[Effects of biologics on psychological status and quality of life in patients with inflammatory bowel disease: a multicenter study]

Objective: To investigate the effects of biologics on psychological status and quality of life in patients with inflammatory bowel disease (IBD). Methods: A cross-sectional survey was conducted in 42 hospitals in 22 provinces (autonomous regions and municipalities directly under the central government) from September 2021 to May 2022. General clinical information and the use of biologics were obtained from adult patients diagnosed with IBD who voluntarily participated in the study. Psychological status was evaluated using the Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), and Inflammatory Bowel Disease Questionnaire (IBDQ) assessment tools. Counts were analyzed via the Chi-square test, and datasets that were not normally distributed were analyzed via nonparametric tests. P<0.05 was considered statistically significant. Results: A total of 2 478 valid questionnaires were collected. The GAD-7 score of the biologics group was significantly lower than that of the non-use group [6 (2, 9) vs. 7 (3, 10), Z=-3.49, P<0.001]. IBDQ scores [183 (158, 204) vs. 178 (152, 198), Z=-4.11, P<0.001], intestinal symptom scores [61 (52, 67) vs. 58 (49, 65), Z=-5.41, P<0.001], systemic symptom scores [28 (24, 32) vs. 27 (23, 31), Z=-2.37, P=0.018], emotional ability scores [69 (58, 77) vs. 67 (56, 75), Z=-3.58, P<0.001] and social ability scores [26 (22, 29) vs. 25 (22, 29), Z=-2.52, P=0.012] in the biologics group were significantly higher than in the non-use group. GAD-7 scores [5 (2, 9) vs. 6 (3, 10), Z=-3.50, P<0.001] and PSQI scores [6 (4, 9) vs. 6 (4, 9), Z=-2.55, P=0.011] were significantly lower in the group using infliximab than in the group not using it. IBDQ scores were significantly higher in patients using vedolizumab than in those not using it [186 (159, 205) vs. 181 (155, 201), Z=-2.32, P=0.021] and were also significantly higher in the group treated with adalimumab than in the group not treated with adalimumab [187 (159, 209) vs. 181 (155, 201), Z=-2.16, P=0.030]. However, ustekinumab had no significant effect on any of the scores. Conclusion: The use of biologics is strongly associated with improvements in anxiety status and quality of life in IBD patients.

Vaccination in patients with inflammatory bowel disease-Asian perspectives: results of a multinational web-based survey in the 8th Asian Organization for Crohn's and Colitis meeting

Background/Aims

Long-term immunosuppressive therapies used to treat inflammatory bowel disease (IBD) are associated with an increased risk of infections, many of which can be prevented by vaccination. We assessed physicians' current approaches and clinical practices regarding vaccinations for IBD patients in different Asian countries/regions.

Methods

An internet-based survey was conducted among members of the Asian Organization for Crohn's and Colitis from September 2020 to November 2020. The questionnaire consisted of 2 parts covering general opinion on the relevance of vaccinations and clinical practice of vaccination.

Results

Overall, 384 Asian medical doctors responded to the survey. The majority of respondents considered it very (57.6%) or sufficiently (39.6%) important to perform vaccinations as recommended by the guidelines. About half of the Asian physicians (52.6%) were usually or always performing vaccinations. The influenza vaccine was the most frequently recommended vaccine for IBD patients. Half of the respondents (51.3%) did not recommend hepatitis A vaccine, especially in China (61.6%) and Japan (93.6%). The diphtheria, tetanus, and pertussis vaccine were never (35.2%) or rarely (29.4%) recommended.

Conclusions

The findings of this survey indicated similarities among countries/regions in terms of the current approaches and practices regarding vaccination of IBD patients; however, there are some differences that might reflect each country's domestic vaccination guidelines and health insurance particularly with certain vaccines in some countries/regions. Although Asian physicians largely recommend vaccination, more awareness among doctors and Asian consensus regarding differences in IBD vaccination among countries/regions may be required.

Development of the global inflammatory bowel disease visualization of epidemiology studies in the 21st century (GIVES-21)

BACKGROUND

There is a rapid increase in the incidence of inflammatory bowel diseases (IBD) in newly industrialized countries, yet epidemiological data is incomplete. We herein report the methodology adopted to study the incidence of IBD in newly industrialized countries and to evaluate the effect of environmental factors including diet on IBD development.

METHODS

Global IBD Visualization of Epidemiology Studies in the 21st Century (GIVES-21) is a population-based cohort of newly diagnosed persons with Crohn's disease and ulcerative colitis in Asia, Africa, and Latin America to be followed prospectively for 12 months. New cases were ascertained from multiple sources and were entered into a secured online system. Cases were confirmed using standard diagnostic criteria. In addition, endoscopy, pathology and pharmacy records from each local site were searched to ensure completeness of case capture. Validated environmental and dietary questionnaires were used to determine exposure in incident cases prior to diagnosis.

RESULTS

Through November 2022, 106 hospitals from 24 regions (16 Asia; 6 Latin America; 2 Africa) have joined the GIVES-21 Consortium. To date, over 290 incident cases have been reported. All patients have demographic data, clinical disease characteristics, and disease course data including healthcare utilization, medication history and environmental and dietary exposures data collected. We have established a comprehensive platform and infrastructure required to examine disease incidence, risk factors and disease course of IBD in the real-world setting.

CONCLUSIONS

The GIVES-21 consortium offers a unique opportunity to investigate the epidemiology of IBD and explores new clinical research questions on the association between environmental and dietary factors and IBD development in newly industrialized countries.

Global Hospitalization Trends for Crohn's Disease and Ulcerative Colitis in the 21st Century: A Systematic Review With Temporal Analyses

BACKGROUND & AIMS

The evolving epidemiologic patterns of inflammatory bowel disease (IBD) throughout the world, in conjunction with advances in therapeutic treatments, may influence hospitalization rates of IBD. We performed a systematic review with temporal analysis of hospitalization rates for IBD across the world in the 21st century.

METHODS

We systematically reviewed Medline and Embase for population-based studies reporting hospitalization rates for IBD, Crohn's disease (CD), or ulcerative colitis (UC) in the 21st century. Log-linear models were used to calculate the average annual percentage change (AAPC) with associated 95% confidence intervals (95% CIs). Random-effects meta-analysis pooled country-level AAPCs. Data were stratified by the epidemiologic stage of a region: compounding prevalence (stage 3) in North America, Western Europe, and Oceania vs acceleration of incidence (stage 2) in Asia, Eastern Europe, and Latin America vs emergence (stage 1) in developing countries.

RESULTS

Hospitalization rates for a primary diagnosis of IBD were stable in countries in stage 3 (AAPC, -0.13%; 95% CI, -0.72 to 0.97), CD (AAPC, 0.20%; 95% CI, -1.78 to 2.17), and UC (AAPC, 0.02%; 95% CI, -0.91 to 0.94). In contrast, hospitalization rates for a primary diagnosis were increasing in countries in stage 2 for IBD (AAPC, 4.44%; 95% CI, 2.75 to 6.14), CD (AAPC, 8.34%; 95% CI, 4.38 to 12.29), and UC (AAPC, 3.90; 95% CI, 1.29 to 6.52). No population-based studies were available for developing regions in stage 1 (emergence).

CONCLUSIONS

Hospitalization rates for IBD are stabilizing in countries in stage 3, whereas newly industrialized countries in stage 2 have rapidly increasing hospitalization rates, contributing to an increasing burden on global health care systems.

Biologics for the Management of Inflammatory Bowel Disease: A Review in Tuberculosis-Endemic Countries

The advent of biologics and biologic therapy has transformed the management of inflammatory bowel disease (IBD) with enhanced early and adequate responses to treatment, fewer hospitalizations, a reduced need for surgery, and unprecedented outcomes including complete mucosal and histologic healing. However, an important issue with the use of anti-tumor necrosis factor (anti-TNF) agents in IBD is the increased risk of tuberculosis (TB). This is compounded by the diagnostic dilemma when differentiating between Crohn’s disease and gastrointestinal TB, and the potentially serious consequences of initiating an incorrect treatment in the case of misdiagnosis. The interplay between IBD and TB is most relevant in Asia, where more than 60% of the 10.4 million new TB cases in 2016 were reported. A number of studies have reported an increased risk of TB with anti-TNF agents, including in patients who had tested negative for TB prior to treatment initiation. The limited evidence currently available regarding adhesion molecule antagonists such as vedolizumab suggests a comparatively lower risk of TB, thus making them a promising option for IBD management in TB-endemic regions. This comprehensive review examines the available literature on the risk of TB with the use of biologics in the TB-endemic regions of Asia, focusing on the diagnostic dilemma, the risk of reactivation, and the optimized management algorithms for latent and active disease.

Asian Organization for Crohn's and Colitis and Asia Pacific Association of Gastroenterology practice recommendations for medical management and monitoring of inflammatory bowel disease in Asia

Inflammatory bowel disease (IBD) has increased in incidence and prevalence in Asian countries since the end of the 20th century. Moreover, differences in the cause, phenotypes, and natural history of IBD between the East and West have been recognized. Therefore, the Asian Organization for Crohn's and Colitis and the Asia Pacific Association of Gastroenterology have established recommendations on medical management of IBD in Asia. Initially, the committee members drafted 40 recommendations, which were then assessed according to Grading of Recommendations Assessment, Development and Evaluation. Eight statements were rejected as this indicated that consensus had not been reached. The recommendations encompass pretreatment evaluation; medical management of active IBD; medical management of IBD in remission; management of IBD during the periconception period and pregnancy; surveillance strategies for colitis-associated cancer; monitoring side effects of thiopurines and methotrexate; and infections in IBD.

Zero COVID-19 infection in inflammatory bowel disease patients: Findings from population-based inflammatory bowel disease registries in Hong Kong and Taiwan

BACKGROUND AND AIM

It is unsure whether inflammatory bowel disease (IBD) is a risk factor for novel coronavirus infection (COVID-19).

METHODS

IBD patients were identified from population-based databases in Hong Kong and Taiwan from January 21, 2020, until April 15, 2020.

RESULTS

Total 2954 and 2554 IBD patients were identified in Hong Kong and Taiwan, respectively. None had COVID-19. Pooled analysis showed that 65.3%, 39.1%, 4.3%, and 12.8% IBD patients in Hong Kong and 75.8 %, 51.4 %, 26.1%, and 52.3 % in Taiwan were on 5-aminosalicylates, immunomodulators, corticosteroids, and biologics, respectively.

CONCLUSION

There were no reported cases of COVID-19 infection amongst IBD patients in Hong Kong and Taiwan. IBD patients should continue their usual medications during the COVID-19 pandemic.

Long-term outcomes of perianal fistulizing Crohn's disease in the biologic era

Background and Aim

While the advent of biologic therapy has led to improved outcomes in perianal fistulizing Crohn's disease (pfCD), loss of response is common. Previous studies suggest that patients who achieve radiological healing (with healing of underlying tracts on magnetic resonance imaging [MRI]) have a longer duration of response. The aim of this study was to characterize MRI outcomes of pfCD at a specialist inflammatory bowel disease (IBD) unit and compare the long-term clinical outcomes between patients achieving MRI and clinical healing.

Methods

A retrospective analysis of perianal fistulizing Crohn's patients treated at one specialist IBD unit was performed. Records were reviewed for patient demographics, disease history, clinical assessments, investigation results, and disease flares. Clinical remission was defined as closure of all baseline fistula openings. Radiological healing was defined as the absence of any T2-hyperintense sinuses, tracts, or collections. The primary end-point was rate of MRI healing. The secondary outcome was defined as flare-free period (time between clinical or radiological healing and patients' first signs/symptoms requiring therapy escalation).

Results

A total of 93 patients were included, with a median follow-up of 4.8 years (interquartile range, 2.4-6 years). Of 44 patients, 22 (50%) achieved clinical remission, while 15 of 93 (16%) achieved radiological healing. Of 22 patients, 10 (45%) with clinical remission had a subsequent disease flare (median time of 7 months) compared with 3 of 15 (20%) patients with MRI healing (median time of 3.6 years). Radiological healing was associated with a significantly longer flare-free period (P = 0.01).

Conclusion

Radiological healing occurs less commonly but represents a deeper form of healing, associated with improved long-term clinical outcomes.

Knowledge and Attitudes Towards Pregnancy in Females with Inflammatory Bowel Disease: An International, Multi-centre Study

BACKGROUND AND AIMS

Poor knowledge of inflammatory bowel disease [IBD] in pregnancy underlies unwarranted voluntary childlessness [VC], and risks poorer obstetric outcomes and adverse fetal outcomes. IBD is increasing worldwide but education on IBD issues might be heterogeneous based on cultural differences and variations in models of care.

METHODS

Consecutive female IBD subjects aged 18-45 years were prospectively recruited from two dedicated IBD-pregnancy clinics, two multidisciplinary IBD clinics and nine general gastroenterology clinics. Subjects completed the validated CCPKnow [score 0-17] with questions on demographics, medical history and pregnancy knowledge. The primary outcome was knowledge per clinic-type and per geographical region.

RESULTS

Surveys were completed by 717 subjects from 13 hospitals across ten countries. Dedicated IBD-pregnancy clinics had the highest knowledge, followed by multidisciplinary IBD clinics then general IBD clinics (median CCPKnow 10.0 [IQR: 8.0-11.0], 8.0 [IQR: 5.0-10.5] and 4.0 [IQR:2.0-6.0]; p < 0.001). Median CCPKnow scores in Western, Asian and Middle Eastern clinics were 9.0, 5.0 and 3.0 respectively [p < 0.001]. Dedicated IBD-pregnancy clinics, IBD support organization membership, childbearing after IBD diagnosis and employment independently predicted greater knowledge. Patient perception of disease severity [r = -0.18, p < 0.01] and consideration of VC [r = -0.89, p = 0.031] negatively correlated with CCPKnow score. The overall VC rate was 15.0% [95% CI: 12.2-18.2]. VC subjects had significantly lower pregnancy-specific IBD knowledge than non-VC subjects (median CCPKnow 4.0 [IQR: 2.0-6.0] and 6.0 [IQR: 3.0-9.0] respectively; p < 0.001). Pregnancy-specific IBD knowledge and dedicated IBD-pregnancy clinic attendance were significant negative predictors of VC.

CONCLUSIONS

In this large international study we identified predictors of pregnancy-specific IBD knowledge. Dedicated IBD-pregnancy clinics had the greatest IBD-related pregnancy knowledge and lowest VC rates, reflecting the benefits of pre-conception counselling.

Ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease of unknown aetiology affecting the colon and rectum. Multiple factors, such as genetic background, environmental and luminal factors, and mucosal immune dysregulation, have been suggested to contribute to UC pathogenesis. UC has evolved into a global burden given its high incidence in developed countries and the substantial increase in incidence in developing countries. An improved understanding of the mechanisms underlying UC has led to the emergence of new treatments. Since the early 2000s, anti-tumour necrosis factor (TNF) treatment has significantly improved treatment outcomes. Advances in medical treatments have enabled a paradigm shift in treatment goals from symptomatic relief to endoscopic and histological healing to achieve better long-term outcomes and, consequently, diagnostic modalities have also been improved to monitor disease activity more tightly. Despite these improvements in patient care, a substantial proportion of patients, for example, those who are refractory to medical treatment or those who develop colitis-associated colorectal dysplasia or cancer, still require restorative proctocolectomy. The development of novel drugs and improvement of the treatment strategy by implementing personalized medicine are warranted to achieve optimal disease control. However, delineating the aetiology of UC is necessary to ultimately achieve disease cure.

Asian Pacific Association of Gastroenterology (APAGE) Inflammatory Bowel Disease (IBD) Working Party guidelines on IBD management during the COVID-19 pandemic

The COVID-19 pandemic, secondary to SARS-CoV-2, has resulted in high mortality and morbidity worldwide. As inflammatory bowel disease (IBD) is a chronic disease, and most patients are on long-term immunosuppressive agents, there is understandable concern, particularly in terms of therapy. In view of this, experts in IBD across the Asia Pacific region were invited to put together recommendations based on their experience and the currently available data. In general, most IBD therapies (with a few exceptions) can be continued safely, and the general consensus is that maintaining disease control should remain the main principle of management. In addition, social distancing measures and the appropriate use of personal protective equipment should be strictly adhered to. During the current pandemic, face-to-face clinic follow ups and non-urgent procedures should be kept to a minimum.

[Study on the expression of non-coding microRNA-376b-3p in serum exosomes of patients with malignant glioma and the mechanism of anti-angiogenesis]

Objective: To screen the different microRNAs in the serum exosomes of patients with malignant glioma, to explore the effect of non-coding microRNA-376b-3p (miR-376b-3p) on the proliferation, invasion and tumor vasculogenic mimicry of glioma cells, and to verify its targeting effect on HOXD10. Methods: HiSeq/MiSeq high-throughput sequencing was used to screen the different microRNA expression profiles, target genes and action pathways in the serum exosomes of patients with malignant glioma. Samples were used to evaluate the expression of candidate microRNAs in serum exosomes of high-grade gliomas. The effects of miR-376b-3p on the proliferation, invasion and angiogenesis of glioma cells were detected by MTT assay, Transwell migration assay and Matrigel vasculogenic mimicry assay. The mRNA and protein expression of HOXD10 were detected to evaluate the regulatory effect of miR-376b-3p on it. Results: There were 144 different expression microRNAs in the serum exosomes between malignant glioma and the normal control. Focal adhesion and tumor protein polysaccharides were involved in the regulation of glioma enriched by KEGG(Kyoto Encyclopedia of Genes and Genomes). MiR-376b-3p was down regulated in malignant glioma, and AUC of malignant glioma was 0.85 (P<0.01). MTT test showed that the proliferation ability of miR-376b-3p inhibitor group was higher than that of the control group, and that of miR-376b-3p mimic group was lower than that of the control group. Transwell migration test showed that the number of transmembrane cells in miR-376b-3p inhibitor group was higher than that in NC inhibitor group, and the number of transmembrane cells in miR-376b-3p mimic group was lower than that in NC mimic group. The number of tubes of vasculogenic mimicry in miR-376b-3p mimic group was lower than that in NC mimic group. MiR-376b-3p inhibitor decreased the expression level of HOXD10 mRNA and protein, and miR-376b-3p mimic increased the expression level of HOXD10 mRNA and protein. Conclusions: MiR-376b-3p is down-regulated in the serum exosomes of malignant glioma patients. The up-regulated miR-376b-3p can reduce the proliferation and invasion of glioma cells, inhibit the formation of vasculogenic mimicry, and increase the expression of HOXD10, which is expected to inhibit the formation of two forms of angiogenesis at the same time. MiR-376b-3p may be a new therapeutic target of anti-angiogenesis for malignant glioma.

Stopping anti-tumour necrosis factor therapy in patients with perianal Crohn's disease

BACKGROUND

Little is known of the outcome of patients with perianal Crohn's disease after stopping anti-tumour necrosis factor (TNF) therapy.

AIM

To evaluate the rate of relapse in perianal Crohn's disease (CD) after stopping anti-TNF therapy.

METHODS

Consecutive perianal CD patients treated with anti-TNF therapy with subsequent discontinuation were retrieved from prospective inflammatory bowel disease database of institutes in Hong Kong, Shanghai, Taiwan, Malaysia, Thailand and Singapore from 1997 to June 2019. Cumulative probability of perianal CD relapse was estimated using Kaplan-Meier method.

RESULTS

After a median follow-up of 89 months (interquartile range [IQR]: 65-173 months), 44 of the 78 perianal CD patients (56.4%) relapsed after stopping anti-TNF, defined as increased fistula drainage or recurrence of previously healed fistula, after stopping anti-TNF therapy. Cumulative probabilities of perianal CD relapse were 50.8%, 72.6% and 78.0% at 12, 36 and 60 months, respectively. Younger age at diagnosis of CD [adjusted hazard ratio (HR): 1.04; 95% CI 1.01-1.09; P = .04] was associated with a higher chance of perianal CD relapse. Among those with perianal CD relapse (n = 44), retreatment with anti-TNF induced remission in 24 of 29 patients (82.8%). Twelve (27.3%) patients required defunctioning surgery and one (2.3%) required proctectomy. Maintenance with thiopurine was not associated with a reduced likelihood of relapse [HR = 1.10; 95% CI: 0.58-2.12; P = .77]. Among the 17 patients who achieved radiological remission of perianal CD, five (35.3%) developed relapse after stopping anti-TNF therapy after a median of 6 months.

CONCLUSIONS

More than half of the perianal CD patients developed relapse after stopping anti-TNF therapy. Most regained response after resuming anti-TNF. However, more than one-fourth of the perianal CD patients with relapse required defunctioning surgery. Radiological assessment before stopping anti-TNF is crucial in perianal CD.

Evaluation of luteinizing hormone regulation of maturation and apoptosis, expression of LHR and FSHR in cumulus-oocyte complexes in Lanzhou fat-tailed sheep

The present study aimed to assess LH effects on in vitro maturation (IVM) and apoptosis and also to explore the gene expressions of LHR and FSHR in cumulus-oocyte complexes (COCs) of the sheep. COCs were in vitro matured 24h in the IVM medium supplemented with varying concentrations of LH (0, 5, 10, 20 and 30 μg/mL). They were allocated into LH-1 (control group), LH-2, LH-3, LH-4 and LH-5 groups, respectively. FSH (10 IU/mL) addition was as a positive control (FSH group). COCs apoptosis was assessed by TUNEL. The qPCR and Western blotting were utilized to detect mRNA and protein expressions of FSHR and LHR, respectively. The results showed maturation rates of oocytes improved as LH concentration increased from 0 to 10 μg/mL (IU/mL), reaching a peak value of 44.3% in the LH-3 group. Maturation rate of LH-5 group was lower than that of LH-3 and FSH-treated groups. The lowest apoptosis rate was found in LH-3 group. The germinal vesicle break down (GVBD) rates of LH-2, LH-3 and LH-4 groups were also increased in comparison with that found in LH-1 group (control group). GVBD rate of LH-5 was lower than that in LH-3 group. The germinal vesicle (GV) rates in LH-3 and LH-4 groups were lower than those in LH-1 and LH-5 groups (p<0.05, or p<0.01). The lowest GV rate was found in LH-3 group. GV rates in LH-2, LH-4 and LH-5 groups were higher than that in FSH group (p<0.05). At hours 20, 22 and 24 after oocytes IVM, caspase-3 concentrations in four LH-treated groups were decreased in comparison with that in LH-1 group. At 24h, caspase-3 concentrations of LH-2 and LH-3 groups were lower than that in LH-1 group (p<0.05). Expression levels of FSHR and LHR mRNAs rose when LH concentrations in IVM medium increased. The greatest expressions of FSHR and LHR mRNAs were found in LH-5 and LH-3 groups (p<0.01) in comparison with those in the control group (LH-1). Meanwhile, FSHR mRNA expressions in LH-2, LH-3 and LH-4 groups were lower than that in FSH group (p<0.01 or p<0.05). Expression levels of FSHR proteins revealed no significant differences among all groups. Expression levels in LHR proteins were increased. LHR protein level in LH-2 group was higher than that in LH-1 group. In conclusion, LH treatment could promote the maturation rate and GVBD rate. LH reduced apoptosis rate, GV rate of sheep oocytes, and caspase-3 concentrations in IVM medium fluids and additionally enhanced expressions of FSHR and LHR mRNAs of sheep COCs.

Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia

The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.

Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia

The Asia-Pacific Working Group on inflammatory bowel disease (IBD) was established in Cebu, Philippines, under the auspices of the Asian Pacific Association of Gastroenterology with the goal of improving IBD care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn’s and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in the conjunction with conventional treatments for ulcerative colitis (UC) and Crohn’s disease (CD) in Asia. These statements also address how pharmacogenetics influence the treatments of UC and CD and provide guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of IBD workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing and future revisions are likely as new data continue to emerge.

Asian Organization for Crohn's and Colitis and Asia Pacific Association of Gastroenterology consensus on tuberculosis infection in patients with inflammatory bowel disease receiving anti-tumor necrosis factor treatment. Part 1: risk assessment

Because anti-tumor necrosis factor (anti-TNF) therapy has become increasingly popular in many Asian countries, the risk of developing active tuberculosis (TB) among anti-TNF users may raise serious health problems in this region. Thus, the Asian Organization for Crohn's and Colitis and the Asia Pacific Association of Gastroenterology have developed a set of consensus statements about risk assessment, detection and prevention of latent TB infection, and management of active TB infection in patients with inflammatory bowel disease (IBD) receiving anti-TNF treatment. Twenty-three consensus statements were initially drafted and then discussed by the committee members. The quality of evidence and the strength of recommendations were assessed by using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Web-based consensus voting was performed by 211 IBD specialists from 9 Asian countries concerning each statement. A consensus statement was accepted if at least 75% of the participants agreed. Part 1 of the statements comprised 2 parts: risk of TB infection Recommendaduring anti-TNF therapy, and screening for TB infection prior to commencing anti-TNF therapy. These consensus statements will help clinicians optimize patient outcomes by reducing the morbidity and mortality related to TB infections in patients with IBD receiving anti-TNF treatment.

Asian Organization for Crohn's and Colitis and Asia Pacific Association of Gastroenterology consensus on tuberculosis infection in patients with inflammatory bowel disease receiving anti-tumor necrosis factor treatment. Part 2: management

Because anti-tumor necrosis factor (anti-TNF) therapy has become increasingly popular in many Asian countries, the risk of developing active tuberculosis (TB) among anti-TNF users may raise serious health problems in this region. Thus, the Asian Organization for Crohn's and Colitis and the Asia Pacific Association of Gastroenterology have developed a set of consensus statements about risk assessment, detection and prevention of latent TB infection, and management of active TB infection in patients with inflammatory bowel disease (IBD) receiving anti-TNF treatment. Twenty-three consensus statements were initially drafted and then discussed by the committee members. The quality of evidence and the strength of recommendations were assessed by using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Web-based consensus voting was performed by 211 IBD specialists from 9 Asian countries concerning each statement. A consensus statement was accepted if at least 75% of the participants agreed. Part 2 of the statements comprised 3 parts: management of latent TB in preparation for anti-TNF therapy, monitoring during anti-TNF therapy, and management of an active TB infection after anti-TNF therapy. These consensus statements will help clinicians optimize patient outcomes by reducing the morbidity and mortality related to TB infections in patients with IBD receiving anti-TNF treatment.

Gut microbiome modulates response to anti-PD-1 immunotherapy in melanoma patients

Preclinical mouse models suggest that the gut microbiome modulates tumor response to checkpoint blockade immunotherapy; however, this has not been well-characterized in human cancer patients. Here we examined the oral and gut microbiome of melanoma patients undergoing anti-programmed cell death 1 protein (PD-1) immunotherapy (n = 112). Significant differences were observed in the diversity and composition of the patient gut microbiome of responders versus nonresponders. Analysis of patient fecal microbiome samples (n = 43, 30 responders, 13 nonresponders) showed significantly higher alpha diversity (P < 0.01) and relative abundance of bacteria of the Ruminococcaceae family (P < 0.01) in responding patients. Metagenomic studies revealed functional differences in gut bacteria in responders, including enrichment of anabolic pathways. Immune profiling suggested enhanced systemic and antitumor immunity in responding patients with a favorable gut microbiome as well as in germ-free mice receiving fecal transplants from responding patients. Together, these data have important implications for the treatment of melanoma patients with immune checkpoint inhibitors.

Asian Organization for Crohn's and Colitis and Asian Pacific Association of Gastroenterology consensus on tuberculosis infection in patients with inflammatory bowel disease receiving anti-tumor necrosis factor treatment. Part 1: Risk assessment

Because anti-tumor necrosis factor (anti-TNF) therapy has become increasingly popular in many Asian countries, the risk of developing active tuberculosis (TB) among anti-TNF users may raise serious health problems in this region. Thus, the Asian Organization for Crohn's and Colitis and the Asian Pacific Association of Gastroenterology have developed a set of consensus statements about risk assessment, detection, and prevention of latent TB infection and management of active TB infection in patients with inflammatory bowel disease (IBD) receiving anti-TNF treatment. Twenty-three consensus statements were initially drafted and then discussed by the committee members. The quality of evidence and the strength of recommendations were assessed by using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Web-based consensus voting was performed by 211 IBD specialists from nine Asian countries concerning each statement. A consensus statement was accepted if at least 75% of the participants agreed. Part 1 of the statements comprised two parts: (i) risk of TB infection during anti-TNF therapy and (ii) screening for TB infection prior to commencing anti-TNF therapy. These consensus statements will help clinicians optimize patient outcomes by reducing the morbidity and mortality related to TB infections in patients with IBD receiving anti-TNF treatment.

Asian Organization for Crohn's and Colitis and Asia Pacific Association of Gastroenterology consensus on tuberculosis infection in patients with inflammatory bowel disease receiving anti-tumor necrosis factor treatment. Part 2: Management

Because anti-tumor necrosis factor (anti-TNF) therapy has become increasingly popular in many Asian countries, the risk of developing active tuberculosis (TB) among anti-TNF users may raise serious health problems in this region. Thus, the Asian Organization for Crohn's and Colitis and the Asia Pacific Association of Gastroenterology have developed a set of consensus statements about risk assessment, detection and prevention of latent TB infection, and management of active TB infection in patients with inflammatory bowel disease (IBD) receiving anti-TNF treatment. Twenty-three consensus statements were initially drafted and then discussed by the committee members. The quality of evidence and the strength of recommendations were assessed by using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Web-based consensus voting was performed by 211 IBD specialists from nine Asian countries concerning each statement. A consensus statement was accepted if at least 75% of the participants agreed. Part 2 of the statements comprised three parts: (3) management of latent TB in preparation for anti-TNF therapy, (4) monitoring during anti-TNF therapy, and (5) management of an active TB infection after anti-TNF therapy. These consensus statements will help clinicians optimize patient outcomes by reducing the morbidity and mortality related to TB infections in patients with IBD receiving anti-TNF treatment.

Splicing mutation of a gene within the Duchenne muscular dystrophy family

The aim of this study was to identify the mutation site and phenotype of the Duchenne muscular dystrophy (DMD) gene in a DMD family. The DMD gene is by far the largest known gene in humans. Up to 34% of the point mutations reported to date affect splice sites of the DMD gene. However, no hotspot mutation has been reported. Capture sequencing of second-generation exons was used to investigate the DMD gene in a proband. Sanger sequencing was performed for mutation scanning in eight family members. Scale-invariant feature transform and PolyPhen were applied to predict the functional impact of protein mutations. A hemizygous splicing mutation IVS44ds +1G-A (c.6438 +1G>A) that induces abnormal splicing variants during late transcription and produces abnormal proteins was located in intron 44. Four missense mutations (p.Arg2937Gln, p.Asp882Gly, p.Lys2366Gln, and p.Arg1745His) that are known multiple-polymorphic sites were found in the coding region of the DMD gene. A heterozygous c.6438+1G>A mutation was detected on the X chromosome of the proband's mother and maternal grandmother.

Differences in the public medical insurance systems for inflammatory bowel disease treatment in Asian countries

BACKGROUND/AIMS

The cost of caring for patients with inflammatory bowel disease (IBD) is high. Without government support, the cost burden will unavoidably rest on the patients and their family. However, the government providing full support will place a large financial burden on the health-care systems of a country. The aim of this study is to understand the current status of public medical insurance systems in caring for IBD patients among Asian countries.

METHODS

Questionnaires inquiring about the availability of public health systems; medical, diagnostic, and endoscopy costs; and coverage rate of biologics use were designed and sent to IBD experts in each of the Asian countries studied. The results were summarized according to the feedback from the responders.

RESULTS

The public health insurance coverage rate is high in Taiwan, Japan, South Korea, China, Hong Kong, and Singapore; but low in Malaysia and India. This probably affected the use of expensive medications mostly, such as biologics, as we found that the percentage of Crohn's disease (CD) treated with biologics were as high as 30%-40% in Japan, where the government covers all expenses for IBD patients. In India, the percentage maybe as low as 1% for CD patients, most of whom need to pay for the biologics themselves.

CONCLUSIONS

There were differences in the public health insurance systems among the Asian countries studied. This reportprovidesthe background information to understand the differences in the treatment of IBD patients among Asian countries.

Hes1 Increases the Invasion Ability of Colorectal Cancer Cells via the STAT3-MMP14 Pathway

The Notch pathway contributes to self-renewal of tumor-initiating cell and inhibition of normal colonic epithelial cell differentiation. Deregulated expression of Notch1 and Jagged1 is observed in colorectal cancer. Hairy/enhancer of split (HES) family, the most characterized targets of Notch, involved in the development of many cancers. In this study, we explored the role of Hes1 in the tumorigenesis of colorectal cancer. Knocking down Hes1 induced CRC cell senescence and decreased the invasion ability, whereas over-expression of Hes1 increased STAT3 phosphorylation activity and up-regulated MMP14 protein level. We further explored the expression of Hes1 in human colorectal cancer and found high Hes1 mRNA expression is associated with poor prognosis in CRC patients. These findings suggest that Hes1 regulates the invasion ability through the STAT3-MMP14 pathway in CRC cells and high Hes1 expression is a predictor of poor prognosis of CRC.

AML1/ETO cooperates with HIF1α to promote leukemogenesis through DNMT3a transactivation

The mechanisms by which AML1/ETO (A/E) fusion protein induces leukemogenesis in acute myeloid leukemia (AML) without mutagenic events remain elusive. Here we show that interactions between A/E and hypoxia-inducible factor 1α (HIF1α) are sufficient to prime leukemia cells for subsequent aggressive growth. In agreement with this, HIF1α is highly expressed in A/E-positive AML patients and strongly predicts inferior outcomes, regardless of gene mutations. Co-expression of A/E and HIF1α in leukemia cells causes a higher cell proliferation rate in vitro and more serious leukemic status in mice. Mechanistically, A/E and HIF1α form a positive regulatory circuit and cooperate to transactivate DNMT3a gene leading to DNA hypermethylation. Pharmacological or genetic interventions in the A/E-HIF1α loop results in DNA hypomethylation, a re-expression of hypermethylated tumor-suppressor p15(INK4b) and the blockage of leukemia growth. Thus high HIF1α expression serves as a reliable marker, which identifies patients with a poor prognosis in an otherwise prognostically favorable AML group and represents an innovative therapeutic target in high-risk A/E-driven leukemia.

In vitro and in vivo studies on nanocrystalline Ti fabricated by equal channel angular pressing with microcrystalline CP Ti as control

Bulk nanocrystalline Ti bars (Grade 4, Φ4 × 3000 mm(3)) were massively fabricated by equal channel angular pressing (ECAP) via follow-up conform scheme with the microcrystalline CP Ti as raw material. Homogeneous nanostructured crystals with the average grain size of 250 nm were identified for the ECAPed Ti, with extremely high tensile/fatigue strength (around 1240/620 MPa) and adorable elongation (more than 5%). Pronounced formation of bonelike apatite for the nanocrystalline Ti group after 14 days static immersion in simulated body fluids (SBF) reveals the prospective in vitro bioactive capability of fast calcification, whereas an estimated 17% increment in protein adsorption represents good bioaffinity of nanocrystalline Ti. The documentation onto the whole life circle of osteoblast cell lines (MG63) revealed the strong interactions and superior cellular functionalization when they are co-incubated with bulk nanocrystalline Ti sample. Moreover, thread-structured specimens were designed and implanted into the tibia of Beagles dogs till 12 weeks to study the in vivo responses between bone and metallic implant made of bulk nanocrystalline Ti, with the microcrystalline Ti as control. For the implanted nanostructured Ti group, neoformed bone around the implants underwent the whole-stage transformation proceeding from originally osteons or immature woven bone to mature lamellar bone (skeletonic trabecular), even with the remodeling being finished till 12 weeks. The phenomenal osseointegration of direct implant-bone contact can be revealed from the group of the ECAPed Ti without fibrous tissue encapsulation in the gap between the implant and autogenous bone.

Abstract LB-11: Clinical and genetic analysis of Peutz-Jeghers syndrome patients in Taiwan

Background/Purpose: Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder characterized by intestinal hamartomatous polyps and mucocutaneous pigmentation. Recently, germline mutations in the LKB1 gene have been reported to underlie PJS. The gene encoding this serine/threonine kinase is located at 19p 13.3. The aim of this study was to investigate the clinical and genetic characteristics of PJS patients in Taiwan.

Methods: We searched the database in the National Taiwan University Hospital, a tertiary medical center in Taiwan, between January 1990 and November 2005. Patients’ clinical information, demographic data, endoscopic pictures, and outcome details for these cases were reviewed and analyzed. After obtaining informed consent, DNA and RNA were extracted from peripheral blood mononuclear cells and the LKB1 gene was sequenced.

Results: A total of 14 non-related patients fulfilling the diagnostic criteria of PJS were included, and seven of them had genetic analysis performed. Mucocutaneous pigmentation was the most frequent presentation. Hamartomas occur most commonly in the small intestine (86%). The frequent abdominal complications include intussusceptions and gastrointestinal bleeding. Four germline mutations were found (57.1%). Three resulted in stop codons at codon 60, 162 (novel mutation), and 308. The fourth mutation was a missense mutation at codon 239 (novel mutation).

Conclusions: Compared to other reports, PJS patients in Taiwan tended to have more extensive polyps in the GI tract, causing intussusceptions as the most common abdominal symptoms. The genetic mutations in the LKB1 gene were identified in 57% of the probands in Taiwan.

Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr LB-11.

Value of coronal reformations in the CT evaluation of acute head trauma

BACKGROUND AND PURPOSE

Routine axial CT images may not be ideally suited for detecting ICH in transversely oriented locations such as the floor of the anterior and middle cranial fossas and vertex. This study was performed to evaluate whether coronal reformations improve detection of ICH in NCCT performed for head trauma.

MATERIALS AND METHODS

All patients undergoing a first NCCT in the ED for evaluation of head trauma were included prospectively during a 6-month interval. NCCT images were reconstructed into standard 5-mm axial datasets and were also reformatted into coronal datasets of 5-mm sections and 2.5-mm intervals. Thirty-two of 213 (15%) scans were interpreted as showing traumatic ICH. These cases were interspersed with 30 studies without ICH. Cases were reviewed for the presence and location of ICH by 2 staff neuroradiologists.

RESULTS

Of 213 patients, 32 NCCTs demonstrated ICH (a total of 104 foci). Fifteen of 104 (14%) ICHs (8 patients) were detected solely on coronal images. Locations included the floor of the anterior and middle cranial fossas, vertex, corpus callosum, falx, tentorium, and occipital convexity. Coronal reformations allowed exclusion of suspicious findings on axial images in 14 instances (7 patients). Coronal images aided interpretation in 29/104 (28%) findings.

CONCLUSIONS

Coronal reformations improve the detection of ICH over axial images alone, especially for lesions that lie in the axial plane immediately adjacent to bony surfaces. The use of coronal reformations should be considered in the routine interpretation of head CT examinations performed for the evaluation of head trauma.

Alkali-heat treatment of a low modulus biomedical Ti-27Nb alloy

This study focuses on the surface modification of a near beta-type Ti-27 wt.% Nb alloy by alkali-heat treatment. The influence of alkali concentration, alkali-treated time and alkali-treated temperature on the microstructure and constitutional phases of the modified surface is investigated by SEM, XRD and ICP. Immersion experiments in a simulated body fluid (SBF) were carried out to examine the Ca-P phase forming ability of the modified surfaces. The SEM observation and XRD analysis revealed that a sodium titanate layer is formed after alkali-heat treatment. The morphology and Ca-P phase forming of the layer are greatly affected by the surface roughness of the samples, the alkali concentration, the alkali-treated time and alkali-treated temperature. The results of SBF immersion, which are obtained by ICP analysis, indicate that the activated sodium titanate layer prepared by alkali-heat treatment is beneficial to further improving the biocompatibility of the Ti-27 wt.% Nb alloy.

Hyperemesis gravidarum presenting as jaundice and transient hyperthyroidism complicated with acute pancreatitis

Hyperemesis gravidarum is an extreme form of nausea and vomiting during pregnancy. Its presenting symptoms include vomiting, disturbed nutrition, electrolyte imbalance, ketosis, extreme weight loss, renal and/or liver damage. It is rare for a hyperemesis gravidarum patient to present with jaundice, hyperthyroidism and idiopathic acute pancreatitis during the same hospitalization period. Here, we report such a case. A 25-year-old pregnant woman without underlying liver or thyroid disease was admitted due to jaundice noted for 2 days at 8 weeks of gestational age. Hyperthyroidism symptoms of tachycardia and finger tremor also bothered her. After treatment with parenteral fluid and antithyroid agents, her clinical condition improved. However, an episode of idiopathic pancreatitis occurred after nausea and vomiting subsided. Bowel rest with parenteral fluid and nutrition supplement was given and the increased pancreatic enzyme level gradually subsided. Follow-up liver and thyroid function were normal after gestational age of 26 weeks. She delivered a healthy female baby without low birth body weight at gestational age of 39 weeks. Rapid diagnosis and supportive care are important for the hyperemesis gravidarum patient with the complication of acute pancreatitis.

A novel mutation of the DSRAD gene in a Chinese family with dyschromatosis symmetrica hereditaria

Dyschromatosis symmetrica hereditaria (DSH) is a pigmentary genodermatosis of autosomal dominant inheritance characterized by a mixture of hyperpigmented and hypopigmented macules distributed on the dorsal aspects of the hands and feet. It is caused by mutations of the RNA-specific adenosine deaminase gene. We report the identification of a Chinese family with a three-generation pedigree of DSH, in whom a novel tyrosine substitution mutation in DSRAD was demonstrated: a heterozygous nucleotide A-->G transition at position 2879 in exon 10 of the DSRAD gene was detected.

Identification of a locus for porokeratosis palmaris et plantaris disseminata to a 6.9-cM region at chromosome 12q24.1-24.2

BACKGROUND

Porokeratosis palmaris et plantaris disseminata (PPPD) is a rare autosomal dominant dyskeratotic disorder characterized by a cornoid lamella with parakeratosis, hyperkeratosis and loss of granular layers. The genetic basis of this disease is still unknown. Two loci for disseminated superficial actinic porokeratosis (DSAP) were found to be located on 12q23.2-24.1 and 15q25.1-26.1. Both PPPD and DSAP are disseminated types of porokeratosis.

OBJECTIVES

To locate the locus for PPPD, thereby facilitating the identification of this disease gene and leading to an understanding of the pathogenesis of porokeratosis.

METHODS

Genotyping was performed in a Chinese family with PPPD using polymorphic microsatellite markers on 12q and 15q.

RESULTS

The locus for PPPD is located within a 6.9-cM region between markers D12S1613 and D12S1341, with a maximum two-point LOD score of 8.14 (theta = 0.00) at D12S1335.

CONCLUSIONS

This study provides a map location for isolation of a gene causing PPPD.

Diagnosis and management of respiratory tract infections for the primary care physician

Respiratory tract infections cause nearly half of deaths owing to infectious disease in the United States. This article has discussed the management of several common respiratory tract infections, with an emphasis on appropriate diagnosis and use of antimicrobial agents. Understanding the cause of various respiratory tract infections enables primary care physicians to avoid unnecessary antibiotic use, decreasing adverse effects owing to medications and preventing the rise in antimicrobial resistance.

Spa contributes to the virulence of type 18 group A streptococci

Streptococcal protective antigen (Spa) is a newly described surface protein of group A streptococci that was recently shown to evoke protective antibodies (J. B. Dale, E. Y. Chiang, S. Liu, H. S. Courtney, and D. L. Hasty, J. Clin. Investig. 103:1261--1268, 1999). In this study, we have determined the complete sequence of the spa gene from type 18 streptococci. Purified, recombinant Spa protein evoked antibodies that were bactericidal against type 18 streptococci, confirming the presence of protective epitopes. Sera from patients with acute rheumatic fever contained antibodies against recombinant Spa, indicating that the Spa protein is expressed in vivo and is immunogenic in humans. To determine the role of Spa in the virulence of group A streptococci, we created a series of insertional mutants that were (i) Spa negative and M18 positive, (ii) Spa positive and M18 negative, and (iii) Spa negative and M18 negative. The mutants and the parent M18 strain (18-282) were used in assays to determine resistance to phagocytosis, growth in human blood, and mouse virulence. The results show that Spa is a virulence determinant of group A streptococci and that expression of both Spa and M18 is required for optimal virulence of type 18 streptococci.

[The use of two-route Cisplatin chemotherapy in the treatment of oral squamous cell carcinoma]

OBJECTIVE

To study the feasibility and efficacy of two-route cisplatin chemotherapy for locally advanced squamous cell carcinoma of oral cavity.

METHODS

23 cases with clinical advanced biopsy-proven oral squamous cell carcinoma received intraarterial chemotherapy with cisplatin (DDP), Pingyangmycin (PYM) and 5-fluorouracilum (5-Fu), at the same time intravenous infusion with natrii thiosulfas (STS) for rescue. DDP at 40-60 mg/d, PYM at 16 mg/d and 5-Fu at 500 mg/d were applied for 5-7 consecutive days.

RESULTS

7 cases (33.3%) obtained a complete response (CR), 11(52.4%) had partial response (PR) with an objective response rate (RR) of 85.7%. No severe toxicity was observed, whereas the most frequent grade I and II drug related toxicities were nausea and vomiting. No nephrotoxicity,hepatotoxicity and severe bone marrow suppression were noted.

CONCLUSION

Two-route cisplatin chemotherapy is, in our experience,a new,effective and safe therapeutic method for oral squamous cell carcinoma.

Endoscopy in acquired immunodeficiency syndrome patients with diarrhea and negative stool studies

BACKGROUND

Diarrhea is a frequent gastrointestinal symptom in patients with acquired immuno-deficiency syndrome (AIDS) and is a major source of morbidity and mortality. A stepwise diagnostic approach is often recommended to search for treatable causes. However, whether the stepwise diagnostic approach is adequate for planning treatment and whether specific treatment for infectious etiologies will affect the survival of patients with AIDS remain unknown.

METHODS

From March 1996 to September 1997, endoscopy was performed in AIDS patients with diarrhea, the etiology of which was not identified by noninvasive methods. Specific treatment was given according to the identified etiologies and symptomatic treatment was given for those without definite diagnosis. The clinical symptoms, signs, and duration of follow-up were recorded and survival patterns were analyzed.

RESULTS

Etiologic diagnoses were made in 26 of 40 patients (65%) who underwent endoscopic studies. Amebic colitis and cytomegalovirus colitis were the 2 leading causes of prolonged diarrhea in patients with AIDS. Thirty-five patients (87.5%) recovered after treatment. The difference in survival time after diarrhea between patients whose symptoms resolved after treatment and those who continued to have diarrhea was statistically significant (p < 0.001).

CONCLUSIONS

Endoscopic studies were helpful for the diagnosis of prolonged diarrhea in AIDS patients who had negative stool studies and did not respond to 2 weeks of empiric treatment. Specific treatment according to the results of endoscopy may improve survival in these patients.

Endoscopic resection of gastrointestinal submucosal tumors

BACKGROUND/AIMS

The occurrence of submucosal tumors in the gastrointestinal tract is not infrequent. According to endoscopic pictures, submucosal tumors can usually be diagnosed without difficulty. However, even with the aid of endoscopic ultrasound, a definite diagnosis is not possible without histological results. Before endoscopy became available, the treatment strategy for gastrointestinal submucosal tumors was either surgery or observation. Due to advances in scientific technology, endoscopic treatment of gastrointestinal submucosal tumors has become increasingly popular. In reviewing the literature, we found that only case reports or small series reports detailing specific tumors in specific locations existed previously.

METHODOLOGY

Endoscopic resection for 12 gastrointestinal submucosal tumors in 11 patients has been successfully performed in our hospital during the past three years.

RESULTS

The group included 5 men and 6 women, ranging in age from 28 to 78 years. The locations of the tumors consisted of 1 in the esophagus, 2 in the stomach, 1 in the jejunum, 5 in the colon and 3 in the rectum. Histological results showed 3 lipomas, 3 carcinoids, 2 leiomyomas, 1 ganglioneuromatous polyp, 1 hemangioma, 1 inflammatory fibroid polyp and 1 myomatous hyperplasia. Bleeding complications occurred in only 2 cases. One stopped spontaneously and the other stopped after epinephrine and sclerosant injection. Only 1 case required a two-step resection in order to avoid perforation. No tumor recurrence was noted during the follow-up period, which ranged from 2 months to 3 years.

CONCLUSIONS

In suitable cases, endoscopic resection of gastrointestinal submucosal tumors can be a safe and valuable method for treating symptomatic tumors and obtaining histological diagnosis of the submucosal tumors.

Bile duct hamartomas. A report of two cases

Bile duct hamartomas (von Meyenburg's complexes) of the liver are usually detected at laparotomy or autopsy as an incidental finding, and usually they are multiple. We report two cases of proved bile duct hamartomas of the liver. The first was in a 65-year-old man whose initial sepsis and many hepatic lesions were interpreted as microabscess of the liver. The second patient was a 39-year-old man, a hepatitis B surface antigen carrier, in whom an incidental hepatic tumor was found. We suggest that liver biopsy be done in hepatic lesions with uncertain clinical features, because the histologic findings may change the treatment plan.

Diagnostic role of endoscopy, stool culture, and toxin A in Clostridium difficile-associated disease

This retrospective study was designed to assess the roles of stool culture for Clostridium difficile, detection of the presence of toxin A, and endoscopic examination in the diagnosis of Clostridium difficile-associated disease (CDAD). From January 1994 through September 1996, there were 213 patients with stool cultures positive for C. difficile in National Taiwan University Hospital. Of these, 126 had CDAD. There were 87 asymptomatic carriers of C. difficile in our study, 12 of whom were positive for toxin A. In addition, seven patients with pseudomembranous colitis (PMC), who were either culture-negative or not tested, were included in the study. The positive predictive values of stool cultures for CDAD and PMC were 59% and 32%, respectively. The positive predictive values of toxin A for CDAD and PMC were 41% and 43%, respectively. Seventy-eight patients (59%) improved with supportive treatment after discontinuing antibiotics. We concluded that stool culture for C. difficile and discontinuation of antibiotics should be the standard approach for patients with suspected CDAD. Endoscopic studies can eliminate some other possible causes of diarrhea such as inflammatory bowel disease, allow biopsies of suspicious lesions, and reveal the severity of CDAD. Toxin assay results need to be interpreted together with the clinical data.

Acute pancreatitis complicated by infarction of the spleen and spinal cord

Complications of acute pancreatitis may include local pancreatic necrosis with pseudocyst or abscess formation, and extrapancreatic manifestations such as pulmonary renal, hepatic, endocrine, and coagulation abnormalities. Coagulation abnormalities associated with acute pancreatitis usually present as thrombophlebitis or widespread microthrombi; most occur in the venous or capillary circulation. We report a rare case of acute pancreatitis complicated by pseudocyst formation, splenic vein thrombosis, splenic infarction, and spinal cord infarction, which resulted in paraplegia. An association between acute pancreatitis and spinal cord infarction has not been reported before.

Case report: successful palliative treatment with intraperitoneal OK-432 injection for epithelioid haemangioendothelioma presenting with intractable ascites

Epithelioid haemangioendothelioma is an unusual type of endothelium-derived vascular tumour of borderline malignancy, which has high variability in clinical presentations, depending on the primary site of involvement. We report on a 20-year-old woman who presented with progressive abdominal fullness for 6 months. Multiple lung and liver nodules with pleural effusion and profuse ascites were found. The diagnosis of epithelioid haemangioendothelioma was made after wedge biopsy of the liver. The ascites was intractable and refractory to strong diuretic therapy and repeated paracentesis. Therefore, six courses of intraperitoneal injection of OK-432 were administered. The ascites subsided to a minimal amount after treatment and the patient remained symptom-free for approximately 8 months. The ascites recurred later and another three courses of intraperitoneal injection of OK-432 were administered. The ascites disappeared again. The patient has remained symptom-free since the end of the second period of treatment.

Rotation and gray-scale transform-invariant texture classification using spiral resampling, subband decomposition, and hidden Markov model

This paper proposes a new texture classification algorithm that is invariant to rotation and gray-scale transformation. First, we convert two-dimensional (2-D) texture images to one-dimensional (1-D) signals by spiral resampling. Then, we use a quadrature mirror filter (QMF) bank to decompose sampled signals into subbands. In each band, we take high-order autocorrelation functions as features. Features in different bands, which form a vector sequence, are then modeled as a hidden Markov model (BMM). During classification, the unknown texture is matched against all the models and the best match is taken as the classification result. Simulations showed that the highest correct classification rate for 16 kinds of texture was 95.14%

[Cerebrovascular emergencies: difficulties and errors in diagnosing various stroke types]

The frequency of and reasons for errors in diagnosing various types of cerebrovascular disease at the emergency room of National Cheng Kung University Hospital were analyzed in 548 consecutive patients from January to December 1990. Each patient was evaluated by neurological residents and a bedside diagnosis was made on the basis of history-taking, physical examination, and diagnostic reasoning. The emergency diagnosis was made after finishing the radiological and/or laboratory investigations. The tentative emergency diagnosis of each patient was judged as correct or not by comparison with the final diagnosis, which was based on either the results of specific investigation or on the typical cerebrovascular syndrome ascertained by the attending physicians if the specific investigation was not helpful. If the tentative emergency diagnosis had been judged to be wrong, the cause for the misdiagnosis was determined by reviewing the records of the entire diagnostic process. The diagnosis in the emergency setting was erroneous in 131 (24%) patients. Primary intraventricular hemorrhage, cerebral venous thrombosis and subarachnoid hemorrhage were frequently misdiagnosed as compared with other types of stroke. The explored reasons for diagnostic inaccuracy were: inadequate basic data (46%), reasoning errors (38%), and lack of fundamental knowledge (16%). These results implied that the education and training for diagnosis of subarachnoid hemorrhage in emergency should be enhanced. Deeply comatose states caused diagnostic difficulties in data collection. Diagnostic errors were frequently encountered in unusual stroke or stroke with atypical presentations. To increase diagnostic ability in cerebrovascular emergencies, residents should strive to improve interview and examination skills and reasoning discipline. Modern technology is not a panacea for diagnostic difficulties.(ABSTRACT TRUNCATED AT 250 WORDS)

Bedside diagnosis for neurological residents in neurological emergencies: a retrospective analysis

BACKGROUND

Critical assessment of diagnostic accuracy is indispensable to resident training and medical education, especially in regard to our situation of the extremely low rate of autopsy. Recent setup of advanced technology for neurological diagnosis has resulted in a tendency to overuse these tools at the expense of using classic bedside diagnostic approach. Disclosing the common errors of daily practices among neurological residents necessitates implementing this pioneer study.

METHODS

The tentative diagnosis of each patient, as performed by neurological residents after finishing bedside diagnostic processes, was assessed by final diagnosis concluded from clinical syndrome and/or the results of laboratory studies. The overall rate of diagnostic error and the frequency of diagnostic inaccuracy in various disease entities were evaluated. The reason for the diagnostic error was determined by reviewing the records regarding the entire diagnostic process.

RESULTS

1336 consecutive patients from January 1990 to December 1990 were recruited for this study. The initial bedside diagnosis was correct in 901 (67%) patients. No definite final diagnosis could be obtained in 169 (13%) patients. The diagnoses were incorrect in 266 (20%) patients. The highest rate of inaccuracy was found in the diagnosis of subdural hematoma (56%). The other common diseases of high rate of diagnostic inaccuracy were myasthenia gravis (50%), subarachnoid hemorrhage (42%), Guillain-Barré syndrome (40%), traumatic disorders (39%), herniation of intervertebral disc (33%), metabolic encephalopathy (30%), infection of central nervous system (30%), intracranial neoplasm (24%), drug overdose or intoxication (22%), and mixed neurological and metabolic encephalopathy (21%). The explored reasons for diagnostic inaccuracy were errors of reasoning (38%), inadequate data base (35%), and inadequate fund of knowledge (27%).

CONCLUSIONS

This study confirmed that the basic methods of bedside diagnosis with a standardized sequence of history taking, physical examination and diagnostic reasoning are currently still the most fundamental process of achieving an accurate diagnosis in neurological emergencies. No shortcut or mechanical substitute is available for clinical diagnosis.

Brain L-glutamate decarboxylase: purification and subunit structure

Glutamate decarboxylase (GDCase; L-glutamate-1-carboxy-lyase, EC 4.1.1.15) was purified from whole rat brain approximately equal to 1300-fold to apparent homogeneity with a specific activity of 2.4 units per mg of protein by a combination of column chromatographies on DEAE-cellulose, hydroxylapatite, and gel filtration, and preparative nondenaturing polyacrylamide gel electrophoresis. The purified preparation contained a single protein band that comigrated with GDCase activity in three diverse analyses: nondenaturing regular (5%) and gradient (3.6-25%) polyacrylamide gel electrophoresis and isoelectric focusing at pH 4-7. The native molecular mass was calculated to be 120 +/- 10 kDa from gradient polyacrylamide gel electrophoresis and 110 +/- 10 kDa from gel filtration. Under the treatment with NaDodSO4 and 2-mercaptoethanol, GDCase dissociated into two subunits of 40 +/- 2 and 80 +/- 4 kDa, as estimated from NaDodSO4 gel electrophoresis. However, only a 40-kDa subunit was detected when GDCase was treated with 4 M urea plus NaDodSO4 and 2-mercaptoethanol, suggesting that the 80-kDa subunit is the dimer of the 40-kDa subunit. In immunoblotting, polyclonal antibodies against GDCase reacted with both 40- and 80-kDa subunits, while monoclonal antibody reacted with only 80-kDa subunits. The isoelectric point of the native enzyme was 5.4. The Km for glutamate was 1.59 X 10(-3) M. In addition to L-glutamate, cysteine sulfinic acid was also decarboxylated at approximately equal to 10% of the rate of glutamate. The pH optimum was fairly broad, with a maximum at approximately equal to 7.3. The enzyme was strongly inhibited by carbonyl-trapping agents, sulfhydryl reagents, thiol compounds, and beta-methylene-DL-aspartate.