Clonal disease of natural killer large granular lymphocytes in Taiwan

Lymphoproliferative diseases of large granular lymphocytes (LDGL) may arise from either CD3+ T cells or CD3- natural killer (NK) cells. LDGL with clonal proliferation of large granular lymphocytes (LGL) is defined as LGL leukaemia. The number of patients with NK-LGL leukaemia reported is limited and the pathogenesis of the disease is not yet clear. From 1991 to 1998 six patients with cytogenetically proved clonal disease of NK-LGL were identified in our institute. All were seropositive for Epstein-Barr virus (EBV). EBV RNA or DNA could be detected in LGL from four patients by EBV in situ hybridization or Southern blot analysis. Most patients ran an aggressive clinical course and five died of the disease. Nonrandom clonal chromosomal abnormalities, including duplication of 1q, rearrangement at 3q and loss of chromosomes Y, 13 or 10, were noted in the six patients from this study and in eight from the literature. The implications of these recurrent cytogenetic aberrations in the development and progression of the disease deserve further studies.

Reconstruction of the shoulder joint using an acetabular allograft. A report of two cases

Wide resection of tumors involving the glenoid region of the scapula compromises a center of motion in the shoulder joint and can cause significant loss of function. Two patients with aggressive tumor of the scapula were treated with wide resection and reconstruction using an osteoarticular acetabular allograft. The ball and socket geometry of the newly reconstructed joint and secure reattachment of soft tissues in the allograft provided a stable shoulder joint. The functional results of the two patients were 87% and 93%, respectively according to the Musculoskeletal Tumor Society system. In a select group of patients with locally aggressive lesions of the scapula, a surgical reconstruction with an osteoarticular allograft would yield satisfactory functional and cosmetic results.

A vanishing liver abscess complicated with Klebsiella pneumoniae chest wall abscess: a case report

Septic metastasis is a unique feature of Klebsiella pneumoniae liver abscess in Taiwan. The case we report is a vanishing K. pneumoniae liver abscess with septic metastasis of the chest wall. The initial finding of a 36 year-old male with no previous medical history, was a huge hepatic mass presented on the sonography during a physical checkup. Hepatitis B, C serology, tumor markers and evidence of metastatic diseases were all negative. A computerized tomography examination was also inconclusive about its nature. Due to the patient's refusal of a liver biopsy, only oral antibiotics were medicated at the outpatient department. Unexpectedly, the follow-up computerized tomography, taken 4 weeks later, demonstrated that the liver mass was nearly absent, while a protruding painful lesion developed over the right chest wall. Under sono-guided aspiration, the chest wall mass was proved to be a pyogenic abscess. The Gram stain revealed gram-negative bacilli and the bacterial culture yielded K. pneumoniae. Under the impression of K. pneumoniae liver abscess with chest wall septic metastasis, after performing percutaneous drainage of the chest wall abscess, the patient was only given parenteral antibiotics for treatment. Both the liver and the chest wall abscesses were at last completely eradicated.

Impaired liver regeneration in inducible nitric oxide synthasedeficient mice

The mechanisms that permit adult tissues to regenerate when injured are not well understood. Initiation of liver regeneration requires the injury-related cytokines, tumor necrosis factor (TNF) alpha and interleukin (IL) 6, and involves the activation of cytokine-regulated transcription factors such as NF-kappabeta and STAT3. During regeneration, TNFalpha and IL-6 promote hepatocyte viability, as well as proliferation, because interventions that inhibit either cytokine not only block hepatocyte DNA synthesis, but also increase liver cell death. These observations suggest that the cytokines induce hepatoprotective factors in the regenerating liver. Given evidence that nitric oxide can prevent TNF-mediated activation of the pro-apoptotic protease caspase 3 and protect hepatocytes from cytokine-mediated death, cytokine-inducible nitric oxide synthase (iNOS) may be an important hepatoprotective factor in the regenerating liver. In support of this hypothesis we report that the hepatocyte proliferative response to partial liver resection is severely inhibited in transgenic mice with targeted disruption of the iNOS gene. Instead, partial hepatectomy is followed by increased caspase 3 activity, hepatocyte death, and liver failure, despite preserved induction of TNFalpha, IL-6, NF-kappabeta, and STAT3. These results suggest that during successful tissue regeneration, injury-related cytokines induce factors, such as iNOS and its product, NO, that protect surviving cells from cytokine-mediated death.

Sequential variceal pressure measurement by endoscopic needle puncture during maintenance sclerotherapy: the correlation between variceal pressure and variceal rebleeding

BACKGROUND/AIMS

The risk factors for esophageal variceal rebleeding are little known. Variceal pressure is one of the major determinants of variceal rupture, but the relationship between variceal pressure and variceal rebleeding during maintenance sclerotherapy has not been determined. This study was undertaken to evaluate the relationship between variceal pressure/gradient change and variceal rebleeding during maintenance sclerotherapy.

METHODS

Patients with liver cirrhosis and recent esophageal variceal hemorrhage underwent consecutive variceal pressure measurements by direct puncture of the varices before each elective sclerotherapy.

RESULTS

In 46 patients, the initial variceal pressure was no different regardless of age, sex, underlying etiology or hepatic reserve. Variceal pressure was higher in large varices, varices with more severe red wale markings, and varices with slower reduction in size during maintenance sclerotherapy. A larger volume of sclerosant was required to eradicate large varices, varices with more severe red wale markings, and varices with slower reduction in size during maintenance sclerotherapy. There was a positive correlation between initial variceal pressure and total amount of sclerosant (r=0.485, p=0.001). Initial variceal pressure was not related to rebleeding. Variceal pressure increased more in patients with rebleeding from varices per se (n=7) than in those without rebleeding (n= 24). There was no difference in pressure change between patients without rebleeding (n=24) and those with rebleeding from variceal ulcers (n=7).

CONCLUSIONS

Large varices, severe red color signs and slow reduction in variceal size were associated with higher initial variceal pressure, and more sclerosant was required to eradicate the varices. An increase in variceal pressure during maintenance sclerotherapy indicates a higher risk of variceal rebleeding, but not of variceal ulcer rebleeding.

Aminoguanidine ameliorates splanchnic hyposensitivity to glypressin in a haemorrhage-transfused rat model of portal hypertension

1. Hyposensitivity to vasopressin is a well-documented phenomenon in animals with portal hypertension and patients with cirrhosis subjected to haemorrhage. Excessive formation of nitric oxide is at least partly responsible for the vascular hyporesponsiveness to vasoconstrictors observed in experimental portal hypertension or in rats with haemorrhagic shock. This study investigated whether addition of aminoguanidine, a preferential inducible nitric oxide synthase inhibitor, to glypressin (a long-acting vasopressin analogue) could enhance its portal hypotensive effect in portal-hypertensive rats with bleeding.2. Portal hypertension was induced by partial portal vein ligation. Fourteen days after operation, systemic and portal haemodynamics were measured in stable or bleeding portal vein-ligated rats receiving intravenous glypressin (0.07 mg/kg) or aminoguanidine (70 mg/kg) followed by glypressin infusion. In rats with a hypotensive haemorrhage, 4.5 ml of blood was withdrawn and 50% of the withdrawn blood was reinfused before the administration of glypressin or aminoguanidine.3. Glypressin resulted in a significantly greater decrease in portal pressure in portal vein-ligated rats without bleeding than in those with bleeding (P<0.001). In contrast, glypressin induced similar changes in mean arterial pressure between the two groups (P>0.05). The addition of aminoguanidine significantly potentiated the portal-hypotensive effect of glypressin in bleeding portal vein-ligated rats (P<0.005) without an effect on the changes in mean arterial pressure induced by glypressin infusion (P>0.05).4. Splanchnic hyposensitivity to glypressin exists in a haemorrhage-transfused rat model of portal hypertension. This hyposensitivity can be ameliorated by the administration of aminoguanidine.

Micromechanical properties of epiphyseal trabecular bone and primary spongiosa around the physis: an in situ nanoindentation study

The elastic modulus and hardness of the mineralized bone around the growth plate was measured to determine its regional micromechanical properties. Multiple nanoindentation tests, >10 sessions, with depths ranging from 100 to 1,000 nm at loading rates of 12.5 and 750 microN/s, were performed on the trabecular bone in the epiphysis, trabecular bone at the junction of the physis and epiphysis, primary spongiosa in the metaphysis, and surrounding cortical bone of the distal femur of 300-gm Sprague-Dawley rats. The indentation load-displacement data obtained in these tests were analyzed to determine the elastic modulus and hardness of the tissues. The nanoindentation results highlighted the regional variations in the material properties of the mineralized tissues around the growth plate. The primary spongiosa had a lower elastic modulus and hardness than both epiphyseal trabecular and cortical bone (p < 0.01). A relatively well-defined thick trabecular band at the physeal-epiphyseal junction had modulus and hardness values comparable to those of cortical bone (p > 0.05). These findings support the hypothesis that the primary spongiosa has micromechanical properties that are significantly lower than the epiphyseal trabecular bone. On this basis, it is speculated that the fracture patterns commonly seen in patients with physeal injuries are influenced by the micromechanical properties of these tissues, as well as by the nature and direction of the applied force.

Colocalization of iron and ceroid in human atherosclerotic lesions

The presence of ceroid, a complex of protein associated with oxidized lipids, is commonly observed in human atherosclerotic lesions. When the human aortic walls were examined by Perls' staining, it was found that the iron deposits were evident in aortas with atherosclerosis. The extent of iron deposition was associated with the severity of the lesion. Furthermore, the iron deposits appeared to be colocalized with ceroids either extracellularly or intracellularly in foam cell-like macrophages or smooth muscle cells. Electron microscopy and X-ray microanalysis revealed that some of the extracellular iron aggregates were present within the ceroids. Likewise, some of the subcellular iron aggregates were found to be located near the lipid droplets or within the ceroids of foam cells. Collectively, these observations support the theory that the lipid oxidation occurring in lipid-laden cells of aortic lesions is facilitated by iron-overload in these cells.

The effect of ciprofloxacin in the prevention of bacterial infection in patients with cirrhosis after upper gastrointestinal bleeding

OBJECTIVES

Cirrhotic patients with upper gastrointestinal bleeding are prone to bacterial infection. The aim of this study was to investigate the efficacy of prophylactic intestinal decontamination with oral ciprofloxacin for the prevention of bacterial infections in cirrhotic patients with upper gastrointestinal bleeding.

METHODS

A total of 120 cirrhotic patients with acute upper gastrointestinal bleeding were enrolled. Sixty patients received ciprofloxacin 500 mg twice daily given orally or through nasogastric tube immediately after upper gastrointestinal endoscopic examination; drug administration continued for 7 days. The remaining 60 patients, who received placebo, served as controls.

RESULTS

The incidence of proven bacterial infection in the ciprofloxacin-treated group was significantly lower than that of placebo group (10% vs 45%, p < 0.001). The incidences of bacteremia, spontaneous bacterial peritonitis, and urinary tract infection in the ciprofloxacin-treated group were significantly lower than those in the placebo group (0% vs 23%, 3.3% vs 13%, and 5% vs 18%, respectively; p < 0.05, respectively). Multivariate logistic regression analysis showed that a lack of prophylactic treatment with ciprofloxacin and severity of cirrhosis were the independent significant predictors for cirrhotic patients with acute gastrointestinal bleeding with infection.

CONCLUSIONS

Prophylactic intestinal decontamination with oral ciprofloxacin is effective in the prevention of bacterial infections in patients with cirrhosis who were suffering from acute upper gastrointestinal hemorrhage.

Effect of long-term octreotide and isosorbide dinitrate on haemodynamics in rats with portal vein stenosis

1. Both octreotide and isosorbide dinitrate have been shown to have portal hypotensive effects in animals with portal hypertension. Moreover, in both animals and humans with portal hypertension, the reduction of portal pressure was enhanced when nitrovasodilators were combined with propranolol or vasopressin. The present study was undertaken to evaluate the effect of long-term administration of octreotide and isosorbide dinitrate on haemodynamics in rats with portal vein stenosis. 2. Portal hypertension was induced by portal vein stenosis. Portal hypertensive rats were allocated into one of four groups (eight rats in each group): vehicle group, octreotide group (100 micrograms/kg via subcutaneous injection every 12 h), isosorbide dinitrate group (5 mg/kg via gastric gavage every 12 h) and combined treatment group. Drug was given for eight consecutive days, starting 1 day before surgery. Haemodynamic values were measured using a radioactive microsphere technique. 3. Long-term octreotide treatment decreased portal pressure and improved the hyperdynamic circulation. In contrast, long-term administration of isosorbide dinitrate reduced portal pressure but did not ameliorate vasodilatation. A combination of octreotide and isosorbide dinitrate improved the hyperdynamic circulation with a reduction of portal pressure. In addition, the mean value of portal pressure after combination treatment was significantly lower than in rats receiving octreotide alone. 4. These results showed that, in rats with portal hypertension, long-term combined administration of octreotide and isosorbide dinitrate improved the hyperdynamic circulation together with a more profound reduction of portal pressure than rats receiving octreotide alone.

Chronic administration of octreotide ameliorates portal hypertension and portal hypertensive gastropathy in rats with cirrhosis

1. Portal hypertension and hyperdynamic circulation have been postulated to play a role in the pathogenesis of portal hypertensive gastropathy. Administration of octreotide to portal hypertensive rats has been shown to reduce portal pressure and ameliorate hyperdynamic circulation. 2. This study investigated the effects of chronic administration of octreotide on systemic and portal haemodynamics and the development of portal hypertensive gastropathy in carbon tetrachloride-induced cirrhotic rats. 3. After 12 weeks of carbon tetrachloride induction, cirrhotic rats were randomly assigned to receive either placebo (5% dextrose in water) or octreotide (65 micrograms/kg in 5% dextrose in water) subcutaneously twice daily for 10 days. Haemodynamic studies with a thermodilution technique and gastric morphometric analyses were performed at 10 days after treatment. 4. In cirrhotic rats, octreotide treatment induced a significant increase in systemic vascular resistance (2.7 +/- 0.2 versus 3.4 +/- 0.2 mmHg/ml.min-1.100 g-1, P < 0.05) and decrease in portal pressure (12.5 +/- 1.2 versus 9.9 +/- 0.5 mmHg, P < 0.05) compared with placebo-treated rats. In addition, octreotide treatment significantly reduced the mean cross-sectional area of gastric mucosal vessels (2290 +/- 145 versus 1810 +/- 101 micron 2, P < 0.05). 5. This study shows that chronic octreotide treatment ameliorates the development of portal hypertensive gastropathy in cirrhotic rats. The effect of octreotide on portal hypertensive gastropathy may, at least partly, be due to the alleviation of portal hypertension and hyperdynamic circulation.

Expression of heme oxygenase-1 in atherosclerotic lesions

Heme oxygenase-1 (HO-1) is a heme-degradation enzyme induced under various oxidative stress conditions. To elucidate the potential involvement of HO-1 in atherogenesis, the expression of this enzyme in atherosclerotic lesions of apolipoprotein E-deficient mice and humans were examined. Both immunostaining and in situ hybridization clearly demonstrated that the expression of HO-1 was prominent in endothelium and foam cells/macrophages of thickened intima in lesions from both humans and experimental animals. The expression of this enzyme was also detected in medial smooth muscle cells of advanced lesions. The induction of HO-1 mRNA was observed in murine peritoneal macrophages after treatment with oxidized low density lipoprotein (LDL) but not with native LDL in a dose-dependent manner. Time course study demonstrated that the induction was prominent at 3 hours, reached a maximal induction at 6 hours, and remained evident up to 24 hours after oxidized LDL treatment. The degree of induction was in concordant with the extent of oxidation in the LDL preparation. Lysophosphatidylcholine, one of the major components present in oxidized LDL, was ineffective to induce the gene expression, suggesting that other lipophilic substances derived from LDL oxidation are responsible for the induction of HO-1. These results clearly demonstrate that HO-1 is one of the stress proteins expressed in atherosclerotic lesions.

Predictive factors for rebleeding in patients with peptic ulcer bleeding after multipolar electrocoagulation: a retrospective analysis

The role of endoscopic therapy for peptic ulcer bleeding is well-documented. Nevertheless, rebleeding occurs in 10% to 30% of patients, and such patients are at high risk for death without early retreatment or definitive surgery. The aim of our study was to predict which patients would rebleed within 1 month after successful multipolar electrocoagulation of 100 patients with active peptic ulcer bleeding (spurting, oozing, or nonbleeding visible vessel). We had achieved initial hemostasis in 97 patients and carried out univariate and multivariate analyses to predict which patients would rebleed. Rebleeding occurred within 1 month in 17 (17.5%) patients. we correlated 20 clinical and endoscopic factors with rebleeding episodes. With univariate analysis, blood transfusion of 500 ml or more at entry (p < 0.0001) and use of cimetidine (p = 0.01) were statistically significant for rebleeding. With multivariate analysis, use of omeprazole was an independent factor for preventing rebleeding (odds ratio, 7.68; 95% confidence interval, 1.642-35.929). We suggest that omeprazole may help to prevent rebleeding in patients who have had hemostasis with multipolar electrocoagulation.

Effect of sucralfate granules in suspension on endoscopic variceal sclerotherapy induced ulcer: analysis of the factors determining ulcer healing

Oesophageal ulcers commonly occur after endoscopic variceal sclerotherapy and usually cause complications and a delay in further sclerotherapy. The aims of this study are to investigate the effect of sucralfate granules in suspension on the treatment of endoscopic variceal sclerotherapy induced ulcer and analyse the factors determining the ulcer healing. Fifty-two patients with oesophageal variceal bleeding received elective endoscopic variceal sclerotherapy. After endoscopically proved oesophageal ulcers, they were randomized to receive either sucralfate granules in suspension (n = 22) or antacid (n = 23). Follow-up endoscopy was performed weekly. Ulcer healing rates were compared between the groups using the log-rank test. Forty-one ulcers receiving sucralfate and 48 ulcers receiving antacid treatment were evaluated. The clinical characteristics of the ulcers were similar in both groups. The ulcers in patients receiving sucralfate healed faster than those receiving antacid (P<0.02). On analysis of factors affecting ulcer healing, ulcers smaller than 1 cm2 (n = 59) appeared to heal faster than those larger than 1 cm2 (n = 30; P= 0.059) and shallow ulcers (n = 46) healed faster than deep ulcers (n = 43; P<0.001). On multifactorial analysis, ulcer depth was the only factor determining ulcer healing. The ulcer healing effects of sucralfate became more prominent when the ulcer was larger than 1.0cm2 (1.7+/-0.6 weeks vs 2.3+/-0.6 weeks, P= 0.011) and deep (1.7+/-0.7 weeks vs 2.5+/-1.0 weeks, P= 0.013) when compared with those receiving antacid. Sucralfate granules in suspension speed the healing of endoscopic variceal sclerotherapy induced ulcer, especially deep and large ulcers.

Severe colonic complications in acute pancreatitis

BACKGROUND

Colonic complications in patients with acute pancreatitis may be very severe and have rarely been analyzed in Chinese patients.

METHODS

We retrospectively evaluated 1,637 patients with acute pancreatitis who were admitted to the Veterans General Hospital-Taipei from January 1986 to December 1995 in order to identify those with severe colonic complications. The clinical, radiologic and pathologic features and surgical findings in these patients are reviewed.

RESULTS

Eight of 1,637 patients with acute pancreatitis had severe colonic complications. Six of them were diagnosed between two and eight weeks after the onset of clinical pancreatitis. All had a Ranson's score of at least 3. Four patients, including one with hematochezia, had a strong positive reaction for occult blood in stool specimens. Computed tomography (CT) revealed necrotizing pancreatitis and colonic wall swelling in all eight patients. Colonic involvement was discovered by CT in two patients prior to surgery, one with colocutancous fistula and the other with colonic perforation. The other six patients were found to have colonic involvement incidentally at the time of laparotomy. All of the colonic involvements were located near the splenic flexure. In addition to necrosectomy, three patients underwent segmental hemicolectomy and the remaining five patients had simple closure of the perforation. Diverting loop ileostomy or colostomy was also carried out in all patients. Three patients (34%) died of overwhelming sepsis superimposed on the subsequent multiple organ failure between 44 and 122 days after the onset of pancreatitis.

CONCLUSIONS

Severe colonic complications of acute pancreatitis are rare. Although preoperative diagnosis is difficult, CT may be helpful to make an early diagnosis. These complications should be suspected in patients with severe acute pancreatitis when acute lower gastrointestinal hemorrhage or positive stool occult blood is found two to eight weeks after the onset of pancreatitis or when CT reveals necrotizing pancreatitis and colonic wall swelling; this will allow early surgical intervention.

A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy

BACKGROUND

A blood clot in a peptic ulcer is unstable in a low pH environment. The use of omeprazole may prevent rebleeding by elevating intragastric pH in patients with bleeding peptic ulcer after hemostasis has been achieved.

OBJECTIVES

To assess the influence of using omeprazole and cimetidine on 24-hour intragastric pH and to determine their ability to prevent rebleeding after having achieved initial hemostasis in patients with active bleeding or nonbleeding visible vessels.

METHODS

One hundred patients with bleeding peptic ulcers who had obtained initial hemostasis were enrolled in this randomized comparative trial. In the cimetidine group (n = 50), a 300-mg intravenous bolus of cimetidine was given, followed by a 1200-mg continuous infusion daily for 3 days. Thereafter, 400 mg of cimetidine was given orally twice daily for 2 months. In the omeprazole group (n = 50), a 40-mg intravenous bolus of omeprazole was given, followed by 160 mg of continuous infusion daily for 3 days. Thereafter, 20 mg of omeprazole was given orally once daily for 2 months. A pH meter was inserted in each patient's fundus under fluoroscopic guidance after the intravenous bolus of cimetidine or omeprazole had been administered.

RESULTS

The stigmata of recent hemorrhage before endoscopic therapy in the omeprazole and cimetidine groups were, respectively, spurting (9 vs 12), oozing (4 vs 9), and nonbleeding visible vessel (37 vs 29) (P > .05). The duration of intragastric pH higher than 6.0 was longer in the omeprazole group (mean [+/- SD], 84.4% +/- 22.9%) than that of the cimetidine group (mean [+/- SD], 53.5% +/- 32.3%) (P < .001). Rebleeding occurred in 2 patients (4%) in the omeprazole group and in 12 patients (24%) in the cimetidine group by day 14 after enrollment (P = .004). There was a tendency for patients in the omeprazole group to require less blood transfusion (median, 0 mL; range, 0-2500 mL) than those in the cimetidine group (median, 0 mL; range, 0-5000 mL) (P = .08). The hospital stay and number of operations and mortality rate were similar between both groups.

CONCLUSIONS

The use of omeprazole is more effective than cimetidine in increasing intragastric pH and reducing rebleeding episodes in patients with bleeding peptic ulcers after successful endoscopic therapy. This suggests that omeprazole should be used routinely after successful endoscopic therapy.

Programmed removal of chondrocytes during endochondral fracture healing

This investigation tested the hypothesis that the removal of chondrocytes during endochondral fracture healing involves an ordered process of programmed cell death. To accomplish this, unilateral closed fractures were created in the femora of 36 Sprague-Dawley rats. The rats were killed in groups of four on days 1, 3, 7, 14, 21, 28, 42, 49, and 56 after fracture. The femora were embedded in paraffin and tested for expression of specific markers of fragmented DNA with use of a terminal deoxyuridyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL) technique. To determine the potential for transdifferentiation of chondrocytes to osteoblasts, calluses were also hybridized to detect expression of osteocalcin mRNA. Cell proliferation was assessed by an immunohistochemical detection method for proliferating cell nuclear antigen. A separate group of four rats was killed on day 28 to represent the later stage of the endochondral ossification, and the calluses were examined for cellular morphology with transmission electron microscopy. The results showed a coordination in both time and space of the activities of cellular proliferation and programmed cell death. Cell proliferation was most active in the earlier phases of fracture healing (days 1 through 14), although TUNEL expression was apparent in hypertrophic chondrocytes on day 14 after fracture and persisted until day 28. In the later stages of fracture healing (days 14 through 28), proliferating cell nuclear antigen was no longer synthesized in hard callus (intramembranous bone) and cell removal was the dominant activity in soft callus chondrocytes. Expression of osteocalcin mRNA was detected in osteoblasts but not in hypertrophic chondrocytes or in any other nonosteoblastic cell type. These findings support the hypothesis that the removal of chondrocytes during endochondral fracture healing is part of an ordered transition of tissue types in which the cellular mechanisms are genetically programmed to involve proliferation, maturation, and apoptotic cell death.

Effects of high dose octreotide on retrograde bile salt-induced pancreatitis in rats

The effects of somatostatin and octreotide (a long acting somatostatin analogue) in acute pancreatitis are inconclusive. This study examined the prophylactic and therapeutic effects of different doses of octreotide on retrograde sodium taurodeoxycholate-induced acute necrotizing pancreatitis in rats. The rats were divided into 4 groups receiving subcutaneous injection of saline, octreotide 10 microg/kg, 20 microg/kg at 0, 8 and 16 h and octreotide 20 microg/kg at 5, 13 and 21 h, separately. The serum levels of amylase and lipase, pancreatic histopathology, mortality and hemodynamics were examined. Octreotide significantly reduced serum levels of amylase and lipase at 12 h and the degree of pancreatic edema, necrosis and hemorrhage at 18-24 h as compared to the control group. Prophylactic octreotide 10 microg/kg significantly decreased the 24-h mortality from 100% to 44.4% (p < 0.05). The 24-h mortality further reduced to 12.5% and 10% with prophylactic and therapeutic octreotide 20 microg/kg, respectively. The decrease of mean arterial pressure at 12 h was significantly lower in octreotide groups than in the control group. We conclude that octreotide improves pancreatic histopathology and survival in acute necrotizing pancreatitis in rats.

The endocrine mechanism of sex reversal in the protandrous black porgy, Acanthopagrus schlegeli: a review

Black porgy, Acanthopagrus schlegeli Bleeker, a marine protandrous hermaphrodite, is a functional male for the first 2 years of life but begin to sexually reverse to female after the third year. This sex pattern provides a very good model to study the mechanism of sex reversal in fish. The gonad at 5 month of age consisted of testicular tissue with few primary oocytes at 5 month of age. The ovarian tissue became dominant at 18 months of age during the non-spawning season. Testicular and ovarian tissues were separated by connective tissue. Plasma estradiol-17 beta(E2), vitellogenin and 11-ketotestosterone (11-KT) profiles in males were significantly different from those in the 3-year-old reversing females. Peak levels of plasma E2 in the reversing females occurred during the early prespawning season (in October). Lower levels of plasma E2 were, however, observed in the males. Plasma 11-KT levels significant decreased but no changes of plasma testosterone were detected in the reversing females. Exogenous E2 suppressed the testicular development but induced the gonadal aromatase activity, ovarian development and sex reversal in 2-year-old black porgy. Exogenous T and LHRH analog did not have effects on the sex reversal. Higher concentrations of pituitary GtH II and mRNA of GtH II-beta subunit were detected in the reversed females. These data suggested that E2 and gonadal aromatase closely associated to the occurrence of sex reversal. A working model of the sex reversal in black porgy is proposed.

Isolation and characterization of the female-specific protein (vitellogenin) in mature female hemolymph of the freshwater prawn, Macrobrachium rosenbergii: comparison with ovarian vitellin

Purification and characterization of the female-specific protein (vitellogenin) from the hemolymph of mature female prawn, Macrobrachium rosenbergii, were the objectives of this study. The comparison of biochemical characteristics between vitellogenin and ovarian vitellin was also conducted. Hemolymph vitellogenin was purified with DEAE, hydroxylapatite, and another DEAE chromatographic column. The specific protein (vitellogenin) was shown in the fractions of chromatographic columns on the basis of ELISA, Western blotting, and immunoprecipitation. A purified vitellogenin was obtained with an apparent molecular weight of 700 kDa as determined by PAGE. The purified vitellogenin was considered as a lipoglycoprotein on the basis of staining data. Three subunits (170, 100, and 89 kDa) in purified vitellogenin and two subunits (100 and 89 kDa) in vitellin were detected with SDS-PAGE. Nondisulfide bonds were found in the binding of polypeptide subunits. Only the 89-kDa subunit was a glycopolypeptide in both vitellogenin and vitellin. The amino acid composition of vitellogenin differed from that of vitellin in a few amino acids. Eight amino acid sequences from the N-terminal end of 89- and 100-kDa subunits were determined and they were identical between vitellogenin and vitellin. Seven amino acid sequence from the N-terminal end of the 170-kDa subunit were also identical to the 100-kDa subunit. Purified vitellogenin was more susceptible to precipitation in a solution with low ionic strength than vitellin. This study suggests a close relationship between vitellogenin and vitellin in M. rosenbergii in their biochemical characteristics.

Analysis of the T cell receptor V beta repertoire in human aortic aneurysms

Human aortic aneurysm is commonly characterized by the presence of advanced atherosclerosis associated with variable chronic adventitial inflammation. Histological examination of human aortic aneurysmal specimens revealed the presence of plasma cells and lymphoid aggregates in media and adventitia of the vessels. Immunostaining further demonstrated that CD3-positive T lymphocytes are present in follicles. Using a highly sensitive reverse transcription-polymerase chain reaction amplification method, the T cell receptor (TCR) V beta gene expression in aortic aneurysms was shown to be polyclonal. Furthermore. there was no preferential expression of any TCR V beta gene in the aortic tissue as compared with that in peripheral blood in aneurysmal patients. These results indicate that the TCR repertoire in aortic aneurysm is not restricted.

Plasma substance P levels in patients with liver cirrhosis: relationship to systemic and portal hemodynamics

OBJECTIVES

Nitric oxide has been proposed as being responsible for the hyperdynamic circulation observed in portal hypertensive states. Substance P, a neuropeptide partly cleared by liver, induces vasodilation through the activation of the endothelial nitric oxide pathway. This study investigated the plasma levels of substance P in cirrhotic patients and the relationship of these levels to systemic and portal hemodynamics.

METHODS

Sixty-four patients with cirrhosis and 53 healthy controls had blood samples taken for determining plasma values of substance P by ELISA. Systemic and portal hemodynamics were measured on the same day of blood sampling using a Swan-Ganz catheterization and thermodilution technique.

RESULTS

Plasma levels of substance P were higher in cirrhotic patients than in healthy controls (45.7 +/- 2.0 vs 32.9 +/- 1.0 pg/ml, p < 0.001) and directly correlated with Child-Pugh's score (r = 0.52, p < 0.0001). Compared with compensated cirrhotic patients, decompensated cirrhotic patients had higher plasma levels of substance P accompanied by a lower systemic vascular resistance and higher hepatic venous pressure gradient. There was no significant correlation between plasma levels of substance P and systemic vascular resistance and hepatic venous pressure gradient. In addition, no significant difference in plasma levels of substance P was observed between cirrhotic patients with and cirrhotic patients without a hepatic venous pressure gradient > 12 mm Hg or between patients with and patients without large esophageal varices.

CONCLUSIONS

Plasma levels of substance P are increased in patients with cirrhosis and may contribute to the pathogenesis and/or maintenance of hyperdynamic circulation in decompensated patients. The severity of cirrhosis is more important than portal hypertension and the severity of esophageal varices for the development of increased plasma substance P levels.

Sequential changes of esophageal motility after endoscopic injection sclerotherapy or variceal ligation for esophageal variceal bleeding: a scintigraphic study

OBJECTIVE

Endoscopic injection sclerotherapy and variceal ligation are two popular endoscopic methods used to treat esophageal variceal hemorrhage. These two methods have not been compared with regard to esophageal dysfunction after treatment. This is a prospective investigation of esophageal dysmotility after endoscopic injection sclerotherapy and variceal ligation.

METHODS

Sequential changes of esophageal motility after endoscopic injection sclerotherapy (n = 25) and variceal ligation (n = 25) were investigated in 50 cirrhotic patients with recent variceal bleeding. Another 22 cirrhotics without esophageal varices were included as controls. Radionuclide esophageal transit tests were performed before initial endoscopic treatment, and 1 and 3 months after variceal eradication.

RESULTS

The baseline esophageal transit time was longer in both the sclerotherapy (n = 25, 7.8 +/- 1.4 s) and ligation groups (n = 25, 8.2 +/- 1.8 s) than in controls (n = 22, 6.7 +/- 0.7 s, p < 0.005). The transit time was longer in patients with large varices than in those with small varices (8.3 +/- 1.7 vs. 7.2 +/- 0.7 s, p < 0.05). In the sclerotherapy group, the transit time was prolonged 1 month after variceal eradication, compared with its pretreatment state (n = 20, 7.6 +/- 1.5 vs. 10.0 +/- 2.2 s, p < 0.0001) but was shortened at 3 months compared with 1 month after variceal eradication (n = 12, 10.7 +/- 1.5 vs. 8.6 +/- 2.2 s, p < 0.05). Multiple regression analysis showed that the number of treatment sessions required to eradicate varices was the only significant factor associated with prolonged transit time (p < 0.05). In the ligation group, the transit time changed little at 1 month or 3 months after variceal eradication.

CONCLUSIONS

Impairment of esophageal motility can be significant with endoscopic injection sclerotherapy but is reversible. However, endoscopic variceal ligation exerts no significant impact on esophageal motility.

Can optimal acid suppression prevent rebleeding in peptic ulcer patients with a non-bleeding visible vessel: a preliminary report of a randomized comparative study

BACKGROUND/AIMS

The hypothesis that profound acid suppression might prevent clot lysis and thus benefit patients with a non-bleeding visible vessel has not been confirmed. Omeprazole can suppress gastric acid remarkably and may be beneficial for patients with peptic ulcer bleeding.

METHODOLOGY

Fifty-two patients with a non-bleeding visible vessel at the ulcer base were enrolled and randomized into four groups (N = 13 in each group). In the cimetidine group, the patients received cimetidine 300 mg i.v. bolus followed by 300 mg i.v. every 6 hr during hospitalization. In the heater probe thermocoagulation + cimetidine group, the patients received heater probe thermocoagulation and cimetidine 300 mg i.v. bolus followed by 300 mg i.v. every 6 h during hospitalization. In the omeprazole q.d. group, the patients received omeprazole 40 mg i.v. bolus followed by 40 mg i.v. daily for two days. In the omeprazole q 12 h group, the patients received omeprazole 40 mg i.v. bolus followed by 40 mg i.v. every 12 h for two days. A 24 hr intragastric pH was recorded for every case.

RESULTS

The mean 24 hr intragastric pH were higher in the omeprazole q.d. (mean 5.8) and the omeprazole q 12 h groups (mean 6.4) than in the cimetidine (mean 4.3) and the heater probe thermocoagulation + cimetidine groups (mean 4.9) (p < 0.05). Rebleeding occurred in 5, 2, 2 and 2 patients in the cimetidine, heater probe thermocoagulation + cimetidine, omeprazole q.d., and omeprazole q 12 h groups, respectively (p > 0.05). Volume of blood transfusion and number of days in hospital were not statistically different among the four groups.

CONCLUSIONS

Omeprazole can remarkably suppress gastric acid when it is compared to that of the H2 receptor blocker. Patients with a non-bleeding visible vessel using omeprazole do not exhibit a decrease in the rebleeding rate as compared with those patients using cimetidine.

Prognostic value of plasma endotoxin levels in patients with cirrhosis

BACKGROUND

Endotoxemia has frequently been observed in patients with cirrhosis. Previous studies have shown that cirrhotic patients with endotoxemia have a higher mortality than those without. We evaluated the clinical value of plasma endotoxin level in predicting short-term (3 months) and long-term (2 years) survival among cirrhotic patients and compared it with the Child-Pugh score.

METHODS

Plasma endotoxin levels were determined in 102 cirrhotic patients without clinical evidence of infection by a quantitative Limulus assay. The patients were followed up for 3 months to assess short-term survival and for 2 years for long-term survival.

RESULTS

Plasma endotoxin levels increased progressively as liver function deteriorated. In short-term survival analysis, plasma endotoxin levels were significantly higher in non-survivors than those in survivors (10.6 +/- 2.2 pg/ml versus 5.8 +/- 0.5 pg/ml; P < 0.05). Both plasma endotoxin and serum bilirubin levels, but not the Child-Pugh score, were significant factors in predicting short-term survival in multivariate analysis. In long-term survival analysis, plasma endotoxin levels did not differ significantly between survivors and non-survivors (6.1 +/- 0.6 pg/ml versus 7.3 +/- 1.1 pg/ml; P > 0.05) and was not an independent predictor of long-term survival. In contrast, both Child-Pugh score and serum bilirubin levels were significant predictors of long-term survival in multivariate analysis.

CONCLUSIONS

In patients with cirrhosis, plasma endotoxin levels progressively increase as liver function deteriorates and may be useful in predicting short-term survival.

Hyperdynamic circulation of cirrhotic rats with ascites: role of endotoxin, tumour necrosis factor-alpha and nitric oxide

1. Hyperdynamic circulation observed in portal hypertensive states is characterized by generalized vasodilation, increased cardiac index and increased systemic and regional blood flows. Endotoxin, tumour necrosis factor-alpha (TNF-alpha) and nitric oxide (NO) have been reported to be involved in the pathogenesis of hyperdynamic circulation, but the interactions between endotoxin, TNF-alpha and NO in cirrhotic rats with ascites have never been specifically addressed. 2. This study was designed to determine systemic and portal haemodynamics and plasma levels of endotoxin, TNF-alpha and nitrate/nitrite in cirrhotic rats with ascites and investigate the relationships between these substances. 3. Plasma concentrations of endotoxin, TNF-alpha and nitrate/nitrite (an index of NO production) were determined in 25 cirrhotic rats with ascites and 17 control rats using the Limulus assay, ELISA and a colorimetric assay respectively. In addition, haemodynamic studies were performed in another ten cirrhotic rats with ascites and ten control rats. 4. Cirrhotic rats with ascites had hyperdynamic circulation accompanied by increased plasma levels of endotoxin, TNF-alpha and nitrate/nitrite, as compared with control rats. Significant correlation existed between plasma levels of endotoxin and nitrate/ nitrite (r = 0.59, P < 0.0001) and between plasma levels of endotoxin and TNF-alpha (r = 0.63, P < 0.0001). No correlation was detected between plasma levels of TNF-alpha and nitrate/nitrite (r = 0.24, P > 0.05). 5. This study suggests that endotoxaemia developed in cirrhotic rats with ascites may stimulate NO formation directly or indirectly via cytokine cascade, and consequently participate in the development and/or maintenance of hyperdynamic circulation.

The concentrations of vitellogenin (vitellin) and protein in hemolymph, ovary and hepatopancreas in different ovarian stages of the freshwater prawn, Macrobrachium rosenbergii

The objectives were to measure the concentrations of vitellogenin (vitellin) and protein in hemolymph, ovary, and hepatopancreas of the freshwater prawn, Macrobrachium rosenbergii, in different stages of ovarian development. The ovarian development of M. rosenbergii was classified into five developmental stages (Stages I-V). Vitellogenin concentrations increased in the hemolymph of prawns in the early stages of ovarian development (Stage I or II) and were maintained at high levels until Stage V. There was no close association between ovarian development and the concentrations of circulating vitellogenin. Concentrations of protein in hemolymph and hepatopancreas remained constant during various stages of ovarian development. The ovarian stages closely correlated with the gonadosomatic index, the concentrations of ovarian vitellin and protein, respectively. Vitellogenin levels in hepatopancreas remained very low in different stages of the prawn although the highest levels were observed in Stage IV. No close association between hemolymph vitellogenin and ovarian vitellin was observed. The increase of vitellogenin concentration in hemolymph occurred earlier than vitellin content in ovary.

Hyperdynamic circulation of cirrhotic rats: role of substance P and its relationship to nitric oxide

BACKGROUND

It has been suggested that excessive formation of nitric oxide (NO) is responsible for the hyperdynamic circulation observed in portal hypertension. Substance P is a neuropeptide partly cleared by the liver and causes vasodilatation through the activation of the endothelial NO pathway. However, there are no previously published data concerning the plasma level of substance P in cirrhotic rats and its relationship to NO.

METHODS

Plasma concentrations of substance P and nitrate/nitrite (an index of NO production) were determined in control rats and cirrhotic rats with or without ascites using an enzyme-linked immununosorbent assay and a colorimetric assay, respectively. In addition, systemic and portal hemodynamics were evaluated by a thermodilution technique and catheterization.

RESULTS

Cirrhotic rats with and without ascites had a lower systemic vascular resistance (2.6 +/- 0.2 and 3.9 +/- 0.4 mmHg ml(-1) x min x 100 g body weight, respectively) and higher portal pressure (14.6 +/- 0.6 and 11.3 +/- 1.8 mmHg) than control rats (6.5 +/- 0.3 mmHg x ml(-1) x min x 100 g BW and 6.8 +/- 0.2 mmHg, respectively, P < 0.05), and cirrhotic rats with ascites had the lowest systemic vascular resistance. Plasma levels of nitrate/nitrite progressively increased in relation to the severity of liver dysfunction (control rats, 2.7 +/- 0.5 nmol/ml; cirrhotic rats without ascites, 5.6 +/- 1.3 nmol/ml; cirrhotic rats with ascites, 8.3 +/- 2.2 nmol/ml; P < 0.05). Cirrhotic rats with ascites displayed higher plasma values of substance P (57.7 +/- 5.9 pg/ml) than cirrhotic rats without ascites (37.9 +/- 3.1 pg/ml, P < 0.05) and control rats (30.1 +/- 1.0 pg/ml, P < 0.05). There was no significant difference in plasma substance P values between control rats and cirrhotic rats without ascites (P > 0.05). No correlation was found between plasma levels of substance P and nitrate/nitrite (r = 0.318, P > 0.05).

CONCLUSIONS

Excessive formation of NO may be responsible, at least partly, for the hemodynamic derangements in cirrhosis. Although substance P may not participate in the initiation of a hyperdynamic circulation in cirrhosis, it may contribute to the maintenance of the hyperdynamic circulation observed in cirrhotic rats with ascites.

Hemodynamic studies and esophageal morphometric analyses in portal hypertensive rats with left adrenal vein ligation

BACKGROUND

Despite many attempts to create esophageal varices in experimental animals, most of them have failed. This study investigated whether rats with partial portal vein ligation (PVL) and left adrenal vein ligation (LAL) develop hyperdynamic circulation and dilated esophageal submucosal veins as compared with sham-operated (Sham) plus LAL rats.

METHODS

Two series of experiments were performed to measure (a) systemic and portal hemodynamics and (b) the cross-sectional area of esophageal submucosal veins in Sham, PVL, Sham plus LAL, and PVL plus LAL rats. Hemodynamic studies with a thermodilution technique and esophageal morphometric analyses were performed 14 days after the operation.

RESULTS

PVL rats with or without LAL had a significantly lower mean arterial pressure and systemic vascular resistance accompanied by a significantly cardiac index and portal pressure than Sham rats with or without LAL (P < 0.05). LAL did not induce changes in mean arterial pressure, cardiac index, systemic vascular resistance, hear rate, or portal pressure in either Sham or PVL rats (P > 0.05). The mean cross-sectional area of esophageal submucosal veins in PVL rats with LAL (7340 +/- 833 microns2) was significantly larger than that in Sham rats with LAL (4236 +/- 556 microns2; P < 0.05). There was no significant difference in the mean cross-sectional area of esophageal submucosal veins between PVL and Sham rats without LAL.

CONCLUSIONS

PVL rats with LAL developed hyperdynamic circulation similar to PVL rats without LAL. In addition, PVL plus LAL rats had larger esophageal submucosal veins than Sham plus LAL rats. This study shows that the esophageal submucosal veins of the 14-day partially portal vein-ligated rats with LAL resemble the structural abnormalities observed in human esophageal varices, suggesting that this model could be useful to investigate this entity.

Increased expression of Gs(alpha) enhances activation of the adenylyl cyclase signal transduction cascade

Expression of the stimulatory G protein, G(S)alpha, can vary over a 3-fold range in human tissues and in rodent central nervous system. In fact, the offspring of alcoholics have higher levels of G(S)alpha expression in certain tissues compared with the offspring of nonalcoholics. The aim of this research was to test the hypothesis that a causal relationship exists between the level of expression of G(S)alpha and induction of the adenylyl cyclase (AC) cascade. The methodology employed transient transfection of HEK 293 cells with a cDNA for the 52-kDa form of G(S)alpha under regulation by inducible metallothionein promoters. Transfectants were exposed to varying concentrations (0-125 microM) of zinc sulfate that produced a 3-fold range of membrane G(S)alpha expression. The range of G(S)alpha expression produced was found to mimic a physiologically relevant spectrum of G(S)alpha expression in membranes derived from human tissues and rat brain. It was observed that induction of G(S)alpha expression increased constitutive as well as stimulated cAMP accumulation. Moreover, induction of G(S)alpha expression increased events distal to the accumulation of cAMP including the phosphorylation of the transcription factor, cAMP response element binding protein and transcriptional activation of cAMP-dependent reporter genes. In summary, these studies show that the amount of G(S)alpha expression has a marked impact on the level of activity of the AC cascade from the membrane through to the nucleus. It is hypothesized that individuals who differ in G(S)alpha expression may also differ in the expression of certain cAMP-dependent genes.

Clinical and biological characteristics of acute promyelocytic leukemia in Taiwan: a high relapse rate in patients with high initial and peak white blood cell counts during all-trans retinoic acid treatment

Acute promyelocytic leukemia (APL) patients treated with all-trans retinoic acid (ATRA) and chemotherapy have been shown to have better outcome than those treated with conventional chemotherapy alone. However, the biological characteristics of leukemic cells and their clinical implications in patients treated with ATRA have not been well established. In this study, the biological and clinical features of 30 APL patients were reported. The risk factors for relapse and for occurrence of retinoic acid (RA) syndrome, which might cause morbidity or mortality of patients after ATRA treatment, were also analyzed. All patients showed 15;17 translocation by cytogenetic and/or gene analysis. Patients in this study had higher white blood cell (WBC) counts and a higher incidence of additional abnormalities than those from other areas. The ratio of long (L) form to short (S) form PML-RAR alpha fusion transcript was 1.8:1, a value lower than that of Latino patients but higher than that of Italians. Leukemic cells from four patients showed coexpression of T cell-associated antigen CD2 which was highly correlated with S form fusion transcript. Nine (36%) of the 25 patients treated with ATRA developed RA syndrome; all but one were successfully controlled by corticosteroid. Complete remission (CR) rate was 84%. Patients with high WBC counts tended to develop RA syndrome and had increased risk of relapse. Isochromosome for the long arm of the derivative chromosome 17, ider(17q), as an additional chromosomal abnormality was also associated with poor outcome in this study. In conclusion, APL in this study showed some different biological characteristics compared with those reported in other areas. High WBC count was a risk factor for relapse and development of RA syndrome after ATRA treatment. The prognostic implication of the presence of ider(17q) needs further clarification.

Regional and temporal changes in the acoustic properties of fracture callus in secondary bone healing

Controlled fractures were created in the right femora of 17 male Sprague-Dawley rats. The fractured limbs were harvested at 2, 4, 6, and 8 weeks after fracture, fixed, and embedded in polymethylmethacrylate. Midsagittal sections from each animal were evaluated with a scanning acoustic microscope, a device that generates an acoustic impedance map of the scanned material. The impedance of the fracture callus was measured in six regions on each specimen. These regions were chosen in an effort to distinguish between the impedance of the callus formed through intramembranous or endochondral ossification, and we found that the time course of increasing impedance differed for the fracture callus formed through the two pathways. Additionally, we found a significant difference in the mean impedance of the callus at each time period (p < or = 0.0013 for all comparisons), which resulted in an extremely linear relationship (r2 = 0.999) between mean callus impedance and healing time. This experimental model has become a popular choice for the investigation of fracture healing. As such, an accurate determination of the mechanical properties of the fracture callus is often sought. We propose that the implementation of scanning acoustic microscopy in the study of fracture healing may determine the changes in the material properties more accurately than conventional testing methods.

Clonal chromosomal abnormalities as direct evidence for clonality in nasal T/natural killer cell lymphomas

Nasal T/natural killer (NK) cell lymphoma is a distinct clinicopathologic entity which is more prevalent in Asia than in America and Europe. The clonal nature of the infiltrating lymphoid cells is difficult to demonstrate because of the lack of immunologic markers for clonality and the absence of clonal T-cell receptor gene rearrangement in most cases. In this study, clonal chromosomal abnormalities were detected in the tumour cells from four patients with nasal T/NK cell lymphoma. This finding provided direct evidence for clonality of the disease. Moreover, nonrandom cytogenetic abnormalities, including isochromosome for the short arm (p) of chromosome 6, isochromosome for the long arm (q) of chromosome 1, partial deletion of 6q, and aberrations at 11q, were disclosed. Isochromosome 6p was the sole structural abnormality in one patient, which may be a pathognomonic change in nasal lymphoma.

Clinical evaluation of primary biliary cirrhosis in Chinese patients without serum anti-mitochondrial antibody

BACKGROUND

Primary biliary cirrhosis (PBC), a chronic, progressive, cholestatic liver disease characterized by frequent presence of the anti-mitochondrial antibody (AMA), is rarely seen in the Asian population. Whether or not the presence of AMA alters the clinical, serological and histological features of the disease remains unclear.

METHODS

During the 25-year period from 1972 to 1996, 71 Chinese patients with PBC who were diagnosed clinically and/or histologically were reviewed. Seventeen (24%) of them repeatedly tested negative for serum AMA. Clinical, biochemical, immunological, histological data and treatment response to ursodeoxycholic acid were compared between PBC patients with positive and negative serum AMA.

RESULTS

Mean serum immunoglobulin M (IgM) level was significantly lower in AMA-negative PBC patients when compared with AMA-positive PBC patients (422 +/- 163 vs. 651 +/- 412 mg/dL, p = 0.042). Serum anti-nuclear antibodies (ANA) were positive in 93% of the AMA-negative PBC patients, a significantly higher percentage when compared with the 66% of AMA-positive patients (p = 0.048). There were no significant differences with regard to age, sex, clinical manifestations, liver biochemistries, histological findings, survival and response to 1-year ursodeoxycholic acid treatment between the AMA-negative and AMA-positive patients. Univariate logistic regression analysis showed relatively lower serum IgM levels, positive serum ANA and anti-centromere type ANA were significant predictive factors to negative serum AMA in PBC patients (p = 0.035, 0.044 and 0.029, respectively). Multi-variate analysis revealed relatively lower serum IgM levels were the only independent significant predictor to negative serum AMA in PBC patients (p = 0.015).

CONCLUSIONS

Twenty-four percent of Chinese patients with PBC were negative for serum AMA. AMA-negative PBC patients were characterized by relatively lower serum IgM levels and a higher rate of positive serum ANA.

Effects of long-term administration of octreotide on sodium retention and atrial natriuretic peptide in carbon tetrachloride-induced cirrhotic rats

BACKGROUND/AIMS

To realize the roles of peripheral vasodilatation and atrial natriuretic peptide in the formation of cirrhotic ascites, the effects of long-term administration of octreotide on carbon tetrachloride-induced cirrhotic rats were evaluated.

METHODS

Urine sodium excretion, hemodynamics, plasma atrial natriuretic peptide levels, renin activities and aldosterone concentrations were compared between cirrhotic and control rats (protocol 1); and between octreotide- (65 micrograms/kg, twice daily for 10 days, subcutaneously) and placebo-treated (5% dextrose) cirrhotic rats (protocol 2). In an in vitro experiment, right atrial tissue of cirrhotic rats was incubated with different concentrations of octreotide to evaluate the release of atrial natriuretic peptide (protocol 3).

RESULTS

Cirrhotic rats had significantly lower urine sodium excretion and systemic vascular resistance, and significantly higher plasma atrial natriuretic peptide levels, renin activities and aldosterone concentrations than control rats. Compared with placebo-treated cirrhotic rats, octreotide caused increased urine sodium excretion (-10 +/- 4% vs. 13 +/- 8% from baseline values, p < 0.05) and systemic vascular resistance (2.6 +/- 0.1 vs. 3.3 +/- 0.3 mmHg.min.100 g.ml-1, p < 0.05); and decreased plasma atrial natriuretic peptide levels (166.7 +/- 24.8 vs. 234.0 +/- 19.2 pg/ ml, p < 0.05), renin activities (2.45 +/- 0.49 vs. 4.36 +/- 0.53 ng.ml-1.h-1, p < 0.01) and aldosterone concentrations (290.2 +/- 40.0 vs. 483.3 +/- 82.6 pg/ml, p < 0.05). In the in vitro experiment, right atrial release of atrial natriuretic peptide of cirrhotic rats was not significantly changed when incubated with different concentrations of octreotide.

CONCLUSIONS

Octreotide ameliorates renal sodium retention and suppresses plasma levels of atrial natriuretic peptide of ascitic cirrhotic rats with a novel mechanism via, at least partly, the modification of peripheral vascular resistance.

Hyperdynamic circulation in prehepatic portal hypertension: role of tumor necrosis factor-alpha

BACKGROUND

Portal hypertension is associated with a hyperdynamic circulation characterized by increased cardiac output and reduced systemic vascular resistance. Tumor necrosis factor-alpha (TNF-alpha) is a peptide mediator released by mononuclear cells on activation by endotoxin, tissue injury and malignancy. This cytokine induces vasodilatation by activating nitric oxide synthesis. The aim of this study is to investigate if TNF-alpha is involved in the pathogenesis of hyperdynamic circulation observed in portal vein-ligated (PVL) rats.

METHODS

Systemic and portal hemodynamics were determined in seven PVL and five sham-operated (SHAM) rats using a thermodilution technique. In addition, plasma TNF-alpha concentrations were determined in another 34 PVL and 16 SHAM rats using commercially available enzyme-linked immunosorbent assay.

RESULTS

PVL rats had a significantly lower mean arterial pressure (109 +/- 17 mmHg vs. 133 +/- 12 mmHg, p < 0.001) and systemic vascular resistance (2.5 +/- 0.6 mmHg.ml-1.min.100 g BW vs. 4.6 +/- 0.8 mmHg.ml-1.min.100 g BW, p < 0.001) accompanied by a significantly higher portal pressure (14 +/- 1.9 mmHg vs. 9 +/- 2.1 mmHg, p < 0.001) and cardiac index (47.0 +/- 12.1 ml.min-1.100 g BW-1 vs. 29.3 +/- 3.5 ml.min-1.100 g BW-1, p < 0.001) when compared with SHAM rats. Also, PVL rats had significantly higher plasma levels of TNF-alpha as compared with SHAM rats (13.8 +/- 0.9 pg/ ml vs. 11.1 +/- 0.5 pg/ml, p < 0.05).

CONCLUSIONS

This study suggests that elevated plasma levels of TNF-alpha observed in PVL rats may participate in the development and/or maintenance of the hyperdynamic circulation occurring in prehepatic portal hypertension.

Aminoguanidine corrects hyperdynamic circulation without ameliorating portal hypertension and portal hypertensive gastropathy in anesthetized portal hypertensive rats

BACKGROUND/AIMS

Portal hypertension and hyperdynamic circulation (i.e. generalized vasodilation and increased cardiac output and regional organ blood flows) may play an important role in the development of portal hypertensive gastropathy. This study investigated the effect of chronic administration of aminoguanidine, a selective inducible nitric oxide synthase inhibitor, to portal hypertensive rats on hemodynamics and the development of portal hypertensive gastropathy.

METHODS

Partial portal vein-ligated or sham-operated rats were randomly assigned to receive either placebo (distilled water) or aminoguanidine (approximately 100 mg/kg per day subcutaneously) for 2 days prior to and 14 days. Hemodynamic studies with a thermodilution technique and gastric morphometric analysis were performed at 14 days after the operation.

RESULTS

In rats given placebo, portal vein-ligated rats had a significantly lower mean arterial pressure and systemic vascular resistance associated with a significantly higher cardiac index and portal pressure than sham-operated rats (p<0.05). In portal vein-ligated rats aminoguanidine induced a significant increase in mean arterial pressure and systemic vascular resistance accompanied by a significant decrease in cardiac index (p<0.05) without changes in portal pressure (p>0.05). Despite persistence of portal hypertension, the aminoguanidine-treated portal vein-ligated rats had similar mean arterial pressure, cardiac index, and systemic vascular resistance as seen in placebo-treated sham-operated rats. The mean cross-sectional area of gastric mucosal vessels was significantly higher in placebo-treated portal vein-ligated than in placebo-treated sham-operated rats (p<0.05). Treatment with aminoguanidine did not induce changes in the mean cross-sectional area of gastric mucosal vessels in either portal vein-ligated or sham-operated rats (p>0.05).

CONCLUSIONS

The results show that in portal hypertensive rats long-term aminoguanidine therapy corrects the hyperdynamic circulation without inducing changes in portal pressure and ameliorating the development of portal hypertensive gastropathy. This study suggests that, instead of correcting hyperdynamic circulation, treatment of portal hypertensive gastropathy should be aimed at reducing portal pressure.

YC-1, a nitric oxide-independent activator of soluble guanylate cyclase, inhibits platelet-rich thrombosis in mice

YC-1 (3-(5'-hydroxymethyl-2'-furyl)-1-benzylindazole), a nitric oxide (NO)-independent activator of soluble guanylate cyclase, has been shown to inhibit platelet activation and aggregation in vitro through the generation of cGMP. In the present study, we assessed the antithrombotic effect of YC-1 in models of experimental thrombosis in mice. YC-1 (10, 30 micrograms/g, i.p.)-treated mice showed a prolonged tail bleeding time 30 min after injection (from control 91.0 +/- 6.4 s to 208.6 +/- 22.7 s and 291.8 +/- 42.4 s, respectively). In contrast, aspirin at a dose of 30 micrograms/g (i.p.) prolonged the bleeding time to more than 600 s. Platelet-rich thrombus formation was induced by irradiation of the mesenteric venule with filtered light in mice pretreated intravenously with fluorescein sodium. YC-1 (30 micrograms/g, i.p.) markedly prolonged the occlusion time of irradiated venules (from control 146.1 +/- 19.0 s to 275.6 +/- 24.5 s) in heparinized (1 U/g) mice. In the same condition, aspirin (100 micrograms/g) only slightly prolonged the time required for occlusion (193.2 +/- 13.2 s). In a model of fatal pulmonary thromboembolism induced by intravenous injection of ADP (300 micrograms/g), YC-1 was effective in reducing mortality when administered intraperitoneally at doses of 10-30 micrograms/g. The antithrombotic effect of YC-1 was correlated with the inhibition of ADP-induced platelet aggregation ex vivo. In contrast, aspirin (30, 100 micrograms/g) did not inhibit ADP-induced pulmonary thromboembolism in vivo or platelet aggregation ex vivo. YC-1 (3, 10 micrograms/g) also exhibited profibrinolytic activity ex vivo, as revealed by shortening of the euglobulin clot lysis time. Therefore, YC-1 is an effective antithrombotic agent in preventing thrombosis in animal models, and its antiaggregating and additional profibrinolytic effects may be of potential clinical benefit in the treatment of thromboembolic diseases.

Preclinical antitumor activity of water-soluble paclitaxel derivatives

PURPOSE

Five water-soluble paclitaxel derivatives were extensively evaluated for their antitumor activities relative to the parent drug.

METHODS

Both subcutaneous (s.c.) murine (M109 lung) and human (A2780 ovarian, L2987 lung) tumor models were used for this purpose.

RESULTS

Consecutive daily intravenous (i.v.) paclitaxel therapy of mice bearing s.c. M109, beginning on day 4 or 5 posttumor implant and continuing for 5 days, resulted in a range of maximum gross log cell kill (LCK) values (reflective of delays in tumor growth) and maximum relative median survival time (% T/C) values (reflective of increases in lifespan) of 1.0-2.1 and 132-162% (and one outlying result of 235%), respectively. Against the same tumor model, using the same treatment schedule, each of the water-soluble derivatives was active, with maximum LCK of 1.3-2.5 and T/C of 124-254%. These LCK and %T/C values were always within 0.5 LCK and 15%, respectively, of the concomitantly obtained maximum effects of paclitaxel. When tested in several experiments against staged (50-100 mg) s.c. A2780 tumors, using various i.v. treatment schedules, the water-soluble derivatives achieved a maximum LCK of 1.4-3.8. Evaluated in parallel, paclitaxel achieved a maximum LCK of 2.1-4.5 following every other day x 5 i.v. therapy. When paclitaxel was assayed in several experiments using the staged (50-100 mg) s.c. L2987 tumor model, maximum LCK of 0.9->4.1 were produced following every other day x 5 i.v. therapy. Concomitant testing of the water-soluble derivatives, using the same i.v. treatment schedule, resulted in maximum LCK of 0.2->4.1. In each of the tumor models used, the consistently active, and usually the most active, water-soluble derivative was BMS-185660. The levels of activity observed were comparable (within 1 LCK) to those achieved concomitantly using paclitaxel, and its potency was only slightly inferior to the parent drug.

CONCLUSIONS

Based on the evaluations performed in three distal site tumor models, we conclude that BMS-185660 is a water-soluble paclitaxel derivative with preclinical antitumor activity comparable to that of the parent drug.

Gastric secretion in Chinese patients with cirrhosis

The role of gastric secretion has been controversial in patients with cirrhosis. Except for studies of gastric secretion in cirrhotic patients who underwent a shunt operation, there is no report correlating gastric secretion with portal pressure in patients with cirrhosis. In this study, we evaluated gastric secretion in cirrhotic patients and correlated it with hemodynamic parameters. Within 12 months, 20 normal volunteers and 16 cirrhotic patients were enrolled. Gastric secretion was assessed in all patients, but portal pressure hemodynamic studies were performed only in cirrhotic patients. We found that the median basal acid output, maximal acid output, and basal pepsin output in the controls (1.41 mmol/h, 9.2 mmol/h, and 0.02 mg/h, respectively) and in the cirrhotic patients (0.6 mmol/h, 7.84 mmol/h, and 1.5 mg/h, respectively) were not statistically different. However, maximal pepsin output was lower in the cirrhotic patients (1.5 mg/h) than in the normal subjects (5.14 mg/h) (p < 0.05). Gastric secretion correlated poorly with hepatic venous pressure gradient (HVPG) and the presence of congestive gastropathy in cirrhotic patients. The severity of congestive gastropathy correlated poorly with HVPG. Helicobacter pylori has difficulty replicating in the stomach when HVPG is > 14 mm Hg. We conclude that patients with cirrhosis have a lower maximal pepsin output than that of the healthy subjects. Gastric secretion correlates poorly with HVPG and the presence of congestive gastropathy in patients with cirrhosis.

Effect of buthionine sulfoximine, a synthesis inhibitor of the antioxidant glutathione, on the murine nigrostriatal neurons

This study analyzed the effects of acute systemic treatment with buthionine sulfoximine (BSO), a synthesis inhibitor of the antioxidant reduced glutathione (GSH), on dopaminergic neurons of the murine nigrostriatal pathway. Part 1 of the study established a dose-response curve and the temporal pattern of GSH loss and recovery in the substantia nigra and striatum following acute BSO treatment. Part 2 of the study determined the effect of acute BSO treatment on the morphology and biochemistry of nigrostriatal neurons. We found that decreases in GSH levels had profound morphological effects, including decreased catecholamine fluorescence per cell, increased levels of lipid peroxidation and lipofuscin accumulation, and increased numbers of dystrophic axons in dopaminergic neurons of the nigrostriatal pathway. However, no measurable effects were observed in biochemical levels of either dopamine or its metabolites. These changes mimic those that have been reported to occur in the nigrostriatal system of rodents with advancing age. Our data suggest that reduction of GSH via BSO treatment results in the same types of nigrostriatal degenerative effects that occur during the aging process and consequently is a good model system for examining the role of GSH in protecting this area of the brain against the harmful effects of age-related oxidative stress.

Sequential hemodynamic changes for large volume paracentesis in post-hepatitic cirrhotic patients with massive ascites

Large volume paracentesis (4.8 to 15.5 liters) was performed in 42 patients with post-hepatitic cirrhosis and massive ascites, not only to derive parameters capable of predicting the development of severe clinical hypotension after large volume paracentesis, but also to determine the optimal time to introduce preventive volume expanders. Systemic hemodynamics were sequentially measured for 72 hours in thirty-two patients. Severe clinical hypotension occurred in 13 (31.0%) patients 4-62 hours from the start of paracentesis. Univariate analysis, with the Mantel-Cox test used to compare Kaplan-Meier curves, and the subsequent multivariate analysis by stepwise Cox regression procedure were utilized to identify two variables, withdrawn ascitic fluid greater than 7.5 liters (p = 0.0121) and the absence of peripheral edema (p = 0.0148), reaching statistical significance to predict the occurrence of severe clinical hypotension. Compared to the baseline value, the cardiac output of patients not developing severe clinical hypotension increased (6.26 +/- 0.66 vs. 6.65 +/- 0.69 liter/min, p < 0.01) one hour from the start of paracentesis and right atrial pressure decreased (11.2 +/- 2.4 vs. 8.7 +/- 2.3 mmHg, p < 0.05). The cardiac output returned to the baseline value at the 9th hour. Based on the results presented herein, we can conclude that severe clinical hypotension occurs in a high percentage of patients with post-hepatitic cirrhosis and massive ascites within 72 hours from the start of large volume paracentesis. At potential risk of this occurring are those patients without peripheral edema and withdrawn ascitic fluid greater than 7.5 liters. Volume expanders should be introduced before 4th hour from the start of large volume paracentesis.

Clinical implications of the white nipple sign and its role in the diagnosis of esophageal variceal hemorrhage

OBJECTIVE

Differentiation of esophageal variceal hemorrhage from other sources of the GI tract is often difficult. This is a prospective investigation of the significance of the white nipple sign in patients with recent esophageal variceal hemorrhage.

METHODS

One hundred sixty-six patients with recent variceal hemorrhage were prospectively studied with respect to presence or absence of the white nipple sign and other stigmata of hemorrhage and compared with 100 patients with known varices but without a clinical history of bleeding.

RESULTS

The white nipple sign correlated positively with severity of bleeding (patients required more blood transfusion), hematemesis, and signs of shock. Patients with the white nipple sign also tended to undergo emergency endoscopy and have active bleeding at the time of endoscopy. There was no correlation between rebleeding rate after endoscopic therapy and presence of the white nipple sign. Appearance of the white nipple sign was closely related to the timing of endoscopy (p < 0.0001). The sensitivity and specificity of the white nipple sign in the diagnosis of esophageal variceal hemorrhage were 21 and 100%, respectively, compared with 100 and 54% for the red color sign. Furthermore, the sensitivity of the white nipple sign increased with shorter times between bleeding and endoscopy.

CONCLUSIONS

In patients with upper GI bleeding, the white nipple sign suggests that the varices bled recently and that the bleeding was severe. However, it has no predictive value for rebleeding after endoscopic therapy. Earlier endoscopy (i.e., within 24 h of bleeding) is suggested to improve the diagnostic rate of esophageal variceal hemorrhage.

Risk factor analysis of patients with chronic hepatitis C in Taiwan

BACKGROUND

Parenteral transmission is the major route for hepatitis C virus (HCV) infection. However, in western countries, 40% of patients with chronic hepatitis C have no apparent risk factor of HCV infection. This study was designed to investigate the possible risk factors of HCV transmission in chronic hepatitis C patients in Taiwan.

METHODS

One hundred and sixty-one consecutive patients with chronic hepatitis C and 161 age- and sex-matched healthy subjects were enrolled. Risk factors, including blood transfusion, injection with nondisposable needles, education status, surgery, dental procedure, tattooing, ear-piercing, sexual behavior and alcoholism, were obtained in every patient through questionnairing and interviewing.

RESULTS

Patients with chronic hepatitis C, compared with healthy controls, had significantly higher rates of previous history of blood transfusion, frequent nondisposable needle injections, and lower education status (43.5% vs. 10.6%, 19.9% vs. 6.2%, 42.2% vs. 23.0%, respectively, all p < 0.05). Univariate logistic regression analysis showed blood transfusion, frequent nondisposable needle injections and low education as significant risk factors of HCV infection (all p < 0.05). Multivariate analysis again revealed them all to be independent significant risk factors associated with HCV infection in chronic hepatitis C patients.

CONCLUSIONS

Parenteral transmission of HCV via transfusion and frequent nondisposable needle injections were the main routes of contracting HCV infection in patients with chronic hepatitis C in Taiwan. Also, people with low education ran the higher risk of transmission by HCV. Meticulous screening of the transfused blood for HCV, usage of disposable needles, and mass public education are important in our efforts to decrease chronic HCV infection in Taiwan.

Utility of lentil lectin affinity of alpha-fetoprotein in the diagnosis of hepatocellular carcinoma

AIMS/METHODS

Frozen sera obtained from 70 patients (35 with hepatocellular carcinoma and 35 with benign chronic liver disease) with serum alpha-fetoprotein > 20 ng/ml were studied to evaluate the diagnostic indices of lentil lectin affinity of alpha-fetoprotein in detecting hepatocellular carcinoma.

RESULTS

The proportion of alpha-fetoprotein-L3 was significantly higher in patients with hepatocellular carcinoma than in those with benign chronic liver disease (41.0 +/- 33.6% vs. 16.4 +/- 15.3%, p < 0.001). This difference led to a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 57, 89, 83, 67 and 73%, respectively, in detecting hepatocellular carcinoma using the proportion of alpha-fetoprotein-L3 > 35% as a parameter. Within a 1-year period, 1500 high-risk persons were collaborating, leading to 22 cases with serum total alpha-fetoprotein > 20 ng/ml. These 22 cases included six pregnant women. The parameter, alpha-fetoprotein-L3 > 35% was used along with sonography to detect hepatocellular carcinoma for the remaining 16 cases. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 75, 83, 60, 91 and 81%, respectively, by the proportion of alpha-fetoprotein-L3 > 35%; and 100, 92, 80, 100 and 94%, respectively, by sonography.

CONCLUSIONS

Lentil lectin affinity of alpha-fetoprotein provides a moderately high sensitivity and a high specificity in the detection of hepatocellular carcinoma for persons with high alpha-fetoprotein levels. It may be a useful adjuvant tool of sonography and total alpha-fetoprotein level in a mass survey of hepatocellular carcinoma for a high-risk population.

Plasma interleukin-8 levels in patients with post-hepatitic cirrhosis: relationship to severity of liver disease, portal hypertension and hyperdynamic circulation

The present study investigated plasma levels of interleukin-8 (IL-8) in patients with post-hepatitic cirrhosis and correlated it with the severity of liver diseases and haemodynamic parameters. Plasma IL-8 levels were significantly higher in 57 post-hepatitic cirrhotic patients (7.5 +/- 1.8 pg/mL; P < 0.005) than those in 41 healthy subjects (2.0 +/- 0.2 pg/mL). Elevated (> 5 pg/mL) plasma IL-8 levels were found in up to 30% of cirrhotic patients. In cirrhotic patients, plasma IL-8 levels progressively increased in relation to the severity of liver dysfunction (4.5 +/- 1.0, 4.9 +/- 1.4 and 20.5 +/- 8.3 pg/mL for Pugh's class A, B and C, respectively; P < 0.005). A significant correlation was observed between plasma IL-8 levels and serum bilirubin levels (r = 0.72; P < 0.001). There were no differences in the hepatic venous pressure gradient (15.4 +/- 1.1 vs 15.1 +/- 0.9 mmHg; P > 0.05) and systemic vascular resistance (1119 +/- 118 vs 1199 +/- 54 dyn.s/cm5; P > 0.05) between cirrhotic patients with and without elevated plasma IL-8 levels. In addition, plasma IL-8 levels did not correlate with hepatic venous pressure gradient (r = 0.26; P > 0.05) and systemic vascular resistance (r = -0.24; P > 0.05). These results demonstrate that plasma IL-8 levels are increased in patients with post-hepatitic cirrhosis. The severity of liver cirrhosis is an important factor for the occurrence of enhanced IL-8 levels. IL-8 does not play a role in the hyperdynamic circulation observed in patients with post-hepatitic cirrhosis.

Adenomyomatosis of the gallbladder

BACKGROUND

Adenomyomatosis of the gallbladder in Chinese patients has rarely been analyzed.

METHODS

The clinical, radiological and pathological features of 18 patients with histologically-proven adenomyomatosis, collected during a 5-year period, were retrospectively analyzed.

RESULTS

According to the extent and site of involvement, adenomyomatosis of the gallbladder was conventionally classified into three types: localized, generalized and segmental. In our series, the disease was localized in 17 patients (15 in the fundus and 2 in the neck), generalized in one patient and segmental in none. Only 5 patients showed sonographic features correlative to pathologic findings, and 2 of them were correctly diagnosed before operation. Only mild nonspecific abnormalities of liver function test or urine analysis were noted in some patients with gallbladder adenomyomatosis. The clinical manifestations were not related to coincidental diseases in 11 patients. All these 11 patients, with gallstone in 9 and without in 2, complained of epigastralgia, right upper quadrant abdominal pain or dyspepsia, which relieved all after cholecystectomy.

CONCLUSIONS

Some patients with adenomyomatosis may be symptomatic and relieved by cholecystectomy. In patients with adenomyomatosis of the gallbladder and right upper quadrant pain of abdomen without other explanation, cholecystectomy may be considered. Infrequent accurate diagnosis in Chinese patients calls for a high suspicion of the disease entity in clinical practice.

Early or delayed endoscopy for patients with peptic ulcer bleeding. A prospective randomized study

The benefit of early endoscopy in the management of peptic ulcer bleeding remains controversial. In this study we looked at the role of early endoscopy in bleeding peptic ulcer patients with clear, "coffee grounds," or bloody nasogastric aspirate. A consecutive series of 325 patients with peptic ulcer bleeding were included (218 patients with clear aspirate, 77 patients with coffee-grounds aspirate, and 30 patients with bloody aspirate). They were randomized to receive early endoscopy (within 12 h of arrival at the emergency room) or delayed endoscopy (12 h after arrival at the emergency room). Early endoscopy did not benefit patients with clear or coffee-grounds aspirate. However, combined with endoscopic therapy, it did significantly benefit patients with bloody aspirate in reducing the need for blood transfusion (mean, 450 ml vs. 666 ml; p < 0.001) and hospital stay (mean, 4 vs. 14.5 days, p < 0.001). Early endoscopy and endoscopic therapy are not needed in bleeding peptic ulcer patients with clear or coffee-grounds nasogastric aspirate. However, early endoscopy and endoscopic therapy benefit patients with bloody nasogastric aspirate.