Low accuracy of chromogranin A for diagnosing early-stage pancreatic neuroendocrine tumors

The aim of the present study was to evaluate the clinical utility of plasma chromogranin A (CgA) in patients diagnosed with early-stage pancreatic neuroendocrine tumors (PNETs) in terms of diagnostic value and treatment response. A total of 35 patients with PNETs were prospectively enrolled from August 2010 to April 2014. Demographic and clinicopathological data were collected, and serial plasma CgA levels were measured. Tumor responses were defined by the Response Evaluation Criteria In Solid Tumors criteria. Pearson's χ2 test was used for the analysis of the association between the plasma CgA level and various factors. Plasma CgA level was significantly associated with the size (P=0.03), metastasis (P=0.02) and tumor stage (P=0.03) of the PNETs. Using 126 U/l as the optimal cutoff value, the sensitivity and specificity were 87.5 and 81.5%, respectively. For localized tumors, the sensitivity of CgA for diagnosing PNETs was relatively low, even following a lowering of the cutoff values (29.6–51.9%). Plasma CgA level was correlated with therapeutic response in those patients with high baseline CgA levels (P=0.025), but not in the patients with low baseline CgA levels (P=0.587). In conclusion, plasma CgA level was associated with tumor size, metastasis and tumor stage in patients with PNET. For early-stage PNETs, CgA exhibited a limited role in diagnosis and treatment response evaluation in the population of the present study.

Temporal trend and risk determinants of hepatocellular carcinoma in chronic hepatitis B patients on entecavir or tenofovir

This study aimed to elucidate the temporal change and determinants for the risk of HCC in patients with chronic hepatitis B continuously receiving NUC. Through analysis of the national healthcare database in Taiwan, we screened a total of 65 426 infected patients receiving entecavir or tenofovir for at least 3 months and excluded those with lamivudine, adefovir or telbivudine exposure, malignancy, end-stage renal failure or a diagnosis of HCC within 3 months of starting treatment. Eligible patients (N = 27 820) were followed until HCC occurrence, completion of the allowed 3-year regimen or 31 December 2013. During a median follow-up of 25.1 (12.1-35.6) months, 802 patients developed HCC, with 1-, 2- and 3-year cumulative incidence of 1.82% (95% CI, 1.66-1.99%), 3.05% (95% CI, 2.82-3.28%) and 4.06% (95% CI, 3.77-4.36%), respectively. HCC annual incidence decreased with an adjusted IRR of 0.73 (95% CI, 0.66-0.80) per yearly interval and was associated with cirrhosis (IRR, 10.07; 95% CI, 6.00-16.90 in age <40 years; 4.69; 95% CI, 3.94-5.59 in age ≧40 years), age (IRR, 3.38; 95% CI, 2.10-5.47 for 40-50 years; 6.92; 95% CI, 4.27-11.21 for 50-60 years; 12.50; 95% CI, 7.71-20.25 for ≧60 years; <40 years as reference), male sex (IRR, 1.71; 95% CI, 1.44-2.04), HCV coinfection (IRR, 1.27; 95% CI, 1.02-1.58) and diabetes (IRR, 1.24; 95% CI, 1.05-1.45). In conclusion, the risk of HCC in patients with chronic hepatitis B receiving entecavir or tenofovir declines over time and is determined by cirrhosis, age, male sex, HCV coinfection and diabetes.

Correction: Role of computed tomography angiography on the management of overt obscure gastrointestinal bleeding

[This corrects the article DOI: 10.1371/journal.pone.0172754.].

Low disabled-2 expression promotes tumor progression and determines poor survival and high recurrence of esophageal squamous cell carcinoma

Patients with esophageal squamous cell carcinomas (ESCCs) have poor survival and high recurrence rate, but lack a prognostic biomarker. Disabled-2 (DAB2) is a crucial tumor suppressor, but its roles in ESCCs are uncertain. We investigated whether low DAB2 expression in ESCCs could lead into tumor progression and poor prognosis. Our results found patients with low-DAB2 expression ESCCs had significantly larger tumor size, deeper tumor invasion depth, lymph node metastasis, worse survival, and higher recurrence rate (P<0.05). The Cox-regression model revealed low-DAB2 expression was an independent factor of poor survival (P<0.05), and also of tumor recurrence with the predictive performance superior to clinical TNM stage (P<0.05). Low-DAB2 cancer cells, validated by DAB2 knockdown or over-expression, had higher phosphorylated ERK and migration abilities, which could be suppressed by ERK inhibitor treatment. TGF-β-induced epithelial-to-mesenchymal transition (EMT) only existed in the high-DAB2 cells, and related to worse prognosis of high-DAB2 ESCCs (P<0.05). In conclusion, DAB2 can suppress the ERK signaling, but correlate to have TGF-β-induced EMT in ESCCs. DAB2 expression could be a biomarker to identify patients with worse survival and high recurrence. Our data suggest DAB2 expression can stratify patients in need of aggressive surveillance and with possible benefit from anti-ERK or anti-TGF-β therapies.

First-line Helicobacter pylori eradication therapies in countries with high and low clarithromycin resistance: a systematic review and network meta-analysis

OBJECTIVE

To determine the optimal regimen of different first-line Helicobacter pylori eradication therapies according to the clarithromycin resistance rate.

DESIGN

Electronic search for articles published between January 2005 and April 2016. Randomised, controlled trials that reported the effectiveness of first-line eradication therapies in treatment-naïve adults were included. Two independent reviewers performed articles screening and data extraction. Network and traditional meta-analyses were conducted using the random effect model. Subgroup analyses were performed to determine the ranking of regimens in countries with high (>15%) and low (<15%) clarithromycin resistance. Data including adverse events and therapeutic cure rate were also extracted and analysed.

RESULTS

117 trials (totally 32 852 patients) for 17 H. pylori eradication regimens were eligible for inclusion. Compared with 7-day clarithromycin-based triple therapy, sequential therapy (ST) for 14 days had the highest effectiveness (OR=3.74, 95% CrI 2.37 to 5.96). ST-14 (OR=6.53, 95% CrI 3.23 to 13.63) and hybrid therapy (HY) for 10 days or more (OR=2.85, 95% CrI 1.58 to 5.37) represented the most effective regimen in areas with high and low clarithromycin resistance, respectively. The effectiveness of standard triple therapy was below therapeutic eradication rate in most of the countries. Longer duration was associated with higher eradication rate, but with a higher risk of events that lead to discontinuation.

CONCLUSIONS

ST and HY appeared to be the most effective therapies in countries with high and low clarithromycin resistance, respectively. The clinical decision for optimal regimen can be supported by referring to the rank ordering of relative efficacies stratified by local eradication rates, antibiotic resistance and safety profile.

TRIAL REGISTRATION NUMBER

CRD42015025445.

Prior gastroscopy and mortality in patients with gastric cancer: a matched retrospective cohort study

BACKGROUND AND AIMS

The role of prior gastroscopy on the outcome of patients with gastric cancer remains unknown. This study determines the association between intervals of prior gastroscopy and mortality in patients with gastric cancer.

METHODS

We identified 20,066 newly diagnosed patients with gastric cancer in the National Health Insurance Database of Taiwan between 2002 and 2007. After we excluded patients who had gastroscopies performed ≤6 months before the diagnosis of cancer, patients were matched into 3 cohorts according to the intervals of prior gastroscopy: 6 months to 2 years (<2 Y cohort), 2 to 5 years (2-5 Y cohort), and none within the previous 5 years (>5 Y cohort). The 3 cohorts were matched for age, curative treatment for gastric cancer, Helicobacter pylori therapy, and propensity scores comprised of sex, comorbidities, and concomitant medication usage. The primary outcome is the hazard ratio (HR) of all-cause mortality.

RESULTS

After matching, we identified 1286, 1286, and 5144 patients for the <2 Y, 2 to 5 Y, and >5 Y cohorts. Compared with the >5 Y cohort, the HR of all-cause mortality for the <2 Y and 2 to 5 Y cohorts was 0.80 (95% confidence interval [CI], 0.72-0.89; P < .001) and 0.83 (95% CI, 0.76-0.91; P < .001), respectively. The HRs of gastric cancer-specific mortality were significantly lower in the <2 Y (0.80; 95% CI, 0.71-0.91; P < .001) and 2 to 5 Y cohorts (0.83; 95% CI, 0.75-0.93; P < .001).

CONCLUSIONS

Patients with gastric cancer who had a gastroscopy performed within 5 years before the cancer diagnosis had significantly lower mortality. Our results may support the role of repeat endoscopic examination or surveillance endoscopy in selected patients.

Quantification of serum hepatitis B core antibody to predict off-entecavir relapse in patients with chronic hepatitis B

BACKGROUND/PURPOSE

The predictors of off-therapy response in patients treated with neucleos(t)ide analogue (NA) have not been elucidated. It remained unexplored whether serum level of hepatitis B core antibody (anti-HBc) at the end of NA therapy was associated with relapse risks.

METHODS

This prospective study monitored 82 chronic hepatitis B (CHB) patients after discontinuing entecavir. All patients had been treated for 3 years or longer and serologically negative for viral DNA and HBeAg at treatment cessation. Patients were monitored for virological relapse (viral DNA > 2000 IU/mL), and clinical relapse (serum alanine aminotransferase > 80 U/L plus virological relapse). The association between anti-HBc levels and the risk of relapse was assessed by the Cox analysis.

RESULTS

Clinical and virological relapses occurred in 29 and 60 participants, respectively, with the cumulative incidences of 23.7% (95% CI, 15.8-34.6%) and 62.0% (95% CI, 51.5-72.5%) at 1 year, and 36.2% (95% CI, 26.2-48.4%) and 78.8% (95% CI, 68.2-87.8%) at 2 years, respectively. There was a trend for an inverse association between anti-HBc and clinical relapse (crude hazard ratio [HR], 0.50; 95% CI, 0.24-1.05). All 3 patients with the level <100 IU/mL had a rapid clinical relapse (P = 0.002). This trend remained after adjustment for HBsAg and age (adjusted HR 0.50, 95% CI, 0.24-1.03). On the other hand, anti-HBc quantity was unrelated to virological relapse (crude HR, 0.97; 95% CI, 0.58-1.62; adjusted HR, 0.97; 95% CI, 0.58-1.60).

CONCLUSION

This pilot study suggests a trend for an inverse association between anti-HBc levels and clinical relapse in CHB patients off entecavir.

Time-varying serum gradient of hepatitis B surface antigen predicts risk of relapses after off-NA therapy

Background

The serum gradient of hepatitis B surface antigen (HBsAg) varies over time after cessation of nucleos(t)ide analog (NA) treatment in patients with chronic hepatitis B (CHB). The association between the time-varying HBsAg serum gradient and risk of relapse has not been elucidated.

Methods

This multicenter cohort study prospectively enrolled CHB patients who discontinued 3 year-NA treatment. Eligible patients were serologically negative for HBeAg and viral DNA at NA cessation. The participants (n = 140) were followed every 3 months through HBsAg quantification. Virological and clinical relapses were defined as viral DNA levels >2000 IU/mL and alanine aminotransferase (ALT) levels >80 U/mL, respectively. The association of time-varying HBsAg levels with relapses was assessed through a time-dependent Cox analysis.

Results

During a median follow-up of 19.9 (interquartile range [IQR], 10.6–25.3) months, virological and clinical relapses occurred in 94 and 49 patients, with a 2-year cumulative incidence of 79.2% (95% confidence interval [CI], 70.9%–86.4%) and 42.9% (95% CI, 34.1%–52.8%), respectively. The serum level of HBsAg was associated with virological (P < 0.001) and clinical (P = 0.01) relapses in a dose–response manner, with adjusted hazard ratios of 2.10 (95% CI, 1.45–3.04) and 2.32 (95% CI, 1.28–4.21). Among the patients (n = 19) whose HBsAg levels ever dropped below 10 IU/mL, only one and three patients subsequently developed clinical and virological relapses.

Conclusion

The serum gradient of HBsAg measured throughout the off-therapy observation is associated with the subsequent occurrence of virological and clinical relapses in CHB patients who discontinue NA treatment.

[The relationship between smoking status and epidermiology of asthma in people aged over 14 years in China]

Objective: To study the relationship between bronchial asthma and smoking status in Chinese people. Methods: Asthma epidemiological survey and stratified-cluster-random method survey were performed in residents over 14 years in 8 provinces (cities) of China from February 2010 to August 2012. Asthma was diagnosed based upon case history, clinical signs and lung function test. Smoking status was investigated by questionnaire. Results: Sampling population was 180 099 and 164 215 were valid. A total of 2 034 subjects were diagnosed as asthma including 79 692 men and 84 523 women. The overall prevalence rate of asthma was 1.24% (2 034/164 215). Smokers were 23.8% (39 137/164 215) in the whole population. Smokers were 34.5% (702/2 034) in asthmatic patients, compared with 23.7% (38 435/162 181) in no-asthmatic population. The incidence of asthma was 1.79% and 1.06% in smokers and non-smokers respectively (P<0.001), suggesting that OR of smoking was 1.70 (95% CI 1.55-1.86, P<0.001). According to asthma control test (ACT) score, the level of asthma control in non smoking group was higher than that in smoking group(43.2% vs 35.3%). The times of hospitalization due to acute exacerbations(0.51 vs 0.41 events/person/year), total hospitalization rate(27.35% vs 20.12%), annual emergency room visits (0.80 vs 0.60 events/person/year) and emergency room visit rate (31.77% vs 24.47%) were all much higher in smoking asthmatic patients than those in non smoking asthmatic patients, indicating that the level of asthma control in smoking patients was significantly worse than in non smoking patients. Conclusions: The smoking rate in Chinese people over 14 years is still high. The prevalence rate of asthma in smokers is significantly higher than that of non-smokers. The level of asthma control in smokers is significantly worse than that in non smokers.

[Analysis of short-term respiratory adverse events in 183 bronchial thermoplasty procedures]

Objective: To analyze the short-term (3 weeks) adverse respiratory events after bronchial thermoplasty(BT) in patients with severe asthma. Methods: The China-Japan Friendship Hospital recruited 62 patients with severe asthma for BT treatment from March 2014 to July 2016, with a total of 183 BT procedures. The data of adverse respiratory events within 3 weeks after procedure were collected to analyze the factors that might potentially influence the occurrence of adverse events. Results: Forty-three patients (69.4%) experienced adverse respiratory events within 3 weeks after treatment. Totally 153 adverse respiratory events occurred after 87 procedures(47.5%). The main adverse events were cough (15 events, 8.20%), sputum production (37 events, 20.22%), temporary PEF reduction (37 events, 20.22%), chest distress (12 events, 6.56%), blood in sputum (11 events, 6.01%), asthma exacerbation (10 events, 5.46%), and pneumonia(6 events, 3.28%). Most events were relieved or resolved with standard therapy in 1 week. No severe adverse events including tracheal intubation, malignant arrhythmias or death occurred within 3 weeks after procedure. The baseline eosinophil percentage in induced sputum and blood, operation times, and preoperative FEV(1) (% predicted) might influence the occurrence of adverse events after treatment. Patients with preoperative FEV(1) (% predicted) ≥60% had lower risk of adverse events. Conclusion: BT showed a good security profile in treating patients with severe asthma within 3 weeks after procedure.

[Chinese expert consensus for non-antiinfective effects and clinical use of macrolides]

Important/potential value of macrolides has been proved in the management of chronic respiratory diseases by increasing basic and clinical trials.Through three face-to-face discussions, 10 experts examined important data and drafted this consensus related to macrolides: (1) mechanism of non-antiinfective effects; (2) clinical use in chronic respiratory diseases; (3) cautions of long-term use.The mechanism out of non-antiinfective effects includes anti-inflammatory effect, modifying airway secretion, immune-regulation related to antibacterial effect, corticoid saving effect and anti-viral effect.The efficacy of long-term use of low-dose macrolides is definitely confirmed in diffuse panbronchiolitis, chronic rhinosinusitis. It is considerably used in bronchiectasia, cystic fibrosis, severe asthma and chronic obstructive pulmonary disease. Further studies should be conducted in cryptogenic organizing pneumonia and respiratory viral infection. It should be paid attention to its possible adverse effects (including drug interactions, cardiac toxicity, ototoxicity and disturbance of intestinal flora) and drug resistance in long-term use.A Chinese consensus for non-antiinfective effects and clinical use of macrolides is developed for the first time, which aims to expand their rational use and the further research.

Primary antibiotic resistance in Helicobacter pylori in the Asia-Pacific region: a systematic review and meta-analysis

BACKGROUND

So far, a comprehensive systematic review and meta-analysis has not been done of the prevalence of primary antibiotic resistance in Helicobacter pylori in the Asia-Pacific region. We aimed to assess the trends and regional differences in primary antibiotic resistance to H pylori in the Asia-Pacific region and to examine the relation between resistance and first-line eradication.

METHODS

We did a systematic review and meta-analysis of primary antibiotic resistance to H pylori and the efficacy of first-line regimens in the Asia-Pacific region. We searched PubMed, Embase, and the Cochrane Library for articles published between Jan 1, 1990, and Sept 30, 2016; we also searched abstracts from international conferences. Both observational studies and randomised controlled trials were eligible for inclusion in the analysis of primary antibiotic resistance, but only randomised controlled trials were eligible for inclusion in the analysis of efficacy of first-line therapies. Meta-analysis was by the random-effects model to account for the substantial variations in resistance across the region. We did subgroup analyses by country and study period (ie, before 2000, 2001-05, 2006-10, and 2011-15) to establish country-specific prevalences of primary antibiotic resistance and first-line eradication rates. This study is registered with PROSPERO, number CRD42017057905.

FINDINGS

176 articles from 24 countries were included in our analysis of antibiotic resistance. The overall mean prevalences of primary H pylori resistance were 17% (95% CI 15-18) for clarithromycin, 44% (95% CI 39-48) for metronidazole, 18% (95% CI 15-22) for levofloxacin, 3% (95% CI 2-5) for amoxicillin, and 4% (95% CI 2-5) for tetracycline. Prevalence of resistance to clarithromycin and levofloxacin rose significantly over time during the period investigated, whereas resistance to other antibiotics remained stable. 170 articles from 16 countries were included in analysis of efficacy of first-line therapies. We noted unsatisfactory efficacy (ie, <80%) with clarithromycin-containing regimens in countries where the clarithromycin resistance rates were higher than 20%.

INTERPRETATION

The prevalence of primary antibiotic resistance varied greatly among countries in the Asia-Pacific region, and thus treatment strategy should be adapted relative to country-specific resistance patterns. Clarithromycin-containing regimens should be avoided in countries where the prevalence of clarithromycin resistance is higher than 20%.

FUNDING

Ministry of Health and Welfare of Taiwan, Ministry of Science and Technology of Taiwan, and Amity University.

Serum viral load at the virological relapse predicts subsequent clinical flares in chronic hepatitis B patients off entecavir therapy

BACKGROUND AND AIM

Therapeutic duration of nucleos(t)ide analogues for chronic hepatitis B (CHB) is not indefinite in many parts of the world. Viral reactivation is common off therapy, but the risk of subsequent clinical outcome remains unclear and unpredictable. We aimed to quantify the incidence of and explore the predictors for clinical flare following virological relapse in CHB patients who discontinue entecavir therapy.

METHODS

This multicenter cohort study prospectively monitored 133 CHB patients who were HBeAg-negative and viral DNA-undetectable when discontinuing entecavir after at least 3 years on therapy. Following virological relapse (viral DNA >2,000 IU/mL) that occurred in 92 patients, the incidences of subsequent clinical flare and persistent (unremittent for 3 months) or severe hepatitis (with jaundice or coagulopathy) were determined, and risk factors were explored. Patients did not resume antiviral therapy until occurrence of persistent or severe hepatitis.

RESULTS

The cumulative incidence of clinical hepatitis 2 years after virological relapse was 61.0% (95% confidence interval [CI], 49.9-72.3%) and that of persistent or severe hepatitis was 53.0% (95% CI, 40.9-66.2%). Serum viral load at the virological relapse was associated with both clinical hepatitis (adjusted hazard ratio [HR], 1.31 per log IU/mL; 95% CI, 1.07-1.60) and persistent or severe hepatitis (adjusted HR, 1.63 per log IU/mL; 95% CI, 1.27-2.10), after adjustment for serum aminotransferase and alfa-fetoprotein levels in the multivariate analysis. Viral DNA >100 000 IU/mL predicted a nearly inevitable occurrence of clinical flare (P < 0.0001).

CONCLUSIONS

A high viral load at the virological relapse predicts subsequent clinical hepatitis in CHB patients who discontinue entecavir.

[A cross-section study of severe asthma in eight provinces of China]

Objective: To analyze the prevalence of severe asthmain China. Methods: The epidemiological data was collected from 2 034 asthmatics who were diagnosed in the last epidemiological survey from 2009 to 2010 in 8 provinces. Results: According to the questionnaire survey, among the 2 034 patients, the previously diagnosed patients accounted for 72.47% (1 474/2 034) and the percentage of newly-diagnosed patients was 27.53% (560/2 034). In those 1 474 previously diagnosed asthmatics, 122 (8.28%) were classified into severe asthma, while 6.00% (122/2 034) of all asthmatics and 0.07% (122/164 215) of total respondents presented as severe cases. Statistically, there was no difference in the prevalence of severe patients between men and women. The morbidity rate of severe asthma was the lowest in the 21-30 year old group and the highest in 61-70 year old group (0.85% and 8.31% respectively). The difference among ages was statistically significant (χ²=18.791, P=0.005). In addition, the prevalence rates of severe asthma were also significantly diverged among patients with different education background(χ²=24.639, P<0.000 1). A negative relation was found between education level and the proportion of severe cases. Moreover, the morbidity of severe asthma in smoking patients and non-smoking patients were significantly different as well (χ²=7.447, P<0.05). Compared with asthma patients who do not smoke, smokers were more likely to suffer severe asthma (OR=1.663, 95% CI 1.150-2.404). Conclusions: The prevalence rate of severe asthma in China is similar to that in other countries.Elderly patients have higher risk of severe asthma. Smoking is considered as a risk factor for severe asthma.

Screening and treating Helicobacter pylori infection for gastric cancer prevention on the population level

Helicobacter pylori infection is the major cause of gastric cancer, and removal of H. pylori infection from a population could theoretically decrease the number of cases by about 89%. However, in real-life settings, few studies have reported the effect of screening and treating this pathogen in population-based programs. This is mainly because of the lack of an adequate infrastructure for delivery of systematic screening services to asymptomatic individuals, the lack of standardization to ensure that each subject receives the correct diagnostic testing and antibiotic treatment, and limited resources. We illustrate our method of implementing two population-based screen-and-treat programs in Taiwan, where the epidemiological characteristics of disease burden have changed from the traditionally Eastern pattern towards that of the Western countries. Our first example is a high-risk population that resides on an offshore island, in which a strategy of mass eradication of H. pylori was applied. The other example is an intermediate-risk population, which is representative of the general average-risk population, in which there is integration of the screen-and-treat method with the established framework of colorectal cancer screening using the fecal-occult blood test. The information provided here may be useful for integration of gastric cancer prevention measures into the healthcare priorities of populations with different gastric cancer risks, such as those with limited resources.

Role of computed tomography angiography on the management of overt obscure gastrointestinal bleeding

Background and aim

The role of computed tomography angiography (CTA) on the management of acute overt obscure gastrointestinal bleeding (OGIB) remains unclear. We designed a study to evaluate the impact of CTA before enteroscopy for acute overt OGIB.

Methods

All patients undergoing CTA followed by enteroscopy for acute overt OGIB were enrolled in this retrospective study. Clinical characteristics and diagnosis were compared between patients with positive and negative CTA findings. We evaluated the impact of CTA on subsequent enteroscopy.

Results

From February 2008 to March 2015, 71 patients including 25 patients with positive CTA findings and 46 patients with negative CTA findings, were enrolled. All 25 patients with positive CTA findings were confirmed to have mid GI lesions, a significantly higher proportion than among patients with negative CTA findings (100% vs. 52.2%, respectively; P <0.001). CTA had a higher diagnostic yield for bleeding from tumor origin than from non-tumor origin (80.0% vs. 23.7%, respectively; P <0.001). The diagnostic yield of CTA and enteroscopy was 35.2% and 73.2%, respectively. The lesions could be identified by the initial route of enteroscopy in more patients with positive CTA findings than in those with negative CTA findings (92.0% vs. 47.8%, respectively; P <0.001). Lesions could be identified in seven of the 25 patients (28.0%) with positive CTA findings by using only push enteroscopy instead of single-balloon enteroscopy (SBE), but all 46 patients with negative CTA findings needed SBE for deep small-bowel examination.

Conclusions

CTA is useful in the diagnosis of acute overt OGIB, especially in patients with bleeding from tumors. In addition, it also can show the precise location of bleeding, and guide subsequent enteroscopic management.

Distinct Clinicopathological Features and Prognosis of Helicobacter pylori Negative Gastric Cancer

Background

Whether the characteristics and prognosis of gastric cancer (GC) are different in patients with and without Helicobacter pylori (HP) remains controversial. The definitions of HP status in patients with atrophic gastritis but negative tests for HP are heterogeneous. We aimed to assess the impact of HP on the prognosis of GC using different definitions.

Methods

From 1998 Nov to 2011 Jul, five hundred and sixty-seven consecutive patients with GC were included. HP status was determined by serology and histology. Patients with any positive test were defined as HP infection. Patients without HP infection whose serum pepsinogen (PG) I <70 ng/dl and PG I/II ratio < 3.0 were defined as atrophic gastritis and they were categorized into model 1: HP positive; model 2: HP negative; and model 3: exclusion of these patients.

Results

We found four characteristics of HP negative GC in comparison to HP positive GC: (1) higher proportion of the proximal tumor location (24.0%, P = 0.004), (2) more diffuse histologic type (56.1%, p = 0.008), (3) younger disease onset (58.02 years, p = 0.008) and (4) more stage IV disease (40.6%, p = 0.03). Patients with negative HP had worse overall survival (24.0% vs. 35.8%, p = 0.035). In Cox regression models, the negative HP status is an independent poor prognostic factor (HR: 1.34, CI:1.04–1.71, p = 0.019) in model 1, especially in stage I, II and III patients (HR: 1.62; CI:1.05–2.51,p = 0.026).

Conclusion

We found the distinct characteristics of HP negative GC. The prognosis of HP negative GC was poor.

A case series on the use of circumferential radiofrequency ablation for early esophageal squamous neoplasias in patients with esophageal varices

BACKGROUND AND AIMS

Endoscopic radiofrequency ablation (RFA) is a rapidly evolving therapeutic modality for early esophageal squamous cell neoplasias (ESCNs). However, the feasibility of RFA for ESCNs in the setting of esophageal varices has not been reported.

METHODS

We retrospectively enrolled 8 consecutive patients with cirrhosis (Child-Pugh score ≤6) with early flat-type ESCNs (high-grade intraepithelial neoplasia/intramucosal cancer, and Lugol unstained lesion [USL] length ≥3 cm extending ≥1/2 the circumference) on or adjacent to esophageal varices, for which circumferential RFA was applied as the initial treatment. The primary endpoint was a complete response at 12 months, and the secondary endpoints were adverse events and procedure-related mortality.

RESULTS

The mean USL length was 5.3 cm (range, 3-10 cm), and the average length of the treatment area was 7.5 cm (range, 5-12 cm), with an average procedure time of 31.9 min (range, 25-40 min). After circumferential RFA, 3 adverse events were recorded, including 2 intramucosal hematomas and 1 mucosal laceration, all of which spontaneously resolved without further management. No massive bleeding, perforation, stricture, or hepatic failure occurred after the procedure. Six of the 8 patients achieved a complete response after single circumferential RFA, but 2 had residual squamous neoplasias. After additional focal-type RFA treatment, all achieved a complete response at 12 months. No neoplastic progression or recurrence occurred during a median follow-up period of 21.6 months (range, 13-42 months).

CONCLUSIONS

RFA was associated with good treatment results, no neoplastic progression, and an acceptable adverse event profile for the treatment of early ESCNs in patients with well-compensated cirrhosis and esophageal varices.

Central Obesity and H. pylori Infection Influence Risk of Barrett's Esophagus in an Asian Population

Background and Aim

The prevalence rates of Barrett’s esophagus (BE) in western countries are higher than Asian ones, but little is known about their difference among risk factors of BE. The aim of this study is to investigate the associations of various risk factors including central obesity, body mass index (BMI), metabolic syndrome and H. pylori infection, with BE.

Methods

A total of 161 subjects with BE were enrolled and compared to age- and gender-matched controls randomly sampled (1:4) from check-up center in same hospital. Central obesity was defined by waist circumference (female>80cm; male>90cm), metabolic syndrome by the modified National Cholesterol Education Program Adult Treatment Panel III criteria in Taiwan. Independent risk factors for BE were identified by multiple logistic regression analyses.

Results

The mean age for BE was 53.8±13.7 years and 75.8% was male. H. pylori infection status was detected by the rapid urease test with the prevalence of 28.4% and 44.4% in the BE patients and controls, respectively. The univariate logistic regression analyses showed the risk was associated with higher waist circumference (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.78–3.60), metabolic syndrome (OR, 2.02; 95% CI, 1.38–2.96) and negative H. pylori infection (OR, 0.50; 95% CI, 0.34–0.74). However, multivariate logistic regression analyses revealed that BE associated with higher waist circumference (adjusted OR, 2.79; 95% CI, 1.89–4.12) and negative H. pylori infection (adjusted OR, 0.46; 95% CI, 0.30–0.70).

Conclusions

Central obesity is associated with a higher risk of BE whereas H. pylori infection with a lower risk in an ethnic Chinese population.

Treatment of Helicobacter pylori infection: Where are we now?

Gastric cancer and Helicobacter pylori infection remain a burden in many Asian countries. In the face of rising antibiotic resistance, the eradication rate of standard triple therapy is declining in many Asian countries. We reviewed the updated epidemiology of gastric cancer, prevalence of H. pylori infection, and antibiotic resistance in Asia. We also reviewed the strategies to improve the efficacy of H. pylori eradication therapies, including the use of high dose proton pump inhibitor, four drug therapies (including bismuth quadruple, concomitant, and sequential therapy), susceptibility guided therapy, extending the treatment duration to 14 days, and development of effective rescue therapy. Four drug therapies are usually more effective than triple therapy when given in the same duration, except in areas with concomitantly high metronidazole resistance and low clarithromycin resistance. The efficacies of different four drug regimens appeared to be similar. However, trials from different geographic areas showed contradictory results, indicating that the optimal therapy should be decided according to the local prevalence of antibiotic resistance. We proposed a prediction model to calculate the efficacy of different regimens according to the prevalence of antibiotic resistance. More large randomized trials which provide information on the antibiotic resistance are urgently needed to build a more accurate and reliable model. It is hoped that we will be able to decide the optimal regimens by routine surveillance of antibiotic resistance.