[Efficacy of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei]

Objective: To evaluate the efficacy and safety of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of pseudomyxoma peritonei (PMP). Methods: In this descriptive case series study, we retrospective analyzed the records of PMP patients treated with CRS and HIPEC between January 2013 and June 2023 at Affiliated Cancer Hospital and Institute of Guangzhou Medical University. The inclusion criteria were as follows: (1) Aged 18 to 75 years and nonpregnant women. (2) Histologically confirmed diagnosis of pseudomyxoma peritonei. (3) Karnofsky Performance Scale (KPS)>70. (4) The functions of major organs such as the heart, liver, lungs, and kidneys can tolerate major surgery for long periods of time. (5) No evidence of extra-abdominal metastasis. Patients with extensive intra-abdominal adhesions or severe infectious diseases were excluded. The main outcomes were overall survival (OS) and postoperative major complications. The postoperative major complications were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 5.0). We used the peritoneal cancer index (PCI) score to quantitatively assess the peritoneal metastases and the completeness of cytoreduction (CCR) score at the end of surgery (CCR-0 and CCR-1 considered to be complete CRS). Results: A total of the 186 PMP patients with a median age of 56 (interquartile range extremes (IQRE), 48-64) years were included, 65 (34.9%) males and 121 (65.1%) females. The median peritoneal cancer index (PCI) score was 28 (20-34). Appendiceal origin accounted for 91.4%. Histological types were low grade in 99 patients (53.2%), high grade in 57 patients (30.6%), and 55 patients (29.6%) received complete cytoreduction (CCR-0/1). The median operative duration was 300 (211-430) minutes for all patients. Treatment-related 30-day mortality was 2.7%; 90-day mortality 4.3%; reoperation 1.6%; and severe morbidity 43.0%. Within the entire series, anemia(27.4%), electrolyte disturbance(11.6%), and hypoalbuminemia(7.5%) were the most frequent major complications (grade 3-4). The incidences of gastrointestinal anastomotic leakage, abdominal bleeding, and abdominal infection were 2.2%, 2.2%, and 4.3%, respectively. After a median follow-up of 38.1 (95%CI:31.2-45.1) months, the 5-year OS was 50.3% (95%CI: 40.7%-59.9%) with a median survival time of 66.1 (95%CI: 43.1-89.1) months. The survival analysis showed that patients with pathological low grade, low PCI, and low CCR score had better survival with statistically significant differences (all P<0.05). Further stratified into complete and incomplete CRS subgroups, the 5-year OS of the CCR-0 and CCR-1 subgroups was 88.9% (95%CI: 68.3%-100.0%) and 77.6% (95%CI: 62.7%-92.5%), respectively; and 42.0% (95%CI: 29.5%-54.5%) in the CCR-2/3 subgroup. Conclusions: CRS and HIPEC may result in a long-term survival benefit for PMP patients with acceptable perioperative morbidity and mortality. This strategy, when complete CRS is possible, could significantly prolong survival for strictly selected patients at experienced centers.

[Emergency management of prevention and control of the novel coronavirus infection in departments of stomatology]

Complying with overall requirements of the government and regulations on public health emergencies, as well as the clinical features of diagnosis and treatment of oral diseases, this article reviews previous guidelines and studies on the infection control in dental practices in China and foreign countries. The emergency management protocol for the prevention and control of COVID-19 has been implemented in Nanjing Stomatological Hospital, which mainly focuses on the implementation of the training programs for dental staff and the infection control project in the hospital environment. This article could be used as a reference for rapid response and emergency management for the prevention and control of COVID-19 in the departments of stomatology.

[Texture analysis of diffusion-weighted magnetic resonance imaging to identify atypically enhanced small hepatocellular carcinoma and dysplastic nodules under the background of cirrhosis]

Objective: To investigate the value of texture analysis based on diffusion-weighted magnetic resonance imaging (DWI) in the differential diagnosis of atypically enhanced small hepatocellular carcinoma (sHCC) and dysplastic nodules (DNs) in liver cirrhosis. Methods: Data of 59 cases with atypical enhancement and solitary cirrhotic nodule (≤2 cm) confirmed by dynamic contrast enhanced MRI and surgical pathology specimen were analyzed retrospectively. Among them, 37 cases were of atypically enhanced sHCC and 22 cases of DNS. The DWI signal characteristics of the lesions were analyzed to measure the average apparent diffusion coefficient (ADC) value of the lesions, and the ADC ratio of the lesion to the liver parenchyma. MaZda software was used to manually draw the region of interest to extract the texture parameters of DWI lesions. The three sets (combination of Fisher coefficient, classification of error probability combined with average correlation coefficient and interactive information) were used to select the thirty optimal texture parameters. Raw data analysis (RDA), principal component analysis (PCA), linear discriminant analysis (LDA) and non-linear discriminant analysis (NDA) were performed for texture classification. The difference of ADC value and ADC ratio between sHCC and DNS group was compared by independent sample t-test, and χ2 test was used to compare the count data (or rate). ROC curve analysis was used to evaluate the diagnostic efficiency. Results: The sensitivity, specificity and accuracy of DWI high-signal in the identification of atypically enhanced sHCC and DNs were 94.6% (35/37), 68.2% (15/22), and 84.7% (50/59), respectively. The ADC ratio of atypically enhanced sHCC was significantly lower than DNs, and the difference was statistically significant (t = 2.99, P = 0.002). The sensitivity, specificity, and accuracy for the diagnosis of atypically enhanced sHCC were 73.0% (27/37), 72.7% (16/22) and 72.9% (43/59), respectively. The sensitivity, specificity and accuracy of DWI texture analysis in diagnosing atypically enhanced sHCC were 94.6% (35/37), 95.5% (21/22) and 94.9% (56/59).The diagnostic efficiency of DWI texture analysis (AUC = 0.94) was significantly higher than DWI high-signal (AUC = 0.81) and ADC ratio (AUC = 0.72). Conclusion: The texture analysis based on DWI can identify atypically enhanced sHCC and dysplastic nodules under the background of cirrhosis, and its efficacy is better than qualitative and quantitative DWI.

[Rationality of performing hyperthermic intraperitoneal chemotherapy 5-8 weeks after primary tumor resection for patients with locally advanced colorectal cancer-based on COLOPEC]

Hyperthermic intraperitoneal chemotherapy (HIPEC) has a unique effect on the prevention and treatment of peritoneal metastasis from malignancies. Recently, the first prospective, multicenter, randomized controlled clinical trial of HIPEC to prevent the development of peritoneal metastasis after curative surgery for patients with locally advanced colon cancer was published in the "Lancet Gastroenterol Hepatol" (COLOPEC). Regrettably, no significant difference was observed in 18-month peritoneal metastasis-free survival between postoperative adjuvant HIPEC and standard systemic chemotherapy for patients with T4 stage or perforated colon cancer. However, we wonder whether we might achieve better outcomes by further optimizing the following issues: (1) We propose that the inclusion criteria for that trial may not be entirely reasonable, which included pT4N0-2M0 and perforation. Additionally, we found that 91% of patients underwent HIPEC 5-8 weeks after primary tumor resection. (2) The imbalance in starting time of postoperative systemic chemotherapy between the two groups may have a negative impact.(3) Nine patients with peritoneal metastasis preceding HIPEC might weaken the potential efficacy of HIPEC. (4) We wonder whether HIPEC using high-dese oxaliplatin (460 mg/m(2)) perfusing 30 minutes for one cycle is the optimal regimen. Therefore, we are planning to conduct a randomized controlled trial (HIPEC-06) in accordcance with the characteristics of Chinese patients, to explore the clinical efficacy of curative surgery combined with HIPEC in the treatment of cT4 colorectal cancer.

A pilot external quality assurance programme for line-probe assay detection of anti-tuberculosis drug resistance

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB; resistance to isoniazid and rifampicin) is difficult to detect and control. Line-probe assays (LiPA) are widely used for the rapid detection of MDR-TB.

OBJECTIVE

To ensure the quality of the test, a pilot external quality assurance (EQA) programme was initiated to assess the feasibility of running such a programme and the possibility of improving the proficiency of TB laboratories in performing the test.

DESIGN

Prepared filter-paper-based Mycobacterium tuberculosis DNA samples were shipped to participant laboratories for LiPA EQA. The tests were performed blind, and the results were returned to the organising laboratory for comparison and analysis.

RESULTS

A total of four rounds of EQA samples were dispatched to five laboratories in four countries. Overall inter- and intra-laboratory reproducibility was respectively 97% and 96%. The strengths and weaknesses of the participant laboratories in performing the test were discussed.

CONCLUSION

A LiPA EQA programme can ensure quality and improve the performance of TB laboratories. This is a critical step during the initial stages at the time of setting up this method of testing.

Random blinded rechecking of sputum acid-fast bacilli smear using fluorescence microscopy: 8 years' experience

BACKGROUND

The Hong Kong TB Reference Laboratory is a high volume laboratory examining around 400 sputum acid-fast bacilli smears daily using fluorescence microscopy (FM).

OBJECTIVE

To assess the effectiveness of blinded rechecking applied to FM in a high-throughput laboratory.

METHOD

From 2003, 2.5% (5% in 2003 and 2004) of all smears were randomly selected, relabelled and assigned to each technician (rechecker) in turn. These smears were restained and re-examined. Discordance between initial screener and rechecker was resolved by a controller.

RESULTS

From 2003 to 2010, low false-negative (LFN) errors (0.10-0.27%) were within the critical values, at 85% (1 year) and 90% (7 years) sensitivity. However, LFN error (0.28-0.62%) among recheckers was prominent. There were also low false-positive (LFP) cases (0.13-0.75%), but subsequent cultures showed these to be mycobacteria culture-positive. This relatively poor performance among the recheckers might be due to background fluorescence increase after restaining and/or inefficiency of the rechecking procedure.

CONCLUSION

In a high-throughput laboratory, blind rechecking is a good means of quality assurance. To minimise false LFP, problems due to restaining should be resolved before blinded rechecking can be generally applied in the field for FM where mycobacterial cultures are not routinely performed.

Bulk acid-fast staining of sputum smears: time to end a taboo

SETTING

A high-throughput laboratory routinely performing fluorescence microscopy for acid-fast bacilli (AFB) smear with automated bulk staining.

OBJECTIVES

To determine the risk of false-positive AFB sputum smears from bulk staining showing as smear-positive, culture-negative specimens, or a decrease in smear- and culture-positives.

DESIGN

Direct AFB smear and Löwenstein-Jensen culture were performed for a total of 39,350 routine sputum specimens. Of these, 6633 were randomly selected for individual AFB staining, while the remaining 32,717 were processed by bulk machine staining. Positives for smear and culture were compared.

RESULTS

Overall, 111 specimens yielded a positive individually stained smear; of these, 100 (90.1%, 95%CI 83.0-95.0) were also culture-positive compared to 504/543 smear-positives after bulk staining (92.8%, 95%CI 90.6-95.0). The proportions of smear-positive, culture-negative and smear- and culture-positive specimens were respectively 1.8% vs. 2.2% and 90.1% vs. 92.8%, for individual and bulk staining (non-significant).

CONCLUSIONS

The risk of transferring AFB from positive to negative smears during bulk AFB staining is negligible, if it occurs at all. Bulk staining should not be discouraged, as even in low-income countries this method will save significant resources, particularly manpower, and improve staining results in laboratories with a high workload.

Quantitative rat liver function test by galactose single point method

Summary

The purpose of this study was to investigate the galactose single point (GSP) method, a residual liver function test recently recommended by the US Food and Drug Administration, which can be a useful tool for rat liver function measurement. Rats were treated either with carbon tetrachloride (CCl4) alone (1 mL/kg, intraperitoneally [i.p.]) for one day or with isoniazid (INH) alone (150 mg/kg, i.p.) or (in order to ameliorate the effects of INH) with a combination of INH and bis- p-nitrophenyl phosphate (BNPP) (25 mg/kg, i.p.) for 21 days. Hepatotoxicity was assayed by plasma aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activities and scores of histological activity index-necroinflammation (HAI-NI) of the respective liver specimens. The GSP method in rats was defined by the galactose blood level after 60 min. Significant differences in GSP values were observed between controls and the CCl4-treated rats. After 21 days of treatment, no significant changes in AST and ALT values were observed among the control, INH and INH-BNPP groups. There were significant differences in average GSP values for controls ( P < 0.001) and INH-BNPP ( P < 0.001) compared with INH alone. Highly significant correlations ( P < 0.001) were obtained between GSP and scores of HAI-NI for all the groups. GSP was concluded to be a more sensitive biomarker of INH-induced hepatotoxicity than AST or ALT in the rats. The GSP method has been proved to be a simple and useful tool for the quantitative determination of liver function in rats, which can possibly be extended to other animals.

Denaturing HPLC for high-throughput screening of rifampicin-resistant Mycobacterium tuberculosis isolates

OBJECTIVE

To evaluate the use of denaturation high-performance liquid chromatography (dHPLC) as a rapid method to detect rifampicin (RMP) resistance based on mutations in the rpoB gene in a high-volume laboratory setting.

METHODS

A total of 132 RMP-resistant Mycobacterium tuberculosis strains with different rpoB mutation were used to optimise the running condition of dHPLC as a pilot study. A blind correlation study was subsequently done between dHPLC and in vitro RMP susceptibility tests on 3167 M. tuberculosis strains in a high-throughput clinical setting.

RESULTS

In the pilot study, rpoB mutation could be detected on 116/132 (87.9%) RMP-resistant strains by dHPLC. In the second phase of the study, 84/3107 (2.7%) clinical M. tuberculosis isolates were RMP-resistant. The sensitivity and specificity of dHPLC in the prediction of RMP resistance were 70/84 (83.3%) and 70/77 (91.0%), respectively. The specificity became 100% when 511 Leu to Pro mutation was excluded from the RMP resistance-related genetic changes.

CONCLUSION

In the detection of RMP resistance in a high-throughput laboratory setting, dHPLC has been demonstrated to be rapid, simple, workable, automatable and inexpensive in terms of running costs and the labour involved.

The Chinese version of the Davidson Trauma Scale: a practice test for validation

The Chinese version of the Davidson Trauma Scale (DTS-C) was developed to respond to the need of Chinese-speaking individuals. The DTS is a validated self-rating scale used in the diagnosis of posttraumatic stress disorder (PTSD). The DTS-C is translated from DTS through a two-stage translation. Subjects were drawn from a sample of 210 survivors of the 21 September 1999, Chi-Chi Earthquake. The scale showed good internal consistency (Cronbach's alpha = 0.97) and test-retest reliability (r = 0.88). Concurrent validity was obtained against the clinical diagnostic interview, with a diagnostic accuracy of 0.85 at DTS-C score of 44. It showed that the sensitivity was 0.9, specificity 0.81, positive likelihood ratio 4.74, and negative likelihood ratio 0.12. The recommended stratum-specific likelihood ratios were 0.10 (95% CI: 0.05-0.20) for the score range 0-39, 4 (2.22-7.23) for the score range of 40-59, and 6.14 (3.42-11.02) for the scores above 60. In PTSD diagnosed subjects, the factor structures closely resembled the DSM-IV grouping of PTSD symptoms. The psychometric strength of DTS-C is reliable for its future use, particularly for screening for subjects with possible diagnosis of PTSD.

Factors predicting local recurrence of desmoid tumours including proliferating cell nuclear antigen

BACKGROUND

A series of 24 patients with desmoid tumours were studied to determine factors predicting local recurrence, and to establish whether these desmoid tumours were oestrogen receptor-positive or -negative.

METHODS

Histology was reviewed and immunohistochemical studies were undertaken. Risk factors for local recurrence were analysed.

RESULTS

The findings indicate that the 24 desmoid tumours were oestrogen receptor- and progesterone receptor-negative. Most tumours were proliferating cell nuclear antigen (PCNA)-positive, and positivity was graded by percentage of cells staining and the intensity of the staining. The presence of incomplete macroscopic or histological surgical resection margins did not correlate with local recurrence. Although all tumours that recurred were strongly PCNA-positive with a high percentage of positive cell staining, this trend was not significant. Local recurrence was more common in desmoid tumours arising in extra-abdominal sites (P = 0.03). Extra-abdominal desmoid tumours were significantly more likely to have incomplete histological margins following resection (P < 0.05).

CONCLUSION

Desmoid tumours are oestrogen receptor- and progesterone receptor-negative. Of factors analysed for local recurrence, only the extra-abdominal site was significant.

Novel single-point plasma or saliva dextromethorphan method for determining CYP2D6 activity

O-Demethylation of dextromethorphan co-segregates with 4-hydroxylation of debrisoquin and is used for CYP2D6 phenotyping. In most previous studies, 8-h urinary samples were collected for determining the dextromethorphan metabolic ratio (dextromethorphan/dextrorphan molar ratio). In addition, a salivary sampling at 3 h had been suggested for the phenotyping. To evaluate the repeatability and validity of previously reported and other potential phenotyping methods, we determined the metabolic ratios from urine samples (for various intervals), or from plasma or saliva (at varying time points) after repetitive single doses of immediate-release or repetitive multiple doses of controlled-release dextromethorphan preparations. For the single-dose study, each of 12 subjects received 15 mg of immediate-release dextromethorphan in period I and period II, respectively, with a 1-week washout period. For the multiple-dose study, each of 16 subjects received 60 mg controlled-release dextromethorphan twice daily for 5 days in period I and period II, respectively, with a 2-week washout period. Dextromethorphan and dextrorphan were assayed by high-performance liquid chromatography. In the single-dose study, most metabolic ratios revealed good repeatabilities for the two periods (paired t test). The metabolic ratio from urine collected for 4 h, 6 h, 8 h or 12 h from plasma at any time between 1 h and 5 h or at 8 h, or from saliva at 2 h or 6 h, could reflect that from 0- to 24-h urine or AUCinfinity. In the multiple-dose study, all metabolic ratios revealed good repeatabilities. The plasma metabolic ratio at any time between 0.5 h and 10 h or the saliva metabolic ratio at any time between 3 h and 12 h, but not the urine metabolic ratio from any interval, could predict the metabolic ratio from ACUSStau. The 2 h, 3 h, 4 h or 5 h plasma metabolic ratio and 6 h saliva metabolic ratios after a single dose correlated significantly with their corresponding multiple-dose metabolic ratio (r > 0.8, P < .05). In conclusion, the plasma sample at 2 h, 3 h, 4 h or 5 h or the saliva sample at 6 h in either the single immediate-release (15 mg) or the multiple controlled-release dose (60 mg) procedure could be used for determining the dextromethorphan metabolic ratio.

Effects of extra-carbohydrate supplementation in the late evening on energy expenditure and substrate oxidation in patients with liver cirrhosis

BACKGROUND

The purpose of this study was to demonstrate the effects of extra-carbohydrate supplementation before bedtime on energy metabolism and substrate oxidation in patients with liver cirrhosis.

METHODS

Sixteen cirrhotic patients and eight control subjects were included in this study. To compare the effect of energy metabolism and substrate oxidation with or without a bedtime snack, indirect calorimetry was assessed at 7 to 8 AM after overnight fasting, following either dinner (6 PM) or a bedtime snack (11 PM) the evening before. The bedtime snack contained about 50 g of carbohydrate. The energy expenditure and substrate oxidation were calculated from the indirect calorimetry measurement and 24-hour urinary nitrogen excretion.

RESULTS

In those who fasted since dinner, the respiratory quotient (RQ) was significantly lower in cirrhotic patients than in control subjects. Also, the energy utilized by cirrhotic patients was derived primarily from fat oxidation (58%), whereas the main energy source for controls was carbohydrate (55%). An extra-carbohydrate supplement before bedtime did not influence the indirect calorimetry measurement in the controls, but there were significant increases in both RQ and carbon dioxide production (Vco2) in cirrhotic patients. The extra-carbohydrate supplementation did not significantly change the absolute resting energy expenditure utilization in control subjects; however, the utilization of carbohydrate significantly increased with a decrease in fat and protein oxidation in the cirrhotic patients.

CONCLUSIONS

These preliminary data suggest that extra-carbohydrate supplementation before bedtime can shorten nocturnal fasting with a more economic fuel utilization and effectively diminish fat and protein oxidation in cirrhotic patients.

Alcoholism and alcoholic organ damage and genetic polymorphisms of alcohol metabolizing enzymes in Chinese patients

It is still not clear why some alcoholic patients acquire certain organ-specific complications of alcoholism whereas other alcoholic patients acquire different ones. As we know the liver alcohol dehydrogenase (ADH), aldehyde dehydrogenase (ALDH), and cytochrome P4502E1 (P4502E1) are polymorphic at the ADH2, ADH3, and ALDH2 loci and the 5'-flanking region of the P4502E1. The aim of this study was to investigate the differences between Chinese alcoholic patients with cirrhosis and acute pancreatitis by studying the genetic polymorphisms of ADH2, ADH3, ALDH2, and P4502E1. Genotyping of ADH2, ADH3, ALDH2, and P4502E1 was performed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) methods on peripheral white blood cell DNA from 75 alcoholic cirrhotic patients, 48 acute alcoholic pancreatitis patients, 19 heavy drinkers without liver disease or pancreatitis, and 235 controls. The results showed that the frequencies of the alleles ADH2*1 and ALDH2*1 in the alcoholic cirrhotic patients were significantly higher than those in the nonalcoholic controls. In acute alcoholic pancreatitis patients, only the frequency of allele ALDH2*1, not ADH2*1 was significantly higher than in the nonalcoholic controls. The allele frequency of ADH2*1 in acute pancreatitis patients was significantly lower (P < .01) than in alcoholic cirrhotic patients. The daily amount of alcohol consumption was significantly lower in patients with acute pancreatitis than in patients with cirrhosis (P < .0005). The genotype distributions of P4502E1, detected by RsaI and PstI, were not different among alcoholic cirrhotic patients, alcoholic pancreatitis patients, heavy drinker, and nonalcoholic controls. In conclusion, ALDH2*1 is the most important alcohol metabolizing gene affecting predisposition to alcoholism whereas the ADH2*2 gene may influence susceptibility to acute alcoholic pancreatitis. The patients with alcohol-induced cirrhosis and with alcohol-induced acute pancreatitis are of two different subpopulations.

Detection of alphafetoprotein-expressing cells in the blood of patients with hepatoma and hepatitis

The presence of tumour cells in the blood circulation may predict disease recurrence and metastasis. We have evaluated the specificity and sensitivity of detecting hepatoma cells in blood using nested polymerase chain reaction with primers specific for the alphafetoprotein (AFP) gene. The nested polymerase chain reaction amplified a 270-base pair AFP DNA fragment from cDNA of Hep 3B hepatoma cells. In a reconstitution experiment, AFP mRNA was detected from peripheral mononuclear cells isolated from 10 ml of blood containing as few as ten Hep 3B cells. Peripheral mononuclear cells from the blood of 20 hepatoma patients were analysed, and 19 patients showed positive AFP mRNA expression. Seven of 13 samples from hepatitis patients also showed positive AFP mRNA expression. All five paired samples of peripheral blood or umbilical cord blood from pregnant mothers and their babies, respectively, showed positive AFP expression. None of 22 control samples was positive. The presence of AFP mRNA in the blood of hepatitis or hepatoma patients suggests the presence of circulating hepatoma cells or hepatocytes in the circulation. The high incidence of AFP mRNA in the blood of hepatoma patients supports the notion of early haematogenous spreading of the disease.

Cystic lymphangioma of the transverse colon: report of a case and review of the literature

A 32-year-old Chinese man with cystic lymphangioma of the transverse colon is described. He presented with a 1-year history of altered bowel habits. Double-contrast barium enema study demonstrated a submucosal lesion in the midportion of the transverse colon with intact mucosa. Computed tomography (CT) showed a round 3.0-cm submucosal cystic mass lesion. Colonoscopy revealed a smooth, soft polypoid mass on a broad base. He underwent segmental resection of the colon. Histologically, the lesion was characterized by cystic lymphangioma originating from the submucosa. The clinical features, radiology, appropriate treatment, and possible pathogenesis of colonic lymphangioma are discussed.

Soluble CD44 isoforms in serum as potential markers of metastatic gastric carcinoma

A splice variant of CD44 (exon V4-V7) confers metastatic behavior in a rat carcinoma model; aberrant expression of splice variants has been detected on a variety of human tumor cell lines as well as primary and metastatic human tumors, including lymphomas, carcinomas (colon, thyroid, mamma, bladder), and glioma. We used enzyme-linked immunosorbent assay to determine the concentration of soluble CD44 in the serum samples of 10 normal individuals and 41 patients with various stages of gastric cancer. Soluble CD44S and its isoforms, V5 and V6, were present in the serum of normal individuals (288.53 +/- 18.33, 25.49 +/- 1.70, and 148.32 +/- 3.15 ng/ml, respectively). The concentrations of soluble CD44 V5 and V6 were elevated in patients with advanced gastric carcinoma (69.39 +/- 6.06 and 216.62 +/- 32.98 ng/ml, respectively). Serum CD44 V5 concentrations correlated with the extent of tumor invasion (T), the status of lymph node involvement (N), and distant metastasis (M) (TNM staging) (p < 0.05), whereas CD44S did not. These results suggest that detection of abnormal regulation of CD44 splicing could be helpful in gastric cancer diagnosis and disease evaluation.

Hydatid cysts in the liver

A 67-year-old Taiwanese woman with multilocular hydatid cysts of the liver presented with a 5-month history of intermittent right upper abdominal discomfort. Abdominal ultrasonography and computed tomography showed multiple cysts in both lobes of the liver. Subsequent selective celiac angiography revealed an avascular space-occupying lesion in the right lobe. She underwent a radical excision of the cyst by total closed (without opening the wall) cystopericystectomy over segments 4, 5 and 6. Histologic study of the lesions showed three structural components: 1) an outer acellular laminated membrane, 2) a thin nucleated germinal membrane and 3) several protoscolices with Echinococcus granulosus suckers. The patient has been well for 5 years since her discharge. Although hydatid cysts of the liver are extremely rare in Taiwan, they may cause life-threatening complications and mortality. Making a preoperative diagnosis is important and is only possible if this rare disease is kept in mind.

A rare case of multiple intussusceptions: intense segmentary lipomatosis of the ileum

We report a patient who presented with intestinal obstruction; his small intestine showed intense segmentary lipomatosis associated with unusually situated multiple intussusceptions. Preoperatively, we diagnosed intussusceptions in the ileocecal region by ultrasonography and computed tomographic scan. During surgery, the ileum was dilated and contained numerous movable polypoid masses. One reducible intussusception was encountered in the ileocecal region. In addition, an ileoileal intussusception that could not be reduced was resected with an end-to-end anastomosis. At histological examination, more than 150 submucosal lipomas were found.

An investigation of whether polymorphisms of cytochrome P4502E1 are genetic markers of susceptibility to alcoholic end-stage organ damage in a Chinese population

The human cytochrome P4502E1 gene (P4502E1), coding for an ethanol-inducible nitrosamine-metabolizing P-450, is involved in the metabolism of ethanol and many known carcinogens. Recently, restriction fragment length polymorphisms (RFLPs) within the P4502E1 have been suggested as genetic markers of susceptibility to alcohol-induced liver disease but the previous studies disagree whether alcoholics with c1 or c2 allele are more susceptible to alcohol-induced liver diseases. Using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method, we determined the RsaI and PstI polymorphism of P4502E1 in 77 Chinese alcoholic patients (54 with alcohol-induced cirrhosis and 23 with acute alcohol-induced pancreatitis) and 164 non-alcoholics and compared them with previously published data. The PCR-RFLPs showed three P4502E1 genotypes: type A, homozygote c1/c1; type B, heterozygote c1/c2; and type C, homozygote c2/c2. The RsaI and PstI polymorphism of P4502E1 were completely linked in both Chinese alcoholics and nonalcoholic controls. The rare allele (c2) occurs at similar frequency of 0.232 and 0.234 (P > .05) in nonalcoholic controls and alcoholics, respectively. The genotype distributions of P4502E1 between Chinese alcoholics and nonalcoholics are not significantly different. The genotype and allele frequencies of P4502E1 for Chinese are significantly different from those of Swedes, European-Americans, and African-Americans, respectively (P < .00001), but very similar to Japanese (P > .05). In conclusion, ethnic variations exist between Asians and Caucasians and between Asians and African-Americans. No allelic variants at loci associated with RsaI/PstI RFLPs result in phenotypes displaying greater susceptibility to alcohol-induced cirrhosis or alcoholism in Chinese populations, which contradicts previous reports from Japanese groups.

Novel galactose single point method as a measure of residual liver function: example of cefoperazone kinetics in patients with liver cirrhosis

A novel, simple, clinically useful quantitative liver function test, called the galactose single point (GSP) method, was developed to assess residual liver function by measuring galactose blood concentration 1 hour after galactose was administered (0.5 g/kg). This method was applied to the study of cefoperazone kinetics in patients with hepatic cirrhosis. To study the influence of hepatic cirrhosis on the residual liver function and the correlation between the residual liver function and the pharmacokinetics of cefoperazone, a dose of 1 g of cefoperazone was administered to 11 healthy volunteers and 12 patients with liver cirrhosis. The GSP method, the galactose elimination capacity (GEC) test, and the modified galactose elimination capacity (MGEC) test were done for each volunteer and patient to measure residual liver function. The galactose concentrations were determined enzymatically. Cefoperazone was administered intravenously, and blood and urine samples were collected at appropriate intervals after drug administration. All blood and urine samples were stored at -30 degrees C until high-performance liquid chromatography analysis. Cefoperazone plasma concentrations were much higher in cirrhosis patients than in normal subjects at all times. The elimination half-life, hepatic clearance, mean residence time, and renal clearance of cirrhosis patients differed significantly from those of healthy volunteers. The plasma protein binding was unaltered in both groups. Urinary excretion of cefoperazone was significantly increased in cirrhosis patients (23.95 +/- 5.06% for normal men and 51.09 +/- 11.50% in cirrhosis patients). Hepatic clearance, fraction excreted in urine, and total clearance significantly correlated with GSP, GEC, and MGEC (P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Determination of galactose in human blood by high-performance liquid chromatography: comparison with an enzymatic method and application to the pharmacokinetic study of galactose in patients with liver dysfunction

Galactose, the C-4 epimer of glucose, is an agent of choice for the quantitation of liver function. A simple, precise, and accurate high-performance liquid chromatographic (HPLC) assay with refractive index detection was developed for the determination of galactose in human whole blood. The method consists of organic solvent-heavy metal deproteinization procedures and reversed-phase chromatography on a cation-exchange column in the calcium form. Calibration graphs were linear over the concentration range 100-2500 microgram/mL, with correlation coefficients > 0.999. The within-day coefficient of variation (CV) ranged from 2.08 to 8.94%, and the between-day CV ranged from 1.61 to 10.9%. The limit of quantitation was 100 micrograms/mL in whole blood. However, the limit of detection was 75 micrograms/mL based on a signal-to-noise ratio of > or = 3. Eight structurally related sugars and polyols were investigated to check for potential interferences using the analytical condition of the assay. The possible metabolites of galactose present in the body were also checked to determine the specificity of this assay. The proposed HPLC assay was compared with an enzymatic assay and an excellent correlation was observed (HPLC = 1.0299Enz. - 12.907, r = 0.952, p < 0.001). This HPLC method has been successfully applied to the pharmacokinetic study of galactose in six patients with liver dysfunction. Following the intravenous administration of a dose of 0.5 g/kg body weight, galactose pharmacokinetics followed a nonlinear two-compartment model with Michaelis-Menten elimination from the central compartment.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of promazine in patients with hepatic cirrhosis--correlation with a novel galactose single point method

We examined promazine pharmacokinetics in nine patients with hepatic cirrhosis and in six healthy subjects. A specific and sensitive HPLC method was used to measure promazine concentrations in plasma, plasma water (free drug), red blood cells, and urine after oral administration of promazine (2 x 50 mg tablet). There were highly significant reductions in total plasma clearance (p < 0.01), free drug total plasma clearance (p < 0.01), metabolic clearance (p < 0.01), metabolic clearance of free drug (p < 0.01), and fraction bound (p < 0.01) in the cirrhotic patients. The elimination half-life and the area under the plasma concentration-time curve were significantly increased (p < 0.001 and p < 0.05, respectively) in the cirrhotic patients. However, the overall excreted promazine in urine, time to the promazine peak concentration, distribution half-life, renal clearance, apparent volume of distribution, and the promazine concentration ratio between plasma and red blood cells were not different. Thus caution is needed in using promazine for patients with hepatic cirrhosis. A newly developed galactose single point (GSP) method was applied to quantitatively measure the residual liver function in cirrhosis patients and successfully correlated it with promazine elimination half-life (r = 0.770, p < 0.01), total plasma clearance of free drug (r = 0.899, p < 0.005), metabolic clearance of free drug (r = 0.902, p < 0.005), and plasma protein binding (r = 0.822, p < 0.005). GSP may be a convenient index for promazine routine dosage adjustment in patients with liver cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of chronic lobular hepatitis on pharmacokinetics of cefoperazone--a novel galactose single-point method as a measure of residual liver function

Cefoperazone is a semisynthetic cephalosporin antibiotic containing a piperazine side chain, which results in antipseudomonal activity. Unlike the other cephalosporins, it is mainly cleared by the liver (60-80%) and it may be more sensitive to changes in the liver function and/or plasma protein binding than other cephalosporins, which are not primarily cleared by the liver. In order to study the influence of chronic lobular hepatitis on the pharmacokinetics of cefoperazone, a dose of 1 g of cefoperazone was administered to 11 normal, healthy volunteers and 16 subjects with chronic lobular hepatitis. In each volunteer or patient, a novel galactose single-point (GSP) method, the galactose elimination capacity (GEC) test, and the modified galactose elimination capacity (MGEC) test were also performed as a measure of residual liver function. Cefoperazone was administered intravenously over a period of 3-5 min. Blood and urine samples were collected at appropriate intervals after drug administration and stored at -30 degrees C until high-pressure liquid chromatographic (HPLC) analysis. The cefoperazone hepatic clearance, mean residence time, and renal clearance in hepatitis patients were significantly different from those of normal healthy volunteers, whereas the plasma protein binding was unaltered between the two groups. Urinary excretion of cefoperazone showed a highly significant increase in patients, 23.95 +/- 5.06% and 37.54 +/- 13.61% for normal men and hepatitis patients respectively. Hepatic clearance and fraction excreted in urine significantly correlated with values of GSP and MGEC respectively (p < 0.05). These results suggest (i) cefoperazone kinetics was significantly altered in patients with chronic lobular hepatitis; (ii) GSP, a novel simple, clinically useful quantitative liver function test, can predict the cefoperazone hepatic clearance in patients with liver dysfunction.

Evolution rate of hepatitis delta virus RNA isolated in Taiwan

The complete RNA sequences of hepatitis delta viruses (HDV) isolated at 3 years apart from a chronic delta hepatitis patient in Taiwan were determined. The sequence analysis showed an overall evolution rate of 3.18 x 10(-3) substitutions/nucleotide/year. The evolution rates in different parts of HDV RNA varied. The hypervariable region evolved faster (4.55 x 10(-3) substitutions/nucleotide/year) than the hepatitis delta antigen (HDAg)-coding region (2.60 x 10(-3) substitutions/nucleotide/year) and the autocatalytic region (1.11 x 10(-3) substitutions/nucleotide/year). These data are compatible with the previous finding that the hypervariable region is more divergent than the HDAg-coding region and the autocatalytic regions among the HDV isolates from different geographic areas. No substitution was found in the four previously identified conserved domains of HDV RNA, further confirming their functional importance in viral replication. The evolution rate of this HDV RNA is higher than that determined from the partial RNA sequences of two Japanese HDV isolates and similar to that found in a Lebanon isolate. Further, it was found that this HDV RNA retained the same microheterogeneities at 15 nucleotide positions detected in the RNA 3 years earlier. It is concluded that HDV RNA in patients' serum is extremely heterogeneous, and that the nucleotide substitutions in certain nucleotide positions likely have conferred evolutionary advantages for HDV. Viral sequence evolution is a possible mechanism for chronic HDV infection.

Sequence determination of hepatitis C virus genome isolated from Taiwan

The partial genome sequence of the hepatitis C virus (HCV) was determined in the serum of a Taiwanese patient with chronic community-acquired type C hepatitis. The cDNA fragments synthesized with the HCV RNA as a template were amplified by polymerase chain reaction using specific oligonucleotide primers. The amplified fragments represented the regions coding for the putative core, matrix and envelope proteins as well as the N-terminal amino acid sequence of the nonstructural protein NS1, the partial nonstructural NS3 and NS4 proteins and the region of the partial 5'-end noncoding sequence. The cDNA fragments were cloned and sequenced. Sequence analysis of these clones showed that they share 83.7%, 93.2% and 93.6% similarity at the nucleotide level, and 86.6%, 94.1% and 92.9% homology at the amino acid level, with the previously published American, Japanese and Taiwanese isolates, respectively. Accordingly, the RNA genome we obtained is HCV type II, probably, the predominant subtype in Taiwan.

Genotyping of alcohol dehydrogenase at the ADH2 and ADH3 loci by using a polymerase chain reaction and restriction-fragment-length polymorphism in Chinese alcoholic cirrhotics and non-alcoholics

We investigated the genotype of ADH2 and ADH3 in Chinese alcoholic cirrhotics and non-alcoholics by using a polymerase chain reaction and restriction-fragment-length polymorphism. This method is non-radioactive, easy to implement with good reproducibility. In the Chinese population, the frequencies of the ADH2*1 and ADH3*2 alleles were significantly higher in the alcoholic cirrhotic patients (53%; 23%) than in the viral hepatitis cirrhotics (32%; 8%) and the gastric and/or duodenal ulcer control patients (25%; 6%). On the other hand, the gastric and/or duodenal ulcer control patients and the viral hepatitis cirrhotic patients showed similar allele frequencies for the polymorphic ADH2 and ADH3 genes. These findings suggest that the alleles ADH2*2 and ADH3*1, coding for the high-Vmax beta 2-ADH and gamma 1-ADH, respectively, may play a protective role against alcoholism in Chinese patients.

Polymorphism of alcohol and aldehyde dehydrogenase genes and alcoholic cirrhosis in Chinese patients

Liver alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH), the principal enzymes responsible for the oxidation of ethanol, are polymorphic at the ADH2, ADH3 and ALDH2 loci in human beings. Our previous studies have shown that, compared with nonalcoholic individuals, Chinese alcoholic patients without liver disease had significantly lower frequencies of the ADH2*2 and ADH3*1 alleles, which encode high maximum velocity beta 2- and gamma 1-ADH subunits, respectively, as well as a lower frequency of the ALDH2*2 allele, which encodes an enzymatically inactive subunit. The data strongly suggest that genetic variation in both ADH and ALDH may influence drinking behavior and the risk of alcoholism developing through acetaldehyde formation. To further investigate the possible role of acetaldehyde in the pathogenesis of alcoholic liver disease, we determined the ADH and ALDH genotype frequencies in patients with alcohol-related cirrhosis (n = 27), viral hepatitis-related cirrhosis (n = 29) and gastric and duodenal ulcer without relevance to alcohol (n = 30). We developed a new restriction fragment length polymorphism method to genotype the mutant and normal ALDH2 alleles by using polymerase chain reaction-directed mutagenesis, which proved to be simpler and faster than the conventional detection methods that use hybridization with allele-specific oligonucleotide probes. We found that the frequencies of the alleles ADH2*2 (57%), ADH3*1 (78%) and ALDH2*2 (9%) in the alcoholic cirrhotic patients were significantly lower than those in the healthy controls and in the patients with cirrhosis from viral hepatitis and with gastric and duodenal ulcer.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary carcinoma of the gallbladder: a review of 10 years of experience at Tri-Service General Hospital

Thirty-two cases of primary carcinoma of the gallbladder proven by surgery and pathological biopsy between January 1982 and June 1991 at the Tri-Service General Hospital, Taipei, were analyzed retrospectively. There were 16 male and 16 female patients with a mean age of 66.1 years. The most common clinical manifestations were right upper quadrant abdominal pain and poor appetite. The most common laboratory finding was an elevation of alkaline phosphatase. The preoperative diagnostic rate of this series was 46.9% (15/32 cases), through use of abdominal sonography, computed tomography, endoscopic retrograde cholangiopancreatography and celiac angiography. The coexisting gallstone incidence was 65.6% and the resectability rate, 59.4%. The histological classifications were adenocarcinoma with variable differentiation in 31 cases, and undifferentiated adenocarcinoma in one. The liver was the most common site for metastasis (53.1%), followed by lymph nodes at porta hepatis (21.9%), omentum (12.5%), peritoneum (9.4%), lung (6.3%), colon (3.1%) and duodenum (3.1%). According to the Nevin's staging system, three patients were in stage I and all survived more than five years. Of the two patients in stage II, one survived longer than five years and the other survived longer than seven months. There were three cases in stage III: one patient died of metastasis eight months postoperatively, while the other two cases lived for seven and nine and a half months respectively. There were 24 cases in stage IV and stage V, all of them died less than six months after diagnosis. Poor prognosis for patients with primary carcinoma of the gallbladder makes early diagnosis and treatment important.

Assessment of liver function using a novel galactose single point method

A novel, simple, clinically useful quantitative liver function test, called the galactose single point (GSP) method, was developed by measurement of galactose blood concentration 1 h after galactose was administered (0.5 g/kg). It was quickly infused intravenously in 55 normal healthy volunteers, 73 patients with chronic hepatitis (CH), 36 with cirrhosis and 41 with hepatocellular carcinoma (HCC). Patients with CH diagnosis were assessed by liver biopsy. Cirrhosis was diagnosed by histological examination or a chronic hepatitis history with esophageal varices or ascites, whereas HCC was diagnosed either histologically, or cytologically proved, or as implied in the 'one imagine study' being positive with AFP > 300 ng/dl. Highly significant galactose blood levels were observed between normal healthy volunteers and patients 50, 60 and 70 min after galactose was administered. Galactose elimination capacity (GEC), modified GEC (MGEC) and consecutive GSP tests were performed in 6 healthy volunteers for 2 days. 0.64-16.87% variation was observed for each subject. The significant differences (p < 0.001) in average GSP values were 247 +/- 18.1, 422 +/- 27.3, 629 +/- 42.8 and 579 +/- 43.6 micrograms/ml for normal healthy volunteers, CH, cirrhosis and HCC patients, respectively. Highly significant correlations (p < 0.001) were obtained among GSP, GEC and MGEC for all patients. Positive correlations were observed between GSP, GEC, MGEC and AST (serum aspartate aminotransferase), ALT (serum alanine aminotransferase), serum bilirubin, albumin, prothrombin time and r-globulin. According to results obtained from 202 normal healthy volunteers and patients, the GSP method may be a simple, clinically useful quantitative measurement of liver function for the determination of a patient's residual liver function, the prognosis of liver function for patients with cirrhosis, postoperational follow-up and, finally, the timing of a liver transplant.

Determination of fenoverine, a modulator of smooth muscle motility, in capsules and in human plasma: application to dosage form stability and a pilot study in humans

Fenoverine is a novel, potent, musculotropic, spasmolytic agent that affects primarily the gastrointestinal tract, bile duct, and female genital organs. A simple, specific, and accurate HPLC method was developed for the determination of fenoverine in capsules and plasma. This method has been successfully applied to stability studies of fenoverine capsules and to a pilot study in a normal, healthy volunteer following oral administration of fenoverine. For the determination of fenoverine in capsules, a Nucleosil 5-micron CN column, with acetonitrile:0.1 M ammonium acetate (60:40) as mobile phase and detection at 254 nm, was employed. The mean correlation coefficient of the calibration curve (n = 6) for the assay was 0.9999 over a concentration range of 24.6 to 147.6 micrograms/mL of fenoverine standard solutions. Fenoverine did not decompose significantly at 4, 45, 55, and 65 degrees C for 3 months. The mean correlation coefficients of within-day and between-day calibration curves were 0.9995 and 0.9999, respectively, over a range of 10 to 1000 ng/mL of fenoverine in plasma. The limit of detection was 10 ng in plasma.

Extracellular matrix alteration in chronic hepatitis

We used immunofluorescence and immunohistochemical PAP methods on 22 paraffin-embedded liver tissue specimens for observation and analysis of the distribution of extracellular matrix (ECM) elements in chronic hepatitis and cirrhosis. Our study revealed that in CLH there was only mild increases of types III, V collagen and fibronectin in spotty necrosis areas. In CPH, types III, V collagen and fibronectin revealed mild to moderate increase in portal area and lobular sinusoid. In CAH, moderate to marked increases of types III, V collagen and fibronectin and mild increase of type IV collagen in portal area, sinusoid lining, piecemeal necrosis and fibroseptum were found. Types I, IV collagen in fibroseptum were also noted. Some periportal hepatocytes showed abundant intracellular fibronectin. In cirrhosis, cases expressed similar finding to CAH except much more type IV collagen deposition. In addition, the basement membrane components including type IV collagen and laminin were found in the "capillarization" of periportal sinusoids in fibrotic liver tissue. In areas of piecemeal necrosis, the hepatocytes, single or assembled in "rosettes", were underlined by linear deposits of laminin and type IV collagen. Our study revealed that, histologically, the ECMs distribution of CAH is similar to that of cirrhosis but could be clearly distinguished from CPH and CLH. The prominent changes of ECMs, especially the basement membrane components, in case of CAH and cirrhosis are consistent with the fact that ECM may play a central role in liver function impairment and fibrogenesis.

Pharmacokinetic properties of ranitidine in Chinese people

The pharmacokinetics and relative bioavailability of two different formulated ranitidine tablets were examined in 12 healthy young Chinese males at one week intervals in a randomized crossover design. Both ranitidine plasma and urine concentrations were measured by a sensitive, accurate and specific High Performance Liquid Chromatography method. No bioavailability differences were found between Glaxo's and Veteran's ranitidine products. However, larger apparent volume of distribution, higher total oral clearance and higher non-renal clearance was observed in Chinese. Further studies are needed to elucidate a higher ranitidine dosage may be required for Chinese to achieve the desired plasma level.

Molecular cloning and characterization of an isolate of hepatitis delta virus from Taiwan

The genomic RNA of an Asian isolate of hepatitis delta virus was cloned from a Chinese patient from Taiwan, using the polymerase chain reaction to amplify cDNA for cloning and sequencing. The sequence of this hepatitis delta virus isolate shares an 86% to 88% similarity with the three published hepatitis delta virus RNA sequences, suggesting heterogeneity of hepatitis delta viruses from different geographical areas. Four highly conserved, long stretches of sequence were found. These four regions corresponded to the sequences required for the autocatalytic cleavage activities of the genomic and antigenomic RNAs and the middle and the carboxyl terminal parts of the open reading frame for the delta antigen on the antigenomic strand. The conservation of nucleotide sequence in these four regions was further confirmed by sequencing additional hepatitis delta virus RNAs obtained from three patients with chronic delta hepatitis who lived in Los Angeles. These findings suggest that the conserved sequences are critical for viral replication. These conserved regions offer ideal sites for primer selection to carry out polymerase chain reactions to detect hepatitis delta virus RNA in patients with hepatitis delta virus infection.

Pharmacokinetics of promazine: I. Disposition in patients with acute viral hepatitis B

Concentrations of promazine in plasma, plasma water, red blood cells, and urine were measured after oral administration of the drug to six patients during and after apparent recovery from the acute phase of viral hepatitis B. None of the promazine pharmacokinetic parameters were significantly different during and after the acute phase; these parameters included clearance, free drug clearance, metabolic clearance, volume of distribution, distribution and elimination half-life values, plasma protein binding, and per cent excreted in the urine. During the acute period of the illness, SGOP, SGPT, alkaline phosphatase, and total bilirubin were increased in all patients; they returned to within or near the upper limits or normal after recovery. Despite the unchanged promazine disposition, four out of six patients had more severe promazine side-effects, such as sedation, postural hypotension, and dizziness during the acute phase of the illness. This study suggests that promazine disposition was not significantly altered as a consequence of viral hepatitis. However, the pharmacodynamic effects of promazine were changed significantly. Care must be taken with patients who are taking promazine during the acute phase of viral hepatitis B.

A clinical controlled trial of endoscopic sclerotherapy for repeated esophageal variceal bleeding

Thirty-seven patients with postnecrotic cirrhosis of the liver and 13 patients with primary hepatoma were proven to have repeated bleeding from ruptured esophageal varices. Clinically controlled trials were performed by assigning patients to either sclerotherapy or control arms (25 patients each). Combined intra-variceal and para-variceal injection before an upper endoscopic examination was performed in the sclerotherapy group. In all 25 sclerotherapy cases (100%) hemostasis was successful, which was a statistically significant success rate compared to the control group (52.0%) (p less than 0.01). In the sclerotherapy group 20% (5/25 cases) developed rebleeding, which was less than the 48.0% (7 cases of continuous bleeding and 5 cases of rebleeding) of the control group (p less than 0.05). Four cases (16.0%) in the sclerotherapy group died of erosive gastritis with massive bleeding, compared to 8 fatalities (32.0%) in the control group, because of uncontrolled esophageal variceal bleeding. Endoscopic sclerotherapy is a very effective method for arresting bleeding esophageal varices, and for decreasing the rebleeding rate.

Diaphragmatic defect as a cause of massive hydrothorax in cirrhosis of liver

A 56-year-old woman with a 2-year history of cirrhosis of the liver and frequent right pleural effusion was admitted with intractable shortness of breath. Chest x-ray examination showed marked pleural effusion of the right lung field with a shift of the mediastinum to the left. Ascites was not conspicuous. Except for the liver cirrhosis, there was no clinical evidence of other underlying diseases. The patient died with a relatively short course after hospitalization. At autopsy, an apparent bleb with 1-mm hole in the tendinous portion of the right diaphragm was noted. We suggest that the ascitic fluid directly crossed the diaphragmatic defect to the pleural cavity, which contributed to the hydrothorax. In this article we review the pertinent literature.