Clinical Trial: Efficacy of Mosapride Controlled-release and Nortriptyline in Patients With Functional Dyspepsia: A Multicenter, Double-placebo, Double-blinded, Randomized Controlled, Parallel Clinical Study

Background/Aims

Prokinetic agents and neuromodulators are among the treatment options for functional dyspepsia (FD), but their comparative efficacy is unclear. We aimed to compare the efficacy of mosapride controlled-release (CR) and nortriptyline in patients with FD after 4 weeks of treatment.

Methods

Participants with FD were randomly assigned (1:1) to receive mosapride CR (mosapride CR 15 mg and nortriptyline placebo) or nortriptyline (mosapride CR placebo and nortriptyline 10 mg) in double-placebo, double-blinded, randomized controlled, parallel clinical study. The primary endpoint was defined as the proportion of patients with overall dyspepsia improvement after 4 weeks treatment. The secondary endpoints were changes in individual symptom scores, anxiety, depression, and quality of life.

Results

One hundred nine participants were recruited and assessed for eligibility, and 54 in the mosapride CR group and 50 in the nortriptyline group were included in the modified intention-to-treat protocol. The rate of overall dyspepsia improvement was similar between groups (53.7% vs 54.0%, P = 0.976). There was no difference in the efficacy of mosapride CR and nortriptyline in a subgroup analysis by FD subtype (59.3% vs 52.5% in postprandial distress syndrome, P = 0.615; 44.4% vs 40.0% in epigastric pain syndrome, P = > 0.999; 50.0% vs 59.1% in overlap, P = 0.565; respectively). Both treatments significantly improved anxiety, depression, and quality of life from baseline.

Conclusion

Mosapride CR and nortriptyline showed similar efficacy in patients with FD regardless of the subtype. Both treatments could be equally helpful for improving quality of life and psychological well-being while also relieving dyspepsia.

2022 Seoul Consensus on Clinical Practice Guidelines for Functional Constipation

Chronic constipation is one of the most common digestive diseases encountered in clinical practice. Constipation manifests as a variety of symptoms, such as infrequent bowel movements, hard stools, feeling of incomplete evacuation, straining at defecation, a sense of anorectal blockage during defecation, and use of digital maneuvers to assist defecation. During the diagnosis of chronic constipation, the Bristol Stool Form Scale, colonoscopy, and a digital rectal examination are useful for objective symptom evaluation and differential diagnosis of secondary constipation. Physiological tests for functional constipation have complementary roles and are recommended for patients who have failed to respond to treatment with available laxatives and those who are strongly suspected of having a defecatory disorder. As new evidence on the diagnosis and management of functional constipation emerged, the need to revise the previous guideline was suggested. Therefore, these evidence-based guidelines have proposed recommendations developed using a systematic review and meta-analysis of the treatment options available for functional constipation. The benefits and cautions of new pharmacological agents (such as lubiprostone and linaclotide) and conventional laxatives have been described through a meta-analysis. The guidelines consist of 34 recommendations, including 3 concerning the definition and epidemiology of functional constipation, 9 regarding diagnoses, and 22 regarding managements. Clinicians (including primary physicians, general health professionals, medical students, residents, and other healthcare professionals) and patients can refer to these guidelines to make informed decisions regarding the management of functional constipation.

Eosinophil and Mast Cell Counts in the Stomach and Duodenum of Patients with Functional Dyspepsia without a Helicobacter pylori infection

BACKGROUND/AIMS

Symptom-based subtyping of functional dyspepsia (FD) is used to segregate patients into groups with homogenous pathophysiological mechanisms. This study examined whether subtyping could reflect the duodenal and gastric microinflammation in FD patients.

METHODS

Twenty-one FD patients without Helicobacter pylori infection were recruited. An endoscopic biopsy was performed in the duodenum 2nd portion, stomach antrum, and body. The eosinophil and mast cell counts per high-power field (×40) were investigated by H&E and c-kit staining, respectively. The degree of inflammatory cell infiltration, atrophy, and intestinal metaplasia was also determined by H&E staining in the stomach. The baseline characteristics and eosinophil and mast cell infiltrations were compared among the three groups (epigastric pain syndrome, postprandial distress syndrome, and overlap).

RESULTS

According to the symptom assessment, seven subjects were classified into the epigastric pain syndrome group, 10 into the postprandial syndrome group, and four into the overlap group. The baseline variables were similar in the three groups. Eosinophil infiltration was more prominent in the duodenum than in the stomach. In contrast, mast cell infiltration was similar in the duodenum and stomach. The eosinophil counts in the duodenum were similar in the three groups. The eosinophil counts in the stomach and mast cell counts in the duodenum and stomach were also similar in the three groups.

CONCLUSIONS

Duodenal eosinophil infiltration was prominent in FD patients, but the eosinophil counts were similar regardless of the symptom-based subtypes of FD. Hence, the current symptom-based subtyping of FD does not reflect duodenal eosinophil and mast cell infiltration.

Antispasmodics

Antispasmodics are effective in reducing abdominal pain associated with visceral organs, bloating, and bowel habit changes and are commonly used as “on-demand therapy.” A relatively regular intake of antispasmodics may help patients with functional gastrointestinal disease exacerbation. Irritable bowel syndrome and functional dyspepsia are representative functional gastrointestinal diseases with abdominal pain and bloating as the main symptoms. Most of the clinical data on antispasmodics are obtained from studies on functional gastrointestinal diseases including irritable bowel syndrome. Antispasmodics can be safely used for prolonged periods without serious adverse effects; however, different antispasmodics have different anticholinergic potencies. Antispasmodics with strong anticholinergic effects should be prescribed with caution to patients with glaucoma or prostatic hypertrophy-induced dysuria and to those driving vehicles, operating machinery, or receiving other anticholinergic drugs in combination. Antispasmodics meeting US Food and Drug Administration guidelines for efficacy, those showing relatively consistent efficacy in different trials, and those with prokinetic effects are currently available. Many patients with upper gastrointestinal symptoms have overlapping functional gastrointestinal disorders and may require antispasmodic drugs. Alternatively, tricyclic antidepressant or ramosetron use can be considered in patients with irritable bowel syndrome. This review summarizes the clinical data and characteristics of antispasmodics, particularly those available in South Korea.

Development and Validity Assessment of a Self-evaluation Questionnaire for Functional Dyspepsia: A Multicenter Prospective Study in Korea

Background/Aims

Patient-reported outcomes (PROs) are essential for clinical decision making, conduction of clinical research, and drug application acquisition in functional gastrointestinal disorders. The aim of this study is to develop a PRO instrument and to determine the respondents’ perception of the efficacy of therapeutic agents for functional dyspepsia (FD).

Methods

A self-evaluation questionnaire for dyspepsia (SEQ-DYSPEPSIA) was developed and validated through a structured process. The 2-week reproducibility was evaluated, and the construct validity was assessed by correlating the scores of SEQ-DYSPEPSIA (including typical and major FD symptom subscales). Finally, the response to medication was assessed by comparing the changes after 4 weeks of treatment.

Results

A total of 193 Korean patients (age 48.5 ± 13.6 years, 69.4% women) completed the questionnaire. SEQ-DYSPEPSIA with 11 items had a good internal consistency (alpha = 0.770-0.905) and an acceptable test-retest reliability (intraclass correlation coefficient = 0.733-0.859). The self-evaluation questionnaire (SEQ)-major FD score highly correlated with the postprandial fullness/early satiety domain of the Patient Assessment of Gastrointestinal Symptom Severity Index (correlation coefficient r = 0.741, P < 0.001), Nepean Dyspepsia Index-Korean version (NDI-K) (r = 0.839, P < 0.001), and NDI-K quality of life (r = −0.275 to −0.344, P < 0.001). After medical treatment, decrease in the SEQ-typical FD and SEQ-major FD was significantly greater in the responder group than in non-responder group (P = 0.019 and P = 0.009, respectively).

Conclusion

This study suggests that the Korean version of SEQ-DYSPEPSIA has good reliability and validity, and can be a useful PRO measurement tool in patients with FD.

Colonic Chicken Skin Mucosa Surrounding Colon Polyps Is an Endoscopic Predictive Marker for Colonic Neoplastic Polyps

Background/Aims

Narrow band imaging provides an accurate diagnosis of colonic polyps. However, these diagnostic modalities are not used as standard endoscopic tools in most institutions. This study aims to investigate whether the chicken skin mucosa (CSM) surrounding the colon polyp yields additional information about colorectal polyps, including histological differentiation of neoplastic and non-neoplastic polyps, under conventional white light colonoscopy.

Methods

This study prospectively observed 173 patients who underwent endoscopic polypectomy and reviewed the clinical data and pathologic reports of 313 polyps from a university hospital. Two endoscopists each performed colonoscopy and polypectomy and assessed the CSM. The association between CSM surrounding colorectal polyps and histology was analyzed.

Results

The majority (91.3%) of CSM-positive polyps were neoplastic (sensitivity, 37.90%; specificity, 86.15%; p<0.001). In logistic regression, the neoplastic polyps were associated with positive CSM (adjusted odds ratio [OR], 3.51; 95% confidence interval [CI], 1.45 to 9.25; p=0.007), protruded polyps (adjusted OR, 4.85; 95% CI, 1.65 to 17.23; p=0.008), and neoplastic histology–associated pit pattern (pit III, IV, and V) (adjusted OR, 10.14; 95% CI, 4.85 to 22.12; p=0.000). Furthermore, advanced adenomas were associated with positive CSM (adjusted OR, 5.64; 95% CI, 1.77 to 20.28; p=0.005), protruded polyps (adjusted OR, 3.30; 95% CI, 1.15 to 9.74; p= 0.026), and ≥10 cm polyp size (adjusted OR, 18.56; 95% CI, 3.89 to 147.01; p=0.001).

Conclusions

Neoplastic and advanced polyps were associated with CSM-positive polyps. These findings suggest that CSM is a useful marker in differentiating neoplastic polyps and advanced polyps under conventional white colonoscopy.

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis.

Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Sleep disorders in patients with functional dyspepsia: A multicenter study from the Korean Society of Neurogastroenterology and Motility

BACKGROUND AND AIM

The few studies concerning the association between sleep disorders and functional dyspepsia (FD) have yielded inconsistent results. We compared the prevalence of sleep disorders in patients with FD and healthy controls, and evaluated whether FD was independently associated with sleep disorders, and the risk factors for sleep disorders in patients with FD.

METHODS

This prospective, multicenter, cross-sectional study was conducted from August 2014 to December 2017 at 12 hospitals in South Korea. The inclusion criterion was the presence of FD (for ≥18 years) according to the Rome III criteria. Healthy controls were recruited from among patients who visited the Health Examination Center for check-ups.

RESULTS

In total, 526 subjects were prospectively enrolled in this study (201 with FD and 325 healthy controls). The prevalence of sleep disorders was significantly higher among the patients with FD than among the healthy controls (41.8% vs 18.8%, P = 0.000). In a multivariate analysis, FD (odds ratio [OR] = 1.851; 95% confidence interval [CI] 1.194-2.870; P = 0.006), female sex (OR = 1.672; 95% CI 1.063-2.628; P = 0.026), and anxiety (OR = 3.325; 95% CI 2.140-5.166; P = 0.000) were independent risk factors for sleep disorders in the overall cohorts. In patients with FD only, low body mass index, heartburn, and anxiety were independent risk factors for sleep disorders in a further multivariate analysis.

CONCLUSION

Sleep disorders were common in patients with FD. FD was significantly associated with sleep disorders in our patient population, irrespective of the presence of heartburn or psychiatric disorders.

813. The Reduction of the acquisition rate of carbapenem resistant Acinetobacter baumannii after room privatization in the intensive care unit

Background

Acinetobacter baumannii is one of the major pathogens of hospital-acquired infection recently and hospital outbreaks have been reported worldwide. On September 2017, New intensive care unit(ICU) with only single rooms, remodeling from old ICU with multibed bay rooms, was opened in an acute-care tertiary hospital in Seoul, Korea. We investigated the effect of room privatization in the ICU on the acquisition of carbapenem-resistant Acinetobacter baumannii(CRAB).

Methods

We retrospectively reviewed medical records of patients who admitted to the medical ICU in a tertiary care university-affiliated 1,800-bed hospital from 1 January 2015 to 1 January 2019. Patients admitted to the medical ICU before the remodeling of the ICU were designated as the control group, and those who admitted to the medical ICU after the remodeling were designated as the intervention group. Then we compared the acquisition rate of CRAB between the control and intervention groups. Patients colonized with CRAB or patients with CRAB identified in screening tests were excluded from the study population. The multivariable Cox regression model was performed using variables with p-values of less than 0.1 in the univariate analysis.

Results

A total of 1,105 cases admitted to the ICU during the study period were analyzed. CRAB was isolated from 110 cases in the control group(n=687), and 16 cases in the intervention group(n=418). In univariate analysis, room privatization, prior exposure to antibiotics (carbapenem, vancomycin, fluoroquinolone), mechanical ventilation, central venous catheter, tracheostomy, the presence of feeding tube(Levin tube or percutaneous gastrostomy) and the length of ICU stay were significant risk factors for the acquisition of CRAB (p< 0.05). In the multivariable Cox regression model, the presence of feeding tube(Hazard ratio(HR) 4.815, 95% Confidence interval(CI) 1.94-11.96, p=0.001) and room privatization(HR 0.024, 95% CI 0.127-0.396, p=0.000) were independent risk factors.

Table 1. Univariate analysis of Carbapenem-resistant Acinetobacter baumannii

Table 2. Multivariable Cox regression model of the acquisition of Carbapenem-resistant Acinetobacter baumannii

Conclusion

In the present study, room privatization of the ICU was correlated with the reduction of CRAB acquisition independently. Remodeling of the ICU to the single room would be an efficient strategy for preventing the spreading of multidrug-resistant organisms and hospital-acquired infection.

Disclosures

All Authors: No reported disclosures

170. Development of Key Indicators for Appropriate Antibiotic Use in Republic of Korea: a Systematic Review followed by Delphi Procedure

Background

The aim of this study was to develop a set of key quality indicators (QIs) for application to nationwide point surveillance of appropriateness of antibiotic usage in Republic of Korea.

Methods

A systematic literature review was performed in order to retrieve a list of potential key QIs. These candidates were evaluated by multidisciplinary expert panel using a RAND-modified Delphi procedure, using two online questionnaires and a face-to-face meeting between them. Twenty-five expert panels with diverse backgrounds (infectious diseases specialist, urologist, laboratory medicine doctors, pediatric infectious disease specialists, otorhinolaryngology doctors, gastrointestinal doctors, pulmonologist, general surgeon, and researcher in National Evidence-Based Healthcare Collaborating Agency) participated in the consensus procedure. A Likert scale (ranging 1–7) was used for the evaluation of appropriateness of the potential key QIs and items with median score 6 or 7 were accepted if there was no disagreement. In addition, we grade each QI into admission, outward, or surgical prophylaxis using the Likert scale. If the score was 6 or 7, we considered it as appropriate application.

Results

The systematic literature review identified 23 potential QIs, from 21 studies. Ultimately, 17 key indicators were retained, with a high level of agreement (13 QIs for admitted patients, 7 for outward patients and 3 for surgical prophylaxis) (Figue 1). After sum of importance score and applicability, 6 key QIs [6 QIs (1–6) for admitted patients and 3 (1, 2 and 5) for outward patients] were finally selected: (1) prescribe empirical antibiotic therapy according to guideline, (2) change empirical to pathogen-directed therapy, (3) take cultures from suspected sites of infection, (4) take 2 blood cultures, (5) adapt antibiotic dosage to renal function, and (6) document antibiotic plan (Table 1). In surgical prophylaxis, prescribe according to guideline and initiate antibiotics one hour before incision was finally selected (Table 2).

Figure 1. Flowchart of the study

Table 1. Ranking in key indicators for admitted and out patients and applicability in point surveillance study.

Table 2. Ranking in key indicators for surgical prophylaxis and applicability in point surveillance study.

Conclusion

We identified key QIs to measure the appropriateness of antibiotics. These QIs can be used to identify targets for improvement and to evaluate the effects of antibiotic stewardship intervention.

Disclosures

All Authors: No reported disclosures

1605. Differences in Clinical Characteristics of Third Generation Cephalosporin Resistance and Treatment Outcomes in Escherichia coli and Klebsiella pneumoniae Bacteremia in Patients with Liver Cirrhosis

Background

This study aimed to identify characteristics of third-generation cephalosporin (3GC) resistance in Escherichia coli bateremia (ECB) and Klebsiella pneumoniae bacteremia (KPB) in patients with liver cirrhosis (LC), and to investigate the effects of appropriateness of empirical antibiotic treatment on outcomes.

Methods

We retrospectively collected demographic, clinical and microbiological information on all ECB and KPB episodes in LC patients ≥ 18 years of age hospitalized to a tertiary-care teaching hospital in South Korea from 2007 to 2018. Clinical characteristics associated with 3GC resistance and treatment failure were analyzed using a multivariate logistic regression model. Treatment failure was defined as persistent bacteremia for ≥ 7 days, or relapsed bacteremia ≤ 30 days, or all-cause mortality ≤ 30 days.

Results

3GC resistance rates of E. coli were 30.3% overall and increased significantly during the study period (P=0.001), while the rates of K. pneumoniae were not changed (24.3% overall) (P=0.994). Of total 356 ECB and KPB episodes, 112 were caused by 3GC resistant strains. The factor associated with 3GC resistance was isolation of 3GC resistant strain ≤ 1 year in both ECB (OR, 7.754; 95% CI, 2.094~28.716) and KPB (OR, 2.774; 1.318~5.838). In ECB, beta-lactam or fluoroquinolone treatment ≤ 30 days was another factor associated with 3GC resistance (OR, 2.774; 95% CI, 1.318~5.838), but not in KPB. The factor associated with treatment failure was high MELD score in both ECB (OR, 1.193 at 1 increase; 95% CI, 1.118~1.272) and KPB (OR, 1.163; 95% CI 1.083~1.250). Additionally, in ECB, non-alcoholic LC (OR 3.262; 95% CI 1.058~10.063), high Charlson Comorbidity Index (OR, 1.285; 95% CI 1.066~1.548), and inappropriate empirical antibiotic treatment (OR, 3.194; 95% CI 1.207~8.447) were associated with treatment failure.

Conclusion

During the study period, 3GC resistance increased in ECB, but not in KPB. In ECB, the severity of the underlying disease and the appropriateness of empirical antibiotics were associated with treatment failure, but there was no correlation in KPB. In ECB of LC patients, the appropriateness of empirical antibiotics was a factor associated with treatment outcome, and is the only correctable factor in the clinical setting.

Disclosures

All Authors: No reported disclosures

1147. Short Course of Voriconazole Therapy as a Risk Factor for Relapse of Invasive Pulmonary Aspergillosis

Background

Invasive pulmonary aspergillosis (IPA) is a life-threatening opportunistic infection which usually occurs in immunocompromised patients. Recommended duration of voriconazole therapy is a minimum of 6-12 weeks for IPA, despite the lack of any firm evidence. In addition, risk factors for relapse of IPA are still unclear. Here, we explored risk factors for IPA relapse after initial treatment.

Methods

All patients with proven or probable IPA who had finished voriconazole treatment between 2005 and 2019 in a tertiary-care hospital were reviewed. IPA relapse was defined as re-diagnosis of proven or probable IPA at the same site within 1 year after treatment termination. Short course of voriconazole treatment was defined as a treatment less than 9 weeks, which is a median of the recommended minimum duration of therapy from the Infectious Disease Society of America. The radiological response was defined as a reduction in IPA burden by more than 50% on chest computed tomography (CT).

Results

Of 87 patients who had completed voriconazole treatment, 14 (16.1%) experienced IPA relapse. Multivariable Cox regression identified that short voriconazole treatment duration (adjusted hazard ratio [aHR], 3.7; 95% confidence interval [CI], 1.1–12.3; P=0.033) and radiological non-response (aHR, 4.6; 95% CI, 1.2–17.5; P=0.026) were independently associated with relapse of IPA after adjusting for several clinical risk factors.

Conclusion

Less improvement in CT, and short duration of voriconazole therapy were the independent risk factors for relapse after treatment of IPA. Longer duration of therapy should be considered for those at higher risk of relapse.

Disclosures

All Authors: No reported disclosures

The prolongation effect of ilaprazole-based standard triple therapy for Helicobacter pylori

BACKGROUND

Helicobacter pylori (HP) infection causes many diseases, such as peptic ulcers, gastritis and gastric cancer, and MALToma. It has been gradually accepted that all HP-infected patients should be treated because HP is regarded as an infection. Therefore, the importance of selecting the optimal treatment regimen has increased. Although the 14-day standard triple therapy (STT) is recommended in the current guidelines, prolonging treatment duration is controversial in real practice because of inconsistent results from previous data and the risk of adverse effects. Additionally, the effect of STT using ilaprazole has not been reported until now. We aimed to compare the eradication rate between 7 and 10 days STT using ilaprazole.

METHODS

A prospective randomized controlled trial was conducted, which was divided into 2 treatment groups: the control group was 7 days of STT, and the test group was 10 days of STT. The eradication regimen was 10 mg ilaprazole, 500 mg clarithromycin, and 1000 mg amoxicillin twice daily. We included patients who were diagnosed with positive results of H pylori examination. We compared the HP eradication rate according to treatment duration, CYP2C19 subtype and endoscopic diagnosis.

RESULTS

We enrolled a total of 254 patients consisting of 127 patients in each treatment arm. The eradication rates of the control and test groups were 65.4% (82/127) and 74.8% (95/127), respectively, in the intention-to-treat analysis (P = .1). In the per-protocol analysis, 70.3% (83/118) and 82.6% (94/115) were eradicated in each group, which was statistically significant (P = .027). The CYP2C19 subtype was examined in 230 patients. The eradication rate was 79.2% (57/72), 75.4% (92/122), and 72.2% (26/36) in each group, which was not significantly different (P = .704).

CONCLUSION

Ten-day STT was more effective than 7-day STT for HP eradication. The eradication rate was not affected by the CYP2C19 genotype.

Treatment pattern and overall survival in esophageal cancer during a 13-year period: A nationwide cohort study of 6,354 Korean patients

Using data from the real world to solve clinical questions that cannot be answered using data from clinical trials is attracting more attention. Clinical outcomes for patients with esophageal cancer in a real-world setting might be different from data in randomized controlled trials. This study aimed to provide real world data on treatment and prognosis in Korean patients with esophageal cancer. This retrospective cancer cohort included newly diagnosed cases of esophageal cancer at 19 tertiary hospitals between January 1, 2005 and December 31, 2017. Cancer staging was defined according to the 7th edition of the American Joint Committee on Cancer criteria. We identified 6,354 patients with newly diagnosed esophageal cancer (mean age: 64.9 ± 9.0 years, 96.9% squamous cell carcinoma). The proportion of early esophageal cancer increased from 24.7% in 2005 to 37.2% in 2015 (p<0.001). Among all cases, surgery alone was 31.3%, followed by definitive concurrent chemoradiotherapy (CCRT) (27.0%), neoadjuvant therapy (12.4%), adjuvant therapy (11.1%), and endoscopic resection (5.8%). The 5-year overall survival rate was 45.7 ± 0.7%. Endoscopic resection provided similar median survival relative to surgery for stage Ia cases. Among stage II–III cases, definitive CCRT was associated with poorer survival than neoadjuvant or adjuvant therapy, although there was no survival difference between neo-adjuvant and adjuvant therapy. Early esophageal cancer is gradually becoming more common and endoscopic resection provided similar long-term survival relative to surgery. Surgery with combined therapy provided better survival in locally advanced esophageal cancer, relative to definitive CCRT.

Clinical Practice Guidelines for Functional Dyspepsia in Korea

Functional dyspepsia (FD) is a chronic upper gastrointestinal (GI) symptom complex that routine diagnostic work-up, such as endoscopy, blood laboratory analysis, or radiological examination, fails to identify a cause. It is highly prevalent in the World population, and its response to the various available therapeutic strategies is only modest because of the heterogenous nature of its pathogenesis. Therefore, FD represents a heavy medical burden for healthcare systems. We constituted a guideline development committee to review the existing guidelines on the management of functional dyspepsia. This committee drafted statements and conducted a systematic review and meta-analysis of various studies, guidelines, and randomized control trials. External review was also conducted by selected experts. These clinical practice guidelines for FD were developed based on evidence recently accumulated with the revised version of FD guidelines released in 2011 by the Korean Society of Neurogastroenterology and Motility. These guidelines apply to adults with chronic symptoms of FD and include the diagnostic role of endoscopy, Helicobacter pylori screening, and systematic review and meta-analyses of the various treatment options for FD (proton pump inhibitors, H.pylori eradication, and tricyclic antidepressants), especially according to the FD subtype. The purpose of these new guidelines is to aid the understanding, diagnosis, and treatment of FD, and the targets of the guidelines are clinicians, healthcare workers at the forefront of patient care, patients, and medical students. The guidelines will continue to be revised and updated periodically.

Evaluation of prognostic factor and nature of acute esophageal necrosis: Restropective multicenter study

Acute esophageal necrosis (AEN) is a serious disease which can causes gastrointestinal bleeding and death. Although black color change is not essential factor of organ necrosis, AEN is also known as "black esophagus." Because of its rarity, there are limited studies regarding risk factors of mortality and recurrence. Thus, we conducted a multicenter retrospective study in order to evaluate the clinical characteristics of AEN. Method Clinical datum of AEN patients from 7 tertiary hospitals located in Daejeon-Choongcheong province were evaluated based on medical records. Our primary endpoint was risk factors for mortality and the secondary endpoint was risk factors for recurrence and clarifying whether "black esophagus" is a right terminology.Fourty one patients were enrolled. Thirty six patients were male, mean age was 69.5 years. Nine patients had died, and 4 patients showed recurrence. Sepsis and white color change in endoscopy were related to high mortality (Chi-Squared test, P < .05). Old age, high pulse rate, low hemoglobin, and low albumin were also related to high mortality. Unexpectedly, heavy drinking showed favorable a mortality. Septic condition and high pulse rate showed poor mortality in logistic regression test (P < .05). Coexisting duodenal ulcer was related to recurrence (Chi-Squared test, P < .05). There was no difference in the underlying condition except patients with a coexisting cancer and white-form displayed lower hemoglobin level. Conclusion: Our results imply that white color change, septic condition, high pulse rate, and low hemoglobin & albumin are poor prognostic factors in AEN. Further evaluation may help clarify the findings of our study.

Comparison of body surface area-based and weight-based dosing format for oral prednisolone administration in small and large-breed dogs

This study compared the pharmacokinetics of Prednisolone (PDS) in small- and large breed dogs with a dosing format based on body surface area (BSA) or body weight (BW). The maximum concentration and area under the curve in large-breed dogs orally administered 2 mg/kg PDS were significantly greater than those in small-breed dogs given 2 mg/kg and in large-breed dogs given 40 mg/m2. The higher blood concentrations that result from BW-based dosing of oral PDS in large-breed dogs can be more than required for effect. Meanwhile, BSA dosing at 40 mg/m may be suboptimal. These findings confirm important differences between standard PDS dosing schemes in dogs while highlighting the need to further optimize PDS dosing in large-breed dogs.

[Impaction of Coin Battery in the Appendix]

Coin batteries are often used in daily life devices and can be easily available. Children can swallow coin batteries, resulting in the need to go to hospital, but this is rare in adults. Adults generally eliminate the swallowed coin battery from the digestive system, unless they have congenital structural abnormalities of the digestive system or complications, such as postoperative stenosis. In this case, a 31-year-old man swallowed three coin batteries, approximately 0.4 cm in diameter emergent endoscopy was unable to find any batteries embedded in the ingested food. An attempt was made to rinse out the batteries by bowel preparation. During the hospital stay, the patient complained of acute abdominal pain and fever. In the abdominal CT scan, impaction of the coin battery into the appendix was confirmed. The patient underwent a laparoscopic appendectomy to prevent appendiceal perforation.

Comparisons of therapeutic outcomes in patients with nonampullary duodenal neuroendocrine tumors (NADNETs): A multicenter retrospective study

Duodenal neuroendocrine tumors (DNETs) are rare tumors that are occasionally found during upper endoscopies. The incidence of DNETs is increasing, although the data regarding treatment outcomes are insufficient. The aim of this study was to evaluate the treatment outcomes in patients with nonampullary DNETs who underwent endoscopic resection or surgery. We evaluated the medical records of patients who were diagnosed with nonampullary DNETs from 2004 to 2017 in 7 university hospitals. We retrospectively analyzed clinical characteristics and compared therapeutic outcomes based on the endoscopic lesion size and treatment method. We ultimately enrolled 60 patients with nonampullary DNETs who underwent endoscopic and surgical treatments. In the endoscopic treatment group, the en bloc resection, endoscopic complete resection (CR) and pathologic CR rates were 88%, 92%, and 50%, respectively. The endoscopic treatment group was divided into 3 subgroups based on the lesion size (1-5 mm, 6-10 mm, and ≥11 mm). The pathologic CR rate was significantly lower in the subgroup with a lesion size ≥11 mm (0%, P = .003) than those in the other 2 subgroups. Lymphovascular invasion occurred significantly more frequently (33.3%, P = .043) among those with a lesion size ≥11 mm. The pathologic CR rate in the surgical treatment group was higher (90.9%) than that in the endoscopic treatment group (50%, P = .017). Surgical treatment appears to be a more appropriate choice because of the risks of incomplete resection and lymphovascular invasion after endoscopic treatment for lesions larger than 11 mm.

Endoscopic Prediction of Tumor Invasion Depth in Early Gastric Signet Ring Cell Carcinoma

INTRODUCTION

Signet ring cell carcinoma (SRC) is a poorly differentiated cancer of the stomach. Recent studies imply that early gastric SRC can be well managed by endoscopic resection. Unfortunately, unlike differentiated cancers, the endoscopic features of early gastric SRC have not been well studied. This study evaluated the endoscopic features of early gastric SRC, as well as the risk factors for submucosal (SM) invasion.

METHOD

The medical records of patients from 7 tertiary hospitals (Daejeon and Chungcheong province) were reviewed to examine endoscopic findings and clinical data. These patients underwent surgery or endoscopic resection between January 2011 and December 2016 and were divided into 2 groups (derivation group and validation group) in order to develop and validate an endoscopic scoring system for SM invasion.

RESULTS

In total, 331 patients (129 in the derivation group and 202 in the validation group) were enrolled in this study. In the derivation group, the risk factors for SM invasion, namely, fold convergence, nodular mucosal change, and deep depression, were identified by logistic regression analysis (ORs 3.4, 5.9, and 6.0, p < 0.05). A depth-prediction score was created by assigning 1 point for fold convergence and 2 points for other factors. When validation lesions of 0.5 point or more were diagnosed as SM invasion, the sensitivity and specificity were 76.8-78.6% and 61.6-74.7% respectively.

CONCLUSION

Fold convergence, nodular mucosal change, and deep depression are risk factors for SM invasion in early gastric SRC. Our depth-prediction scoring system may be useful for differentiating SM cancers.

Clinical Practice Guidelines for Irritable Bowel Syndrome in Korea, 2017 Revised Edition

In 2011, the Korean Society of Neurogastroenterology and Motility (KSNM) published clinical practice guidelines on the management of irritable bowel syndrome (IBS) based on a systematic review of the literature. The KSNM planned to update the clinical practice guidelines to support primary physicians, reduce the socioeconomic burden of IBS, and reflect advances in the pathophysiology and management of IBS. The present revised version of the guidelines is in continuity with the previous version and targets adults diagnosed with, or suspected to have, IBS. A librarian created a literature search query, and a systematic review was conducted to identify candidate guidelines. Feasible documents were verified based on predetermined inclusion and exclusion criteria. The candidate seed guidelines were fully evaluated by the Guidelines Development Committee using the Appraisal of Guidelines for Research and Evaluation II quality assessment tool. After selecting 7 seed guidelines, the committee prepared evidence summaries to generate data exaction tables. These summaries comprised the 4 main themes of this version of the guidelines: colonoscopy; a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; probiotics; and rifaximin. To adopt the core recommendations of the guidelines, the Delphi technique (ie, a panel of experts on IBS) was used. To enhance dissemination of the clinical practice guidelines, a Korean version will be made available, and a food calendar for patients with IBS is produced.

Seroprevalence of Helicobacter pylori in Korea: A multicenter, nationwide study conducted in 2015 and 2016

BACKGROUND

The Korean College of Helicobacter and Upper Gastrointestinal Research has studied Helicobacter pylori (H. pylori) prevalence since 1998 and found a dynamic change in its prevalence in Korea. The aim of this study was to determine the recent H. pylori prevalence rate and compare it with that of previous studies according to socioeconomic variables.

METHODS

We planned to enroll 4920 asymptomatic Korean adults from 21 centers according to the population distribution of seven geographic areas (Seoul, Gyeonggi, Gangwon, Chungcheong, Kyungsang, Cholla, and Jeju). We centrally collected serum and tested H. pylori serum IgG using a chemiluminescent enzyme immunoassay.

RESULTS

We analyzed 4917 samples (4917/4920 = 99.9%) from January 2015 to December 2016. After excluding equivocal serologic results, the H. pylori seropositivity rate was 51.0% (2414/4734). We verified a decrease in H. pylori seroprevalence compared with previous studies performed in 1998, 2005, and 2011 (P < .0001). The H. pylori seroprevalence rate differed by area: Cholla (59.5%), Chungcheong (59.2%), Kyungsang (55.1%), Jeju (54.4%), Gangwon (49.1%), Seoul (47.4%), and Gyeonggi (44.6%). The rate was higher in those older than 40 years (38.1% in those aged 30-39 years and 57.7% in those aged 40-49 years) and was lower in city residents than in noncity residents at all ages.

CONCLUSIONS

Helicobacter pylori seroprevalence in Korea is decreasing and may vary according to population characteristics. This trend should be considered to inform H. pylori-related policies.

Quality of life, patient satisfaction, and disease burden in patients with gastroesophageal reflux disease with or without laryngopharyngeal reflux symptoms

BACKGROUND AND AIM

Patients with gastroesophageal reflux disease (GERD) have decreased health-related quality of life (HRQL). The quality of life in patients with laryngopharyngeal reflux (LPR) symptoms is also significantly impaired. However, the impact of LPR symptoms on HRQL in GERD patients has not been studied.

METHODS

A nationwide, random-sample, and face-to-face survey of 300 Korean patients with GERD was conducted from January to March 2013. Gastroesophageal reflux symptoms were assessed using the Rome III questionnaire, LPR symptoms using the reflux symptom index, and HRQL using the EuroQol five dimensions (EQ-5D) questionnaire. A structured questionnaire on patient satisfaction, sickness-related absences, and health-related work productivity was also used.

RESULTS

Among the 300 patients with GERD, 150 had LPR symptoms. The mean EQ-5D index was lower in patients with GERD and LPR symptoms than in those without LPR (0.88 vs 0.91, P = 0.002). A linear regression model showed that the severity of LPR symptoms was related to decreased HRQL and was independent of age, marital status, body mass index, or household income. The overall satisfaction rate regarding treatment was lower in patients with GERD and LPR (40.0% vs 69.1%, P = 0.040). GERD patients with LPR symptoms reported greater sickness-related absent hours per week (0.36 vs 0.02 h, P = 0.016) and greater percentages of overall work impairment than those without LPR (31.1% vs 20.8%, P < 0.001).

CONCLUSIONS

Gastroesophageal reflux disease patients with LPR symptoms have a poorer HRQL, a lower satisfaction rate, and a greater disease burden than those without LPR.

Acetic acid chromoendoscopy for determining the extent of gastric intestinal metaplasia

BACKGROUND AND AIMS

The diagnosis of gastric intestinal metaplasia (IM) is currently performed by histologic assessment of multiple endoscopic biopsies, methylene blue chromoendoscopy, or narrow-band imaging with magnification. However, practical and readily available methods are lacking. We assessed the diagnostic accuracy and reproducibility of acetic acid chromoendoscopy (AAC) for determining the extent of gastric IM.

METHODS

One hundred twenty-six participants were enrolled. The participants underwent screening EGD with 1.5% acetic acid instillation for the detection of acetowhite reaction. Subsequently, targeted biopsies were performed at the 5 standard intra-gastric locations of the updated Sydney system. The accuracy of AAC was calculated using the histology results as a reference. Two endoscopists, each of whom was blinded to the other's result, determined the presence or absence of acetowhite reaction.

RESULTS

The overall diagnostic accuracy of AAC was 89.0%, and the sensitivity and specificity were 77.6% and 94.4%, respectively. The specificity for the gastric body was >94%. The proportion of extensive IM, a strong risk factor for gastric cancer, increased from 0.9% to 18.1% when AAC was used instead of conventional EGD alone (P < .001). Endoscopically determined atrophy had a negative effect on the diagnosis of AAC (odds ratio, 3.012; 95% confidence interval, 1.625-5.583). There was substantial inter- and intra-observer agreement.

CONCLUSIONS

AAC is a valid and reproducible tool for determining the extent of gastric IM and may serve as a practical method of identifying populations at high risk of gastric cancer. (Clinical trial registration number: NCT01499576.).

Pharmacokinetic study of meropenem in healthy beagle dogs receiving intermittent hemodialysis

Meropenem, a second carbapenem antimicrobial agent with a broad spectrum of activity, is used to treat sepsis and resistant-bacterial infections in veterinary medicine. The objective of this study was to identify the pharmacokinetics of meropenem in dogs receiving intermittent hemodialysis (IHD) and to determine the proper dosing in renal failure patients receiving IHD. Five healthy beagle dogs were given a single i.v. dose of 24 mg/kg of meropenem and received IHD. The blood flow rate, dialysate flow, and ultrafiltration rate were maintained at 40 mL/min, 300 mL/min, and 40 mL/h, respectively. Blood samples were collected for 24 h from the jugular vein and from the extracorporeal arterial and venous line. Urine samples and dialysate were also collected. The concentrations of meropenem were assayed using HPLC/MS/MS determination. The peak plasma concentration was 116 ± 37 μg/mL at 15 min. The systemic clearance was 347 ± 117 mL/h/kg, and the steady-state volume of distribution was 223 ± 67 mL/kg. Dialysis clearance was 71.1 ± 34.3 mL/h/kg, and the extraction ratio by hemodialysis was 0.455 ± 0.150. The half-life (T_1/2 ) in dogs with IHD decreased compared with those without IHD, and the reduction in T_1/2 was greater in renal failure patients than in normal patients. Sixty-nine percent and 21% of the administered drug were recovered by urine and dialysate in the unchanged form, respectively. In conclusion, additional dosing of 24 mg/kg of meropenem after dialysis could be necessary according to the residual renal function of the patient based on the simulated data.

Guidelines for the Diagnosis and Treatment of Chronic Functional Constipation in Korea, 2015 Revised Edition

The Korean Society of Neurogastroenterology and Motility first published guidelines for chronic constipation in 2005 and was updated in 2011. Although the guidelines were updated using evidence-based process, they lacked multidisciplinary participation and did not include a diagnostic approach for chronic constipation. This article includes guidelines for diagnosis and treatment of chronic constipation to realistically fit the situation in Korea and to be applicable to clinical practice. The guideline development was based upon the adaptation method because research evidence was limited in Korea, and an organized multidisciplinary group carried out systematical literature review and series of evidence-based evaluations. Six guidelines were selected using the Appraisal of Guidelines for Research & Evaluation (AGREE) II process. A total 37 recommendations were adopted, including 4 concerning the definition and risk factors of chronic constipation, 8 regarding diagnoses, and 25 regarding treatments. The guidelines are intended to help primary physicians and general health professionals in clinical practice in Korea, to provide the principles of medical treatment to medical students, residents, and other healthcare professionals, and to help patients for choosing medical services based on the information. These guidelines will be updated and revised periodically to reflect new diagnostic and therapeutic methods.

The pharmacokinetics of the β2-adrenoceptor agonist, tulobuterol, in Beagle dogs following transdermal and intravenous administration

Tulobuterol is a β2-adrenergic agonist that was the first bronchodilator approved as a transdermal patch for humans. Previous studies have examined the pharmacokinetics of tulobuterol in humans but not in the veterinary species. In this study, the pharmacokinetics of tulobuterol was examined in healthy Beagle dogs after transdermal and intravenous administration. The Cmax was 2.09 ng/mL at 16.0 h for a 0.2 mg/kg patch and 4.85 ng/mL at 13.6 h for a 0.4 mg/kg patch. The effective blood level in humans is 1-3 ng/mL, a concentration achieved using the 0.2 mg/kg patch in dogs. In conclusion, application of a 0.2 mg/kg tulobuterol patch to healthy dogs led to an apparently effective blood concentration for 24 h.

[Comparison of malnutrition risk between patients with liver cirrhosis and viral hepatitis carrier: a single center study]

BACKGROUND/AIMS

It is well-known that patients with chronic liver disease commonly have nutritional deficiency. In the present study, we investigated the differences in malnutrition risk between patients with liver cirrhosis and viral hepatitis carrier.

METHODS

Patients with chronic liver disease who have been hospitalized at Konyang University Hospital from May 2012 to April 2013 were analyzed retrospectively. The malnutrition risk was divided into three categories (low, intermediate, and high) according to Konyang University Hospital Malnutrition Screening, which include BMI, serum albumin, total lymphocyte count (TLC), hemoglobin, weight change, appetite, and dysphagia, within 24 hours of hospitalization.

RESULTS

Among a total of 460 patients, 313 had liver cirrhosis (LC), and 147 were viral hepatitis carriers. Age (p<0.001), serum albumin level (p<0.001), TLC (p=0.011), hemoglobin (p<0.001) and serum cholesterol level (p=0.005) were significant different between the two groups. However, there were no difference in height, weight, and BMI. The malnutrition risk of the patients with viral hepatitis carrier was significantly lower than that of the patients with LC (p<0.001). In addition, among 313 patients with LC, malnutrition risk of the patients with Child-Pugh class A (n=150) was significantly lower than that of the patients with class B (n=90) or C (n=73) (p<0.001).

CONCLUSIONS

Viral hepatitis carrier group had significantly lower malnutrition risk than LC group. The risk of malnutrition in Child-Pugh class A group was significantly lower than that in class B or C group.

Acute mediastinitis arising from pancreatic mediastinal fistula in recurrent pancreatitis

Acute mediastinitis is a fatal disease that usually originates from esophageal perforation and surgical infection. Rare cases of descending necrotizing mediastinitis can occur following oral cavity and pharynx infection or can be a complication of pancreatitis. The most common thoracic complications of pancreatic disease are reactive pleural effusion and pneumonia, while rare complications include thoracic conditions, such as pancreaticopleural fistula with massive pleural effusion or hemothorax and extension of pseudocyst into the mediastinum. There have been no reports of acute mediastinitis originating from pancreatitis in South Korea. In this report, we present the case of a 50-year-old female suffering from acute mediastinitis with pleural effusion arising from recurrent pancreatitis that improved after surgical intervention.

Various upper endoscopic findings of acute esophageal thermal injury induced by diverse food: a case series

Esophageal thermal injury caused by food has been reported to occur mostly after drinking hot liquid food, and is known to produce alternating white and red linear mucosal bands. In addition, thermal injury caused by ingestion of hot solid foods is documented to be a cause of esophageal ulcers or pseudomembranes. From January 2006 to August 2012, five patients with suspected esophageal thermal injury underwent esophagogastroduodenoscopy with biopsy. A "candy-cane" appearance was observed in one case, pseudomembrane was observed in two cases, an esophageal ulcer was observed in one case, and a friable and edematous mucosa was noted in one case. We believe that the endoscopic findings of esophageal thermal injury depend on the following factors: causative materials, amount of food consumed, exposure period, and time to endoscopy after the incident. Therefore, physicians who encounter patients with suspected esophageal thermal injury should carefully take the patient's history considering these factors.

[Current issues in functional dyspepsia]

Functional dyspepsia is one of the most common gastrointestinal disorders encountered in clinical practice. Functional dyspepsia is currently defined by Rome III criteria as the chronic dyspeptic symptoms (postprandial fullness, early satiety, epigastric pain or burning) in the absence of underling structural or metabolic disease that readily explain the symptoms. According to the Rome III consensus, functional dyspepsia can be subdivided into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). Although the Rome III criteria have been published more than 8 years ago, not much effort has been put into validating these criteria and direct scientific evidence supporting the validity of the subdividing functional dyspepsia into PDS and EPS are lacking. This article is intended to review the validity of the Rome III criteria on the subdivisions of functional dyspepsia, i.e. PDS and EPS. The impact of sleep disorder, Helicobacter pylori-associated dyspepsia, and the emerging drug therapies in functional dyspepsia will also be discussed in this article.

Is there a difference in the prevalence of gastroesophageal reflux disease between peritoneal dialysis and hemodialysis patients?

BACKGROUND/AIMS

Gastroesophageal reflux disease (GERD) is a common upper gastrointestinal disorder in patients with chronic kidney disease (CKD). However, little is known about the prevalence of GERD in dialysis patients. The aim of the present study was to investigate the difference in the prevalence of GERD in peritoneal dialysis and hemodialysis patients.

METHODS

From July 2010 to August 2011, peritoneal dialysis patients (n=30) and hemodialysis patients (n=38) were enrolled. The prevalences of GERD were assessed at a single center with endoscopic findings and interviews using a questionnaire. Also, risk factors of GERD were evaluated.

RESULTS

The prevalences of GERD in peritoneal dialysis and hemodialysis patients were 33.3% and 39.5% (p=0.748), respectively. The prevalences of erosive reflux esophagitis (ERD) in peritoneal dialysis and hemodialysis patients were 16.7% and 23.7% (p=0.477), respectively. The prevalences of nonerosive reflux disease (NERD) in peritoneal dialysis and hemodialysis patients were 16.7% and 13.2% (p=0.685), respectively. The prevalences of GERD, ERD and NERD were higher than those of the general population. The risk factor for GERD was age in hemodialysis patients.

CONCLUSIONS

The prevalence of GERD in dialysis patients was higher than that in the general population. However, there was no significant difference between peritoneal dialysis and hemodialysis patients.

Outbreak among healthy newborns due to a new variant of USA300-related meticillin-resistant Staphylococcus aureus

BACKGROUND

The prevalence of community-associated meticillin-resistant Staphylococcus aureus (CA-MRSA) is increasing throughout the world and is an important cause of skin and soft tissue infection (SSTI) in children and neonates.

AIM

To describe the successful control of an outbreak caused by a new strain of CA-MRSA in a newborn nursery.

METHODS

The investigation of the outbreak in July 2012 is reported with the control measures taken. Molecular typing of the MRSA isolates was performed.

FINDINGS

An outbreak of SSTI caused by CA-MRSA occurred in a newborn nursery. Six neonates were infected in a one-month period [infection rate: 8.5% (6/71)]. A new variant of CA-MRSA was responsible, which was characterized as USA300-related, Panton-Valentine Leucocidin (PVL) positive, arginine catabolic mobile element (ACME) negative, sequence type 8 (ST8), staphylococcal cassette chromosome mec (SCCmec) type IVa, agr type I and spa type t008. The outbreak among term neonates followed a rapid transmission pattern and was successfully controlled by implementing various outbreak control measures, including universal chlorhexidine bathing.

CONCLUSION

This is the first report of a hospital outbreak caused by a USA300-related CA-MRSA clone in Korea. Early recognition and reinforcement of infection control measures are important in decreasing transmission of CA-MRSA in a hospital setting.

Differential diagnosis of left-sided abdominal pain: Primary epiploic appendagitis vs colonic diverticulitis

AIM: To investigate the clinical characteristics of left primary epiploic appendagitis and to compare them with those of left colonic diverticulitis.

METHODS: We retrospectively reviewed the clinical records and radiologic images of the patients who presented with left-sided acute abdominal pain and had computer tomography (CT) performed at the time of presentation showing radiological signs of left primary epiploic appendagitis (PEA) or left acute colonic diverticulitis (ACD) between January 2001 and December 2011. A total of 53 consecutive patients were enrolled and evaluated. We also compared the clinical characteristics, laboratory findings, treatments, and clinical results of left PEA with those of left ACD.

RESULTS: Twenty-eight patients and twenty-five patients were diagnosed with symptomatic left PEA and ACD, respectively. The patients with left PEA had focal abdominal tenderness on the left lower quadrant (82.1%). On CT examination, most (89.3%) of the patients with left PEA were found to have an oval fatty mass with a hyperattenuated ring sign. In cases of left ACD, the patients presented with a more diffuse abdominal tenderness throughout the left side (52.0% vs 14.3%; P = 0.003). The patients with left ACD had fever and rebound tenderness more often than those with left PEA (40.0% vs 7.1%, P = 0.004; 52.0% vs 14.3%, P = 0.003, respectively). Laboratory abnormalities such as leukocytosis were also more frequently observed in left ACD (52.0% vs 15.4%, P = 0.006).

CONCLUSION: If patients have left-sided localized abdominal pain without associated symptoms or laboratory abnormalities, clinicians should suspect the diagnosis of PEA and consider a CT scan.

Development and Validation of the Korean Rome III Questionnaire for Diagnosis of Functional Gastrointestinal Disorders

Background/Aims

A self-report questionnaire is frequently used to measure symptoms reliably and to distinguish patients with functional gastrointestinal disorders (FGIDs) from those with other conditions. We produced and validated a cross-cultural adaptation of the Rome III questionnaire for diagnosis of FGIDs in Korea.

Methods

The Korean version of the Rome III (Rome III-K) questionnaire was developed through structural translational processes. Subsequently, reliability was measured by a test-retest procedure. Convergent validity was evaluated by comparing self-reported questionnaire data with the subsequent completion of the questionnaire by the physician based on an interview and with the clinical diagnosis. Concurrent validation using the validated Korean version of the Short Form-36 Health Survey (SF-36) was adopted to demonstrate discriminant validity.

Results

A total of 306 subjects were studied. Test-retest reliability was good, with a median Cronbach's α value of 0.83 (range, 0.71-0.97). The degree of agreement between patient-administered and physician-administered questionnaires to diagnose FGIDs was excellent; the κ index was 0.949 for irritable bowel syndrome, 0.883 for functional dyspepsia and 0.927 for functional heartburn. The physician's clinical diagnosis of functional dyspepsia showed the most marked discrepancy with that based on the self-administered questionnaire. Almost all SF-36 domains were impaired in participants diagnosed with one of these FGIDs according to the Rome III-K.

Conclusions

We developed the Rome III-K questionnaire though structural translational processes, and it revealed good test-retest reliability and satisfactory construct validity. These results suggest that this instrument will be useful for clinical and research assessments in the Korean population.

Pseudomonas aeruginosa bacteremia in patients with liver cirrhosis: a comparison with bacteremia caused by Enterobacteriaceae

Background

This study was performed to detect risk factors for Pseudomonas aeruginosa bacteremia in patients with liver cirrhosis.

Methods

A retrospective case–control study was designed to identify risk factors for P. aeruginosa bacteremia in cirrhotic patients. The cases were cirrhotic patients with P. aeruginosa bacteremia and the controls were cirrhotic patients with Enterobacteriaceae bacteremia.

Results

Sixty-one cases and the same number of controls were enrolled. In a multivariate analysis, younger age {adjusted odds ratio (aOR) per one year: 0.96, 95% confidence interval: 0.93 - 0.99}, nosocomial acquisition (aOR 3.87, 95% confidence interval: 1.50 - 9.94), preexisting biliary disease (aOR 4.79, 95% confidence interval: 1.92 - 10.47), and recent exposure to immunosuppressive agent (aOR 3.10, 95% confidence interval: 1.23 - 7.82) were associated with P. aeruginosa bacteremia. In the case group the frequency of appropriate initial antibiotic regimens was considerably lower than in the control group: 29.5% vs. 65.6% (P <0.01). However, thirty day mortality did not differ significantly between cases and controls (19.7% vs. 24.6%).

Conclusions

Nosocomial acquisition, preexisting biliary disease, and recent use of immunosuppressive agents are strong predictive factors for P. aeruginosa bacteremia in cirrhotic patients.

The PCR-based detection ofBabesia gibsoniinfection in dogs (German shepherds) reared in South Korea

German-shepherd dogs from the South Korean provinces of Gangwon and Gyunggi were used in a study exploring both the detection of Babesia gibsoni infection, by use of a PCR-based assay, and the nucleotide sequences of part of the P18 gene of the parasite. Nine (1.8%) of the 501 dogs checked were found PCR-positive. Although the prevalence of the infection appeared slightly higher in the male dogs than in the female (2% v. 1.7%), and in the dogs aged <3 years than in the older animals (2.7% v. 1.1%), these differences were not statistically significant. In addition, the prevalences of infection among the dogs from Gangwon (in the east of the country) and those from Gyunggi (in the west) appeared similar. All nine PCR-positive dogs were confirmed to have B. gibsoni infection by the microscopical examination of thin bloodsmears, which revealed that 0.1%-3% (mean=1.5%) of the dog's erythrocytes harboured the parasite. The nucleotide sequences of the P18 gene of B. gibsoni from each of the PCR-positive dogs were identical to each other and to the corresponding sequence - recorded under accession number AB053292 in the DNA Data Bank of Japan (DDBJ) - previously determined for isolates of B. gibsoni from Japanese dogs. Although the PCR products sequenced in the present study represent only a part of the P18 gene of B. gibsoni, it seems that South Korean and Japanese dogs carry a similar strain of B. gibsoni. These results may help to clarify the phylogenetic position of the B. gibsoni found in South Korea.

Fractalkine increases mesangial cell proliferation through reactive oxygen species and mitogen-activated protein kinases

Mesangial cell proliferation is one of the main features of chronic renal allograft rejection. One unique feature of fractalkine (CX3CL1) is its existence as both a membrane-tethered and a soluble form. Fractalkine expression is increased in acute and chronic allograft rejection. However, its role in mesangial cell proliferation has not yet been clearly explored. Thus, the present study examined whether fractalkine induced mesangial cell proliferation through production of reactive oxygen species (ROS) and activation of mitogen-activated protein kinase (MAPK), two known mediators of mesangial cell proliferation. Growth-arrested and synchronized mouse mesangial cells were stimulated with fractalkine in the presence versus absence of inhibitors against ROS, extracellular signal-regulated protein kinase (ERK), and p38 MAPK. Cell proliferation was assessed by methylthiazoletetrazolium assay, dichlorofluorescein (DCF)-sensitive cellular ROS production by a fluorometer, and MAPK activation by Western blot analysis. Fractalkine (10-50 ng/mL) significantly increased mesangial cell proliferation at 24 hours in a dose-dependent manner, an effect that was abrogated by the ROS and MAPK inhibitors. Fractalkine (50 ng/mL) also induced cellular ROS production and activation of ERK1/2 and p38 MAPK in mesangial cells. These results demonstrated that fractalkine can induce mesangial cell proliferation through production of cellular ROS and activation of MAPK.

Lipopolysaccharide increases monocyte binding to mesangial cells through fractalkine and its receptor

Fractalkine (CX3CL1) is a unique chemokine that functions not only as a chemokine but also as an adhesion molecule. Fractalkine plays an important role in the recruitment of macrophages into the kidneys by binding to its specific receptor CX3CR1, and renal fractalkine expression was shown to be increased in chronic renal allograft rejection. Considering that microcapillary inflammation is a key feature of chronic renal allograft rejection, the present study examined whether monocytes bind to mesangial cells cultured in the presence of lipopolysaccharide (LPS) through fractalkine/CX3CR1 in order to understand their regulation with respect to inflammation-induced renal allograft dysfunction. Mouse mesangial cells were stimulated with LPS in the presence or absence of fractalkine or CX3CR1 siRNA. Calcein-AM-labeled monocytes were used to evaluate monocyte binding. Fractalkine and CX3CR1 mRNA and protein expression were measured by real-time quantitative polymerase chain reaction and enzyme-linked immunosorbent assay, respectively. LPS at 100 ng/mL significantly increased monocyte binding to mesangial cells. Each siRNA against fractalkine or CX3CR1 effectively inhibited LPS-induced monocyte-mesangial cell binding. Fractalkine and CX3CR1 mRNA expression were enhanced in mesangial cells stimulated with LPS. Fractalkine protein synthesis in media and lysate of mesangial cells were also induced by LPS. These results demonstrated that LPS induces monocyte-mesangial cell binding through the fractalkine/CX3CR1 system and suggested that fractalkine/CX3CR1 system may contribute to renal inflammation leading to chronic renal allograft rejection.

Endothelin-1 enhances the proliferation of normal human melanocytes in a paradoxical manner from the TNF-α-inhibited condition, but tacrolimus promotes exclusively the cellular migration without proliferation: a proposed action mechanism for combination therapy of phototherapy and topical tacrolimus in vitiligo treatment

BACKGROUND

Vitiligo is an acquired pigmentary disorder caused by the destruction of melanocytes. Two of the major theories regarding the pathogenesis of vitiligo are the autoimmune theory and autocytotoxicity theory, but, the precise pathogenetic mechanism is still not clarified.

OBJECTIVES

We investigated the effects of ET-1, tacrolimus and tumour necrosis factor-α (TNF-α) on proliferation and migration of cultured normal human melanocytes (NHMs). We also sought to clarify the theoretical rationale underlying the topical tacrolimus monotherapy or tacrolimus-UV combination therapy as tools for vitiligo treatment.

METHODS

The effects of ET-1, tacrolimus and TNF-α on proliferation/migration of cultured NHMs were investigated by MTT assay/Boyden chamber transwell migration assay. We also examined roles of CXC-chemokine receptor II (CXCR II) and matrix metalloproteinases (MMPs) in such conditions.

RESULTS

ET-1 exerted a stimulatory effect on melanocyte proliferation and migration, but, tacrolimus exerted a stimulatory effect only on melanocyte migration higher than ET-1. TNF-α inhibited melanocyte proliferation in a dose-dependent manner. Paradoxically, TNF-α-pretreated NHMs exhibited an enhanced proliferative efficiency after being switched to ET-1. We found CXCRII was highly expressed in TNF-α-incubated melanocytes than the agents-free control, and ET-1 treatment after TNF-α preincubation showed the higher levels of CXCRII expression than the condition incubated with TNF-α alone. Moreover, the greater activities of MMP-2 and MMP-9 induced by tacrolimus than ET-1, reflected tacrolimus would enhance migration stimulatory effect in cultured NHMs.

CONCLUSIONS

Topical tacrolimus can be used an effective agent for vitiligo treatment as monotherapy, maybe due to its migration stimulatory action or TNF-α inhibitory property, and also as a component in combination therapy with UV treatment, considering the more upregulated MMPs activities are induced and the more effective migrations are feasible by itself than ET-1.

Healing effects of rebamipide and omeprazole in Helicobacter pylori-positive gastric ulcer patients after eradication therapy: a randomized double-blind, multinational, multi-institutional comparative study

BACKGROUND AND AIMS

A recent placebo-controlled trial showed that rebamipide, which is a mucosal-protective antiulcer agent, promoted gastric ulcer healing without affecting the Helicobacter pylori status. We conducted a randomized, double-blind trial to compare the healing effects of rebamipide and the proton-pump inhibitor omeprazole in H. pylori-positive gastric ulcers after H. pylori eradication therapy.

METHODS

After completion of 1 week of eradication therapy, 132 patients with H. pylori-positive gastric ulcer were enrolled in 5 Chinese and 4 Korean institutions. Patients were randomly assigned to take either 20 mg of omeprazole (n = 63) or 300 mg of rebamipide (n = 65) daily for 7 weeks. Healing was defined as complete recovery and S1 and S2 stage ulcer according to the Sakita-Miwa classification.

RESULTS

Healing rates at 12 weeks were 81.5% (53/65) and 82.5% (52/63) in the rebamipide and omeprazole groups, respectively. There was no significant difference in treatment efficacy, as evidenced by gastric ulcer healing rates (absolute difference -1.0%; 95% confidence interval -10.7 to 8.7; p = 0.88). The H. pylori eradication rate and ulcer healing rate did not differ between the groups, the latter regardless of eradication outcome.

CONCLUSIONS

Rebamipide is as effective as omeprazole in treating of H. pylori-positive gastric ulcer after eradication therapy.

Role of F-FDG PET Scans in Patients with Helicobacter pylori-Infected Gastric Low-Grade MALT Lymphoma

Background/Aims

Endoscopic ultrasound (EUS) plays a crucial role in the assessment and treatment of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma; however, interobserver variation, inadequate accuracy in judging the depth of tumor invasion, and histological heterogeneity of the tumor can limit its role. Thus, we have assessed the role of ¹⁸F-FDG PET scans in the management of Helicobacter pylori-infected gastric MALT lymphoma.

Methods

Eighteen patients with H. pylori-infected low-grade gastric MALT lymphoma underwent an ¹⁸F-FDG PET scan prior to receiving H. pylori eradication therapy. We analyzed these patients' clinicopathologic data and measured the baseline and change in the metabolic activity of the tumor using standardized uptake values (SUVs).

Results

Two patients failed to achieve complete remission of the low-grade gastric MALT lymphoma after successful H. pylori eradication. The baseline SUVs were significantly higher in these patients compared to successfully treated patients, 13.35±0.07 vs 2.98±0.93, respectively (n=2 vs n=16, p<0.001). The reduction in the SUV was significantly greater in the complete remission patients compared to treatment failure patients (p=0.018).

Conclusions

A high SUV at baseline ¹⁸F-FDG PET and a lower reduction in the SUV within 3 months after eradication therapy are associated with treatment failure in H. pylori-positive low-grade gastric MALT lymphoma patients undergoing eradication treatment.

Dosimetric characterization of an image-guided stereotactic small animal irradiator

Small animal irradiation provides an important tool used by preclinical studies to assess and optimize new treatment strategies such as stereotactic ablative radiotherapy. Characterization of radiation beams that are clinically and geometrically scaled for the small animal model is uniquely challenging for orthovoltage energies and minute field sizes. The irradiator employs a commercial x-ray device (XRAD 320, Precision x-ray, Inc.) with a custom collimation system to produce 1-10 mm diameter beams and a 50 mm reference beam. Absolute calibrations were performed using the AAPM TG-61 methodology. Beam's half-value layer (HVL) and timer error were measured with an ionization chamber. Percent depth dose (PDD), output factors (OFs) and off-axis ratios were measured using radiochromic film, a diode and a pinpoint ionization chamber at 19.76 and 24.76 cm source-to-surface distance (SSD). PDD measurements were also compared with Monte Carlo (MC) simulations. In-air and in-water absolute calibrations for the reference 50 mm diameter collimator at 19.76 cm SSD were measured as 20.96 and 20.79 Gy min(-1), respectively, agreeing within 0.8%. The HVL at 250 kVp and 15 mAs was measured to be 0.45 mm Cu. The reference field PDD MC simulation results agree with measured data within 3.5%. PDD data demonstrate typical increased penetration with increasing field size and SSD. For collimators larger than 5 mm in diameter, OFs measured using film, an ion chamber and a diode were within 3% agreement.

A case of hepatocellular carcinoma in the caudate lobe successfully treated by transcatheter arterial chemoembolization using drug-eluting beads

Hepatocellular carcinoma (HCC) in the caudate lobe remains one of the most intricate locations where various treatments tend to pose problems with regard to the optimal approach. Surgical resection has been regarded as the most effective treatment; however, isolated resection of the caudate lobe is strenuous and associated with a high rate of early recurrence. Percutaneous ablation might be technically difficult or impossible to perform due to the deep location of tumors and adjacent large vessels. Treatment with drug-eluting beads (DEB) can potentially enhance the therapeutic efficacy for patients with unresectable HCC by drawing on the slower, more consistent drug delivery process. We described a case of a 62-year-old man with HCC in the caudate lobe who was successfully treated by DEB.