[Dexmedetomidine up-regulates peripheral blood microRNA 183 to improve remifentanil-related hyperalgesia]

Objective: To investigate the effect of dexmedetomidine on remifentanil-induced hyperalgesia and its underlying mechanism through a prospective cohort study. Methods: From July 2018 to July 2019, 80 patients who underwent day surgery in Taizhou Central Hospital (including patients with laparoscopic cholecystectomy and oophorocystectomy) were selected, there were 46 males and 34 females with a mean age of (28.8±4.3) years. The patients were divided into dexmedetomidine group and control group with random number table, 40 cases in each group. After anesthesia induction, the dexmedetomidine group was managed with intravenous infusion of dexmedetomidine (1 μg/kg) within 10 minutes, while the control group was treated with an equal volume of normal saline. The patient's general information and the intraoperative data were recorded. The visual analogue scale (VAS) was evaluated before the operation and 1, 6 and 12 h after the surgery. The Von Frey cilia method was conducted to determine the mechanical pain threshold of the patient's non-surgical body parts. The vein blood was extracted at the corresponding time point to evaluate the expression level of miR-183 via the RT-PCR method. The demographic and preoperative parameters were comparable between the two groups. Results: Compared with the control group, the mechanical pain threshold in the dexmedetomidine group increased significantly at 1, 6, and 12 h after surgery (all P<0.05), and the VAS score at the corresponding time point declined significantly (all P<0.05). At the same time points, the serum miR-183 levels in the dexmedetomidine group were all significantly higher than those in the control group after surgery (2.07±0.41 vs 1.68±0.60, 1.99±0.33 vs 1.74±0.54, 1.88±0.36 vs 1.67±0.54, respectively, all P<0.05). Conclusion: A perioperative dose of dexmedetomidine in day surgery can significantly improve the remifentanil-related hyperalgesia, and it may be related to up-regulation of the expression of miR-183 in the blood.

Pancreatic Neuroendocrine Neoplasms: CT Spectral Imaging in Grading

RATIONALE AND OBJECTIVES

The purpose of this study was to define the CT spectral imaging characteristics of pancreatic neuroendocrine neoplasms (PNENs) and evaluate their potential for differential diagnosis of nonlow grade (non-LG) PNENs from low grade (LG) PNENs.

MATERIALS AND METHODS

CT spectral imaging data of 54 pathologically proven PNENs were retrospectively reviewed. Patients were divided into two groups: 40 cases with grade 1 in LG PNENs group and 14 cases with grade 2 and grade 3 in non-LG PNENs group.

RESULTS

Gender, calcification, inhomogeneity, invasiveness, PD dilatation, lymph node enlargement, size, normalized iodine (water) concentration in arterial phase (AP) (Iodine (ap)), normalized effective-Z (Z_ap), slope of normalized CT spectral curves in both AP, and portal venous phase were found to be significant variables for differentiating non-LG PNENs from LG PNENs (p < 0.05). Non-LG PNENs had larger size and lower Z_ap and Iodine (ap) than LG PNENs. The tumor size, Z_ap and Iodine (ap) had fair to good diagnostic performance with the area under receiver-operating-characteristic curve (AUC) 0.843, 0.733, and 0.728, respectively. Multivariate analysis with logistic regression had higher AUC (p<0.05) than all the single parameters except for size.

CONCLUSION

There were significant differences in CT spectral imaging parameters between non-LG and LG PNENs. Tumor size was the most promising independent parameter and the combination of quantitative parameters with qualitative parameters is the best predictor in differentiating of non-LG PNENs from LG PNENs. CT spectral imaging can help determine the malignancy of PNENs, which can better assist in surgical planning.

[Trans-oral robotic submandibular gland removal]

Submandibular gland excision was performed on two patients using trans-oral robotic surgery (TORS). Complications such as the injury of marginal mandibular branch of facial nerve, ranula in the floor of the mouth, and postoperative hemorrhage were not observed. Visible cervical scar can be avoided and esthetic outcome can be expected by using this surgical modality.

[Trends of in-hospital mortality and constituent ratio of patients with acute myocardial infarction]

Objective: To analyze the trends on constituent ratio of non-ST-segment-elevation (NSTEMI) and ST-segment-elevation myocardial infarction (STEMI) and related in-hospital mortality in acute myocardial infarction (AMI) patients hospitalized in Beijing Anzhen Hospital from 2004 to 2014. Methods: This is a single-center, retrospective study. We reviewed all patients hospitalized for AMI in Beijing Anzhen Hospital from January 1 2004 to December 31 2014, and collected all related information including hospitalization stay, the type of AMI, revascularization and in-hospital mortality. We analyzed the trends of constituent ratio of NSTEMI and STEMI, and their in-hospital mortalities during the 11 years. Results: Data from a total of 23 864 patients with AMI, including 5 539 STEMI and 18 325 NSTEMI, were analyzed. Compared with STEMI patients, NSTEMI patients were older, less likely to be male (P<0.001), had higher prevalence of hypertension, hyperlipidemia, diabetes (P<0.001), and lower prevalence of smoking (P<0.001). Additionally, patients with NSTEMI were more likely to have prior history of MI (12.6% (695/5 539) vs. 7.4% (1 354/18 325), P<0.001) and coronary artery bypass graft surgery (2.7% (152/5 539) vs. 0.7% (124/18 325), P<0.001). The constituent ratio of NSTEMI was significantly increased during the observation period, rising from 15.8% (107/802) in 2004 to 35.7% (1 273/3 583) in 2014 (P value for trend <0.001). The in-hospital mortality of NSTEMI patients was significantly lower compared with those with STEMI (1.84% (102 cases) vs. 2.74% (502 cases), P<0.001). The mortality of both STEMI and NSTEMI were significantly decreased during the 11 years (both P value for χ(2) trend test <0.001). After adjusting for other risk factors, NSTEMI was independently associated with lower in-hospital mortality (OR=0.50, 95%CI 0.40-0.63, P<0.001). Conclusions: In patients with AMI, the constituent ratio of NSTEMI versus STEMI is increased during the 11 years. The in-hospital mortality is decreased for both STEMI and NSTEMI patients in the past 11 years, and the in-hospital mortality rate of NSTEMI patients is lower than STEMI patients in this patient cohort during the observation period.

Biological effects of low-dose-rate irradiation of pancreatic carcinoma cells in vitro using 125I seeds

AIM: To determine the mechanism of the radiation-induced biological effects of ¹²⁵I seeds on pancreatic carcinoma cells in vitro.

METHODS: SW1990 and PANC-1 pancreatic cancer cell lines were cultured in DMEM in a suitable environment. Gray’s model of iodine-125 (¹²⁵I) seed irradiation was used. In vitro, exponential phase SW1990, and PANC-1 cells were exposed to 0, 2, 4, 6, and 8 Gy using ¹²⁵I radioactive seeds, with an initial dose rate of 12.13 cGy/h. A clonogenic survival experiment was performed to observe the ability of the cells to maintain their clonogenic capacity and to form colonies. Cell-cycle and apoptosis analyses were conducted to detect the apoptosis percentage in the SW1990 and PANC-1 cells. DNA synthesis was measured via a tritiated thymidine (³H-TdR) incorporation experiment. After continuous low-dose-rate irradiation with ¹²⁵I radioactive seeds, the survival fractions at 2 Gy (SF2), percentage apoptosis, and cell cycle phases of the SW1990 and PANC-1 pancreatic cancer cell lines were calculated and compared.

RESULTS: The survival fractions of the PANC-1 and SW1990 cells irradiated with ¹²⁵I seeds decreased exponentially as the dose increased. No significant difference in SF2 was observed between SW1990 and PANC-1 cells (0.766 ± 0.063 vs 0.729 ± 0.045, P < 0.05). The ¹²⁵I seeds induced a higher percentage of apoptosis than that observed in the control in both the SW1990 and PANC-1 cells. The rate of apoptosis increased with increasing radiation dosage. The percentage of apoptosis was slightly higher in the SW1990 cells than in the PANC-1 cells. Dose-dependent G2/M cell-cycle arrest was observed after ¹²⁵I seed irradiation, with a peak value at 6 Gy. As the dose increased, the percentage of G2/M cell cycle arrest increased in both cell lines, whereas the rate of DNA incorporation decreased. In the ³H-TdR incorporation experiment, the dosimetry results of both the SW1990 and PANC-1 cells decreased as the radiation dose increased, with a minimum at 6 Gy. There were no significant differences in the dosimetry results of the two cell lines when they were exposed to the same dose of radiation.

CONCLUSION: The pancreatic cancer cell-killing effects induced by ¹²⁵I radioactive seeds mainly occurred via apoptosis and G2/M cell cycle arrest.

The value of multidetector-row CT in the preoperative detection of pancreatic insulinomas

PURPOSE

The authors sought to quantitatively analyse enhancement characteristics of pancreatic insulinomas in different phases and determine the value of multidetector-row computed tomography (CT) for detecting insulinomas.

MATERIALS AND METHODS

Forty-six patients with surgically proven insulinomas diagnosed between 2002 and 2007 were retrospectively reviewed. These patients underwent single-phase (group 1) or dual-phase (group 2) helical CT scanning.

RESULTS

Sensitivity for detecting insulinomas in group 2 was superior to that in group 1 (p<0.05).The sensitivity for insulinoma detection in the arterial phase was superior to that in the portal-venous phase (p<0.05). The mean attenuation values of the insulinomas and normal pancreas during the unenhanced arterial and portal-venous phases were, respectively, 40.5+/-8.75 HU (Hounsfield units), 114.48+/-27.30 HU, 112.19+/-19.52 HU and 44.56+/-6.48 HU, 81.16+/-15.22 HU, 90.54+/-13.80 HU, and there was statistical difference between them (p=0.000). The contrast enhancement of insulinomas in the arterial and portal-venous phases was 74.03+/-29.51 HU and 70.90+/-21.93 HU, respectively, and there was no statistical difference between them (p=0.499). The tumour to normal-pancreas attenuation differences in the arterial and portal-venous phases were respectively 33.32+/-20.96 HU and 20.58+/-16.32 HU, respectively, and there was statistical difference between them (p=0.011).

CONCLUSIONS

Dual-phase CT has a promising sensitivity in detecting pancreatic insulinomas. The acquisition of images in the arterial phase is more helpful for detecting insulinomas.

Easier hepatic resections with a straight needle

BACKGROUND

A stainless-sheathed, straight needle with a hook near the top of the inner needle was designed to facilitate hepatic resections.

METHODS

First, using this needle, two rows of interlocking mattress sutures were made along the division line; then, hepatic transection was performed between these rows by electrocautery or forceps.

RESULTS

Since 1997, we have performed this kind of hepatic resections in 43 cases, including 9 right lobectomies, 5 bisegmentectomies, 7 segmentectomies, 4 subsegmentectomies, 2 partial hepatectomies, 15 left lateral segmentectomies, and 1 hepatorrhaphy. In most cases, intraoperative hemorrhage was minimal. Neither specified inflow nor backflow control procedures were needed.

CONCLUSION

Use of this needle may reduce the difficulty of the technique and blood loss for right hepatic lobectomy, left lateral segmentectomy, and some segmental or partial hepatectomy procedures.

Expression of oncogene products HER2/Neu and Ras and fibrosis-related growth factors bFGF, TGF-beta, and PDGF in bile from biliary malignancies and inflammatory disorders

The expression of several growth factors and K-ras gene mutation in bile were studied to better understand the pathogenesis and improve early diagnosis of bile duct cancers. Bile samples were collected from 12 cholangiocarcinomas (CLC), 10 ampullary cancers (APC), 3 gallbladder cancers (GBC), 7 pancreatic cancers (PNC), 9 biliary tract infection (BTI), 8 biliary stone disease (ST), and 5 normal controls (NC). The highest mean value of TGF-beta in bile was in patients with BTI; the mean levels of bFGF and PDGF were highest in CLC, and patients with APC and CLC had higher expression of HER2/Neu than other groups. In bile, a K-ras gene codon 12 mutation was found in 5 of 6 (83%) cases of CLC by the PCR-RFLP method. The results suggest overexpression of bFGF, PDGF, and HER2/Neu and the presence of K-ras mutation are important for carcinogenesis of bile duct cancers, and detection of the above abnormalities in bile is helpful for early diagnosis.

Multiple mucosal lesions in the duodenum: exploring the potential clinical backgrounds and concurrent diseases

BACKGROUND/AIMS

Multiple mucosal lesions of the duodenum (MMLD), presenting with multiple mucosal redness and ulcers with or without blood clots in the proximal duodenum, may be occasionally discovered during gastroduodenal endoscopy. This study was undertaken to investigate the clinical implications of MMLD.

METHODOLOGY

Endoscopic pictures and charts of patients with MMLD were retrospectively reviewed. The endoscopic features of MMLD were recorded for both location and severity. The endoscopic severity of MMLD was defined as follows: Grade I: multiple mucosal redness; Grade II: multiple ulcers with clear base; Grade III: multiple ulcers with reddish base or fresh blood clot coating.

RESULTS

A total of 229 (1.08%) MMLD events in 207 patients were identified out of a total of 21,223 upper gastrointestinal endoscopies. Common backgrounds of patients with MMLD included diabetes, hypertension, and some chemical exposure, such as cigarettes, alcohol, nonsteroidal anti-inflammatory drugs and anti-Helicobacter pyloric regimens. Common concurrent diseases included peptic disease, sepsis, malignancy, renal insufficiency, and portal hypertension. MMLD associated with sepsis usually involved only the second portion of the duodenum, but when associated with nonsteroidal anti-inflammatory drugs was less often only involved with the second portion. MMLD with renal insufficiency was less prone to involve the bulb alone. Diabetes-related MMLD tended to present with mild severity as defined by Grade I, H. pylori infection with Grade II, and renal insufficiency and portal hypertension with higher severity such as Grade III. Nine patients had fatal outcomes due to uncontrolled concurrent diseases, other than MMLD.

CONCLUSIONS

MMLD, an uncommon occurrence in endoscopy, can develop from several clinical settings. When encountering MMLD while performing endoscopy, the best policy is to search and correct the concurrent diseases as early as possible.

Erythrocyte Lewis antigen phenotypes of dyspeptic patients in Taiwan--correlattion of host factor with Helicobacter pylori infection

BACKGROUND AND AIMS

Because of the molecular mimicry between Helicobacter pylori lipopolysaccharide and host Lewis blood-group antigens, Lewis antigen may mediate specific H. pylori binding to surface epithelial cells in gastric mucosa. We, therefore, tested whether different Lewis antigen phenotypes have different prevalence rates of H. pylori infection, and determined the specific H. pylori-related disease entities or histologic features.

METHOD

A total of 342 dyspeptic patients without previous anti-H. pylori therapy were enrolled after endoscopy. The Lewis phenotypes, defined as Le(a-b-), Le(a-b+), Le(a+b-), and Le(a+b+) subtypes, were determined from the expression or absence of Lewis antigens (Le(a) and Le(b)) on erythrocytes in each patient using monoclonal antibodies. The H. pylori-specific gastric histology was evaluated using the updated Sydney's system.

RESULTS

Of 342 patients, 233 (68.1%) had H. pylori infection. The H. pylori infection rates were significantly higher in patients with Lewis phenotypes Le(a+b-) and Le(a+b+) (p < 0.05). Patients expressing the Le(a) antigen had a higher H. pylori infection rate than those without the Le(a) antigen (80.8 vs 64%, p < 0.005). In H. pylori-infected patients, patients expressing Le(b) antigen had a lower rate of gastroduodenal ulcers than those without Le(b) antigen (46.9 vs 61.4%, p < 0.05). H. pylori-positive patients who expressed the Le(b) antigen had higher bacterial density and inflammation severity in the gastric cardia than those who did not. Patients who expressed the Le(a) antigen had lower bacterial density, less chronic inflammation severity, and lower frequency of lymphoid follicles in the gastric cardia than those who did not (p < 0.05).

CONCLUSION

The erythrocyte Lewis phenotype can be a significant host factor related to susceptibility, different histologic patterns, and clinical outcomes of H. pylori infection in Taiwan.

Protective effect of melatonin on renal injury of rats induced by bile duct ligation

Oxygen radicals have been implicated in the pathogenesis of renal injury induced by extrahepatic cholestasis. We conduct this study to investigate whether melatonin can have a protective effect against such injury. Either normal saline or gentamicin with or without melatonin was injected into rats that received either a bile duct ligation or a sham operation. The serum levels of malondialdehyde and total antioxidative activity were measured. The kidney was fixed for histologic scoring of renal injury. The serum malondialdehyde level was highest in the rats that received both bile duct ligation and gentamicin injection. Treatment with melatonin significantly increased the serum total antioxidative activity and reduced the serum malondialdehyde concentration. The mean score of renal injury, highest in the rats receiving bile duct ligation and gentamicin injection, was significantly reduced with melatonin treatment. By reducing the systemic oxygen radicals, supplementation with antioxidants exerts a protective effect on the renal injury induced by extrahepatic cholestasis.

Ranitidine bismuth citrate or omeprazole-based triple therapy for Helicobacter pylori eradication in Helicobacter pylori-infected non-ulcer dyspepsia

AIM

To test the eradication rate of Helicobacter pylori by ranitidine bismuth citrate-based triple therapy, and evaluate the symptomatic response of Helicobacter pylori eradication therapy for non-ulcer dyspepsia.

METHODS

A total of 59 consecutive Helicobacter pylori infected non-ulcer dyspepsia patients were randomly selected to receive either one of two triple therapy regimens, including metronidazole, amoxycillin plus ranitidine bismuth citrate (RAM group) or omeprazole (OAM group). To determine the success of eradication, patients underwent the 13C-urea breath test, 6 weeks and one year after treatment. The dyspeptic symptom scores were also assessed at the time of enrolment, 6 weeks and one year after treatment.

RESULTS

Per-protocol and intention-to-treat eradication rates were 77.7% and 70% in RAM group and 83.8% and 68.9% in OAM group (p = non significant). At both the 6th week and at the first year after treatment, the mean symptom scores were lower than pre-treatment scores in the study population, regardless of whether treatment was successful or not. However, patients, whether eradicated successfully or not-eradicated, presented similar 6-week and 1-year scores.

CONCLUSIONS

One-week RAM triple therapy, which is cheaper than the OAM regimen, is a relatively effective alternative regimen for Helicobacter pylori eradication in Taiwanese. Triple therapy for Helicobacter pylori eradication was not the whole management for the relief of dyspeptic symptoms of non-ulcer dyspepsia patients.

In vitro and in vivo studies for modified ethyl cyanoacrylate regimens for sclerotherapy

Cyanoacrylates have known for their ability to polymerize rapidly in the presence of traces of weakly basic moieties such as water. The tissue adhesive, Histoacryl(R) (N-butyl 2-cyanoacrylate), has been reported to control bleeding through endoscopic sclerotherapy. But the commercially available Histoacryl(R) is expensive, and it has the problem like other cyanoacrylates that the glue tends to flow/run away from the point of application, which is inherent to the low viscosity, making precise application difficult. In this study, ethyl cyanoacrylate (ECA), the main constituent of "super glue," was employed instead of Histoacryl(R) due to its lower cost. The aim of the research is to modify the compositions of ECA regimen and evaluate its feasibility for sclerosant application through both in vitro flow circuit model and in vivo animal tests. It was noted that the difference in the relative hardening rate between the in vitro Hepes-Tyrodes buffer flowing model and the in vivo rat model for the ECA and Histoacryl(R) was related to the existence of the blood protein, such as albumin, in the physiological milieu. It was also noticed that the ECA setting rate was greatly increased either in Hepes-Tyrodes buffer or in blood (to a comparable rate as Histoacryl(R) in vivo) by adding a few doses of caffeine, which acts as a polymerization initiator. This would lead to far better injection precision during sclerotherapy. Furthermore, in vivo histological examination for the occluded lumen of the rat's inferior vena cava and a clinical piglet portal vein occlusion experiment have suggested this new sclerosant regimen, caffeine/ECA, is of great promise in endoscopic sclerotherapy.

Characterization of a proximal element in the rat preadipocyte factor-1 (Pref-1) gene promoter

Preadipocyte factor-1 (Pref-1) was shown to negatively regulate adipocyte differentiation. We recently reported that ZOG, a rat homolog of Pref-1, was specifically expressed in the adrenal zona glomerulosa. Results of the investigation of Pref-1 expression in preadipocyte and in undifferentiated adrenal cortex suggested that down-regulation of Pref-1 gene was closely correlated with the differentiation process. In this study we demonstrate that an upstream region (from -76 to -47) of the rat Pref-1 gene was essential for its expression in adrenocortical carcinoma-derived H295R cells. A nucleotide sequence found in this region, GCGTGGGCGTGGGCGGGGG (Egr/GC-box), seemed to contain three elements, two early growth response (Egr) elements and one GC-box, overlapping each other. Mutations of four or five nucleotides in a 7-nucleotides-stretch in the midst of the Egr/GC-box eliminated the binding of Sp1/3, abolished the activation by Egr-factor(s) and diminished the Pref-1 promoter activity. When mutations were introduced into the outside of the middle portion, the binding of Sp1/3 to the Egr/GC-box was abolished similarly. However, the decrease in the promoter activity was less than that found with the construct mutated at the middle. These results indicated that an element present at the 7-nucleotides-stretch in the midst of the Egr/GC-box might be important for the Pref-1 promoter activity, and this proximal element was possibly activated by a still-unidentified nuclear factor(s). This element would function as the promoter of the Pref-1 gene in H295R cells, but not in HeLa cells.

Electrochemical therapy--comparison with other local treatment methods on rat model

BACKGROUND/AIMS

Electrochemical therapy is an alternative to treat hepatoma. We compare this method with the other local injection methods on rat liver.

METHODOLOGY

Five groups of Wister rats (24 in each) were anaesthetized. Electrochemical therapy was set under direct current, 6 volts, electrodes were 0.5 cm apart, 0.5 cm deep into exposed parenchyma for 10 min. Local injection was done with 50 microL of 95% alcohol, 30 microL of 20% acetic acid, 30 microL of 35% hydrochloric acid, and 30 microL of 20% sodium hydroxide via a 27-gauge needle under direct vision into each rat. Rats and their livers were examined postmortem on day 1, 3, 7 and 14.

RESULTS

In electrochemical therapy, the treated area showed coagulation necrosis and without blood cells on day 1; then the margin became blurred. Mononuclear cell infiltration, reperfusion and fibrous band formation were prominent from day 3 through day 14. In local injection groups, the necrosis is quite irregular and unpredictable. The regeneration went under similar process.

CONCLUSIONS

To destroy tissue locally, electrochemical therapy is unique for its predictability in destructive area and the recovery process and is as effective as the other injection methods. Therefore, it has great potential for hepatoma treatment.

Intensity-noise suppression by ytterbium codoping in heavily erbium-doped fiber lasers with partly clustered erbium ions

The effect of ytterbium codoping in heavily erbium-doped fibers with partly clustered erbium ions on the intensity noise stemming from both pump-rate and cavity-loss fluctuations is theoretically investigated with a modified ion-cluster model. Numerical results indicate that low-frequency (below 1 MHz) noise can be greatly suppressed by ytterbium codoping.

Hepatofugal flow on computed tomography of arterial portography: its correlation with esophageal varices bleeding

BACKGROUND/AIMS

To study the portal flow patterns from CTAP (computed tomography of arterial portography), then to predict the existence of esophageal varices bleeding clinically.

METHODOLOGY

192 patients who underwent CTAP from superior mesenteric artery infusion were recruited in this study. The obtained images were classified according to our proposed criteria. Stage 0: hepatopetal flow, when all the contrast medium from the superior mesenteric vein entered the portal vein. Stage 1: when the contrast medium opacified the splenic vein or the other collateral vessels. Stage II: when the contrast medium opacified the paraesophageal vessels without entering the inner wall of the esophagus. Stage III: when the contrast medium opacified the collaterals up to the inner wall of the esophagus.

RESULTS

The incidence of bleeding esophageal varices was correlated to the different stages of collateral flows pattern obtained. The esophageal varices bleeding rates were 0/137, 1/16, 1/14, 16/25 for stage 0, I, II and III, respectively. The incidence of bleeding esophageal varices was significantly higher in stage III group than in the other groups (P < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of stage III patients in regard to the occurrence of bleeding esophageal varices were estimated as 80.0%, 98.8%, 88.9%, 94.8%, and 94.3%, respectively.

CONCLUSIONS

Our results show that CTAP demonstrates the portal flow patterns and collateral veins clearly, which can serve as an excellent imaging modality to predict the risk of esophageal varices bleeding.

Lower-dose (13)C-urea breath test to detect Helicobacter pylori infection-comparison between infrared spectrometer and mass spectrometry analysis

BACKGROUND

The expense of the (13)C-urea breath test (UBT) to detect Helicobacter pylori infection is mainly due to the cost of (13)C-urea and the analysis using isotope ratio mass spectrometry (IRMS).

AIM

To test whether a UBT, using a lower dose of urea and lower-priced isotope-selective nondispersive infrared spectrometry (INIS), can preserve diagnostic efficacy in clinical practice.

METHODS

A total of 177 dyspeptic patients received endoscopy for H. pylori culture and histology. All of them received a UBT in which the duplicate baseline, 10 min, and 15 min breath samples after ingestion of 50 mg (13)C-urea were collected to analyse the excess (13)CO(2)/(12)CO(2) ratio (ECR) by IRMS (ABCA, Europa Scientific, UK) and INIS (UBiT-IR200, Photal Otsuka Electronics, Japan), respectively.

RESULTS

Of the 177 patients, 84 were infected and 93 were uninfected with H. pylori. A close correlation of ECR was found between IRMS and INIS (r=0.9829 at 10 min; r=0.9918 at 15 min, P < 0.0001). Analysing the 15-min samples, UBT by both IRMS and INIS achieved the same sensitivity (96. 4%) and specificity (98.9%).

CONCLUSIONS

INIS is as effective as IRMS for UBT, and can use a lower dose of (13)C-urea. This can provide an economic UBT, using the lower-priced INIS and a low dose of (13)C-urea.

Human biliary beta-glucuronidase activity before and after relief of bile duct obstruction: is it the major role in the formation of pigment gallstones?

BACKGROUND AND AIMS

The bacterial beta-glucuronidase (bBG) can deconjugate conjugated bilirubin to form calcium bilirubinate gallstone. Yet, the role of the human biliary beta-glucuronidase (hBG) in the pathogenesis of pigment gallstone formation still remains unsolved.

METHODS

Hepatic bile was collected from bile-duct-obstructed patients on the day of, and 3 days after, biliary drainage. Patients were divided into pigment-stone (PS) group (n = 34) and stone-free (SF) group (n = 29). All patients of the PS group had the complication of cholangitis. The concentrations of bile contents and the activities of bBG and hBG were measured.

RESULTS

The activities of hBG and bBG in bile obtained on the day of biliary drainage were higher in the PS group than in the SF group (activities corrected for bile salt concentration: hBG 128.7 +/- 340.0 vs 13.1 +/- 25.0 U/mmol; bBG 12.5 +/- 22.2 vs 4.6 +/- 7.7 U/mmol, P < 0.05). This difference disappeared after biliary drainage. The changes of enzyme activity in the bile of the SF group were unremarkable before and after biliary drainage. The mean concentrations of bile pigments and free calcium in the PS group were lower than those in the SF group.

CONCLUSIONS

An increase in the activity of hBG may be a secondary response, developed after bile duct inflammation because it was elevated only when the bile duct obstruction was associated with infection.

Impact of Helicobacter pylori antimicrobial resistance on the outcome of 1-week lansoprazole-based triple therapy

PURPOSE

To determine the effect of Helicobacter pylori antimicrobial resistance on the efficacy of different proton pump inhibitor (PPI)-based triple therapies.

METHODS

One-hundred and twelve dyspeptic patients with H. pylori infection, as demonstrated by positive histology and culture, were randomized to receive one of the three PPI-based triple therapies. The regimens included lansoprazole (L) plus any two of the following three antibiotics: amoxicillin (A), metronidazole (M), and clarithromycin (C); patients were allocated to ALC, MLC, and ALM subgroups. Six weeks after the start of triple therapy, the 13C-urea breath test (UBT) was performed to evaluate the success of H. pylori eradication. Patients with positive UBT results underwent endoscopy for H. pylori culture. The pre- and post-treatment H. pylori isolates were analyzed for initial and acquired resistance using the E-test.

RESULTS

One hundred patients completed the study. The H. pylori eradication rates were 70% (21/30) in the ALM subgroups, 79% (26/33) in the MLC subgroup, and 89% (33/37) in the ALC subgroup. The frequencies of pretreatment H. pylori antimicrobial resistance were 0% for amoxicillin resistance (AR), 32% for metronidazole resistance (MR), and 6% for clarithromycin resistance (CR). For H. pylori isolates with initial MR, the eradication rates in the ALM (40%) and MLC (67%) subgroups were apparently lower than that in the ALC (92%) subgroup. In the ALM and MLC subgroups (i.e., patients who received metronidazole), the eradication failure rate was significantly higher for patients with MR isolates than for patients with metronidazole-susceptible isolates (47% vs 16%, p < 0.05). In the ALC and MLC subgroups (i.e., patients who received clarithromycin), the eradication failure rate was significantly higher for patients with CR isolates than for those with clarithromycin-susceptible isolates (100% vs 11%, p < 0.05).

CONCLUSIONS

The results indicate that H. pylori antimicrobial resistance is relevant to the success of eradication. The high MR but low CR and AR prevalence among H. pylori isolates in this study suggests that PPI-based triple therapy including amoxicillin and clarithromycin may achieve the most favorable eradication rate.

Melatonin prevents pigment gallstone formation induced by bile duct ligation in guinea pigs

Free radical-mediated oxidative stress has been implicated in the genesis of gallstone in vitro. This study was designed to examine the oxidative stress changes during pigment gallstone formation and to investigate whether melatonin (MLT) could act as a chemopreventive agent for cholelithiasis in a guinea pig model. The common bile duct of guinea pigs was ligated with or without MLT pretreatment. Animals were studied on day 7, 9, 12, and 14 after surgery. Stone and/or sludge developed in ligated guinea pigs without MLT. Fourier transform infrared spectra of the sludge showed the presence of calcium bilirubinate, whose peak height per milligram of sludge gradually increased with time after ligation. Total antioxidant activity (TAA) in bile of guinea pigs at day 14 after ligation reduced to one third of the level in sham-operated controls (P <.001). In addition, the bile of ligated guinea pigs had increased pH (P <.001), bile salts (P <.01), and malondialdehyde (MDA) (P <.05), compared to sham controls. Pretreatment of guinea pigs with MLT at a dose of 1,000 microg/kg significantly decreased the incidence of pigment gallstone formation at day 14 after ligation, as compared to no pretreatment (0/7 vs. 8/10). MLT also reverted the ligation-induced changes in biliary bile salts, pH, MDA, and TAA to control levels. These in vivo findings support a causative role of oxidative stress in the bile duct ligation-induced pigment gallstone formation. Antioxidants may prove useful in preventing pigment gallstone formation in humans.

Selection of lower cutoff point of [13C]urea breath test is helpful to monitor H. pylori eradication after proton pump inhibitor-based triple therapy

Our objectives were to test the efficacy of [13C] urea breath test (UBT) for H. pylori infection in patients before and after proton pump inhibitor (PPI) based triple therapy, and thus to trace the optimal cutoff value of UBT to monitor H. pylori eradication; and to analyze the histologic bacterial density and distribution of H. pylori in patients with equivocal UBT. A total of 441 dyspeptic cases patients enrolled and completed the study design, including 120 noninfected and 321 H. pylori-infected patients. All 441 cases had received the same protocol of UBT. in which the baseline and 15-min gas samples after ingestion of 100 mg 13C-labeled urea were analyzed for excess 13CO2/12CO2 ratio (ECR). In addition, a first endoscopy was performed in each patient to evaluate the initial status of H. pylori by culture and histology. Of the 321 H. pylori-infected patients, 286 received a second endoscopy and a second UBT six weeks after completing any one of four regimens of the PPI-based triple therapy to document the success of H. pylori eradication. During both sessions of endoscopy, topographic gastric biopsies for histology were sampled to evaluate the distribution and density of H. pylori. Based on the diagnostic standard by culture and histology, the sensitivity and specificity of the first UBT achieved most optimally was 97.5% and 96.7%, respectively, by setting the cutoff point of ECR at 4.0. In contrast, using the same cutoff point of 4.0, the sensitivity and specificity of the second UBT in patients after therapy achieved just 80% and 97.6%, respectively. By applying cutoff points downward of 4.0, 3.5, 3, and 2.5 for the second UBT, the sensitivity was elevated to 80%, 82.8%, 88.6%, and 94.3%, respectively, while the specificity was preserved at more than 95.2%. The overall eradication rate of H. pylori was 87.8% (251/286). Seven of 35 patients with failure of therapy had equivocal ECR at the second UBT (range 2-5), and this accounted for the false negative result. All seven patients had low bacterial densities, and three patients had bacteria distributed only in high body near the cardia. In conclusion, selection of a lower cutoff value of ECR at 2.5 is helpful to maintain the diagnostic accuracy of UBT for monitoring the H. pylori eradication. The equivocal ECR of UBT after therapy would be related to the low bacterial load and its distribution.

Carbon urea breath test is not as accurate as endoscopy to detect Helicobacter pylori after gastrectomy

BACKGROUND

This study was conducted to determine (1) whether Helicobacter pylori infection decreases in conjunction with time elapsed after gastrectomy and (2) the diagnostic efficacy of (13)C urea breath test (UBT) for H pylori in patients after gastrectomy.

METHODS

From January 1997 to June 1998, 86 patients who had undergone gastrectomy and 180 patients with dyspepsia without gastrectomy were enrolled. A UBT for the analysis of excess (13)CO(2)/(12)CO(2) ratio (ECR) was obtained for each patient. Each patient also underwent endoscopy to obtain gastric biopsies for histology and H pylori culture. The presence of H pylori by either histology or culture served as the standard to test the efficacy of UBT. The 86 patients with a prior gastrectomy were categorized into 3 subgroups (I, less than 1 year; II, 1 to 3 years; III, greater than 3 years), according to the interval between surgery and UBT. The initial H pylori status of these 86 patients was determined by histologic evaluation of the resected stomach.

RESULTS

At trial initiation, the postgastrectomy group had a lower H pylori infection rate (52.3%) as compared with the dyspeptic control group (80%). The initial H pylori status among subgroups I, II, and III was similar. There was a trend for the presence of H pylori in the stomach to decrease with increasing time elapsed after surgery (I to III: 68.8%, 48.3%, 36%, respectively; p < 0.05). The maximum UBT sensitivity and specificity achieved were 82.2% and 87.8% in the gastrectomy group and 97.2% and 96.3% in the dyspeptic group, with cutoff points of 2.5 and 4.0, respectively.

CONCLUSION

The prevalence of H pylori diminishes with time elapsed after gastrectomy. UBT for detection of H pylori is more effective in patients without prior gastrectomy than in patients who have undergone gastrectomy and is less effective than endoscopy for patients who have had a gastrectomy.

Modified technique for introducer-type percutaneous endoscopic gastrostomy and jejunostomy: assisted by a novel trocar and fasteners

BACKGROUND AND PURPOSE

Commercially available kits for percutaneous endoscopic gastrostomy (PEG) and jejunostomy comprise a substantial proportion of the cost of patients for this procedure. A modified introducer-type technique and new instrumentation for PEG and jejunostomy that substantially reduces the cost of the kit were tested for efficacy and safety.

METHODS

This technique was tested on 10 pigs as a pilot study, and then applied to seven consecutive patients undergoing gastrostomy and three patients undergoing gastrostomy with jejunostomy. The endoscopy and site selection for gastrostomy were the same as in standard PEG. Two novel fasteners for fixing the gastric wall to the abdominal wall and a guide-wire in the selected site were inserted separately into the stomach through 15-gauge needles. A stainless steel trocar with a detachable sheath was introduced into the stomach over the guide-wire. After the inner stylet was removed, a 24-French Foley catheter was inserted as a feeding tube. Gastrostomy was completed after balloon inflation and external fixation. If jejunostomy was indicated, a 12-French nasogastric tube was inserted through the gastrostomy. The procedure time, complications, and costs were compared with those for another 15 consecutive patients who underwent the conventional pull-through method of PEG and jejunostomy using commercially available kits.

RESULTS

No significant difference was found in procedure time between patients who underwent the modified or conventional gastrostomy procedures (mean +/- standard deviation, 15.4 +/- 5.6 min). There was a similar incidence of short-term complications in the two treatment groups. The feeding catheters required replacement more quickly than did those in the commercial kits (80 +/- 58 vs 217 +/- 140 d). The cost to patients was much less with the new method than with conventional PEG.

CONCLUSIONS

The new gastrostomy method achieves the same medical quality at far less cost for patients.

Ultraviolet-initiated reactions of H(2) with germanosilicate fibers and H(2) concentration dependence of the Bragg wavelength of a fiber grating

We present a model with which to calculate the index increase induced in standard single-mode fiber by hydrogen loading. Also, we propose that the dominant products of reaction in UV-written hydrogenated standard communication fibers are GeE? and Si-OH. Based on the above models, we calculate the Bragg wavelength shifts that are due to hydrogen diffusion out of the fiber gratings. The relative effective index change that is due to hydrogen dissolved in fiber can be as much as 6 x 10(-4) if standard telecom fiber is hydrogen loaded with a concentration of ~1.44 mol.%. Theoretical results agree with experimental results.

Serologic response to lower-molecular-weight proteins of H. pylori is related to clinical outcome of H. pylori infection in Taiwan

The study aimed to examine the serum serological response among H. pylori-infected patients with various upper gastrointestinal diagnoses; to ascertain whether it could be predictive to the diagnostic outcome of dyspepsia. One hundred seventy H. pylori-infected patients with dyspeptic symptoms but without previous treatment were enrolled, including those with duodenal ulcer disease (N = 47), gastric ulcer (N = 23), nonulcer dyspepsia (N = 60), gastric cancer (N = 34), and MALToma (N = 6). Sera from dyspeptic patients without H. pylori infection (N = 33) were used as controls. During endoscopy, gastric biopsies were taken for CLO-test, histology, and culture for the detection of H. pylori infection, defined by a positive culture or positive results of both CLO-test and histology. Total H. pylori IgG antibody was tested by an ELISA method. Antibody responses to specific H. pylori proteins were tested by a western blotting system. Of patients with H. pylori-infected gastroduodenal diseases, 76.5%, 42.9%, 23.6%, 46.7%, 84.1%, 76.5%, 82.9%, and 32.4% on average, showed responses to the 116-kDa (CagA), 89-kDa (VacA), 60-kDa, 45-kDa, 35-kDa, 30-kDa, 26.5-kDa, and 19.5-kDa H. pylori-specific proteins, respectively. A significant association was found between the serological response to 19.5-kDa and 26.5-kDa proteins and malignant outcome of H. pylori infection (P<0.02). Among patients without malignancy, the absence of a band at 19.5 kDa was statistically associated with the presence of an ulcer (P<0.05). The presence of serum antibody against CagA is not different between patients with ulcer and with malignancy in clinical diagnosis. The serum test for detecting antibodies against lower-molecular-weight proteins of H. pylori, such as those of 19.5 and 26.5 kDa, could be useful to identify H. pylori-infected patients at risk of peptic ulcer or malignancy.

Saturated saline enhances the effect of electrochemical therapy

We conducted this experiment to assess the effect of saline injection in electrochemical therapy. Platinum electrodes using direct current were inserted into egg white or liver parenchyma. Pure water or 0.9%, 3%, or 26% sodium chloride were injected into various objects to compare with the control group (no injection). Power was set at 10 V. In the egg-white experiment, gas bubbles and coagulated protein developed around the electrodes. In ex vivo liver, frothy reddish debris developed around the cathodes, while a hardening and shrunken surface occurred around the anodes. The pH was 14 around the cathodes, 0 around the anodes. The electric current, the amount of coagulated protein, and the severity of tissue damage were all in proportion to the concentrations of the injected saline. The volume destroyed in the 26% saline group was 8.1 times larger than that of the control group. Therefore, injected saline, especially saturated saline, can enhance the effect of electrochemical therapy.

The effects of bile duct obstruction on the biliary secretion of ciprofloxacin in piglets

OBJECTIVE

The aim of this study was to evaluate the effect of bile duct obstruction on biliary secretion of ciprofloxacin and to look for useful parameters to guide clinical use of antibiotics in patients with acute cholangitis.

METHODS

Twenty-five Landrace piglets were used in this study. Their common bile ducts were ligated, with a duration ranging from 1 to 7 days. The changes of liver biochemical tests, intrabiliary pressure, diameter of common bile duct, and concentration of ciprofloxacin in bile were compared among the piglets with different severity of bile duct obstruction.

RESULTS

The bile-to-serum ratio of the ciprofloxacin concentration was 586.4% +/- 140.3% before the ligation of bile duct and was reduced significantly to 94.5% +/- 118.0% after 1-day obstruction. The biliary secretion of ciprofloxacin was greatly affected by the intrabiliary pressure in that the bile-to-serum ratio of ciprofloxacin concentration was reduced to 12.2% +/- 14.8% when the intrabiliary pressure reached to 32 cm H2O. The change in the intrabiliary pressure was correlated with the diameter of common bile duct, with a correlation coefficient of 0.90 (p < 0.001).

CONCLUSIONS

Biliary secretion of ciprofloxacin is decreased in proportion to the increase of intrabiliary pressure. In obstruction, a markedly dilated common bile duct usually indicates high intrabiliary pressure, and thus biliary concentrations of antibiotics will be lower than expected. Hence, our observations suggest that choosing an antibiotic with high antimicrobial activity, or establishing a biliary drainage to lower the intrabiliary pressure, would be beneficial for patients suffering from cholangitis with a dilated biliary tree.

A three-day course of intravenous omeprazole plus antibiotics for H. pylori-positive bleeding duodenal ulcer

BACKGROUND/AIMS

This prospective trial aimed to test the efficacy of 3-day intravenous omeprazole plus antibiotics for Helicobacter pylori (H. pylori) eradication rate, and to see whether individualized response to omeprazole in intragastric pH elevation will alter the success of eradication.

METHODOLOGY

One hundred and thirty-eight cases with H. pylori-positive duodenal ulcer bleeding were randomized into four therapy groups: Group 1 (n = 32) received a 3-day course of intravenous omeprazole (80 mg loading then 40 mg q 9 am & 9 pm) plus ampicillin/salbactum (1.5 gm i.v. loading then 750 mg q 9 am, 3 pm, & 9 pm); Group 2 (n = 35) followed protocol as for Group 1 except the antibiotics were metronidazole and erythromycin (both 500 mg i.v. q 9 am, 3 pm, & 9 pm). Group 3 (n = 31) followed protocol as for Group 1 and further added with erythromycin (both 500 mg i.v. q 9 am, 3 pm, & 9 pm). Group 4 served as a control group (n = 40) receiving oral dual therapy after leaving the emergency room (omeprazole 20 mg and amoxycillin 1 g bid x 2 weeks). In each case, three gastric biopsies were done for total histologic density of H. pylori (THPD) (range: 0-15) before, 1 day and 6 weeks after completion of therapy. Except for the control group, the 24-hour ambulatory intragastric pH meter (MIC Inc, Gastrograph Spark III, Swiss) was inserted as possible on the 2nd day of therapy.

RESULTS

The 3-day intravenous regimens achieved high clearance rates of H. pylori (Group 1: 93.8%; Group 2: 93.9%; Group 3: 100%). The eradication rates of H. pylori in Groups 1-4 were 43.8%, 57.1%, 58.1%, and 72.8%, respectively. In Groups 1-3, the H. pylori-eradicated cases had lower pre-treatment THPD than non-eradicated cases (6.01 vs. 9.24, p < 0.001). Among 72 cases with pH meter insertion, the percentage of intragastric pH > 5.3 during 24-hour was not different among 35 H. pylori non-eradicated and 37 eradicated cases (78.7 vs. 76.7%, p > 0.05).

CONCLUSIONS

The 3-day intravenous regimens may achieve clearance of H. pylori quickly. However, they were not so effective for eradication, especially in cases with higher bacterial loads. The interindividual response to omeprazole in intragastric pH elevation under the study dosage had insignificant variations to alter the success of eradication.

Percutaneous and endoscopic management of bile leak following endoscopic stone retrieval--a case report

Endoscopic sphincterotomy with stone removal is the method of choice for the treatment of choledocholithiasis. The main complications of this procedure are bleeding, pancreatitis, intestinal perforation and cholangitis. Herein, we report on a case of bile peritonitis in a patient who underwent sphincterotomy and stone retrieval. The literature regarding the etiology and management of bile peritonitis is also reviewed.

Experimental assessment of the feasibility of integrating an endoscopic imaging system into an existing hospital information system

The National Cheng Kung University (NCKU) Hospital operates a comprehensive integrated hospital information system. This was designed and installed as an integral component of the building of the hospital, which opened in 1988. The information system provides a service to all staff in the hospital, administrative and clinical, across the whole of the hospital. To make sure that the information is accessible, where and when it is needed, a comprehensive communications network consisting of both hardware and software mechanisms supports the information system. This paper explores the requirements for a computerised image system for endoscopy and assesses two approaches to the implementation of such a system, as a stand-alone system and as a subsystem of the NCKU hospital information system already in place. The latter would satisfy the original design specification of developing a single system to cover all aspects of hospital operation but places additional demands on the endoscopy systems designer to ensure integration. Both operational modes are set out in the paper and their implications assessed.

Interactive 3-D virtual colonoscopy system

We describe a low-cost three-dimensional (3-D) virtual colonoscopy system that is a noninvasive technique for examining the entire colon and can assist physicians in detecting polyps inside the colon. Using the helical CT data and proposed techniques, we can three-dimensionally reconstruct and visualize the inner surface of the colon. We generate high resolution of video views of the colon interior structures as if the viewer's eyes were inside the colon. The physicians can virtually navigate inside the colon in two different modes: interactive and automatic navigation, respectively. For automatic navigation, the flythrough path is determined a priori using the 3-D thinning and two-pass tracking schemes. The whole colon is spatially subdivided into several cells, and only potentially visible cells are taken into account during rendering. To further improve rendering efficiency, potentially visible cells are rendered at different levels of detail. Additionally, a chain of bounding volume in each cell is used to avoid penetrating through the colon during navigation. In comparison with previous work, the proposed system can efficiently accomplish required preprocessing tasks and afford adequate rendering speeds on a low-cost PC system.

Development of Helicobacter pylori infection model in BALB/c mice with domestic cagA-positive and -negative strains in Taiwan

We aimed to develop an H. pylori-infected mouse model using clinically stored strains in Taiwan and to test whether development of H. pylori infection in an in vivo animal model is related to the status of the cagA gene. A total of 100 male BALB/c mice, 6-8 weeks old, including 80 in the experimental group and 20 in the control group, were used. Two clinically stored H. pylori isolates, a cagA-positive and a cagA-negative strain, were selected to induce the H. pylori infection in half (N = 40) of the mice in the experimental group. Bacterial isolates of 0.8 x 10(9) CFU/ml were orally inoculated in each mouse of the experimental group for three consecutive days. Ten mice in the control group were sacrificed to confirm the initial absence of H. pylori. Eight weeks after inoculation of the experimental group and no inoculation of the remaining 10 mice of the control group, each mouse was killed. Gastrectomy was then performed for rapid urease test (CLOtest) and histology. In the control group, none of 20 mice had positive results from the CLOtest or histology. In contrast, excluding eight of 80 mice that died before the eighth week, 90.3% (65/72) of the mice challenged with H. pylori showed persistent presence of H. pylori by histology. The severity of gastritis at the eighth week was more evident in H. pylori-infected mice than in control and noninfected mice (P < 0.05). Although gastritis was more severe in mice inoculated with the cagA-positive strain than with the cagA-negative strain, the rates of H. pylori infection in mice were not different between cagA-positive and -negative strains (91.4% vs 89.2%, P > 0.05). In summary, stored strains of H. pylori can be applied to induce an infection model in BALB/c mice. The less virulent cagA-negative strain can induce H. pylori infection in mice as effectively as the cagA-positive strain. The high prevalence of cagA-positive strains in Taiwanese patients may be related to factors other than only the cagA gene of the bacteria.

Quantitative result of 13C urea breath test at 15 minutes may correlate with the bacterial density of H. pylori in the stomach

BACKGROUND/AIMS

We tried to test the diagnostic efficacy of a new 13C-labeled urea agent made in Taiwan for urea breath test (UBT) of H. pylori infection, and to assess the correlation between the bacterial load of H. pylori in the stomach and the results of UBT from different timings.

METHODOLOGY

One hundred and ninety-six dyspeptic patients without usage of antibiotics and proton pump inhibitors in the last 4 weeks were recruited for endoscopy, which included CLO test and H. pylori culture. Three additional bits of gastric biopsy (each one from antrum, body, and cardia) were taken for histology to assess the H. pylori density (HPD, range 0-5) in each specimen and the total bacterial density (TBD, a sum of HPD from three sites, range 0-15). Every study patient had been assigned to complete the UBT protocol. The gas samplings of UBT at baseline, 15 min and 30 min after ingestion of 100 mg 13C-labeled urea (INER-Hp 13C-tester, Taiwan) were collected for the ratio of 13CO2/12CO2 and labeled A, B, and C respectively. Both delta15 (B minus A) & delta30 (C minus A) were recorded to express the excess delta13CO2 per milliliter. During the 30 min period of UBT, the patient was scheduled to change lying positions every 5 minutes for even coating of the stomach with test agent.

RESULTS

Based on two positive results of three invasive methods (CLO test, culture, and histology), 91 cases were confirmed to have H. pylori infection. The diagnostic efficacy of UBT was quite good with 96.7% sensitivity for both delta15 and delta30, and with 97.1% and 96.2% specificity for delta15 and delta30 respectively. Both delta15 and delta30 of UBT were well correlated with the TBD of H. pylori in histology (delta15: r=0.7574; delta30: r=0.7432, p<0.0001).

CONCLUSIONS

The new C13-labeled urea for UBT can achieve a high diagnostic yield for H. pylori infection. Furthermore, the density of H. pylori in the stomach can be assessed indirectly by UBT by applying 15-minute gas sampling.

Liver, spleen and tumor volume measured by personal computer

BACKGROUND/AIMS

Computed tomography (CT) scans are common examinations for patients with chronic liver diseases. To quantitate the organ or tumor volume from the scans and to accomplish the task in an efficient way with the most economic equipment, we developed a system based on a personal computer.

METHODOLOGY

We used color-markers and transparency to sketch the edges of liver, hepatoma, and spleen. Each organ or tumor of interest is marked out by fine-point markers on pieces of transparency. The sketch was scanned into a digitized image format on a personal computer (Pentium 133). The calculation involves edge detection, three-dimensional reconstruction, and voxel counting. By using summation-of-the-area and trapezoid approximation technique, the voxels of each structure are counted. In this study, we illustrate the potential application in the management of a hepatic cancer patient.

RESULTS

After digitalization, the data size of CT images is about 1 to 1.5 megabytes. It takes less than 5 min to complete volume calculation.

CONCLUSIONS

By this method, tumor load before and after chemotherapy can be estimated easily and accurately. This would be helpful in clinical practice.

Enhanced dissolution of gallstone by combining ethanol with two commonly used cholelitholytic solvents

BACKGROUND/AIMS

Contact dissolution therapy is one of the non-surgical treatments for patients with gallstone. Among the various solvents, methyl tert-butyl ether (MTBE) is used for cholesterol gallstone, while tetrasodium ethyl-dimethyl tetraacetate (EDTA-4Na) solution is used to dissolve calcium bilirubinate stones. However, the contents of gallstone cannot be precisely predicted while they are still present in the human body. This study was designed to test if the MTBE and EDTA can be mixed together and to test the solubility of different kinds of gallstone in each original solution and mixture.

METHODOLOGY

Each 0.1 gm of mixed cholesterol stone, brown stone and pigment stone from 18 patients was used. Pure ethanol was chosen to enhance the miscibility between the organic phase of MTBE and the aqueous phase of EDTA. The contents of gallstone after dissolution were examined with scanning electromicroscopy.

RESULTS

We found the mixture of ethanol, MTBE and EDTA to be the most efficient solvent in gallstone dissolution in comparison with the other two original solvents. The mixture reached a dissolution percentage of 97.96 +/- 1.00, 88.96 +/- 6.51 and 67.75 +/- 14.26 for cholesterol, brown and black pigment gallstone, respectively.

CONCLUSIONS

We concluded that ethanol can be used to mix the MTBE and EDTA with good preservation in their litholytic effects on gallstone. The ethanol-MTBE-EDTA solvent is, therefore, a promising universal cholelitholytic agent which deserves further tests for its safety and efficacy in the in vivo study.

Biliary sludge and pigment stone formation in bile duct-ligated guinea pigs

We studied the effects of bile stasis in a guinea pig model of pigment gallstone. The common bile ducts of guinea pigs were partially ligated, and the guinea pigs killed one or two weeks later. Biliary sludge or stones were examined with the Fourier transform infrared spectroscopy and the scanning electromicroscopy. The bile was analyzed for pH, free calcium, bile acids and bilirubin fractions, and the activities of both bacterial and endogenous beta-glucuronidase. After bile duct ligation, calcium bilirubinate precipitates or stones formed in all except one of the animals studied. The bile pH and the proportion of unconjugated bilirubin rose after bile duct ligation, with a concomitant fall of bilirubin monoglucuronide. The activity of bacterial beta-glucuronidase decreased after ligation, while the activity of endogenous beta-glucuronidase rose at week 2. Our results imply that precipitation of calcium bilirubinate in this animal model was induced by an increased bile pH and the nonenzymatic hydrolysis of conjugated bilirubin.

Cardiac biopsy of stomach may improve the detection of H. pylori after dual therapy

BACKGROUND/AIMS

To determine whether gastric cardia biopsy may improve the detection of Helicobacter pylori (H. pylori) before and after eradication therapy.

METHODOLOGY

A total of 150 dyspeptic patients with H. pylori infection completing a 2-week course of dual therapy (amoxicillin plus omeprazole) were studied. Endoscopy was carried out at the initial stage and 4 weeks after the completion of dual therapy. During each endoscopy, gastric biopsies were sampled in order from cardia, lower body, and antrum and stored separately to survey the distribution of H. pylori by histology.

RESULTS

Before treatment, 88% (132/150) of the study cases had H. pylori found in antrum and 3.3% (5/150) of cases presented with bacteria only in cardia. After treatment, 38 cases had failure of dual therapy. The detection rates of H. pylori by biopsies without cardia decreased after the dual therapy (by antrum only: 88% to 60.5%, p < 0.05; antrum and body: 96.7% to 81.6%, p < 0.05). In contrast, the incidence of patients with only cardia involvement by H. pylori significantly increased from 3.3% (5/150) before to 18.4% (7/38) after treatment (p < 0.01). Among the 7 patients with H. pylori only in cardia after dual therapy, 3 cases had recurrent dyspepsia during follow-up because of no further anti-H. pylori therapy. Two of these 3 cases disclosed diffuse bacterial involvement in antrum and body besides cardia; the last case later had a positive result of urea breath test.

CONCLUSIONS

Biopsy obtained from gastric cardia can improve the detection rate of H. pylori especially after dual therapy, which encounters antibiotics with possible sanctuary sites here. Thus, it will be useful to prevent over diagnosis of H. pylori eradication.

Eradiction of H. pylori results in regression of B-cell low grade gastric MALToma with evident B-symptoms

Although it is well known that eradication of H. pylori may result in either complete or partial regression of low-grade B-cell mucosa-associated lymphoid tissue lymphoma (MALToma), it would be of clinical interest to determine whether the B-symptoms of patients with MALToma could be relieved by eradication of H. pylori. Here, we report on a 29 year-old female case with B-cell low-grade gastric MALToma with apparent B-symptoms. Her peripheral blood also disclosed large granular lymphocytes (LGL). The B-symptoms of this patient were quickly relieved within 2 weeks after starting an anti-H. pylori regimen; peripheral blood LGLs were clearly decreased as well. Complete regression of MALToma was determined 4 months after the anti-H. pylori regimen. Thereafter, the patient has been disease-free and in good general condition during a 2-year follow-up.

Expression of fibroblast growth factor-1 and fibroblast growth factor-2 in normal liver and hepatocellular carcinoma

This study was performed to examine the immunohistochemical expression of fibroblast growth factor-1 and fibroblast growth factor-2 in normal liver and a total of 31 cases of hepatocellular carcinoma (HCC). Reactivity for both types of angiogenic factor did not exist in any cellular component of normal liver. For HCC, variable amounts of fibroblast growth factor-1 were detected in 6 of 31 cases (19.4%). There was no apparent relationship between the expression pattern and clinicopathologic factors (P > 0.1, respectively), except a positive correlation with histologic grading (P = 0.04). No tumor showed reactivity for fibroblast growth factor-2 in their cancer cells. However, both types of peptide could be demonstrated in the pericellular stroma of HCC. With a mean follow-up at 60 months, fibroblast growth factor-1 expression did not correlate with patients' outcome (P > 0.1). Our study suggested that fibroblast growth factor-1 appears to play a certain role in hepatocarcinogenesis.

The normal adult human liver biopsy: a quantitative reference standard

In assessing adult human liver histology, questions remain concerning the normal number of portal tracts and bile ducts in a liver biopsy. We therefore reviewed liver biopsies obtained with use of a percutaneous Menghini cutting needle (14G, internal diameter 1.6 mm), from 16 patients undergoing liver biopsy for screening procedures (age 49 +/- 14 years, +/-SD) and found to be normal by histological examination. The average aggregate length of the liver tissue was 1.8 +/- 0.8 cm (area of 16.4 +/- 10.7 mm2), representing 7 +/- 3 tissue fragments. Portal triads containing at least one profile each of a portal vein, hepatic artery, and interlobular bile duct numbered 11 +/- 6 per biopsy (range 3-23). Portal dyads, which did not contain one of these profiles, usually the portal vein, numbered 8 +/- 5 (range 1-18). On a per-specimen basis, 38% of portal tracts did not contain a portal vein, 7% did not contain a bile duct, and 9% did not contain a hepatic artery. Because of multiplicity of profiles within portal tracts, however, the average number of profiles per portal tract was 6 +/- 5 (range 2-35). Notably, on average there were 2.3 +/- 2.2 interlobular bile ducts per portal tract, compared to 2.6 +/- 2.3 hepatic arteries and 0.7 +/- 0.7 portal veins. The average minimum external diameter of interlobular bile ducts was 13 +/- 4 microm, of hepatic arteries 12 +/- 5 microm, and of portal veins 35 +/- 25 microm. Bile ducts greater than 30 microm in diameter were rare, only one each in two biopsies were observed. In contrast, probable canals of Hering were occasionally evident at the periphery of portal tracts (6 +/- 6 per biopsy) and within the lobular parenchyma as strings of cuboidal cells (5 +/- 5 per biopsy). We conclude that, although multiplicity of profiles is normal, portal dyads are almost as common as portal triads in normal peripheral liver tissue. On average, there are two interlobular bile ducts, two hepatic arteries, and one portal vein per portal tract, with 6 full portal triads per linear cm of tissue obtained by external Menghini biopsy technique with use of a 14G needle, equivalent to 0.8 +/- 0.5 portal triads per mm2. By serving as a reference standard for adult human liver histology, these findings may assist in the histopathological assessment of liver biopsies, particularly those performed for disease conditions featuring loss of intrahepatic bile ducts.

Effects of ion clusters on the performance of a heavily doped erbium-doped fiber laser

A cluster model is proposed for study of the effects of the number of ions per cluster on the performance of a heavily erbium-doped fiber laser. The results indicate that both the threshold pump power and the unstable-operation region of the fiber laser increase with increasing numbers of ions per cluster.

Liver volume in patients with or without chronic liver diseases

BACKGROUND/AIMS

The size of the liver is an important clinical parameter; the aim of this study is to examine the correlation between liver volume and etiology and the severity of disease, and to evaluate its usefulness in predicting survival.

METHODOLOGY

Patients observed in this study were comprised of thirty three patients with non-liver disease and 44 patients with chronic liver disease (alcoholic hepatitis, 9; hepatitis B, 24; and hepatitis C, 11). The liver volume was measured from digitized CT scan images. Techniques of planimetry and summation of areas were utilized for calculation.

RESULTS

The prediction model to estimate liver volume in patients without liver disease was: liver volume (ml)= [13 x height (cm)] +[12 x weight (Kg)] - 1530. The volume ratio (%) [(volume from reconstructed image /predicted volume) x 100] of alcoholic patients was 135.9+/-25.8, which was significantly higher than that of chronic hepatitis B (73.6+/-15.4) and chronic hepatitis C (74.5+/-20.7). Patients with chronic viral hepatitis were classified into Child-Pugh class A (N=10), B (N=14) and C (N=11). Analysis of variance and trend test revealed that the volume ratio had a significant decreasing trend from the control group (100.5+/-8.1), class A (83.4+/-13.9), class B (72.2+/-13.2) to class C (63.3+/-14.4).

CONCLUSIONS

Liver volume can be predicted from patients' weight and height if they have no liver disease. The liver volume ratio correlates much better with etiology and severity of the disease and is a reliable predictor for patient's survival.

Indicators of liver excretory function in patients undergoing biliary decompression for obstructive jaundice

BACKGROUND/AIMS

The recovery of liver function after biliary drainage in patients with obstructive jaundice may be different depending on the severity and duration of the obstruction. We conducted this study to determine whether there are any clinical factors that can be used to monitor the course of recovery.

METHODOLOGY

Serum and bile from 12 patients were collected for biochemical testing on the day of drainage and every 3 days for 6 days. Liver function was evaluated by the indocyanine green retention test (ICG R15) before and 6 days after decompression. Patients with an ICG R15 reduction ratio of less than 50% were considered to have a poor recovery (group 1, n = 6), while a good recovery was indicated by a reduction ratio higher than 50% (group 2, n = 6). Sequential data were compared between the groups and correlated with the results of the ICG test.

RESULTS

After drainage, the patients in group 1 had less bile acid excretion on day 3 (1.0 +/- 0.8 vs. 3.4 +/- 1.1 mmol/day, p < 0.05), a slower reduction ratio of serum bilirubin on day 3 (0.38 +/- 0.14 vs. 0.60 +/- 0.12, p < 0.05) and more biliary output on day 6 (1.11 +/- 0.25 vs. 0.60 +/- 0.25 L/day, p < 0.05). The ICG R15 reduction ratio was well correlated with the bilirubin reduction ratio, the bile volume and the amount of excreted bile acids checked on day 3 (gamma = 0.73, -0.71 and 0.74, respectively, p < 0.01).

CONCLUSIONS

The presence of choleresis implies ductular cell hyperplasia, while decreased excretion of bile acids and a slow reduction of hyperbilirubinemia represents severe liver damage. Both conditions are sequelae of prolonged obstruction; therefore, they might indicate a long and poor recovery.

One-week proton pump inhibitor-based triple therapy eradicates residual Helicobacter pylori after failed dual therapy

The purposes of this study were to assess the efficacy of a 1-week proton pump inhibitor (PPI)-based triple therapy after failure of dual therapy in Helicobacter pylori eradication, and to compare the effectiveness of clarithromycin and metronidazole in this regimen. Between January 1996 and March 1997, 67 patients with persistent H. pylori infection after a 2-week course of dual therapy (amoxicillin plus omeprazole) were enrolled. They were randomly assigned to receive amoxicillin (1000 mg twice daily) and omeprazole (20 mg twice daily) plus either metronidazole (500 mg twice daily) or clarithromycin (250 mg twice daily). Endoscopy was performed in each patient to assess the status of H. pylori using the rapid urease test (CLOtest) and the histologic findings before dual therapy, after dual therapy, and after triple therapy. H. pylori isolates were tested for antibiotic resistance when triple therapy failed. The 1-week triple therapy was well tolerated in both groups with no adverse effects severe enough to cause withdrawal from the trial. Residual H. pylori was eradicated in 94% (33/35) of patients in the clarithromycin group and 84% (27/32) in the metronidazole group; the difference was not statistically significant. All seven patients in whom triple therapy failed were infected with metronidazole-resistant isolates and two also had clarithromycin-resistant isolates. This 1-week triple therapy is safe and effective in eradicating residual H. pylori after dual therapy failure. Failure of the rescue regimen is related to antimicrobial agent resistance. Because of the high metronidazole resistance rate in Taiwan, clarithromycin appears to be more promising than metronidazole for the control of H. pylori.