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Background Both elevated and low resting heart rates are associated with atrial fibrillation (AF), suggesting a U-shaped relationship. However, evidence for a U-shaped causal association between genetically-determined resting heart rate and incident AF is limited. We investigated potential directional changes of the causal association between genetically-determined resting heart rate and incident AF. Method and results Seven cohorts of the AFGen consortium contributed data to this meta-analysis. All participants were of European ancestry with known AF status, genotype information, and a heart rate measurement from a baseline electrocardiogram (ECG). Three strata of instrumental variable-free resting heart rate were used to assess possible non-linear associations between genetically-determined resting heart rate and the logarithm of the incident AF hazard rate: 75 beats per minute (bpm). Mendelian randomization analyses using a weighted resting heart rate polygenic risk score were performed for each stratum. We studied 38,981 individuals (mean age 59±10 years, 54% women) with a mean resting heart rate of 67±11 bpm. During a mean follow-up of 13±5 years, 4,779 (12%) individuals developed AF. A U-shaped association between the resting heart rate and the incident AF-hazard ratio was observed. Genetically-determined resting heart rate was inversely associated with incident AF for instrumental variable-free resting heart rates below 65 bpm (hazard ratio for genetically-determined resting heart rate, 0.96; 95% confidence interval, 0.94–0.99; p = 0.01). Genetically-determined resting heart rate was not associated with incident AF in the other two strata. Conclusions For resting heart rates below 65 bpm, our results support an inverse causal association between genetically-determined resting heart rate and incident AF.

Summary Background Increased blood pressure is the biggest contributor to the global burden of disease and mortality. Data suggest that less than half of the population with hypertension is aware of it. May Measurement Month was initiated to raise awareness of the importance of blood pressure and as a pragmatic interim solution to the shortfall in screening programmes. Methods This cross-sectional survey included volunteer adults (≥18 years) who ideally had not had their blood pressures measured in the past year. Each participant had their blood pressure measured three times and received a a questionnaire about demographic, lifestyle, and environmental factors. The primary objective was to raise awareness of blood pressure, measured by number of countries involved, number of people screened, and number of people who have untreated or inadequately treated hypertension (defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, or both, or on the basis of receiving antihypertensive medication). Multiple imputation was used to estimate the mean of the second and third blood pressure readings if these were not recorded. Measures of association were analysed using linear mixed models. Findings Data were collected from 1 201 570 individuals in 80 countries. After imputation, of the 1 128 635 individuals for whom a mean of the second and third readings was available, 393 924 (34·9%) individuals had hypertension. 153 905 (17·3%) of 888 616 individuals who were not receiving antihypertensive treatment were hypertensive, and 105 456 (46·3%) of the 227 721 individuals receiving treatment did not have controlled blood pressure. Significant differences in adjusted blood pressures and hypertension prevalence were apparent between regions. Adjusted blood pressure was higher in association with antihypertensive medication, diabetes, cerebrovascular disease, smoking, and alcohol consumption. Blood pressure was higher when measured on the right arm than on the left arm, and blood pressure was highest on Saturdays. Interpretation Inexpensive global screening of blood pressure is achievable using volunteers and convenience sampling. Pending the set-up of systematic surveillance systems worldwide, MMM will be repeated annually to raise awareness of blood pressure. Funding International Society of Hypertension, Centers for Disease Control and Prevention, Servier Pharmaceutical Co.

Thiazide diuretics, commonly used antihypertensives, may cause QT interval (QT) prolongation, a risk factor for highly fatal and difficult to predict ventricular arrhythmias. We examined whether common single-nucleotide polymorphisms (SNPs) modified the association between thiazide use and QT or its component parts (QRS interval, JT interval) by performing ancestry-specific, transethnic and cross-phenotype genome-wide analyses of European (66%), African American (15%) and Hispanic (19%) populations (N = 78 199), leveraging longitudinal data, incorporating corrected standard errors to account for underestimation of interaction estimate variances and evaluating evidence for pathway enrichment. Although no loci achieved genome-wide significance (P

Summary Background Patients with peptic ulcer bleeding and uraemia are prone to re-bleeding. Aim To compare the efficacy of an intravenous proton pump inhibitor in treating peptic ulcer bleeding in patients with uraemia and those without uraemia. Methods High-risk peptic ulcer bleeding patients received endoscopic therapy with epinephrine (adrenaline) injection plus intravenous omeprazole (40 mg bolus followed by 40 mg infusion every 12 h) for 3 days. Re-bleeding, volume of blood transfusion, hospital stay, need for surgery, and mortality were analysed. Results The uraemic group had similar 7-day re-bleeding rate (6/42, 14.29% vs. 6/46, 13.04%, P = 0.865) to that of non-uraemic patients, but more re-bleeding episodes beyond 7 days (4/42, 9.52% vs. 0/46, 0%, P = 0.032, OR [95% CI] = 1.105 [1.002–1.219]) and all-cause mortality (4/42 vs. 0/46 P = 0.032, OR [95% CI] = 1.105 [1.002–1.219]). The uraemic group also had more units of blood transfusion after endoscopic therapy (mean ± s.d. 4.33 ± 3.35 units vs. 2.15 ± 1.65 units, P

To delineate the clinical features of traumatic adrenal haematoma, to help emergency physicians recognise the condition early and so to prevent adrenal crisis.Review of the records of all patients admitted to Chi-Mei Medical Center, Tainan, Taiwan, with traumatic torso injuries, between 1 August 2003 and 31 August 2005. Of the 305 patients reviewed, 8 had adrenal haematoma. Injury Severity Scores, hospital course, need for intensive care unit admission and surgery or vascular embolisation, and concomitant injuries, were compared between patients with and without adrenal haematoma.No adrenal haematoma was recognised in the emergency department. No case of adrenal haematoma needed surgery or vascular embolisation, but each had associated injuries to other internal organs. All eight patients with, but only 106 patients without, adrenal haematoma sustained injuries to more than one internal organ (p0.01). The mean Injury Severity Scores and lengths of hospital and intensive care unit stays among the two groups were not significantly different. There was no statistical significance in the differences in rates of admission to the intensive care unit, mortality, laparotomy or vascular embolisation between the two groups.Emergency physicians were liable in trauma cases to miss adrenal haematoma, which of itself was a benign condition but was associated with increased internal organ injuries and days in the intensive care unit. Emergency physicians should be aware of the possibility of adrenal haematoma in trauma cases in order not to miss the bilateral condition, which might lead to a deadly adrenal crisis.

Persons with non-A, non-B hepatitis (cases) identified in 5 transfusion studies in the early 1970s have been followed ever since and compared for outcome with matched, transfused, non-hepatitis controls from the same studies. Previously, we reported no difference in all-cause mortality but slightly increased liver-related mortality between these cohorts after 18 years follow-up. We now present mortality and morbidity data after approximately 25 years of follow-up, restricted to the 3 studies with archived original sera. All-cause mortality was 67% among 222 hepatitis C-related cases and 65% among 377 controls (P = NS). Liver-related mortality was 4.1% and 1.3%, respectively (P = .05). Of 129 living persons with previously diagnosed transfusion-associated hepatitis (TAH), 90 (70%) had proven TAH-C, and 39 (30%), non-A-G hepatitis. Follow-up of the 90 TAH-C cases revealed viremia with chronic hepatitis in 38%, viremia without chronic hepatitis in 39%, anti-HCV without viremia in 17%, and no residual HCV markers in 7%. Thirty-five percent of 20 TAH-C patients biopsied for biochemically defined chronic hepatitis displayed cirrhosis, representing 17% of all those originally HCV-infected. Clinically evident liver disease was observed in 86% with cirrhosis but in only 23% with chronic hepatitis alone. Thirty percent of non-A, non-B hepatitis cases were unrelated to hepatitis viruses A,B,C, and G, suggesting another unidentified agent. In conclusion, all-cause mortality approximately 25 years after acute TAH-C is high but is no different between cases and controls. Liver-related mortality attributable to chronic hepatitis C, though low (

BACKGROUNDPeptic ulcers with active bleeding or a non-bleeding visible vessel require aggressive endoscopic treatment.AIMSTo determine whether endoscopic adrenaline injection alone or contact probe therapy following injection is a suitable treatment for peptic ulcer bleeding.METHODSA total of 96 patients with active bleeding or non-bleeding visible vessels received adrenaline alone, bipolar electrocoagulation alone, or combined treatment (n=32 in each group).RESULTSInitial haemostasis was not achieved in one patient in the adrenaline group, two in the gold probe group, and two in the injection gold probe group (p>0.1). Rebleeding episodes were fewer in the injection gold probe group (2/30, 6.7%) than in the gold probe group (9/30, 30%, p=0.04) and in the adrenaline group (11/31, 35.5%, p=0.01). Treatment failure (other therapy required) was rarer in the injection gold probe group (4/32, 12.5%) than in the adrenaline group (12/32, 37.5%, p=0.04). The volume of blood transfused after entry of the study was less in the injection gold probe group (mean 491 ml) than in the adrenaline group (1548 ml, pCONCLUSIONSFor patients with peptic ulcer bleeding, combined adrenaline injection and gold probe treatment offers an advantage in preventing rebleeding and decreasing the need for blood transfusion.

From May 1992 to February 1993, 22 cases of hypertensive putaminal haemorrhage (HPH) treated at our hospital were serially measured with transcranial Doppler (TCD) sonography. Among them, 13 patients underwent surgical intervention (3 stereotaxic surgery and 10 craniotomies), and 9 were conservatively treated. Most of the patients of the two operative groups had larger haematomas and developed clinical and/or neurological deterioration, which was the indication for subsequent surgery. Therefore the groups represent different clinical and physiological entities. On admission, the peak MCA velocities (Vs) in the surgical group (stereotaxic and craniotomy) were significantly lower than those in the conservative group (mean +/- S.E.M.: 38.33 +/- 4.26 and 42.00 +/- 2.62 cm/sec vs. 57.22 +/- 3.23 cm/sec; p0.005, respectively). The surgical group also had significantly lower diastolic (Vd) and mean (Vm) velocities than those of the conservative group (p0.001). Rather, the admission pulsatility indices (PI = (Vs-Vd)/Vm) in the surgical group were significantly higher than those of the conservative group (mean +/- S.E.M.: 1.42 +/- 0.04 and 1.31 +/- 0.09 vs. 0.95 +/- 0.01; p0.005, respectively). Time course velocity curves reached a peak around the 3rd hospital day in all the 3 groups. The Glasgow coma scale (GCS) scores positively correlated with the mean MCA velocities (n = 22; r = 0.63, p0.005; y = 2.04 x + 8.74), but negatively with PI values on admission (n = 22; r = -0.53, p0.05; y = 1.68-0.053 x). On the 7th hospital day, 2 patients with peak MCA velocities below 50 cm/sec had an unfavourable outcome. All the 3 patients in the stereotaxic group had higher peripheral resistance, as compared with those in conservative craniotomy groups (mean +/- S.E.M.: 1.28 +/- 0.13 vs. 0.99 +/- 0.07 and 0.87 +/- 0.06; p0.05, respectively). Our study supports TCD as a safe and valid monitoring method in patients with HPH. "Compromised cerebral haemodynamic status" (Vs50 cm/sec, Vd15 cm/sec, Vm25 cm/sec, PI1.15) may offer an aid in the decision for surgical intervention in HPH. Postoperatively, patients who made a favourable recovery had a significant increment in the MCA velocities in contrast to those severely disabled, whose MCA velocities remained low.

This investigation examined the cumulative survival rate of the implant-supported overdenture using two types of attachments in patients treated at Show Chwan Memorial Hospital Implant Center from 1992 to 2006. Fifty-one patients (30 men and 21 women) were treated with mandibular implant-supported overdentures. Attachment systems used were the Hader bar with bilateral, cast ERA attachments (Group A, 31 patients with 15 men and 16 women, 134 implants) and the Hader bar with bilateral, distal extension cantilevers (Group B, 20 patients with 15 men and 5 women, 85 implants). Two hundred and four implants remained at the end of the follow-up period. Among failed implants, 10 implants were in Group A (failure rate: 10/134 = 7·5%), whereas five implants were in Group B (failure rate: 5/85 = 5·9%). Sixty-six point seven per cent (10/15) of failed implants were placed in the distal anterior mandible, and 33·3% (5/15) were placed in the middle anterior mandible. Survival was also examined with respect to condition of the opposing arch. Patients wearing a maxillary removable partial denture had the highest implant failure rate (5/51 = 9·8%), whereas the failure rate of the maxillary complete denture group was only 5·7%. The most frequent need for maintenance was wear over patrix component of ERA or Hader clip (n = 56). Eight patients experienced connector fracture between ERA and Hader bar, and one experienced distal extension cantilever fracture. The implant-supported overdenture can be an effective and reliable alternative to the conventional complete mandibular denture. Fewer prosthetic complications were seen in overdentures retained with distal extension cantilever attachments.

Infection is a major medical problem in patients with acute stroke. Recent evidences suggest that statins reduce infection-associated complications. The purpose of this study was to examine the influence of statin treatment on mortality and functional outcomes in patients with stroke-associated infection.In this prospective observational cohort study, 514 patients with acute ischaemic stroke or transient ischaemic attack (mean age, 74 ± 11 years; men, 48%) with infection occurring in the first 7 days after admission were included. We examined the effect of in-hospital statin treatment on mortality and favorable functional outcome (modified Rankin Scale score ≤2) at 3 months follow-up. Infection occurred at 0.93 ± 1.49 days after admission. All patients had not received statin treatment prior to admission, and 121 patients (24%) received statin at 1.71 ± 1.28 days after admission. Follow-up at 3 months was completed for 511 patients (99%). National Institutes of Health Stroke Scale score and Charlson index were the most important independent predictors of mortality and functional outcome. Univariate [hazard ratio (HR), 0.82; 95% confidence intervals (CI), 0.47-1.42] and multivariate (HR, 1.68; 95% CI, 0.79-3.56) Cox regression analysis showed that statin did not significantly decrease the morality. In propensity analysis, statin treatment still had no significant association with mortality (HR, 1.54; 95% CI, 0.68-3.47) in the multivariate analyses after adjusting for age, sex, and propensity score. Statin use was not associated with a better functional outcome or survival in patients with stroke-associated infection.

A percutaneous endoscopic gastrostomy (PEG) tube (Flexiflo 16-Fr DURA-PEG, Abbott pull-type, Abbott Laboratories, Sligo, Ireland) was placed in a ventilator-supported 73-year-old man with amyotrophic lateral sclerosis. The PEG tube …

Background. Treating patients of bleeding peptic ulcers with heater probe thermocoagulation and haemoclip is considered to be safe and very effective. Yet, there is no report comparing the haemostatic effects of endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline–epinephrine injection in these patients. Aim. To compare the clinical outcomes of both therapeutic modalities in patients with peptic ulcer bleeding. Methods. A total of 93 patients with active bleeding or non-bleeding visible vessels were randomised to receive either endoscopic haemoclip ( n =46) or heater probe thermocoagulation plus hypertonic saline–epinephrine injection ( n =47). Five patients from the haemoclip group were excluded because of the inability to place the haemoclip. Results. Initial haemostasis was achieved in 39 patients (95.1%) of the haemoclip group and 47 patients (100%) of the heater probe group ( P >0.1). Rebleeding occurred in four patients (10.3%) of the haemoclip group and three patients (6.4%) of the heater probe group ( P >0.1). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery and the mortality rates were not statistically different between the two groups. Conclusions. If the haemoclip can be applied properly, the clinical outcomes of the haemoclip group would be similar to those of the heater probe group in patients with peptic ulcer bleeding. However, if the bleeders are located at the difficult-to-approach sites, heater probe plus hypertonic saline injection is the first choice therapy.

Polyps of the gastrointestinal tract are usually removed due to their link to bleeding, obstruction and malignancy. However, complications may occur following polypectomy. The aim of this study was to assess whether submucosal epinephrine injection before polypectomy could reduce the incidence of bleeding and perforation.Between June 1997 and November 1999, patients with sessile polyps of the gastrointestinal tract found in our endoscopic unit were randomized to receive submucosal epinephrine injection (epinephrine group) or no injection (control group) before polypectomy. In the epinephrine group, epinephrine (1:10,000) was injected surrounding the stalk of the polyp until the mucosa was blanched and bulged. The patients were observed for complications in the following month.A total of 120 patients with 151 sessile polyps were enrolled in this study. In the epinephrine group, 75 polyps (n = 68) were randomized to receive epinephrine injection before polypectomy. In the control group, 76 polyps (n = 61) underwent polypectomy without epinephrine injection. In both groups, there was no significant difference in clinical features including the sizes of the polyps and their stalks, the location of polyps and the pathological diagnosis. There were a total of nine episodes of post-polypectomy hemorrhage, two in the epinephrine group and seven in the control group (2/75 vs. 7/76) (P = 0.07). One case in the epinephrine group experienced delayed bleeding (4 days later). Immediate hemorrhage occurred less in the epinephrine group than that in the control group (1/75 vs. 7/76, P = 0.03). There was one case of perforation in each group.Epinephrine injection prior to polypectomy is effective in preventing immediate bleeding.

The difference of prognosis in patients with the same WHO grade of astrocytic tumors suggests that such tumors comprise a heterogeneous group in biological behavior. The correlation between p53 immunoreactivity and prognosis has often been reported but remains controversial. From the perspective of clonal expansion of p53 immunopositive cells, the distribution patterns of p53 immunoreactivity can be divided into four types: negative, scattered, focally clustered, and diffusely clustered. The survival rate was evaluated by classifying the p53 immunoreactivity into two groups: the significantly immunopositive patterns (focally and diffusely clustered types) and the significantly immunonegative patterns (negative and scattered types). The survival analysis showed a highly significant difference between these two patterns within the same WHO grade of astrocytic tumors (p = 0.0185). Our studies demonstrate that the distribution patterns of p53 immunoreactivity, which reflect the trends of clonal expansion of p53 immunopositive cells, are significantly valuable in predicting the prognosis of patients with the same WHO grade of astrocytic tumors.

One-week triple therapy has been recommended as a standard regimen for eradicating Helicobacter pylori infection. The emergence of antibiotic-resistant strains, adverse drug effects, poor compliance and high cost of therapy add problems to the management of these patients. In this study, we assessed whether a 3-day triple therapy could be effective in eradicating Helicobacter pylori infection in bleeding peptic ulcer patients.Peptic ulcer patients with Helicobacter pylori infection were enrolled in this study. Patients enrolled at the outpatient department (group A) received a 7-day oral regimen: bismuth subcitrate colloid 300 mg + amoxicillin 500 mg + metronidazole 250 mg four times per day. Patients who were admitted to the wards due to peptic ulcer bleeding (group B) received a 3-day regimen including omeprazole 40 mg intravenously every 6 hours, amoxicillin 500 mg + metronidazole 250 mg orally four times daily after hemostasis had been achieved. Patients of both groups received omeprazole 20 mg once per day or cimetidine 400 mg twice daily per os for at least-one month after anti-Helicobacter pylori therapy. We followed every patient endoscopically two months after anti-Helicobacter pylori therapy.From June 1997 to April 1999, a total of 57 patients (30 in group A and 27 in group B) with gastric or duodenal ulcer and Helicobacter pylori infection completed anti-Helicobacter pylori therapy. Two months after anti-Helicobacter pylori therapy, peptic ulcer was found to be healed with a scar in 26 (86.7%) of group A and 23 (85.2%) of group B (P0.1). The eradication rates of Helicobacter pylori in the two groups were not significantly different in an intention-to-treat analysis [group A: 78.8% (26/33), 95% CI: 64.9-92.7%; group B: 80% (24/30), 95% CI: 65.7-94.3%, P0.1] and in a per protocol analysis [group A: 86.7% (26/30), 95% CI: 74.5-98.9%, group B: 88.9% (24/27), 95% CI: 77.1-100.7%, P0.1]. Fewer side effects occurred in group B (3/30) than those in group A (7/33) (P0.1).In patients with peptic ulcer bleeding a 3-day anti-Helicobacter pylori therapy is a good alternative for eradicating Helicobacter pylori infection.

The difference in histologic patterns of lung cancer between men and women in Taiwan may be associated with the heterogeneity in causal factors of lung cancer between the sexes. A sex- and age-matched case-control study was designed to investigate such a relationship.Cases consisted of 236 male and 291 female incident cases with newly diagnosed and histologically confirmed primary carcinoma of the lung, and were compared to one or two individually matched controls.Cigarette smoking, occupations, and previous tuberculosis history were found to independently correlate with an elevated risk of squamous/small cell carcinoma and adenocarcinoma for male patients. However, there was little difference in the effect of these risk factors except smoking. The use of fume extractors in the kitchen, and the habit of waiting to fry after the fumes were emitted, separately explained the majority of the attributable fraction of female squamous/small cell carcinoma (28.2%) and adenocarcinoma (47.7%). With the exception of a kitchen with fume extractors and a clinical history of tuberculosis, the environmental causal factors of lung cancer were heterogeneous between these two histologic cell groups.Our results suggested that the causal factors of lung cancer might be specific for the type of tumor concerned. The gender-specific risk factors of lung cancer could partly explain the difference in cell-type distribution between men and women.

Relative survival rates can offer a general description of tumor outcome and, traditionally, are used for surveillance and comparison purposes. However, they are not informative for individual tumor survivors. Conditional survival estimates can calculate the probability of surviving next some years given survival to a specific period of time after craniotomy for individual tumor survivors. However, clinically, they have not been used for predicting the tumor outcome.We calculated conditional probabilities of survival within 6 years after craniotomy in 112 patients with primary supratentorial astrocytic tumors and evaluated factors affecting the survival time more than 2 years after craniotomy.Our data showed that the conditional probability of survival can predict yearly survival rate when patients survive for a specific period of time. The conditional survival rates within 6 years after craniotomy were always higher than those evaluated by relative survival rates. Overall, the longer the patients survived, the higher the conditional probabilities of surviving sixth year postoperatively were.Our study demonstrates the conditional probabilities of survival have good availability and are important estimates for individual tumor survivors.

Purpose Collateral venous pathways occurring with superior vena cava (SVC) obstruction were examined based on CT scans obtained from the thoracic inlet to the pubic symphysis. Similarities and variations from the prior classification scheme were analyzed. Method A retrospective review of our database resulted in a cohort comprising 21 CT scans from 19 patients. The location and frequency of each collateral pathway and the level of the SVC obstruction were tabulated. An accepted classification scheme was applied to the collateral patterns in each case. Additional and atypical features were noted. Results Fifteen common collateral veins were found that could be grouped into one to four collateral pathways. Unusual shunts, including hepatic parenchymal and pulmonary pathways, were found. Thirteen cases (62%) varied from the standard classification owing to different occlusion levels or presence of other collaterals. No statistically significant relationship between the level of occlusion and the number of collateral pathway groups was found. The most common abdominal collateral veins were those along the liver surface (52.3% of cases), although 18 patients (94.7%) had at least one collateral vein visible in the abdomen. Conclusion The spectrum of venous collateral formations as seen on thoracoabdominal CT scans often includes collaterals at or below the level of the diaphragm, including intrahepatic shunts. Many collateral patterns found in this series could not be classified with the existent classification scheme.

Scanning laser polarimetry has been used recently for the measurement of retinal nerve fiber layer (RNFL) thickness, taking advantage of the birefrigence of the RNFL. We observe the RNFL with the instrument and try to find out a set of normal basic values of the RNFL thickness for clinical comparison. One hundred normal volunteers of different age groups were recruited for this study. There are 44 males and 56 females with a mean (1SD) age of 36.17(14.77) years. Three consecutive 15-degree polarimetric maps were acquired for each subject. RNFL thickness measurements were obtained at 1.75 disc diameters ring from the optic nerve. Four 90-degree quadrants were identified. As a result, the average of RNFL thickness is 90.69 (20.20) microns in the superior quadrant, 80.45 (17.4) microns in the inferior quadrant, 59.28 (15.37) microns in the nasal quadrant, and 48.98 (15.72) microns in the temporal quadrant with a mean thickness value of 69.86 (13.97) microns. Superior and inferior quadrants showed a comparatively thicker nerve fiber layer than nasal and temporal quadrants. The temporal quadrant was always the lowest. The axial length does not affect the RNFL thickness and no significant difference between males and females exists. However, an obvious inverse linear correlation between age and the RNFL thickness in all quadrants is found. The average RNFL thickness decreased with age by 0.26 micron per year. (R2 = 0.081, p-value = 0.004). When compared with the normal range, age-match would be necessary.

The role of omeprazole in preventing rebleeding in patients with peptic ulcer bleeding after successful endoscopic therapy has been controversial. In this study, we used 3 different formulas of intravenous omeprazole in the above patients. We wished to compare the intragastric pH and outcomes among them.Between July 1996 and May 1997, after having obtained initial hemostasis with endoscopic therapy, a total of 20 patients with peptic ulcer bleeding (spurting/oozing/non-bleeding visible vessel: 6/4/10) received intravenous bolus of omeprazole 20 mg every 3 hours; 20 patients (3/5/12) received intravenous bolus of omeprazole 40 mg every 6 hours; and, 20 patients (5/4/11) received intravenous bolus of omeprazole 80 mg every 12 hours for 3 days. One intragastric pH meter (Gastrograph Mark III, Medical Instruments Corp. Switzerland) was used to record 24-hour intragastic pH.The intragastric pH in the patients receiving omeprazole 20 mg every 3 hours was 6.1, 6.0-6.2 (mean: 95% CI); in patients receiving omeprazole 40 mg every 6 hours it was 6.4, 6.2-6.5; and, in patients receiving omeprazole 80 mg every 12 hours it was 5.8, 5.7-5.9. The duration of intragastric pH6.0 in omeprazole 20 mg every 3 hours was 70.9%, 57.3%-84.4% (mean: 95% CI); in omeprazole 40 mg every 6 hours it was 83.1%, 73.1%-93.1%; and, in omeprazole 80 mg every 12 hours it was 66%, 51.5%-80.4%. Patients with peptic ulcers receiving omeprazole 40 mg intravenous bolus every 6 hours had the highest intragastric pH as compared with the other 2 groups (p0.0001). There were no significant differences concerning rebleeding rates, volume of blood transfusion, hospital stay, numbers of operation and mortality among the 3 groups.After initial hemostasis had been obtained, patients with peptic ulcer bleeding receiving 40 mg intravenous bolus every 6 hours had the highest intragastric pH. However, they had similar outcomes with the other 2 groups.

Both Helicobacter pylori and non-steroidal anti-inflammatory drugs are reported to affect gastroduodenal prostaglandin synthesis. However, their influence on gastric mucosal prostaglandins remains unclear. The aim of this study was to investigate the influence of nonsteroidal anti-inflammatory drugs on mucosal prostaglandin synthesis in patients with Helicobacter pylori infection.We enrolled 87 Helicobacter pylori-infected patients in this study (gastric ulcer: 33, duodenal ulcer: 41, and non-ulcer dyspepsia: 13). Of them, 27 patients received non-steroidal anti-inflammatory drugs. Endoscopy was performed and biospy specimens from gastric body, antrum and duodenal bulb were assessed for Helicobacter pylori and prostaglandin concentration.A significantly lower mucosal prostaglandin E2 level at gastric body (142.2 +/- 28.1 ng/mg vs. 222.0 +/- 12.4 ng/mg, mean +/- SEM) and antrum (131.3 +/- 26.4 ng/mg vs. 226.0 +/- 19.0 ng/mg) was noted in Helicobacter pylori-infected gastric ulcer patients with non-steroidal anti-inflammatory drugs ingestion than in that of patients without non-steroidal anti-inflammatory drugs ingestion (p0.05). Using a multivariate analysis, we found that non-steroidal anti-inflammatory drug was an independent variable affecting gastric and duodenal mucosal prostaglandin E2 synthesis in patients with Helicobacter pylori-infected gastric ulcer.Non-steroidal anti-inflammatory drugs decrease gastroduodenal mucosal prostaglandin E2 synthesis in gastric ulcer patients with Helicobacter pylori infection.

Controversy exists concerning the influence of Helicobacter pylori on gastric secretion. Hyper-, normo- and hyposecretion of gastric acid in normal subjects with H pylori infection have been reported, although there is no such report for Chinese subjects. The goal of this study was to identify the effect of H pylori on gastric secretion in normal Chinese subjects.Twenty normal subjects with a normal upper gastrointestinal tract by endoscopy were recruited. H pylori status was assayed by a rapid urease test. Gastric secretion and gastrin release were also measured.Among the subjects studied, nine were infected with H pylori. All enrolled subjects were males. Age and body weight were similar between both groups. No significant difference was found in basal acid output, maximal acid output, basal pepsin output or maximal pepsin output between the H pylori-positive group (median, 1.1 mmol/hour, 95% confidence interval 0.2-3.6 mmol/hour; 8.0, 3.0-18.3 mmol/hour; 0, -1.3-11.2 mmol/hour; and 4.1, -4.2-59.3 mmol/hour, respectively) and the H pylori-negative group (2.5, -1.3-11.3 mmol/hour; 12.2, 8.7-26.9 mmol/hour; 4.3, 1.8-13.5 mmol/hour; and 14.8, -5.7-73.0 mmol/hour, respectively). Serum basal gastrin and pepsinogen I concentration were 63.5, 50.0-78.6 pg/ml and 75.1, 50.6-89.8 ng/ml in the H pylori-positive group, and 65.9, 50.2-79.8 pg/ml and 79.1, 59.5-120.1 ng/ml in the H pylori-negative group (p0.05).H pylori plays no role in the gastric secretion and gastrin release in normal Chinese subjects.

Cervical cancer is a worldwide malignancy particularly prevalent in older women. Due to the increasing population ratio of older women and their more complicated illnesses, doctors in Taiwan are concerned about the care of older patients with cervical cancer. Few studies have been performed on the association between referral initiative and illness severity upon referral as well as the tendency of older patients with cervical cancer to return to the referring doctor and to the consultant at the medical center for follow-up. The purpose of this study was to investigate the referral association by adjusting for confounding variables.This study included 214 women aged 65 years and over with cervical cancer diagnosed between 1987 and 1995. Patients were referred to a tertiary teaching hospital by 71 primary care gynecologists. The International Federation of Gynecology and Obstetrics clinical stage and clinical severity were assessed in each patient. Histopathologic results were reviewed to confirm the diagnosis.Of all the cervical cancer referrals, 20.2% were initiated by patients or families and 79.8% were initiated by primary care doctors. No statistically significant differences were found in the Basic Activities of Daily Living or Instrumental Activities of Daily Living between doctor- and patient-initiated referrals. High Geriatric Depression Scale and low Mini-Mental State Examination were associated with doctor-initiated referrals. Higher cancer stage and greater clinical severity of patients with cervical cancer was found in patient- rather than doctor-initiated referrals. After adjusting for marriage, family type, medical payment, mental status, cancer stage and clinical severity, the data showed that, if the referral was initiated by a primary care doctor, older patients with cervical cancer had a similar likelihood to return to both the primary care doctor and the tertiary teaching hospital for follow-up.If a referral was initiated by a doctor, older women with cervical cancer were not only likely to return to their consulting physician at the medical center, but also likely to return to their primary care doctor. Continuous care is more likely to occur when the primary care doctor initiated the referral.

The role of p53 gene mutations in the formation or progression of human astrocytic tumors is controversial. We studied the distribution pattern of p53 immunoreactivity and analyzed p53 gene mutations to define the significance of p53 gene mutations in astrocytoma tumorigenesis or malignant progression. Twenty-three astrocytic tumors were evaluated with immunohistochemistry, single-strand conformation polymorphism (SSCP) analysis, and sequence analysis. We also searched MEDLINE to collect data on p53 gene mutation frequencies in astrocytic tumors in order to evaluate the association of p53 mutations and tumor grade. Strong immunoreactivity with a diffuse clustering pattern was found in three of five glioblastomas and seven of 12 anaplastic astrocytomas. Three of four low-grade astrocytomas were immunonegative. The p53 immunopositive cells in the only positively staining low-grade astrocytoma in our study appeared sparsely scattered. The results of immunostaining suggested that clonal expansion was associated with astrocytoma progression. Mutations of the p53 gene were detected in four of the 23 astrocytomas (one glioblastoma and three anaplastic astrocytomas). In the genetic data analysis, 76 of 367 astrocytomas had p53 gene mutations. A significantly greater p53 gene mutation frequency was found in anaplastic astrocytomas or glioblastomas than in the low-grade astrocytomas. The results of these immunohistochemical and genetic studies support the view that p53 gene mutation is associated with the malignant progression from low-grade to high-grade astrocytomas rather than with tumor initiation or promotion.

Molecular pathology may play an important role in predicting the tumor prognosis, particularly p53, epidermal growth factor receptor (EGFR), and c-erbB-2. We investigated six variables (age, sex, histopathological grade, p53, EGFR, and c-erbB-2) to identify the role of such factors in predicting the outcome of patients with supratentorial astrocytic tumors. Thirty-seven tumors were studied including 9 well-differentiated astrocytomas (WHO grade 2), 19 anaplastic astrocytomas (WHO grade 3), and 9 glioblastomas multiforme (WHO grade 4). In univariate analysis, no statistical significance was found for the prognostic value of the sex (p = 0.2188), age (p = 0.5530), p53 immunostain (p = 0.2194), and c-erbB-2 immunostain (p = 0.4203). A significant correlation with the prognosis was found with respect to the histopathological grade (p = 0.0049) and EGFR expression (p = 0.0284). In multivariate analysis, the histopathological grade was shown to be significant independent variable (p = 0.0152). In WHO grade 2 and 3 astrocytomas, expression of p53 or EGFR was associated with poorer patient outcome. In glioblastomas, expression of p53 was also associated with poorer prognosis. Our studies suggested that conventional histological assessment of supratentorial astrocytic tumors remains the best guide to prognosis. Although no statistical significance was found between the immunostains and survival in variant grades of astrocytomas, there was a trend between p53 or EGFR proteins expression and the decrease of survival time.

Cruciferous vegetables, especially broccoli, may prevent cancer through anticarcinogenic compounds. For example, broccoli contains isothiocyanates that induce carcinogen-detoxifying enzymes. Glutathione transferase enzymes conjugate isothiocyanates, leading to excretion. We hypothesized that broccoli consumption in combination with the glutathione transferase M1 (GSTM1) null genotype would be associated with a lower prevalence of colorectal adenomas because of higher isothiocyanate levels. We used a case-control study of mainly asymptomatic subjects aged 50-74 years who underwent a screening sigmoidoscopy at either of two Southern California Kaiser Permanente Medical Centers during 1991-1993. Cases (n = 459) had a first-time diagnosis of histologically confirmed adenomas detected by flexible sigmoidoscopy. Controls (n = 507) had no polyp detected. Subjects had a 45-min in-person interview for information on various risk factors and basic demographic data and completed a 126-item, semiquantitative food frequency questionnaire. Blood samples were used for GSTM1 genotyping. Subjects with the highest quartile of broccoli intake (an average of 3.7 servings per week) had an odds ratio of 0.47 (95% confidence interval, 0.30-0.73) for colorectal adenomas, compared with subjects who reportedly never ate broccoli. When stratified by GSTM1 genotype, a protective effect of broccoli was observed only among subjects with the GSTM1 null genotype (P for trend, 0.001; P for interaction, 0.01). The observed broccoli-GSTM1 interaction is compatible with an isothiocyanate mechanism.

Tumorigenesis is the result of sequential or multiple genetic alterations. The overexpression or amplification of various oncogenes in diverse human brain tumors have been observed. While numerous studies on the immunohistochemical demonstration of EGFR-overexpression have been reported, little has been found in the literature about the c-erbB-2 protein in human astrocytic tumors. In the present study, we evaluated the expression of EGFR and c-erbB-2 protein in 33 astrocytic tumors with immunohistochemistry. According to the World Health Organization brain tumor classification, the study included 9 low-grade astrocytomas (grade 2), 15 anaplastic astrocytomas (grade 3), and 9 glioblastomas multiforme (grade 4). The positive EGFR immunoreactivity was detected in 28 (85%) of 33 tumors. The expression of EGFR increased with the grade of malignancy in low-grade astrocytomas (67%), anaplastic astrocytomas (87%), and glioblastomas (100%). For the expression of c-erbB-2 protein, 17 (51.5%) of 33 tumors were positive immunostain, including 3 low-grade astrocytomas (37.5%), 9 anaplastic astrocytomas (81.8%), and 5 glioblastomas (62.5%). Different degrees of immunoreactivity for c-erbB-2 protein were found in variant grades of astrocytomas. However, the positive immunostain of EGFR displayed moderate or strong reactivity. The coexpression of EGFR and c-erbB-2 protein was found in 17 (15.5%) of 33 tumors. The results emphasize that the overexpression of EGFR parallels astrocytoma progession and higher frequency of c-erbB-2 immunoreactivity was seen in snaplastic astrocytomas and glioblastomas than in low-grade astrocytomas.

Clarithromycin is a new macrolide antibiotic which is known to be highly effective in eradicating Helicobacter pylori (H. pylori). In Chinese, the role of clarithromycin for H. pylori is still unclear.Between January 1995 and February 1996, 75 patients with active H. pylori-positive duodenal ulcer were enrolled in this study. Three groups were randomized to have (1) 2 x 150 mg nizatidine twice daily, 2 x 250 mg amoxicillin four times daily, and 2 x 250 mg clarithromycin three times daily for two weeks (niz-amox-clar group, N = 25); or (2) 20 mg omeprazole twice daily plus 2 x 250 mg clarithromycin three times daily for two weeks (ome-clar group, N = 25); or (3) 300 mg bismuth subsalicylate four times daily, and 2 x 250 mg amoxicillin four times daily, 250 mg metronidazole four times daily for two weeks (triple therapy group, N = 25). All the patients received H2 receptor antagonist (150 mg nizatidine or ranitidine, or 400 mg cimetidine, twice daily) for the consecutive six weeks.The eradication rate of H. pylori eight weeks after the entry of study was 80%(20/25) in the niz-amox-clar group, 76%(19/25) in the ome-clar group, 88%(22/25) in the triple therapy group (p0.05 among the three groups). The ulcer healing rates eight weeks after the entry of study for the niz-amox-clar, the ome-amox, and the triple therapy groups were 84%(21/25), 80%(20/25), and 80%(20/25), respectively (p0.05 among the three groups). The number of patients experiencing adverse effects in the niz-amox-clar group, the ome-clar group, and the triple therapy group were 10(40%), 7(28%), and 4(16%), respectively (p0.05 among the three groups).Both nizatidine/amoxicillin/clarithromycin and omeprazole/clarithromycin regimens can achieve good eradication rates and may provide an effective alternative anti-H. pylori treatment in duodenal ulcer diseases.

Background Although cigarette smoking is considered to be the most important cause of lung cancer, smoking behaviour cannot fully explain the epidemiological characteristics of lung cancer in Taiwanese women, who rarely smoke but contract lung cancer relatively often. There are other causes of lung cancer that have produced variability in lung cancer incidence. Methods A case-control study involving interviews with 117 female patients (including 106 non-smoking) suffering from lung cancer and the same number of individually matched hospital controls was conducted in Kaohsiung, Taiwan between 1992 and 1993. The questionnaire administered to cases and controls collected information on cigarette smoking and suspected risk factors for lung cancer. Multivariate logistic regression analysis was applied to assess smoking for all women and suspected risk factors for non-smoking women. Results The relationship between cigarette smoking and lung cancer was statistically significant although only a small proportion (9.4%) of female patients had smoked. However, the risk of contracting cancer for non-smoking women appears to be associated with certain cooking practices, especially preparing meals in kitchens not equipped with a fume extractor at cooking age of 20-40 years (odds ratio [OR] = 8.3; 95% confidence interval [CI]: 3.1-22.7. These factors and a history of pulmonary tuberculosis plus low consumption of fresh vegetables explained 78% of the summary attributable risks for non-smoking women in a multivariate logistic regression model. Conclusions Exposure to fumes from cooking oils, when not reduced by an extractor, may be an important factor in causing lung cancer in non-smoking Taiwanese women.

Smoking and a high intake of red meat are risk factors for colorectal tumors. These effects could be due to aromatic amine carcinogens. Individual susceptibility to aromatic amines has been related to acetylation phenotype, which plays a role in the bioactivation of arylamines. Polymorphisms in both N-acetyltransferase genes, NAT1 and NAT2, have been associated with an increased risk of colorectal tumors. We studied the NAT1*10 fast acetylator allele (1088 T--A mutation) and distal adenomas in a sigmoidoscopy-based case-control study (441 cases, 484 controls). We found neither an increased adenoma prevalence in subjects homozygous or heterozygous for the NAT1*10 fast acetylator allele (odds ratio 1.04; 95% confidence interval 0.79-1.36), nor a gene-gene interaction between NA1 and NAT2 (P(interaction) = 0.59). Further NAT1 alleles must be considered for more conclusive results regarding the relevance of NAT1 activity to colorectal tumorigenesis.

In a prospective study from November 1989 to December 1993, the accuracy of computed tomography (CT), endoscopic ultrasonography (EUS) and intraoperative surgical assessment were compared for the evaluation of the depth of invasion (T category) and involvement of lymph nodes (N category) in patients with gastric carcinoma. Sixty-nine consecutive patients who received preoperative CT and EUS underwent subsequent surgery. CT and EUS results were compared with histopathologic staging of tumor invasion depth and regional lymph node metastasis (pT and pN categories). T categories were staged correctly in 42% of the cases by CT, 71% by EUS and 55% by intraoperative surgical assessment. CT correctly staged 49% of N1 and N2 lymph nodes compared with 65% for EUS and 45% for intraoperative surgical assessment. CT was more accurate for advanced cancer but had a tendency to understage the T and N categories. EUS was more accurate for serosal cancer and displayed a tendency to overstage T categories and understage N categories. Intraoperative surgical assessment overstaged early T stages, understaged the T4 stage and had a tendency to overstage N categories. CT and intraoperative surgical assessment of T and N categories were of limited value in the staging of gastric carcinoma compared to EUS. EUS is a valuable form of assessment to evaluate gastric cancer staging before surgery.

The aim of this study is to identify factors that will predict which patients with benign gastric outlet obstruction will not respond to endoscopic balloon dilation, in a long-term observation.Over a 51-month period, 42 patients with benign gastric outlet obstruction received endoscopic balloon dilation. The "through-the-scope" technique with the aid of a guide wire was used for dilation. Fifteen factors were analyzed prospectively in 40 patients. Multivariate analysis was used to find the independent factors of the failure of treatment.The median follow-up period was 23 months (range 1-51 months). Twenty-eight (67%) patients achieved sustained improvement, and 14 (33%) patients underwent surgery. The overall symptom-free rates in 12, 24, 36, and 48 months were 85.3%, 78%, 68.8%, and 68.8%, respectively. The independent prognostic factor for failure of treatment was the need for more than two courses of endoscopic balloon dilation to relieve symptoms (odds ratio, 6.857; 95% confidence interval, 1,031-45,606).Endoscopic balloon dilation for the treatment of benign gastric outlet obstructions is an effective alternative to surgery. Patient who needs more than two courses of endoscopic balloon dilation to relieve symptoms should receive surgery.

P53 immunohistochemistry in astrocytic tumors has usually been evaluated by the percentage of positive cells. However, in this study we analyzed the P53 immunopositive cells by their patterns of distribution. Formalin-fixed and paraffin-embedded sections from 38 patients with astrocytic tumors were examined. The distribution pattern of P53 immunostaining cells was divided into 3 types: negative, locally scattered, and diffuse clustering. There were 2 positive stains in 5 astrocytomas (40%), 12 positive in 24 anaplastic astrocytomas (50%), and 7 positive in 9 glioblastoma multiformes (78%). In astrocytomas, the positive cells were locally scattered. In anaplastic astrocytoma and GBM, the positive cells appeared locally scattered or as diffuse clustering. For the variant immunoreactive expression, the mean ages for patients with negative, locally scattered and diffusely clustered P53 immunostaining were as follows: 51.4, 52.6, and 28.4 years (P0.01), respectively. In anaplastic astrocytoma and GBM, the diffusely clustered pattern was more common in younger patients, whereas elderly patients in same groups tended to have few or no P53 immunopositive cells. Thus, our results implicate that clonal expansion of P53 immunopositive cells is associated with brain tumor progression.

Omeprazole/amoxicillin regimen has proved elsewhere to be effective in the eradication of Helicobacter pylori (H. pylori). However, in the Chinese, its role in H. pylori is still unclear.Between November 1993 and June 1994, 112 patients with active, H. pylori positive peptic ulcer were enrolled in this study. Five groups were arranged randomly to have 20 mg omeprazole q.d. for 28 days plus 750 mg amoxicillin b.i.d. for the first 10 days (omep-20-amox group, N = 22), 20 mg omeprazole b.i.d. for 28 days plus 750 mg amoxicillin b.i.d. for the first 10 days (omep-40-amox group, N = 22), 300 mg bismuth subsalicylate q.i.d. for 28 day, and 750 mg amoxicillin b.i.d., 500mg metronidazole t.i.d. for the first 7 days (triple therapy group, N = 25), 20 mg omeprazole q.d. for 28 days (omep-20 group, N = 22), or 150 mg ranitidine b.i.d. or 400 mg cimetidine b.i.d. for 28 days (H2-antagonist group, N = 21).The eradication rate of H. pylori eight weeks after the entry of study was 38.1% in the omep-20-amox group, 66.7% in the omep-40-amox group, 77.3% in the triple therapy group, 4.7% in the omep-20 group and 0% in the H2 antagonist group (p0.05 between the triple therapy and the omep-20-amox, the omep-20, and the H2 antagonist groups). Eleven patients in the triple therapy group suffered from adverse effects (45.8%) (p0.05 as compared with other groups). The ulcer healing rates four weeks after the entry of study for the omep-20-amox, the omep-40-amox, the triple therapy, and the omep-20 groups were 80.9%, 80.9%, 68.2%, and 85.7% respectively (p0.05). For the H2 antagonist group, the ulcer healing rate eight weeks after the entry of study was 70%.Both medium-dose omeprazole/amoxicillin and triple therapy can achieve good eradication rates. However, medium-dose omeprazole/amoxicillin had a much lower side effect. Therefore, we recommend medium-dose omeprazole/amoxicillin for the eradication of H. pylori.

In patients with peptic ulcer bleeding, acid can enhance platelet disaggregation and cause lysis of the clot. Omeprazole, a potent acid suppressor, may be helpful in reducing their rebleeding rate.Between March and October 1994, 40 patients with a non-bleeding, visible vessel (NBVV) at ulcer bases were enrolled for study. They were randomized into four groups. Group 1 (n = 10) patients received cimetidine 300mg intravenously (i.v.) q6h; Group II (n = 10) patients received heater probe thermocoagulation therapy and cimetidine 300mg i.v. q6h; Group III (n = 10) patients received omeprazole 40mg intravenous bolus initially followed by 40mg i.v. qd and Group IV (n = 10) patients received omeprazole 40mg intravenous bolus initially followed by 40mg i.v. q12h. Endoscopic examination was done for follow-up, daily, for 1-3 days.Preliminary results showed that the age, initial hemoglobin, ulcer size as well as NBVV size in Groups I-IV were not significantly different (p0.05). The rebleeding rates were 40% in Group I, 20% in Group II, 20% in Group III and 0% in Group IV, (p0.05 when Group IV is compared with Group I).Intravenous omeprazole 40mg given q12h can reduce the rebleeding rate of patients with a NBVV.

Pseudomelanosis duodeni is an uncommon endoscopic sign characterized by diffuse small black spots on the first and second portions of the duodenum. It occurs predominantly in female and elderly patients and is linked to chronic illnesses and related medications. Between 1988 and 1994, the authors saw eight patients with pseudomelanosis duodeni. To evaluate the nature of the pigments, special staining was performed in seven cases. Iron stain was strongly positive in three cases. Electron microscopy was performed in two cases. This revealed amorphous bodies within macrophage lysosomes in one case and angular crystals in another case. These tests suggest that in pseudomelanosis duodeni iron metabolism may be impaired and iron is pooled within macrophages.

Colorectal cancer is caused by environmental exposures and genetic predisposition. However, little is known of hereditary factors that influence development of common, non-Mendelian forms of this cancer. Interactions among carcinogen exposure, hereditary variants of enzymes involved in carcinogen metabolism, and other host factors may play a role. Genetic polymorphisms of carcinogen metabolism, such as the glutathione transferase M1 (GSTM1) null genotype, are thus possibly related to cancer risk. The GSTM1 enzyme detoxifies mutagens formed from polycyclic aromatic hydrocarbons which are found in tobacco smoke. We analyzed GSTM1 genotypes and smoking among 488 controls and 446 individuals with a first time diagnosis of colorectal adenomas which are precursors to cancer. Subjects were from two Kaiser Permanente sigmoidoscopy clinics in southern California. We observed no overall effect of the GSTM1 null genotype on the risk for colorectal adenomas (odds ratio, 0.85; 95% confidence interval = 0.65-1.10). The odds ratio for smokers with the null genotype was 2.07 (95% confidence interval = 1.14-3.77) when compared to "never smokers" without the null genotype. Using this same reference group, the odds ratio for smokers without the null genotype was 1.73 (95% confidence interval = 1.03-2.90). These two odds ratios were not significantly different (P = 0.30).

The mortality rate of peptic ulcer bleeding has kept around 6-10% over the past thirty years. Rebleeding is the most important adverse prognostic factor. Heat probe thermocoagulation is suspected to have good hemostatic effect, there is doubt whether the experience of performing the HPT treatment for peptic ulcer bleeding will influence the hemostatic rate. So we report our experience of a large series for heat probe thermocoagulation.Patients with an active bleeding source (spurting or oozing) or a nonbleeding visible vessel (NBVV) in a peptic ulcer disease were enrolled in this study. We used an Olympus GIF IT-10 or GIF 2T-10 panendoscope, an Olympus heat probe unit and a 3.2 mm probe (Olympus Co., Taipei, R.O.C.) to treat peptic ulcer bleeding. We classified the faculty into junior physician, having experience in less than 20 procedures, and senior physician, having experience in more than 20 procedures.Between September 1986 and October 1993, we treated 329 patients with active bleeding or nonbleeding visible vessels at the ulcer craters. The stigmata of recent hemorrhage in these patients included spurting hemorrhage in 102 cases (31%), oozing hemorrhage in 105 cases (31.9%), nonbleeding visible vessels in 122 cases (37.1%). The bleeders were most frequently found in the stomach (181,55%), then the duodenum (133,40.4%). The energy applied to each case was 886 +/- 844 joules (mean +/- SD). The initial hemostatic rate was 95.1% (313/329). Rebleeding occurred in 74 cases (23.6%), and 52 cases received a second heat probe thermocoagulation with to result in ultimate hemostasis in 43 cases (82.7%). Junior physician obtained similar initial hemostasis rate and rebleeding rate (92.6%, 26.4%) as compared with 96.2% and 22.7% of senior physician. Totally 33 patients received emergency operation, and 5 patients died. The volume of total blood transfusion was 2830 +/- 2184 ml (mean +/- SD). The hospital stay was 7.4 +/- 4.6 days (mean +/- SD).Heat probe thermocoagulation is very effective in the arrest of peptic ulcer bleeding with minimal complications and it is easy to learn in a short period of time.

The long-term rebleeding rate of a bleeding ulcer after endoscopic hemostasis is, so far, not clear. The goal of this study is to present the natural history of bleeding ulcers after heater probe thermocoagulation.Between September 1986 and June 1991, we used heater probe to treat 202 patients with active bleeding or nonbleeding visible vessels at the ulcer craters. We were able to follow 159 patients for 2-7 yr (mean +/- SD: 54.5 +/- 19.9 months). Patients with active bleeding or nonbleeding visible vessels who did not receive endoscopic hemostasis or surgery in our previous studies served as controls.The energy applied to each patient in the heater probe group was 886 +/- 844 J (mean +/- SD). The ultimate hemostatic rate in the heater probe group was 91.2% (145/159). In the period of long-term follow-up, there were 32 episodes of rebleeding in 24 patients (16.6%). Most rebleeding episodes (22/32) subsided spontaneously. Only one rebleeding patient died before a surgical attempt. The rebleeding rate was less than that of the controls (43/87, p0.0001).Heater probe thermocoagulation is very effective in arrest of peptic ulcer bleeding. In the long-term follow-up, heater probe thermocoagulation can decrease rebleeding rate in most patients with peptic ulcer hemorrhage.

In 1986-1988, the authors had experiences with thoracic epidural anesthesia for a variety of major abdominal operations in 303 patients. It is proved to be reliable and effective. The puncture levels were between T8 to T12. 2% lidocaine, in plain form or with 1:200,000 epinephrine, was used as anesthetic agent. Perioperative complications were carefully managed with satisfactory results. Post-operative conditions were evaluated and seemed to be superior to those of general anesthesia in many aspects. No patient had neurologic deficit as a result of the epidural anesthesia. We concluded that thoracic epidural anesthesia is an excellent alternative technique in major abdominal surgeries.

To determine the prevalence and significance of hepatitis C virus infection in kidney transplant recipients, paired serum samples collected from 100 renal allograft recipients on admission for kidney transplantation and 1 yr after transplantation were tested for antibody to hepatitis C virus with second-generation enzyme immunoassay and recombinant immunoblot assay and for hepatitis C virus RNA with reverse transcription-polymerase chain reaction. Before kidney transplantation, hepatitis C virus antibody was detected with second-generation enzyme immunoassay in 18 patients (12 second-generation recombinant immunoblot assay-positive, 6 second-generation recombinant immunoblot assay-indeterminate). Nine of 12 second-generation recombinant immunoblot assay-positive and 2 of 6 second-generation recombinant immunoblot assay-indeterminate samples were hepatitis C virus RNA positive. In addition, 7 of 82 patients who had no detectable antibody on second-generation enzyme immunoassay or second-generation recombinant immunoblot assay were hepatitis C virus RNA positive. After kidney transplantation, hepatitis C virus antibody was detected in 19 patients (12 second-generation recombinant immunoblot assay-positive, 7 second-generation recombinant immunoblot assay-indeterminate, 14 seropositive for hepatitis C virus antibody). Eleven of 12 patients with second-generation recombinant immunoblot assay-positive results and 4 of 7 with second-generation recombinant immunoblot assay-indeterminate results were positive for hepatitis C virus RNA. Hepatitis C virus RNA was present in 28 patients 1 yr after kidney transplantation. Six patients appeared to have acquired active hepatitis C virus infection 1 yr after kidney transplantation (seroconverted to hepatitis C virus RNA positivity).(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate the clinical efficacy of interferon-alpha in hepatocellular carcinoma, 71 adult Chinese patients with histologically proven inoperable hepatocellular carcinoma were randomized to receive recombinant interferon-alpha 2a (50 x 10(6) IU/m2) intramuscularly three times a week (n = 35) or no antitumor therapy (n = 36). The survival of interferon-alpha-treated patients was significantly better than that of patients who received no antitumor therapy (p = 0.0471); median lengths of survival were 14.5 and 7.5 wk, respectively. Objective tumor regression greater than 50% was observed in 31.4% (11 of 35) of patients receiving interferon-alpha. Interferon-alpha induced tumor regression greater than 50% in 11 (31.4%) patients. Compared with the group receiving no antitumor therapy, the interferon-alpha therapy group had more tumor regression (p0.0001) and less tumor progression (p = 0.001). This high-dose interferon-alpha therapy was relatively well tolerated; only 34.3% of patients required reduction of dosage by one third or one half because of persistent fatigue. Two patients with diabetes mellitus (one also had tabes dorsalis) exhibited mental deterioration that might have been partially attributable to interferon-alpha therapy. We conclude that interferon-alpha is useful in a proportion of Chinese patients with inoperable hepatocellular carcinoma, both in prolonging survival and in inducing tumor regression.

The inflammatory fibroid polyp is a rare, polypoid lesion in the gastrointestinal tract. It occurs in the stomach, small intestine, and large intestine in descending order of frequency. This case report shows an ileal inflammatory fibroid polyp that causes ileoileal intussusception. So far, the histogenesis and pathogenesis of these kinds of polyps are still uncertain. Under the microscopic examination, the lesion appears to be made up of spindle-shaped or stellate cells that are morphologically identical to proliferating fibroblasts. Immunostaining results are strongly positive for vimentin and focally positive for S100 protein. However, epithelial membrane antigen, factor VIII R Ag, smooth muscle actin, and lysozyme test are all negative. This favors the view that the inflammatory fibroid polyp is fibroblastic in origin.

Malignancy is the first of the ten leading causes of death in Taiwan area, however, since 1978, esophageal cancer is on the first ten causes of malignancy. Esophageal cancer is an aggressive neoplasm with a generally poor prognosis. This is usually related to the advanced stages of the neoplasm at presentation and at diagnosis. In this study, the DNA content in tumor was analyzed by flow cytometry, and compared it with clinical- pathological data, especially the survival time. All thirty seven cases (36 male, 1 female, mean age: 56.5 +/- 10.3 y/o) received operation at Kaohsiung Medical College Hospital in the past 11 years and 29 cases (27 male, 2 female, mean age: 62.2 +/- 9.6 y/o) proved to be esophageal cancer by endoscopic biopsy were assayed in this study. The formalin fixed-paraffin embedded block is used to analyze DNA content by flow cytometry. After comparing these results with clinical-pathological data, there were no significant difference in sex, age, duration, tumor location and length. However, there is a significant correlation between ploidy and tumor cell differentiation, that is, most of the diploid cells were well differentiated while most of the aneuploid cells were poorly differentiated. The median survival time of diploid cases was 325 days which was longer than the 277 days in aneuploid group, but there was no significant difference between these two groups. The same result was noticed in DNA index. Multiple variables analysis of prognostic factors disclosed that there were significant difference in correation with age tumor location tumor length, and whether there was combined radiotherapy and operation. But there were no significant relationship between survival and DNA ploidy DNA index distant metastasis surrounding tissue invasion sex duration and tumor cell differentiation. These data suggest that DNA folw cytometry analysis alone, may not provide a sueful biologic basis for the variable prognosis seen with esophageal tumors.

From November 1, 1990 to January 31, 1991, 381 patients visited our emergency unit with the chief complaints of hematemesis (n = 153) and melena (n = 228). Of these patients, 298 (78.2%) received UGI endoscopy at the emergency unit, 29 (7.6%) received examination after they were admitted to wards, 3 (0.8%) received endoscopy at outpatient clinic and 51 (13.4%) did not have endoscopy. The percentages of endoscopic diagnoses in 330 patients who had UGI endoscopy were gastric ulcer (GU) 33.6%, duodenal ulcer (DU) 32.7%, esophageal varices (EV) 17.0%, and others 15.5%. Negative findings were noted in 3 cases and no definite bleeding source was found in 1 patient who had blood retention in stomach. The diagnostic rate of endoscopy was 98.8%. Of the 56 patients with EV, 45 (80.4%) had hematemesis; in contrast, 85 of the 108 DU patients (78.8%) complained of melena only. Of the 219 patients with bleeding GU/DU, 64 (29.2%) had endoscopic therapies and 7 (3.2%) needed operation. Sixty-four (29.2%) of them received UGI endoscopy within 6 hours after arrival. They had significantly higher frequency of stigmata of recent hemorrhage (SRH) and more endoscopic therapies than the remaining patients. The overall mortality rate in our patients was 6.0%; the mortality rate in patients with EV was much higher than that of the patients with GU/DU (19.6% vs. 1.8%, P less than 0.001). Of the 23 expired cases, only 11 died of hypovolemic shock. The remaining 12 patients died of deterioration or complications of their underlying diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

Over a period of 10 months, we conducted a prospective randomized controlled trial of endoscopic injection for the arrest of peptic ulcer hemorrhage in 84 patients. We injected pure alcohol (PA, 99.8%), 50% glucose in water (G/W), 3% NaCl solution, and normal saline solution (N/S, controls) to stop bleeding. The ultimate success rates in the four groups were: 81% (17/21) in the PA group, 80% (16/20) in the 50% G/W group, 65.2% (15/23) in the 3% NaCl group, and 80% (16/20) in the N/S group (p greater than 0.05). The volume of blood transfusion (mean +/- s. e. m.) for each patient was 1,200 ml +/- 433 ml in the PA group, 1,130 +/- 356 ml in the 50% G/W group, 1,704 +/- 330 ml in the 3% NaCl group, 1,400 +/- 548 ml in the N/S group (p greater than 0.05). The duration of hospitalization (mean +/- s. e. m.) was 5.7 +/- 1.5 days in the PA group, 3 +/- 1.3 days in the 50% G/W group, 6.1 +/- 1.1 days in the 3% NaCl group, and 5 +/- 1.1 days in the N/S group (p greater than 0.05). No complication of perforation or aspiration pneumonia was observed during hospitalization. We suggest that endoscopic injection with the above solutions be used as the first line of therapeutic endoscopy for arrest of peptic ulcer hemorrhage.

An automated system operating on the Peltier principle and using a two-alternative forced-choice testing technique was applied to measure the heat and cold thermal thresholds (HT and CT) in 63 normal subjects and 68 diabetic patients who had no clinical symptoms of peripheral neuropathy. To compare large and small nerve fiber functions, 34 of the diabetic group were also tested for vibration perception threshold (VPT) and nerve conduction velocity (NCV). The testing algorithm of the devices selected for used, including reference temperature and number of turns, was investigated for assessment of variability and reliability. The age effect on thermal thresholds was found in the normal group (p less than 0.001). There was a significant difference between HT and CT in an individual (p less than 0.01). CT was greater than HT in 68% of the subjects. The diabetic group had significantly higher thermal thresholds than the normal group (HT, 0.30 +/- 0.32 degree C vs 0.10 +/- 0.05 degree C, p less than 0.005; CT, 0.39 +/- 0.43 degree C vs 0.15 +/- 0.09 degree C, p less than 0.005). Thermal thresholds greater than the linear regression estimate for age plus three standard errors of estimate were defined as abnormal. The abnormality rate in diabetics was 33.8% for HT and 22.1% for CT. Of the 34 patients, 91.1% had abnormal results in at least one of the three tests: 47.1% abnormal for HT or CT, 67.6% for VPT, and 26.4% for NCV. No correlation existed between the thermal threshold and VPT (p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)