These results suggest that the underlying pathogenic mechanisms of erosive oesophagitis and NERD are distinct.

Genetic variants of organic cation transporter 2 (OCT2) significantly reduce metformin uptake in oocytes

1. The authors sought to evaluate the contribution of organic cation transporters (OCTs) to the renal tubular transport of metformin using LLC-PK1 cells as an in vitro model for the renal proximal tubule, and to investigate the effects of three non-synonymous genetic variants of OCT2 on the transport activity of metformin in vitro using an oocyte over-expression system. 2. The basolateral-to-apical transport of metformin was significantly greater than the apical-to-basolateral transport and showed concentration dependency with the kinetic parameters: maximum transport rate (V(max)), 922 pmol min(-1) per 5 x 10(5) cells; Michaelis-Menten constant (K(m)), 393 microM; intrinsic clearance (CL(int)), 2.35 microl min(-1) per 5 x 10(5) cells; and diffusion constant (K(d)), 0.33 microl min(-1) per 5 x 10(5) cells. The basolateral-to-apical transport of metformin was inhibited by phenoxybenzamine, an inhibitor of OCTs, but not by cyclosporine A, MK571, or fumitremorgin C, which are inhibitors of P-glycoprotein, multidrug resistance proteins (MRPs), and breast cancer resistance protein (BCRP), respectively, suggesting that OCTs play a role in renal tubular secretion of metformin. 3. Metformin uptake was much greater in oocytes expressing OCT2-wild type (OCT2-WT) than OCT1-WT compared with uptake in water-injected oocytes. Uptake was significantly decreased in oocytes expressing OCT2-T199I, -T201M, and -A270S compared with that in OCT2-WT, suggesting that metformin is a better substrate for OCT2 than for OCT1 and that the amino acid-substituted variants of OCT2 cause a functional decrease in metformin uptake. 4. In conclusion, the genetic variants of OCT2 (OCT2-T199I, -T201M, and -A270S) decreased the transport activity of metformin and thus may contribute to the inter-individual variation in metformin disposition as OCT2 plays a pivotal role in renal excretion, the major disposition route of metformin.

Metabolic syndrome and visceral obesity as risk factors for reflux oesophagitis: a cross-sectional case-control study of 7078 Koreans undergoing health check-ups

BACKGROUND

Obesity has been associated with reflux oesophagitis. However, the relationship between metabolic syndrome characterised by visceral obesity and reflux oesophagitis is unclear.

AIM

To investigate whether metabolic syndrome or visceral obesity is a risk factor for reflux oesophagitis.

METHODS

A cross-sectional study of 7078 subjects undergoing upper endoscopy during health check-ups was conducted (3539 patients with reflux oesophagitis vs age- and sex-matched controls). We further analysed according to categories of visceral adipose tissue and subcutaneous adipose tissue area with 750 cases and age-, sex- and waist circumference-matched controls who underwent abdominal CT scan.

RESULTS

The prevalence of metabolic syndrome was higher in cases than controls (26.9% vs 18.5%, p<0.001). Multivariate analysis demonstrated that metabolic syndrome is associated with reflux oesophagitis (odds ratio (OR) = 1.42; 95% confidence interval (CI), 1.26 to 1.60). Among the individual components of metabolic syndrome, waist circumference (OR = 1.47; 95% CI, 1.30 to 1.65) and triglyceride (OR = 1.20; 95% CI, 1.05 to 1.36) independently increased the risk for reflux oesophagitis. On sub-analysis, cases showed higher mean visceral adipose tissue area (cm(2)) (136.1 (SD 57.8) vs 124.0 (SD 54.7), p<0.001) and subcutaneous adipose tissue area (cm(2)) (145.9 (SD 56.8) vs 133.5 (SD 50.7), p<0.001). However, only visceral adipose tissue area was an independent risk factor for reflux oesophagitis after adjusting for multiple confounders including smoking, alcohol, body mass index (BMI) and subcutaneous adipose tissue area (OR = 1.60; 95% CI, 1.03 to 2.48, lowest quartile vs highest quartile).

CONCLUSIONS

Metabolic syndrome was associated with reflux oesophagitis. Abdominal obesity, especially visceral obesity, was an important risk factor for reflux oesophagitis.

Dietary salt does not influence the disposition of verapamil enantiomers in relation to efflux transporter ABCB1 genetic polymorphism in healthy Korean subjects

To evaluate the effects of dietary salt on the stereoselective disposition of verapamil enantiomers in relation to the transporter ABCB1 2677GG/3435CC and 2677TT/3435TT haplotypes, ten healthy subjects were asked to take diets of three different salt levels for 7 days in a randomized, three-way crossover manner. The plasma concentrations of verapamil and norverapamil enantiomers were determined after a single oral dose of 240 mg verapamil on the last day of each phase. Pharmacokinetic parameters were calculated by non-compartmental analysis techniques and compared among the three different dietary salt phases. Compared with the medium salt diet, the high and low salt diets had no significant effect on the disposition of verapamil enantiomers. Moreover, the ABCB1 haplotypes did not alter the impact of dietary salt, although ABCB1 2677TT/3435TT subjects had slightly, but not significantly, higher C(max) and area under the curve (AUC) and lower T(max) for the verapamil enantiomers than did 2677GG/3435CC subjects in each salt phase.

Genetic variants of the organic cation transporter 2 influence the disposition of metformin

Genetic variants of the organic cation transporter 2 (protein, OCT2; gene, SLC22A2) were evaluated for their contribution to the variations in the pharmacokinetics of metformin, especially to its renal elimination. Genetic variants of SLC22A2 (c.596C>T, c.602C>T, and c.808G>T) showed significant differences in metformin pharmacokinetics when compared with the reference genotype, with higher peak plasma concentration (C(max)) and area under the curve (AUC) and lower renal clearance (Cl(renal)), thereby suggesting that a decrease in transport function associated with the SLC22A2 variants results in reduced Cl(renal) of metformin and consequently leads to increased plasma concentrations.

Helicobacter pylori eradication for low-grade gastric mucosa-associated lymphoid tissue lymphoma is more successful in inducing remission in distal compared to proximal disease

A series of studies has shown that Helicobacter pylori eradication induces remission in most patients with low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma. However, there have been few reports about the effect of bacterial treatment on the gastric MALT lymphoma in Korea, a well-known H. pylori endemic area. A total of 111 H. pylori-infected patients were prospectively enrolled in Seoul National University Hospital and 99 among them were completely followed up according to our protocol. After H. pylori eradication, tumoural response was evaluated by endoscopy and histopathology every 2–3 months till complete remission (CR) and every 6 months after achieving CR. Median follow-up period was 41 months (range, 11–125 months). Helicobacter pylori was successfully eradicated in all 99 patients and CR was obtained in 84 (84.8%) of 99 patients. The median time to reach CR was 3 months and 94% of CR is in continuous complete remission. Five patients with CR relapsed after 10–22 months without the evidence of H. pylori reinfection. Cumulative recurrence rate was 2.3, 7.7 and 9.3% at 1, 2 and 3 years, respectively. Tumours were mainly located in distal stomach (67.7%) and tumours in distal stomach were associated with more favourable response than those in proximal stomach (P=0.001). Majority of patients with low-grade gastric MALT lymphoma treated by exclusive H. pylori eradication have a favourable long-term outcome, offering a real chance of cure. Tumour location could be a predictive factor for remission following H. pylori eradication.

Development of the “Inje Cocktail” for High-throughput Evaluation of Five Human Cytochrome P450 Isoforms in vivo

To develop and validate an in vivo cocktail method for high-throughput phenotyping of CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A, 12 healthy subjects received five probe drugs alone or simultaneously. The in vivo phenotyping index of CYP2C9, the ratio of 8 h urine concentration of losartan to its metabolite after a single administration of losartan, was not significantly different from that obtained using the five-drug cocktail. Similarly, the ratios of [omeprazole]/[5-hydroxyomeprazole] (CYP2C19) and [paraxanthine]/[caffeine] (CYP1A2) in 4 h plasma samples and the log ratio of [dextromethorphan]/[dextrorphan] (CYP2D6) in 8 h urine samples and the 4 h plasma concentrations of midazolam (CYP3A) after single administration or well-established three-drug cocktail of caffeine, omeprazole, and dextromethorphan were not significantly different from those after the new five-drug cocktail. In conclusion, the new five-drug cocktail regimen, named the "Inje cocktail," can be used as a tool to phenotype in vivo enzyme activities of CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A with only 4 h blood sampling and 8 h urine collection following simultaneous administration of the five probe drugs.

Omeprazole may be superior to famotidine in the management of iatrogenic ulcer after endoscopic mucosal resection: a prospective randomized controlled trial

BACKGROUND

Acid suppressing agents are widely used to treat the iatrogenic ulcers following endoscopic mucosal resection for gastric neoplasms. However, the relative merits of proton pump inhibitor or histamine(2)-receptor antagonist for endoscopic mucosal resection-induced ulcers are not known.

AIM

To prospectively compare omeprazole and famotidine for the healing of endoscopic mucosal resection-induced ulcers and for bleeding control.

METHODS

After endoscopic mucosal resection, patients were randomly assigned to omeprazole (20 mg/day) or to famotidine (40 mg/day) group for a 28-day treatment period. The ulcer sizes and stages, bleeding rates and ulcer-related symptoms were compared.

RESULTS

A total of 100 patients were randomized equally to each group. Forty-one patients in each group were finally compared. The two groups were comparable in terms of baseline characteristics. Twenty-eight days after treatment, the two groups were not different with respect to ulcer stage (P = 0.137) or ulcer reduction ratio (P = 0.380). No difference was observed with respect to ulcer-related symptoms (P = 0.437) and no bleeding episode occurred in any of the 82 patients. In subgroup that underwent endoscopic submucosal dissection, fewer patients in the omeprazole group showed active ulcers than those in the famotidine group (P = 0.035).

CONCLUSION

Our results demonstrate that omeprazole may be superior to famotidine for iatrogenic ulcers following endoscopic mucosal resection, especially for large ulcers.

Intraoperative gastroscopy for gastric surgery

BACKGROUND

Few reports are available on the use of intraoperative gastroscopy for gastric surgery.

METHODS

The details of 33 patients (25 early gastric cancers and eight gastric submucosal tumors) who underwent intraoperative gastroscopy from June 2003 to June 2004 were analyzed. The type of operation or resection margin was determined by evaluating both sides of the stomach simultaneously by combined operative and gastroscopic methods.

RESULTS

Preoperative endoscopic clipping was done preferentially for early gastric cancer. However, when precise localization was needed, intraoperative gastroscopy was used. Curative gastric resection was possible in 25 early gastric cancer patients after accurate lesion localization. Laparoscopic wedge resections of submucosal tumors were performed in seven patients without stenosis by combined laparoscopic and gastroscopic methods.

CONCLUSIONS

Intraoperative gastroscopy can be used effectively during gastric surgery for early gastric cancer or submucosal tumors and can be regarded as a modern stethoscope to gastric surgeons.

Primary colon lymphoma in Korea: a KASID (Korean Association for the Study of Intestinal Diseases) Study

Although almost all primary colorectal lymphomas are of B-cell lineage in Western countries, primary colorectal T-cell lymphomas are not uncommon in the East. The aim of this study was to review the clinical characteristics and treatment outcomes of primary colorectal lymphomas, with special emphasis on the differences between T-cell and B-cell lymphomas. Ninety-five cases of primary colorectal lymphomas that satisfied Dawson's criteria were identified from the clinical databases of 13 university hospitals in Korea. The mean age at the time of presentation was 51.1 years and the male:female ratio was 64:31. The clinical information, including endoscopic and histological characteristics, was retrospectively analyzed. Of the primary colorectal lymphomas, 78 cases (82.1%) were of B-lineage and 17 cases (17.9%) were of T-cell lineage. Patients with T-cell lymphomas presented at a younger age than patients with B-cell lymphomas (42.8 vs 52.9 years, respectively; P = 0.016). The most common presenting symptom was abdominal pain (87.1%) for B-cell lymphomas, whereas hematochezia or night fever was more common for T-cell lymphomas (52.9% and 35.3%, respectively). The most common endoscopic type was fungating mass (54.0%) for B-cell lymphomas and ulcerative/ulcero-infiltrative lesions (80.0%) for T-cell lymphomas. Intussusception was more common in B-cell lymphomas than in T-cell lymphomas (30.8% vs 5.9%, respectively; P = 0.035), but perforation was more common in T-cell lymphomas than in B-cell lymphomas (23.5% vs 3.8%, respectively; P = 0.005). The prognosis was significantly worse for T-cell lymphomas than for B-cell lymphomas (P = 0.002). Primary colorectal T-cell lymphomas are characterized by multifocal ulcerative lesions in relatively young patients, a high rate of hematochezia, fever, or perforation, and a poor prognosis even for cases of localized disease.

Is a 9-month treatment sufficient in tuberculous enterocolitis? A prospective, randomized, single-centre study

BACKGROUND

Tuberculosis has increased in parallel with the acquired immunodeficiency syndrome epidemic and the use of immunosuppressive therapy, and the growing incidence of extra-pulmonary tuberculosis, especially with intestinal involvement, reflects this trend. However, the duration of anti-tuberculous therapy has not been clarified in intestinal tuberculosis.

AIM

To compare the efficacy of different treatment durations in tuberculous enterocolitis in terms of response and recurrence rates.

METHODS

Forty patients with tuberculous enterocolitis were randomized prospectively: 22 patients into a 9-month and 18 into a 15-month group. Diagnosis was made either by colonoscopic findings of discrete ulcers and histopathological findings of caseating granuloma and/or acid-fast bacilli, or by clinical improvement after therapeutic trial. Patients were followed up with colonoscopy every other month until complete response or treatment completion, and then every 6 months for 1 year and annually. Complete response was defined as a resolution of symptoms and active tuberculosis by colonoscopy.

RESULTS

Complete response was obtained in all patients in both groups. Two patients in the 9-month group and one in the 15-month group underwent operation due to intestinal obstruction and perianal fistula, respectively. No recurrence of active intestinal tuberculosis occurred during the follow-up period in either group.

CONCLUSIONS

Tuberculous enterocolitis can be managed by 9-month chemotherapy without disease recurrence. Further investigations are needed in immunocompromised patients.

Survey of nitrate and nitrite contents of vegetables grown in Korea

A scientific basis for the evaluation of the risk to public health arising from excessive dietary intake of nitrate in Korea is provided. The nitrate () and nitrite () contents of various vegetables (Chinese cabbage, radish, lettuce, spinach, soybean sprouts, onion, pumpkin, green onion, cucumber, potato, carrot, garlic, green pepper, cabbage and Allium tuberosum Roth known as Crown daisy) are reported. Six hundred samples of 15 vegetables cultivated during different seasons were analysed for nitrate and nitrite by ion chromatography and ultraviolet spectrophotometry, respectively. No significant variance in nitrate levels was found for most vegetables cultivated during the summer and winter harvests. The mean nitrates level was higher in A. tuberosum Roth (5150 mg kg(-1)) and spinach (4259 mg kg(-1)), intermediate in radish (1878 mg kg(-1)) and Chinese cabbage (1740 mg kg(-1)), and lower in onion (23 mg kg(-1)), soybean sprouts (56 mg kg(-1)) and green pepper (76 mg kg(-1)) compared with those in other vegetables. The average nitrite contents in various vegetables were about 0.6 mg kg(-1), and the values were not significantly different among most vegetables. It was observed that nitrate contents in vegetables varied depending on the type of vegetables and were similar to those in vegetables grown in other countries. From the results of our studies and other information from foreign sources, it can be concluded that it is not necessary to establish limits of nitrates contents of vegetables cultivated in Korea due to the co-presence of beneficial elements such as ascorbic acid and alpha-tocopherol which are known to inhibit the formation of nitrosamine.

The effect of rebamipide on the expression of proinflammatory mediators and apoptosis in human neutrophils by Helicobacter pylori water-soluble surface proteins

BACKGROUND

Helicobacter pylori infection elicits persistent neutrophil infiltration in gastric mucosa. The expression of cyclooxygenase (COX)-2 and inhibition of apoptosis in the neutrophils could contribute to the pathogenesis of H. pylori infection. Rebamipide, a mucosal protective and ulcer-healing drug, has been known to inhibit neutrophil activation.

AIM

To evaluate the effect of rebamipide on the neutrophils activated by H. pylori water-soluble proteins.

METHODS

After neutrophils were stimulated with H. pylori water extract (HPWE) or pre-treated with rebamipide, the expression of COX-2 mRNA and protein was assessed by quantitative RT-PCR and Western blotting, respectively. Prostaglandin (PG) E2 synthesis was determined by radioimmunoassay. Neutrophil apoptosis was evaluated by cytosolic oligonucleosome-bound DNA ELISA and caspase-3 activity was measured by the detection of p-nitroanilide after cleavage from labelled substrate.

RESULTS

Stimulation with HPWE up-regulated COX-2 expression and PGE2 secretion, and inhibited neutrophil apoptosis. Rebamipide suppressed PGE2 secretion from neutrophils dose-dependently. Rebamipide, however, did not affect neutrophil apoptosis and caspase-3 activity.

CONCLUSIONS

Rebamipide effectively suppressed PGE2 secretion from neutrophils activated by H. pylori water-soluble proteins. This is another possible mechanism of gastric mucosal protection by rebamipide.

Effect of Helicobacter pylori eradication on duodenal ulcer scar in patients with no clinical history of duodenal ulcer

BACKGROUND

Helicobacter pylori eradication has become the standard treatment for duodenal ulcer. However, there is no relevant evidence for antibacterial treatment of the white scar stage of duodenal ulcer (duodenal ulcer scar) in patients with no past history of duodenal ulcer.

AIM

To investigate whether H. pylori eradication could decrease duodenal ulcer recurrence in patients with duodenal ulcer scar and no past history of duodenal ulcer.

PATIENTS AND METHODS

We prospectively enrolled 66 patients with duodenal ulcer scar: 53 were H. pylori-positive and 13 were H. pylori-negative. H. pylori-positive patients were randomly assigned into two groups (two-to-one allocation): 36 patients were assigned to the treatment group and 17 to the follow-up group. Thirteen H. pylori-negative patients were followed up according to the study protocol. Follow-up endoscopy was performed to evaluate ulcer scar changes and H. pylori status 6 weeks after anti-H. pylori treatment and then every 6 months for up to 30 months.

RESULTS

Active duodenal ulcer recurrence was identified in seven of 23 H. pylori-positive/non-cured patients (30%). There was no duodenal ulcer recurrence in 43 H. pylori-negative/cured patients (0%), which was significantly different in terms of duodenal ulcer recurrence (P=0.001).

CONCLUSIONS

H. pylori eradication is effective at preventing active duodenal ulcer recurrence in patients with duodenal ulcer scar and no past history of duodenal ulcer.

Expression of cyclooxygenase-2 in human neutrophils activated by Helicobacter pylori water-soluble proteins: possible involvement of NF-kappaB and MAP kinase signaling pathway

Helicobacter pylori infection elicits persistent neutrophil infiltration in gastric mucosa. The expression of cyclooxygenase (COX) -2 by the neutrophils results in prostaglandin (PG) E2 synthesis, which may account for alterations in tissue homeostasis. In this study, we found that COX-2 mRNA was up-regulated in the neutrophils when stimulated with both H. pylori water extract (HPWE) and live H. pylori in a transwell model and determined by quantitative RT-PCR. PGE2 synthesis was also enhanced in the neutrophils activated by both the HPWE and live H. pylori. A specific COX-2 inhibitor (NS-398) blocked PGE2 synthesis, and an anti-ulcer agent (rebamipide) suppressed it dose dependently. An NF-kappaB inhibitor (pyrrolidine dithiocarbamate), a MAP kinase (MEK) inhibitor (PD98059), and a p38 MAP kinase inhibitor (SB203580) significantly suppressed the COX-2 gene transcription and PGE2 synthesis in the neutrophils. In conclusion, H. pylori water-soluble proteins may enhance the COX-2 expression, and this action could be mediated through the NF-kappaB and MAP kinase signaling pathways. The increased section of PGE2 by the neutrophils may play a proinflammatory role in the gastric mucosal response to H. pylori.

Expression of cyclooxygenase-2 in human neutrophils activated by Helicobacter pylori water-soluble proteins: possible involvement of NF-kappaB and MAP kinase signaling pathway

Helicobacter pylori infection elicits persistent neutrophil infiltration in gastric mucosa. The expression of cyclooxygenase (COX) -2 by the neutrophils results in prostaglandin (PG) E2 synthesis, which may account for alterations in tissue homeostasis. In this study, we found that COX-2 mRNA was up-regulated in the neutrophils when stimulated with both H. pylori water extract (HPWE) and live H. pylori in a transwell model and determined by quantitative RT-PCR. PGE2 synthesis was also enhanced in the neutrophils activated by both the HPWE and live H. pylori. A specific COX-2 inhibitor (NS-398) blocked PGE2 synthesis, and an anti-ulcer agent (rebamipide) suppressed it dose dependently. An NF-kappaB inhibitor (pyrrolidine dithiocarbamate), a MAP kinase (MEK) inhibitor (PD98059), and a p38 MAP kinase inhibitor (SB203580) significantly suppressed the COX-2 gene transcription and PGE2 synthesis in the neutrophils. In conclusion, H. pylori water-soluble proteins may enhance the COX-2 expression, and this action could be mediated through the NF-kappaB and MAP kinase signaling pathways. The increased section of PGE2 by the neutrophils may play a proinflammatory role in the gastric mucosal response to H. pylori.

Caspase-3 activity and expression of Bcl-2 family in human neutrophils by Helicobacter pylori water-soluble proteins

BACKGROUND

Persistent infiltration of neutrophils is an almost invariable feature of Helicobacter pylori-infected gastric mucosa. A prolongation of neutrophil life-span could contribute to the pathogenesis of H. pylori infection. Recently, we have demonstrated that H. pylori water extracts (HPWE) inhibited neutrophil apoptosis. To elucidate the regulation of intracellular apoptotic signals by HPWE, we examined the activity of caspase-8, -3 and expression of Bcl-2 family in neutrophils.

MATERIALS AND METHODS

Human neutrophils were obtained from the peripheral blood of healthy volunteers by density gradient separation. HPWE was prepared from a supernatant of the H. pylori suspension in distilled water. After neutrophils were incubated with HPWE, expression of Bcl-2 family [antiapoptotic (Bcl-2, Bcl-XL and Mcl-1) and proapoptotic (Bax, Bak and Bcl-XS)] was determined by RT-PCR and Western blotting, respectively. Western blot for Bcl-2 family also performed in neutrophilic differentiated HL-60 cells by all-trans-retinoic acid. The activity of caspase-8, -3 was measured by the detection of p-nitroanilide after cleavage from labeled substrate.

RESULTS

HPWE suppressed the activation of caspase-8 and -3, and upregulated the expression of Bcl-XL mRNA and proteins in neutrophils. The expression of Bax and Bak was upregulated and Bcl-2, Bcl-XL and Mcl-1 downregulated in HL-60 cells during neutrophilic differentiation.

CONCLUSION

Bcl-XL may have an important role in the neutrophilic development and inhibition of neutrophil apoptosis by H. pylori.

Contribution of ion pair complexation with bile salts to biliary excretion of organic cations in rats

The objective of this study was to examine whether ion pair complexation with endogenous bile salts in hepatocytes contributes to the preferential biliary excretion of organic cations (OCs). Tributylmethylammonium (TBuMA; mol wt 200) and triethylmethylammonium (TEMA; mol wt 116) were selected as model OCs that exhibit significant and negligible biliary excretion, respectively, in rats. The apparent lipophilicity of TBuMA, but not that of TEMA, was increased by the presence of either rat bile or specific bile salts, suggesting the formation of lipophilic ion pair complexes for TBuMA with bile salts in the liver. The uptake of TBuMA into canalicular liver plasma membrane (cLPM) vesicles, but not that of TEMA, was increased in the presence of bile salts, with a significant increase for both ATP-dependent transport and passive diffusion. The uptake of TBuMA in the presence of the bile salts was inhibited by representative P-glycoprotein (P-gp) substrates and vice versa, suggesting the involvement of P-gp in the canalicular excretion of TBuMA-bile salt complexes in vivo. Increased affinity toward P-gp is suggested as the mechanism responsible for the increased ATP-dependent transport for the ion pair complexes. We propose that ion pair formation with bile slats in hepatocytes may be responsible for the preferential biliary excretion of high-molecular-weight OCs including TBuMA.

Inhibition of apoptosis in human neutrophils by Helicobacter pylori water-soluble surface proteins

BACKGROUND

Helicobacter pylori infection in humans causes persistent neutrophil infiltration into the gastric mucosa. It is believed that a prolongation of neutrophil life-span could contribute to the pathogenesis of H. pylori infection. We therefore examined whether the water-soluble surface proteins of H. pylori can influence the apoptosis of neutrophils.

METHODS

After neutrophils were incubated with H. pylori water extract (HPWE), neutrophil apoptosis was evaluated by TUNEL assay, Hoechst 33342 staining, electron microscopy and ELISA for cytosolic oligonucleosome-bound DNA for up to 48 h. To investigate the regulatory mechanisms of neutrophil apoptosis associated with HPWE, mRNA expression and protein production of Fas, Fas ligand (FasL) and tumor necrosis factor receptor 1 (TNF-R1) were analyzed by RT-PCR, ribonuclease protection assay, Northern blot and Western blotting. Cell surface expression of these death factors was also measured by flow cytometry.

RESULTS

HPWE inhibited neutrophil apoptosis and cytotoxicity for up to 48 h. The mRNA and protein expression of FasL and the cell surface expression of Fas, FasL and TNF-R1 in HPWE-treated neutrophils were suppressed compared with the controls.

CONCLUSION

The water-soluble surface proteins of H. pylori could suppress neutrophil apoptosis. This may be caused by the suppression of FasL expression in neutrophils and Fas, FasL and TNF-R1 expression on the surface of neutrophils.

Hepatopulmonary syndrome in poorly compensated postnecrotic liver cirrhosis by hepatitis B virus in Korea

BACKGROUND

Hepatopulmonary syndrome (HPS) refers to the association of hypoxemia, intrapulmonary shunting and chronic liver disease. But there is no clear data about the prevalence of HPS in postnecrotic liver cirrhosis by hepatitis B virus (HBV), the most common cause of liver disease in Korea. The aim of this study was to investigate the prevalence of HPS in poorly compensated postnecrotic liver cirrhosis by HBV, and the correlation of the hepatopulmonary syndrome with clinical aspects of postnecrotic liver cirrhosis by HBV.

METHODS

Thirty-five patients underwent pulmonary function test, arterial blood gas analysis and contrast-enhanced echocardiography. All patients were diagnosed as HBV-induced Child class C liver cirrhosis and had no evidence of intrinsic cardiopulmonary disease.

RESULTS

Intrapulmonary shunt was detected in 6/35 (17.1%) by contrast-enhanced echocardiography. Two of six patients with intrahepatic shunts had significant hypoxemia (PaO2 < 70 mmHg) and four showed increased alveolar-arterial oxygen gradient over 20 mmHg. Only cyanosis could reliably distinguish between shunt positive and negative patients.

CONCLUSIONS

The prevalence of intrapulmonary shunt in poorly compensated postnecrotic liver cirrhosis by HBV was 17.1% and the frequency of hepatopulmonary syndrome was relatively low (5.7%). 'Subclinical' hepatopulmonary syndrome (echocardiographically positive intrapulmonary shunt but without profound hypoxemia) exists in 11.4% of cases with poorly compensated postnecrotic liver cirrhosis by HBV. Cyanosis is the only reliable clinical indicator of HPS of HBV-induced poorly compensated liver cirrhosis. Further studies are required to determine if the prevalence and clinical manifestations of HPS varies with etiology or with geographical and racial differences.

Upregulated cyclooxygenase-2 inhibits apoptosis of human gastric epithelial cells infected with Helicobacter pylori

Helicobacter pylori induces apoptosis and alters the proliferation of gastric mucosal epithelial cells. Cyclooxygenase-2 (COX-2), the inducible form of prostaglandin (PG) synthesis, is known to cause alteration in epithelial cell growth. The goal of this study was to determine whether COX-2 gene expression by H. pylori infection could influence gastric epithelial cell apoptosis. Expression of COX-2 mRNA and proteins was up-regulated in Hs746T gastric epithelial cell lines infected with H. pylori, when assessed by quantitative RT-PCR and western blot. Inhibition of COX-2 expression using NS-398, a specific COX-2 inhibitor, showed a significant increase of gastric epithelial cell apoptosis and caspase-3 activation in Hs746T cells infected with H. pylori. Moreover, the effect of NS-398 on H. pylori-induced apoptosis was reversed by the addition of PGE2. These results suggest that up-regulated COX-2 expression by H. pylori infection can inhibit apoptosis of gastric epithelial cells.

Helicobacter pylori in dental plaque and saliva

BACKGROUND

About half of the world population is infected with H. pylori, but the transmission and the source of this infection are still unclear. Recently, dental plaque (DP) and saliva have been implicated as possible sources of H. pylori infection. This study was done to investigate the detection rates of H. pylori in the DP and saliva by use of PCR depending on H. pylori infection state of gastric mucosa.

METHODS

In 46 subjects, gastric H. pylori colonization was evaluated with CLO test, microscopy of Gram stained mucosal smear, culture and histology after modified Giemsa staining in the antrum and body, respectively. A patient was regarded as H. pylori positive if one or more of the four aforementioned test methods demonstrated H. pylori colonization of the gastric mucosa. For detection of H. pylori in the DP and saliva, PCR assay was done with ET4-U and ET4-L primers. To estimate the sensitivity and specificity of this PCR, H. pylori positivity was evaluated in the antrum and body, separately.

RESULTS

The sensitivity of mucosal PCR was 50.0% (27/54) and the specificity 86.8% (33/38). When a subject was regarded as H. pyloi positive, if either antrum or body mucosal H. pylori was is positive, the positive rate of mucosal PCR was 62.1% (18 subjects) in the 29 H. pylori-positive and 17.6% (3 subjects) in the 17 H. pylori-negative subjects. DP PCR was positive in 2 of 29 H. pylori-positive subjects (6.9%) and none in the 17 H. pylori-negative (0%). Saliva PCR was positive in 4 of 14 H. pylori-positive subjects (28.6%) and none of 6 H. pylori-negative (0%).

CONCLUSION

The detection rates of H. pylori in DP and saliva by PCR were rather low, 6.9% and 28.6%, respectively, and these rates might have been underestimated by low sensitivity of the PCR method used in this study. However, the results that H. pylori was found in the DP and saliva suggest that the oral cavity can perform a role as a reservoir of H. pylori in Korea.

Virulence factors of Helicobacter pylori in Korean isolates do not influence proinflammatory cytokine gene expression and apoptosis in human gastric epithelial cells, nor do these factors influence the clinical outcome

The cytotoxin-associated gene (cagA) and vacuolating cytotoxin (Vac) production have been reported to be major virulence factors of Helicobacter pylori. However, there have been some disputes regarding the correlation between these virulence factors and clinical outcomes. We evaluated whether the cagA-positive genotype and Vac production might be correlated with various gastroduodenal diseases in Korea and whether this correlation could be due to differences in proinflammatory cytokine gene expression and apoptosis of gastric epithelial cells in vitro. The presence of the cagA gene was examined by the polymerase chain reaction (PCR), and Vac production was detected using the bacterial culture supernatant and HeLa cells after H. pylori was isolated from Korean patients. Gastric epithelial cells were infected with cagA+Vac+, cagA+Vac-, or cagA-Vac- strains, after which cytokine gene expression was evaluated, using quantitative reverse transcription (RT)-PCR. Apoptosis and caspase-3 activation were measured in H. pylori-infected gastric epithelial cells. There was no significant correlation between the presence of these virulence factors in H. pylori isolates and peptic ulcer or gastric cancer. Upregulation of cytokine gene expression, including that of interleukin (IL)-1alpha, IL-8, granulocyte macrophage colony-stimulating factor (GM-CSF), and monocyte chemotactic protein (MCP)-1, as well as apoptosis and caspase-3 activation, were similar in infections with cagA-positive and cagA-negative strains, but were not correlated with the production of Vac. These results suggest that the lack of correlation between virulence factors of isolated H. pylori strains and serious gastroduodenal disease entities in Korea may be due to the similar capacity for proinflammatory cytokine gene expression and apoptosis caused by infection with each of the H. pylori strains.

Hypoalbuminemia as a risk factor for progressive left-ventricular hypertrophy in hemodialysis patients

BACKGROUND

This study was performed to evaluate the changes in left-ventricular (LV) mass in the patients starting maintenance hemodialysis and the risk factors for the progression of LVH.

METHODS

From June 1994 to February 1997, baseline echocardiography was obtained within six months after the initiation of hemodialysis in 111 patients with end-stage renal disease. Of the patients who had LVH on baseline echocardiography, 32 patients underwent follow-up echocardiography after 15 months (range: 9-24 months). LVH was defined as a left-ventricular mass index (LVMI) greater than 131 g/m(2) in males and 100 g/m(2) in females. Progressive LVH was defined as a follow-up LVMI greater than 105% of the baseline value. Hemoglobin, blood urea nitrogen, creatinine, cholesterol, albumin, prealbumin, parathyroid hormone, Kt/V, nPCR, fibrinogen, homocysteine and ACE gene polymorphism were also measured.

RESULTS

LVH was detected in 91 of 111 (82%) ESRD patients starting maintenance hemodialysis. Of the 32 patients in whom follow-up echocardiography was performed, progressive LVH occurred in 19 patients (M:F = 12:7). Progressive LVH was associated with lower diastolic blood pressure (81 +/- 11 vs. 90 +/- 12 mm Hg, p = 0.036) and lower serum albumin (3.5 +/- 0.4 vs. 3.9 +/- 0.4 g/dl, p = 0. 009). Serum albumin was negatively (r = -0.420, p = 0.017) correlated to Delta LVMI (follow-up LVMI minus baseline LVMI). Hypoalbuminemia was an independent risk factor for progressive LVH in multiple logistic regression analysis (R.R. = 1.29, p = 0.046). The association of progressive LVH with age, gender, diabetes mellitus, smoking history or other laboratory parameters was not significant.

CONCLUSION

LVH was highly prevalent in the patients starting maintenance hemodialysis for ESRD. In the follow-up echocardiography, LVH progressed in a substantial portion of the patients, and hypoalbuminemia was a risk factor for progressive LVH.

Incidence and prevalence of ulcerative colitis in the Songpa-Kangdong District, Seoul, Korea, 1986-1997

BACKGROUND AND AIMS

Ulcerative colitis (UC) is regarded as a rare disease in developing countries, but accurate data are generally lacking. We performed the present study to evaluate the incidence and prevalence of UC in Korea.

METHODS

A retrospective study was performed from 1986 to 1997 in the Songpa-Kangdong district of Seoul, Korea. To recruit UC patients as completely as possible, multiple information sources including all medical facilities in the study area and three referral centres located nearby, but outside the study area were used. The incidence and prevalence rates were adjusted using the 1997 Korean population statistics.

RESULTS

During the study period, a total of 94 incident cases were identified, for an adjusted mean annual incidence rate of 0.68 per 100,000 inhabitants. On 31 December 1997, 91 patients with UC lived in the study area, giving an adjusted prevalence rate of 7.57 per 100,000 inhabitants. By using the Poisson regression analysis, the annual incidence rate increased significantly from 0.20 per 100,000 inhabitants in 1986-1988 to 1.23 per 100,000 inhabitants in 1995-1997 (P < 0.005). Patient age at diagnosis, the interval from onset of symptoms to diagnosis, and the disease extent at diagnosis were fairly constant throughout the study period.

CONCLUSIONS

The incidence and prevalence of UC in our study area are still low compared with those of Western countries, but the incidence rate is steadily increasing.

Long-term effects of Helicobacter pylori eradication on intestinal metaplasia in patients with duodenal and benign gastric ulcers

This study was conducted to investigate whether or not the eradication of H. pylori could lead to the regression of intestinal metaplasia (IM) in patients with either duodenal ulcer (DU) or benign gastric ulcer (BGU). The initial antral IM grade was 0.21 in the 72 patients of the H. pylori-eradicated DU group, this decreased to 0.17, 0.14, 0.13, and 0.09 after periods of four weeks, one year, two years, and four years, respectively, but without statistical significance. In the corpus of the DU group, where IM grade was low (0.02), there was no detectable change in IM. The initial antral IM grade of 0.69 in the 41 patients of the H. pylori-eradicated BGU group decreased substantially to 0.61, 0.44, and 0.39 after periods of four weeks and one and two years, respectively, but again without statistical significance. The initial corporal IM grade of the BGU group of 0.27 decreased to 0.20, 0.15, and 0.06 after periods of four weeks and one and two years, again without statistical significance. In contrast, the IM grades of the noneradicated DU group (N = 20) and the BGU group (N = 16) showed nearly no change in the antrum and corpus. Gastritis grades of antrum and corpus in the H. pylori-eradicated DU or BGU group significantly decreased with respect to time (P = 0.0001), but there were no significant changes in the corresponding noneradicated groups. Although there was no statistical significance, IM decreased in the antrum and corpus of the stomach with BGU and in antrum of those with DU over a two to four-year period after H. pylori eradication, suggesting the possible reversibility of IM.

Prediction of the clinical course of Behçet's colitis according to macroscopic classification by colonoscopy

BACKGROUND AND STUDY AIMS

The lesions in Behçet's colitis show aphthoid or punched-out ulceration, but the macroscopic types of lesion found have not been defined. To predict the clinical outcome in patients with Behçet's colitis according to the colonoscopic findings, we classified the characteristic colonic ulcers, evaluated the efficacy of medical treatment on colonoscopic lesions, and calculated the operation rates and recurrence rates relative to the macroscopic types.

PATIENTS AND METHODS

The medical records and colonoscopic photographs of 50 patients with Behçet's colitis were reviewed. The colonic lesions were examined by colonoscopy in patients with Behçet's disease and gastrointestinal symptoms. The colonoscopic findings were categorized into three types of ulceration: volcano-like, geographic, and aphthous. The efficacy of medical treatment was assessed by follow-up colonoscopy or double-contrast barium enema four to eight weeks after treatment, and recurrence of the lesions was evaluated during the follow-up periods. Cumulative surgery rates were obtained using the Kaplan-Meier method.

RESULTS

The macroscopic classification of colonic ulcers identified 25 of 50 patients (50%) with volcano-type lesions, 11 (22%) with the geographic type, and 14 (28%) with the aphthous type. The rates of complete remission after medical treatment and surgery, respectively, were six of 25 (24%) and 13 of 25 (52%) with volcano-type ulcerations; eight of 11 (73%) and one of 11 (9%) with the geographic type; and nine of 14 (64%) and two of 14 (14%) with the aphthous type. The endoscopic and clinical recurrence rates were nine of 19 (47%) in volcano-type ulcerations, one of nine (11%) in the geographic type, and one of 11 (9%) in the aphthous type.

CONCLUSION

Volcano-type ulcerations in Behçet's colitis showed a less favorable response to medical treatment, a more frequent requirement for surgery, and more frequent recurrences than the geographic and aphthous types of ulcerations.

Long-term clinical course and prognostic factors in intestinal Behçet's disease

PURPOSE

The present study was aimed at evaluating the long-term course of intestinal Behçet's disease and determining predictive factors of prognosis.

METHODS

This report is a retrospective study based on the records of 43 patients with intestinal Behçet's disease. The mean follow-up duration was 73 +/- 60 months. We evaluated the efficacy of medical treatment for the intestinal lesion at initial eight weeks. The cumulative probabilities were calculated by using Kaplan-Meier method, and the results were compared by using the log-rank test.

RESULTS

Sixteen patients (38 percent) achieved a complete remission of intestinal lesions eight weeks after medical treatment had begun. The patients who achieved a complete remission had a lower probability of receiving an operation than those who had not (13 percent at 2 and 5 years vs. 36 and 43 percent, respectively; P = 0.028). The recurrence probability of intestinal lesions was 25 percent at two years and 49 percent at five years after complete remission with medical treatment. Patients who had a history of intestinal perforation or fistula had a higher probability of recurrence after operation than those without such history (59 vs. 33 percent at 2 years; 88 vs. 57 percent at 5 years; P = 0.020). Patients who had taken azathioprine had a lower probability of receiving reoperation than those who did not (7 vs. 25 percent at 2 years; 25 vs. 47 percent at 5 years; P = 0.035). The length of ileal resection and whether hemicolectomy was performed had no significant effect on the recurrence or reoperation rate.

CONCLUSIONS

Intestinal Behçet's disease frequently requires a surgical treatment and has a high recurrence rate. The patients who achieved a complete remission with medical treatment, who had no history of intestinal perforation, and who received azathioprine after operation showed better clinical courses. Resection of a short segment of bowel would be a more appropriate surgical procedure.

Substance P induction of murine keratinocyte PAM 212 interleukin 1 production is mediated by the neurokinin 2 receptor (NK-2R)

The neurological system plays an important role in modulating some inflammatory skin diseases. Neuro-cutaneous interactions may be mediated by the release of neuropeptides such as substance P (SP) which activate immunocompetent cells in the skin by binding to high affinity neurokinin receptors (NKR). Since epidermal keratinocytes produce a variety of cytokines and are intimately associated with cutaneous sensory fibers, we tested the ability of these cells to participate in the cutaneous neuroimmune system by the secretion of potent cytokines such as interleukin 1 (IL-1) in response to released SP. RT-PCR studies demonstrated that cultured PAM 212 murine keratinocytes expressed mRNA for NK-2R but not NK-1R. Correspondingly, the addition of SP to these cells resulted in a rapid increase in intracellular Ca2+ levels that could be specifically blocked by an NK-2R antagonist. NK-2R was also shown in normal mouse epidermis by immunohistochemistry. SP augmented the expression of PAM 212 keratinocyte IL-1alpha mRNA in a dose and time dependent manner and this induction was inhibited by an NK-2R antagonist. Secretion of bioactive IL-1alpha by the PAM 212 keratinocytes was likewise stimulated by SP in a dose dependent manner. These data support the hypothesis that SP released from cutaneous sensory nerves contributes to neuroimmune inflammatory responses in the skin by modulating the expression and release of cytokines from epidermal keratinocytes.

Helicobacter pylori water-soluble surface proteins activate human neutrophils and up-regulate expression of CXC chemokines

To elucidate the mechanisms of the persistent neutrophil recruitment in H. pylori-infected gastric mucosa, we evaluated the activation of human neutrophils and CXC chemokine expression in neutrophils by H. pylori water-soluble surface proteins. H. pylori water extract (HPWE) was prepared from a supernatant of the H. pylori suspension in distilled water. After neutrophils were stimulated with HPWE, the mobilization of intracellular free calcium, the expression of lymphocyte function-associated antigen-1beta, and the secretion of myeloperoxidase (MPO) were enhanced in the neutrophils. In H. pylori-infected gastric mucosa, transendothelial and transepithelial migration of neutrophils were observed by electron microscopy and mucosal MPO levels were elevated. Up-regulation of the expression of interleukin-8 (IL-8) and growth-related oncogenes (GROs; GROalpha, GRObeta and GROgamma) mRNA and protein in neutrophils by HPWE was demonstrated by quantitative reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay, respectively. In conclusion, H. pylori-induced neutrophil recruitment may be mediated by CXC chemokines which are expressed by neutrophils activated by H. pylori water-soluble surface proteins.

Apoptosis of human gastric epithelial cells via caspase-3 activation in response to Helicobacter pylori infection: possible involvement of neutrophils through tumor necrosis factor alpha and soluble Fas ligands

BACKGROUND

Infection with Helicobacter pylori activates a proinflammatory gene program in human gastric epithelial cells and neutrophils and is associated with significant epithelial cell damage, including an increased level of apoptosis. We evaluated whether immune mediators produced by neutrophils could modulate gastric epithelial cell apoptosis in response to H. pylori infection.

METHODS

After gastric epithelial cells were infected with H. pylori in the presence of immune mediators, including tumor necrosis factor alpha (TNF-alpha) and Fas ligand (FasL), apoptosis and caspase-3 activity were assessed. The neutrophils were obtained from healthy volunteers, and Western blot for FasL and quantitative reverse transcription polymerase chain reaction for TNF-alpha transcripts were performed. Fas expression in gastric epithelial cells was explored by flow cytometric analysis.

RESULTS

Activation of caspase-3 was first apparent 12 h after bacterial infection, and the phenotypic expression of apoptosis was first apparent 18 h after bacterial infection. The extent of apoptosis was similar in cases of cagA+ cytotoxin+, cagA+ cytotoxin-, cagA- cytotoxin- H. pylori-infected gastric epithelial cells. Approximately 20% of the Hs746T cells expressed Fas within 24 h of H. pylori infection. The soluble FasL was upregulated in neutrophils after treatment with H. pylori-soluble proteins for 24 and 48 h. The addition of TNF-alpha and the soluble form of FasL, produced by neutrophils, significantly increased H. pylori-infected cell apoptosis and caspase-3 activation. However, the combination of these two immune mediators showed only an additive increase.

CONCLUSION

These results suggest that H. pylori-induced gastric epithelial cell apoptosis and caspase-3 activation can be modulated by the immune response of neutrophils.

A precipitation reaction found in patients with hepatitis C as a marker for the purification of virus-like particles

Even after the molecular cloning of the hepatitis C virus (HCV), an HCV-specific precipitation reaction has not yet been identified. We attempted to develop a precipitation system exclusively for anti-HCV-positive sera as a first step in finding an HCV-specific antigen and HCV-associated particles. In some patients being in a final stage of different liver diseases, we found sera (179/132,761; designated 'a-CK') which specifically precipitated with anti-HCV- and HCV-RNA-positive sera (designated 'CK'). When CK-positive sera were searched for in patients with various liver diseases using standard a-CK-positive plasma, CK was detected in 420 (57.9%) of 726 anti-HCV-positive sera and in none of the 1,630 anti-HCV-negative ones. The nature of CK and a-CK has not been fully clarified yet; CK demonstrated inter-betagamma mobility, whereas a-CK showed beta-globulin mobility; CK was not detected in cryoprecipitate, but HCV RNA was present in precipitates of CK-positive plasma incubated with one that was a-CK positive. Transmission electron microscopy revealed two size ranges of particles in the precipitate of CK- and a-CK-positive plasmas, 23-38 nm and 48-65 nm. We have found a novel precipitation system which is exclusive to anti-HCV-positive sera and which specifically precipitates an HCV-RNA-containing serum fraction and particles. This system can be useful for the purification and characterization of the circulating particles. Furthermore, it may be a new approach to the nature of HCV-RNA-carrying material.

Effect of DA-6034, a derivative of flavonoid, on experimental animal models of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a multifactorial disorder with unknown etiology and pathogenesis. DA-6034, 7-carboxymethyloxy-3', 4', 5-trimethoxy flavone, is a synthetic flavonoid known to possess anti-inflammatory activity. This study was performed to evaluate the oral therapeutic effect of DA-6034 in three experimental animal models of IBD: two chemical-induced IBD models of rats and the human leukocyte antigen (HLA)-B27 transgenic rat model known to develop spontaneous colitis without the use of exogenous agents. Acute chemical colitis was induced by intracolonic instillation of 1.2 ml of 4% acetic acid solution. Prednisolone (1 mg/kg), sulfasalazine (100 mg/kg) and DA-6034 (0.3 to approximately 3 mg/kg) were orally administered twice daily for 6 days in these rats. In addition, chronic chemical colitis was induced by intracolonic administration of trinitrobenzene sulfonic acid (TNBS) 30 mg in 50% ethanol and agents were orally administered for 6 or 20 days. In chemical-induced IBD models, all of these agents reduced the severity of colitis and specially, DA-6034 (3 mg/kg) showed more potent effect than other drugs in macroscopic lesion score. In HLA-B27 transgenic rats, DA-6034 (3 mg/kg) and prednisolone (0.5 mg/kg) were treated orally twice daily for 6 weeks. The HLA-B27 transgenic rats showed only mild colitis, compared with the chemical-induced colitis models. DA-6034 ameliorated the loose stool and decreased microscopic damage, which is the important indicator of this model. In conclusion, oral therapy of DA-6034 attenuated the macroscopic and histologic damages of the colon in all three experimental models of IBD, which suggest that DA-6034 could be a promising drug in the treatment of IBD.

Establishment of BALB/c mice model infected with Helicobacter pylori

OBJECTIVES

Considering the geographic differences in the prevalence of virulence factors such as CagA or VacA of H. pylori isolated from Korean adults compared with those from western countries, the establishment of a mouse model infected with H. pylori isolated from Korean adults is needed to investigate the pathogenesis and to develop vaccines against H. pylori infection in Korea. The aim of this study was to establish the BALB/c mouse model infected with H. pylori isolated from Korean.

METHODS

Six-week-old BALB/c mice were inoculated intragastrically with 10(9) CFU of H. pylori. Loss of glandular architecture, erosions and infiltration of inflammatory cells within the lamina propria compared with normal gastric mucosa were scrutinized. Evidence for H. pylori infection was assessed by rapid urease test of gastric mucosa and by microscopic examination using the H & E stain and Warthin-Starry silver stain.

RESULTS

Rapid urease test was positive in 55% of all inoculated mice. Definite histologic changes and the evidence of H. pylori colonization were observed in the H. pylori infected group. Significant infiltration of inflammatory cells was observed 6 weeks after the last inoculation and the level of serum IgG against H. pylori was increased from 2 weeks after the last inoculation.

CONCLUSIONS

The H. pylori isolated freshly from Korean adults could colonize the stomach of BALB/c mice and induce pathologic alterations that mimics human gastric diseases. This model would facilitate the investigations for the pathogenetic mechanisms of H. pylori infection.