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Background Non-bismuth containing quadruple therapy (concomitant therapy) is an alternative treatment for Helicobacter pylori (H. pylori) eradication with increasing clarithromycin-resistant strains over times. This study compared the efficacies of non-bismuth containing quadruple therapy (concomitant therapy) in the treatment of first-line anti-Helicobacter Pylori between two time intervals (January 2013 to June 2014 and June 2016 to December 2017). Methods H. pylori-infected patients were recruited in the intention-to-treat (ITT analysis) and divided into EACM-A group (enrolled from January 2013 to June 2014, N = 98) and EACM-B group (enrolled from June 2016 to December 2017, N = 99). Patients were prescribed with 7-day esomeprazole 40 mg bid., clarithromycin 500 mg bid., amoxicillin 1 g bid. and metronidazole 500 mg bid. Ninety patients and 93 patients were analyzed in the per protocol (PP) analysis (8 and 6 patients lost follow-up in each group). Urea breath tests were performed 4–8 weeks thereafter. Results The eradication rates for EACM-A and EACM-B groups were 87.8% (95% confidence interval [CI] = 79.7%–93.5%) and 84.8% (95% CI = 76.2%–91.2%) (p = 0.55) in intention-to-treat (ITT) analysis; 95.6% (95% CI = 89.1%–98.8%) and 90.3% (95% CI = 82.4%–95.5%) (p = 0.17) in per protocol (PP) analysis. The adverse event rates were 16.7% vs. 10.8% in the 2 groups (p = 0. 0.24). The antibiotic resistance rates between the 2 groups were amoxicillin (0%), tetracycline (0%); clarithromycin (11.8% vs. 17.8%, p = 0.46); metronidazole (32.4% vs. 33.3%, p = 0.93) and levofloxacin (14.7% vs. 37.8%, p = 0.02). Conclusion The success rate of 7-days concomitant therapy encountered an approximately 5% decrease across 4-year time interval (2013–2017) with the changes of clarithromycin resistance from 11.8% to 17.8% in Taiwan.

Introduction: There is increasing need for more testing in non-small cell lung cancer given the introduction of newer targeted therapies. Cytological specimens including conventional smears (CS), cell blocks (CB), and liquid-based cytology (LBC) are an alternative to histologic tissue (HT) specimens in detecting EGFR mutations, but the concordance of these 2 specimens is yet to be determined. The aim of the present systematic review is to determine the concordance rates between different cytologic specimens with HT in detecting EGFR mutations. Methods: PubMed, Cochrane Library, and Google Scholar were utilized in the primary search, along with reference lists of electronically retrieved full-text articles. Concordance rates were pooled together if 2 or more studies reporting the same type of cytologic specimen were available. Results: Overall, 15 studies were included in this review, with 13 studies included in the pooled analysis. There was an overall concordance rate of 92.8% in 593 paired cytologic and HT specimens, with LBC having the highest concordance rate of 96.0%, followed by CS and CB, each with a concordance rate of 95.8%, although the concordance rate of CS and/or CB was lower at 90.6% with a larger pool of studies. LBC was found to have a significantly higher concordance rate than CS and/or CB. Conclusion: Cytological specimens have a high concordance rate in detecting EGFR mutations, when compared to HT. LBC has shown superior concordance rates compared to CS and CB. Cytological specimens should be considered as an additional and alternative source of diagnostic material for EGFR testing.

INTRODUCTION An intrauterine contraceptive device (IUCD) is a common contraception method used for family planning. IUCD erosion into adjacent organs is a rare but serious complication of IUCD use. CASE PRESENTATION A 41-year-old female presented to us with a leaking left ectopic pregnancy. Emergency laparotomy and left salpingectomy were performed. A copper ICUD was found intraperitoneally and part of it had completely eroded into the sigmoid colon. Sigmoid colotomy was performed and the IUCD was removed successfully. Further history revealed that the patient had her IUCD inserted 12 years previously but was forgotten. The patient was discharged well after 4 days of admission. DISCUSSION Erosion of an IUCD into the colon is uncommon and may be asymptomatic or present with bowel perforation and obstruction. There should be a high index of suspicion for pregnancy occurring among women post-IUCD insertion. A misplaced IUCD can cause chronic inflammation of the fallopian tube, which may alter tubal functionality and increase the risk of ectopic pregnancy. Family planning is commonly done in primary health care. Primary care education and counselling are essential to improve awareness of fertile women to prevent similar complications. Periodic examination of IUCD string either by users or primary health-care practitioners is crucial. Ultrasound can be advocated if there are difficulties with the insertion. An abdominal radiograph is useful and should be performed in the case of missing IUCDs.

Paik Ling Chuah,1 Nurnina Fareeha Jamal,1 Chai Jin Siew,1 Ros Suzanna Ahmad Bustamam,2 Vaishnavi Jeyasingam,2 Khei Choong Khong3 1Department of Pharmacy, Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, Malaysia; 2Department of Radiotherapy and Oncology, Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, Malaysia; 3Department of Pharmacy, National Cancer Institute, Ministry of Health, Putrajaya, MalaysiaCorrespondence: Paik Ling ChuahDepartment of Pharmacy, Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, MalaysiaTel +60 3 2615 5834Email paik_ling@moh.gov.myPurpose: To evaluate the rate and predictors of non-adherence to imatinib in gastrointestinal stromal tumor (GIST) patients, as well as to compare the difference in health-related quality of life (HRQOL) between adherent and non-adherent patients.Patients and Methods: A cross-sectional study at the Oncology Clinic, Hospital Kuala Lumpur was conducted from March to August 2018. All patients with metastatic and/or unresectable GIST aged ≥ 18 years old and on at least 3 months of imatinib were included. Adherence to imatinib was assessed using the 10-item validated Medication Compliance Questionnaire, with a score of < 100% indicating non-adherence. Non-adherence predictors were determined by multiple logistic regressions. HRQOL was evaluated by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). The difference in the mean HRQOL scores between adherent and non-adherent groups was determined by multivariate analysis of variance.Results: A total of 89 patients were enrolled, of which 49 (55.1%) were considered non-adherent. The significant predictors of non-adherence were age (adjusted odds ratio [OR] 0.93; CI 0.89– 0.98; P = 0.007), presence of nausea and vomiting (OR 5.63; CI 1.25– 25.27; P = 0.024), and presence of comorbidities (OR 4.56; CI 1.44– 14.40; P = 0.010). Patients who were in the adherent group showed significantly better score in overall HRQOL, F (15, 73) = 2.09, P < 0.02; Pillai’s trace = 0.3, partial eta squared = 0.30.Conclusion: Non-adherence to long-term treatment with imatinib among patients with GIST should not be underestimated. Significant predictors of non-adherence among this population are younger age, presence of nausea and vomiting, as well as comorbidities. Patients with good adherence portrayed better HRQOL.Keywords: compliance, imatinib, gastrointestinal stromal tumor, quality of life

Primary hepatic liposarcoma is an extremely rare mesenchymal tumor that accounts for only 0.1% to 2% of primary malignant liver tumors. Due to its rarity, there is a lack of knowledge about its clinical course, management, and prognosis. Only 15 cases of primary liposarcoma of the liver have been reported since 1973. Among these 15 cases, only two involved primary liver liposarcoma with a pleomorphic subtype. Here we report the third and fourth cases of primary pleomorphic liver liposarcoma. A 57-year-old female presented with abdominal discomfort and progressive abdominal distension for two weeks. Computed tomography (CT) of her abdomen revealed a large well-defined solid nodule mass with an area of necrosis and hemorrhage occupying segment IV-B of the liver. Wide local excision was performed. She had an uneventful recovery and remained well at six months post-treatment. A 65-year-old male presented with an abdominal mass for two-month. CT demonstrated a mass in the left lobe of the liver with mixed soft tissues and fat attenuation. He underwent wide local excision. He was discharged on day three postoperatively. Histological analysis for both cases revealed liposarcoma of the liver with a pleomorphic subtype.

Small intestinal bacterial overgrowth (SIBO) is prevalent in irritable bowel syndrome (IBS), but its’ association with other functional gastrointestinal disorders (FGIDs) is less certain. This study aimed to explore SIBO in a multi-racial Asian population with various FGIDs compared to non-FGID controls. Consecutive Asian adults with Rome III diagnosed common FGIDs (functional dyspepsia/FD, IBS and functional constipation/FC) and non-FGID controls were subjected to glucose breath testing, with hydrogen (H2) and methane (CH4) levels determined. A total of 244 participants (FGIDs n = 186, controls n = 58, median age 45 years, males 36%, Malay ethnicity 76%) were recruited. FGIDs had a higher prevalence trend of SIBO compared to controls (16% FGIDs vs. 10% controls, p = 0.278) with 14% in FD, 18% in IBS and 17% in FC. Compared to controls, SIBO was associated with diarrhoea-predominant IBS (IBS-D) (24% vs. 10%, P = 0.050) but not with other types of FGIDs. IBS-D remained an independent predictor of SIBO (OR = 2.864, 95% CI 1.160–7.071, p = 0.023) but not PPI usage nor history of diabetes (both p > 0.050) at multivariate analysis. Compared to controls, SIBO in IBS-D was associated with an elevated H2 level (≥ 20 ppm from baseline) (18% vs. 3%, p = 0.017), but not CH4 levels (≥ 10 ppm) (9% vs. 7%, p = 0.493). In addition, no difference was found in the prevalence of methane-positive SIBO between chronic constipation (constipation-predominant IBS and FC) compared to controls (9% vs. 7%, P = 0.466). SIBO is prevalent amongst multi-ethnic Asian adults with and without FGIDs. Amongst various FGIDs, only IBS-D is significantly associated with SIBO.

Cheng-Kun Wu,1 Chien-Ning Hsu,2,3 Wei-Ru Cho,1 Shih-Cheng Yang,1 An-Che Liu,4 Wei-Chen Tai,1 Chen-Hsiang Lee,5 Yao-Hsu Yang,6– 8 Seng-Kee Chuah,1 Chih-Ming Liang1 1Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; 2Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; 3School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; 4Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; 5Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; 6Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan; 7Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan; 8School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, TaiwanCorrespondence: Chih-Ming LiangDivision of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Dabi Road, Kaohsiung, 833, TaiwanTel +886-7-731-7123, ext. 8301Fax +886-7-732-2402Email gimy54861439@gmail.comBackground and Aim: Endoscopic sphincterotomy (ES) abolished the barrier between the hepatobiliary system and duodenum and might be at risk of pyogenic liver abscess (PLA). We aimed to identify the association factors of PLA in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) procedures for treatment of choledocholithiasis.Methods: This study was based on the Chung Gung Research Database (CGRD) between January 1, 2001 and December 31, 2018. Those who had an International Classification of Diseases, Ninth and Tenth Revision (ICD9 and ICD10) codes of choledocholithiasis and received ERCP were enrolled. After strict exclusions, 11,697 patients were further divided into the endoscopic sphincterotomy (ES) group (n=7,111) and other ERCP group (n=4,586) for analysis.Results: Patients receiving ES had significantly higher rates of PLA than those of the other ERCP group (5-year cumulative incidence 2.4% versus 1.7%; 10-year cumulative incidence 3.9% versus 3.2%, log-rank p=0.0177). Aging, male gender, surgery for hepato-pancreato-biliary system and hepatobiliary malignancy were significant association factors of PLA. On multivariate analysis, the ES increased the risk of PLA (adjusted hazard ratio [aHR]=1.49; 95% CI=1.12– 1.98; p=0.0058) but decreased the risks for acute pancreatitis (aHR=0.72; 95% CI=0.60– 0.85; p=0.0002) and cholangitis (aHR= 0.91; 95% CI=0.84– 0.99; p=0.0259). There was no significant difference about recurrent choledocholithiasis between groups.Conclusion: This study demonstrated a significant risk of PLA after patients receiving ES compared with the other ERCP group. We should also carefully monitor the association factors of PLA after ERCP treatment of choledocholithiasis including aging, male gender, surgery for the hepato-pancreato-biliary system and hepatobiliary malignancy.Keywords: pyogenic liver abscess, endoscopic sphincterotomy, choledocholithiasis, endoscopic retrograde cholangiopancreatography

Pulmonary vein thrombosis (PVT) is a potentially life-threatening condition that is often underdiagnosed or undetected. PVT resulting from a non-surgical cause has been rarely reported, especially in patients without any risk factors. Here, we present a case of an elderly patient with a ventricular permanent pacemaker (PPM) who was found to have features suggestive of PVT on contrasted-enhanced computed tomography pulmonary angiogram (CTPA). We hypothesize that a ventricular PPM could alter flow dynamics in the pulmonary vein predisposing to PVT. This case highlights the importance of atypical presentations and considering broad differentials, particularly in the elderly. A high index of suspicion is necessary for an early diagnosis to prevent further deterioration of the patient.

Although early coagulopathy increases mortality in adults with traumatic brain injury (TBI), less is known about pediatric TBI.To describe the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet levels of children with moderate to severe TBI to identify predictors of early coagulopathy and study the association with clinical outcomes.Using the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) TBI retrospective cohort, we identified patients16 yr old with a Glasgow Coma Scale (GCS) ≤13. We compared PT, APTT, platelets, and outcomes between children with isolated TBI and multiple trauma with TBI. We performed logistic regressions to identify predictors of early coagulopathy and study the association with mortality and poor functional outcomes.Among 370 children analyzed, 53/370 (14.3%) died and 127/370 (34.3%) had poor functional outcomes. PT was commonly deranged in both isolated TBI (53/173, 30.6%) and multiple trauma (101/197, 51.3%). Predictors for early coagulopathy were young age (adjusted odds ratio [aOR] 0.94, 95% CI 0.88-0.99, P = .023), GCS 8 (aOR 1.96, 95% CI 1.26-3.06, P = .003), and presence of multiple trauma (aOR 2.21, 95% confidence interval [CI] 1.37-3.60, P = .001). After adjusting for age, gender, GCS, multiple traumas, and presence of intracranial bleed, children with early coagulopathy were more likely to die (aOR 7.56, 95% CI 3.04-23.06, P .001) and have poor functional outcomes (aOR 2.16, 95% CI 1.26-3.76, P = .006).Early coagulopathy is common and independently associated with death and poor functional outcomes among children with TBI.

Background This study aimed to investigate the clinical outcome of adjuvant S-1 with 2-week administration followed by a 1-week rest for locally advanced gastric cancer (GC) patients. Methods The current study was a single retrospective cohort study that focused on the efficacy and toxicity of adjuvant S-1 with a 3-week schedule. A total of 60 patients who underwent total or subtotal gastrectomy plus D2 lymph node dissection and adjuvant S-1 treatment were identified. S-1 treatment began within 4 weeks after the operation; it was administered orally for 2 weeks, followed by a 1-week rest. The dose of S-1 was adjusted depending on adverse events (AEs), with at least 80 mg administered daily. The completion of 1-year S-1 was defined as S-1 continuation for 1 year with over 70% of the planned dose. Patients were followed up with for 5 years postoperatively and underwent hematologic tests and assessments of clinical symptoms every 3-6 weeks for 1 year after surgery. Computed tomography of the abdomen and panendoscopy were performed every 6 months during the first 2 years and at 1-year intervals thereafter until year 5 after surgery. Results The completion rate of 1-year adjuvant S-1 was 71.7%, and the 3-year disease-free survival and overall survival rates were 70.2% and 79.5%, respectively. Seventeen patients did not complete S-1 for 1 year, including 11 patients with tumor recurrence and 6 patients who developed intolerance. Most AEs of S-1 were grade 1-2, and the most frequent AEs (>20%) included anemia, fatigue, pigmentation, nausea, and diarrhea. The most common grade 3-4 AE was fatigue, which was observed in 6.7% of patients. Most patients tolerated the side effects. Conclusions The results of our study confirm that the efficacy and safety of schedule modification of adjuvant S-1 treatment in patients with GC who underwent gastrectomy with D2 lymph node dissection are equal to those in a previous phase 3 study.

BACKGROUND AND AIM Ustekinumab is a monoclonal antibody that targets interleukin-12/23. In Scotland, it was approved for the treatment of moderate to severe Crohn's disease in 2017. The objective of this study was to establish the real-world effectiveness and safety of ustekinumab in the treatment of Crohn's disease. METHODS We conducted a retrospective study of patients receiving ustekinumab across eight Scottish National Health Service health boards between 2017 and 2019. Inclusion criteria included a diagnosis of Crohn's disease with symptoms attributed to active disease plus objective signs of inflammation at baseline (C-reactive protein ≥ 5 mg/L or fecal calprotectin ≥ 250 μg/g or inflammation on endoscopy/magnetic resonance imaging) and completion of induction plus at least one clinical follow-up at 8 weeks. Kaplan-Meier survival analysis was used to establish 12-month cumulative rates of clinical remission, mucosal healing, deep remission, and perianal fistula response. Rates of serious adverse events were described quantitatively. RESULTS Our cohort consisted of 216 patients (female sex, 37.9%; median age, 39.0 years, interquartile range [IQR] 28.8-51.8 years; disease duration, 9.9 years, IQR 6.0-16.5 years; prior biologic, 98.6%) with a median follow-up of 35.0 weeks (IQR 17.4-52.0 weeks). Twelve-month cumulative rates of clinical remission, mucosal healing, and deep remission (clinical remission plus mucosal healing) were 32.0%, 32.7%, and 19.3%, respectively. In patients with active perianal disease (n = 37), the 12-month cumulative perianal response rate was 53.1%. The serious adverse event rate was 13.6 per 100 patient-years of follow-up. CONCLUSION Ustekinumab is a safe and effective treatment for the treatment of complex Crohn's disease.

Background Carbapenem-resistant Enterobacteriaceae (CRE) infection has become a major challenge to clinicians. The aim of this study is to identify the risk factors of acquiring CRE to guide more targeted screening for hospital admissions. Methods This is a retrospective case-control study (ratio 1:1) where a patient with CRE infection or colonisation was matched with a control. The control was an individual who tested negative for CRE but was a close contact of a patient testing positive and was admitted at the same time and place. Univariate and multivariate statistical analyses were done. Results The study included 154 patients. The majority of the CRE was Klebsiella species (83%). From univariate analysis, the significant risk factors were having a history of indwelling devices (OR: 2.791; 95% CI: 1.384-5.629), concomitant other MDRO (OR: 2.556; 95% CI: 1.144-5.707) and hospitalisation for more than three weeks (OR: 2.331; 95% CI: 1.163-4.673). Multivariate analysis showed that being unable to ambulate on admission (adjusted OR: 2.345; 95% CI: 1.170-4.699) and antibiotic exposure (adjusted OR: 3.515; 95% CI: 1.377-8.972) were independent predictors. The in-hospital mortality rate of CRE infection was high (64.5%). CRE acquisition resulted in prolonged hospitalisation (median=35 days; PConclusion CRE infection results in high morbidity and mortality. On top of the common risk factors, patients with mobility restriction, prior antibiotic exposures and hospitalisation for more than three weeks should be prioritised in the screening strategy to control the spread of CRE.

Objective To explore the differences in frequency and epidemiology of functional gastrointestinal disorders (FGIDs) in a primary care setting, and to examine the health-related quality of life (HRQOL) and healthcare utilization of FGID patients based on the Rome III and Rome IV criteria. Methods A cross-sectional study of consecutive adults in a primary healthcare setting was conducted. Differences in epidemiology, and HRQOL of common FGIDs (functional dyspepsia [FD], irritable bowel syndrome [IBS], functional diarrhea, functional constipation [FC]) between the Rome III and IV criteria were explored. Results Among a total of 1002 subjects recruited, the frequency of common FGIDs was 20.7% and 20.9% among subjects based on the Rome III and Rome IV criteria, respectively. The frequency of IBS reduced from 4.0% (Rome III) to 0.8% (Rome IV), while that of functional diarrhea increased from 1.2% (Rome III) to 3.3% (Rome IV). In contrast, there was no significant change in the frequency of FD (7.5% [Rome III] vs 7.6% [Rome IV]) and FC (10.5% [Rome III] vs 11.7% [Rome IV]). Most of the Rome III IBS subjects (52.5%, n = 21) who did not meet Rome IV IBS criteria, fulfilled the criteria for FC, functional diarrhea, FD, or overlap syndrome. Subjects with all FGIDs, regardless of criteria, had more healthcare utilization and lower HRQOL compared to non-FGID controls. Conclusions The Rome IV criteria alter the frequency of IBS and functional diarrhea, but not FD and FC, when compared to the Rome III criteria. Regardless of criteria, FGIDs had a significant impact on healthcare burden and HRQOL.

Hospital readmission shortly after discharge is contributing to rising medical care costs. Attempts have been exerted to reduce readmission rates by predicting patients at high risk of this episode on the basis of unstructured clinical notes. Discharge summary as part of the clinical prose is effective at modeling readmission risk. However, the predictive value of notes written upon discharge offers few opportunities to reduce the chance of readmission because the target patient might have already been discharged. This paper presents the use of early clinical notes in building a machine learning model to predict readmission at 48 h immediately after a patient's admission. Extensive feature engineering, testing multiple algorithms, and algorithm tuning were performed to enhance model performance. A risk scoring framework that combines the data- and knowledge-driven feature scores in risk computation was developed. The proposed predictive model showed better prognostic capability than the machine learning model alone in terms of the ability to detect readmission. In specific, the proposed algorithm showed improvements of 11%–28% in sensitivity and 1%–3% in the area-under-the-receiver operating characteristic curve.

Background: Malignant transformation of heterotopic pancreatic tissue is a rare entity with only several case reports published in the scientific literature. Adjuvant chemotherapy following oncological resection for lesions with nodal metastasis has not been well described and there are no guidelines available to guide the management of these patients. Case Presentation: We present a case of gastric heterotopic pancreatic carcinoma with nodal metastasis in a young patient with breast cancer gene (BRCA) 2 mutation. He had undergone a laparoscopic wedge resection for a gastric lesion initially thought to be a gastrointestinal stroma tumor. Given the involvement of the wedge resection margins, the patient underwent a distal gastrectomy with oncological lymph nodal clearance. One out of the 33 harvested lymph nodes harboured micrometastasis while the main gastrectomy specimen did not have any residual malignancy. Following the histological diagnosis, he received an adjuvant chemotherapy regime akin to that prescribed for locally advanced pancreatic adenocarcinoma with good response. This is, to our knowledge, also the first such case report in a patient with BRCA2 mutation. Conclusions: Pre-operative diagnostic confirmation is challenging and endoscopic procedures pose significant false negatives. Reports of nodal metastasis following oncological resection are limited and there are no guidelines regarding adjuvant therapies. We would recommend a chemotherapy regimen similar to that for primary locally advanced pancreatic carcinoma in patients found to have nodal metastasis.

Background Low-dose aspirin is widely used in the prevention of cardiovascular diseases. However, the use of aspirin is associated with an increased risk of gastrointestinal injury. Methods Low-dose aspirin users with a history of peptic ulcers who did not have gastroduodenal mucosal breaks at initial endoscopy were randomly assigned to receive famotidine (20 mg bid) or omeprazole (20 mg qd) for 6 months. Follow-up endoscopy was carried out at the end of the 6th month and whenever epigastric discomfort, hematemesis or melena occurred. The primary end point was the occurrence of gastroduodenal mucosal breaks. The secondary end points were (1) the occurrence of gastroduodenal ulcers, and (2) the occurrence of gastroduodenal bleeding. Result Between November 2013 and June 2018, 170 patients were randomly assigned to receive either famotidine (n = 84) or omeprazole (n = 86). The incidence of gastroduodenal mucosal breaks was 33.8% among the patients receiving famotidine, and 19.8% among those receiving omeprazole (95% confidence interval [CI]: 0.4% - 27.5%; p = 0.045). The two patient groups had comparable incidence rates of gastroduodenal ulcers (20.0% vs 9.8%; p = 0.071), and gastroduodenal bleeding (2.5% vs 0%; p = 0.243). Multivariate analysis showed that use of the proton pump inhibitor was an independent protective factor (Odds ratio: 0.47; 95% CI: 0.23 - 0.99; p = 0.047), and that smoking was a risk factor for mucosal breaks (Odds ratio: 3.84; 95% CI: 1.52 - 9.71; p = 0.004). Conclusion Proton pump inhibitor was superior to histamine-2 receptor antagonist in the prevention of gastroduodenal mucosal breaks in high-risk users of low-dose aspirin, and smoking was an independent risk factor for developing gastroduodenal mucosal breaks.

BACKGROUND AND AIM Clopidogrel is widely prescribed for patients with of aspirin-related upper gastrointestinal bleeding (UGIB) history. This study aimed to compare the risk of a major adverse cardiovascular event (MACE), UGIB, and mortality between aspirin and clopidogrel in patients at risk of bleeding. METHODS We analyzed adult patients at high risk of UGIB following aspirin-related bleeding for secondary MACE prevention between 2000 and 2012. Secondary prevention was for those patients who had ever been hospitalized for cardiovascular disease and reused aspirin or changed to clopidogrel after discharge. Study endpoints were recurrence of MACE, UGIB, and death in 90 days of follow-up. The associations between study outcomes and the use of clopidogrel (vs aspirin) were analyzed. RESULTS Among 947 eligible patients, 653 reused aspirin (in combination with a proton-pump inhibitor), and 294 were treated with clopidogrel (in combination with a proton-pump inhibitor) after discharge for UGIB. Compared with aspirin treatment, clopidogrel showed an increased risk of MACE (adjusted hazard ratio [aHR] 1.65; 95% confidence interval [CI] 0.87-3.12) and UGIB (aHR 1.25; 95% CI 0.66-2.36), but without statistical significance in 90 days' follow-up. Clopidogrel use was associated with greater than four times the risk of any cause of mortality (aHR 4.84; 95% CI 1.59-14.75), but the significance did not hold in propensity score-matched cohort analysis (P = 0.06). CONCLUSIONS A nonsignificant difference between clopidogrel and aspirin for short-term MACE prevention as well as UGIB recurrence was found in the present study. Further research to assess 90-day mortality would assist clinical decision making.

Objectives In Malaysia, the prevalence of Helicobacter pylori resistance to clarithromycin is increasing. This study aimed to determine mutations in the 23S rRNA domain V directly using bacterial DNA extracted from gastric biopsy specimens with a urease-positive result. Methods A 1085-bp fragment of 23S rRNA domain V from samples of 62 treatment-naive patients with H. pylori infection was amplified by PCR with newly designed primers, followed by sequencing. Results Of the 62 cases, 42 patients were treated with clarithromycin-based triple therapy and 20 patients were treated with amoxicillin and proton pump inhibitor only; both therapies showed successful eradication rates of 70–73.8%. Sequencing analysis detected 37 point mutations (6 known and 31 novel) with prevalences ranging from 1.6% (1/62) to 72.6% (45/62). A2147G (aka A2143G) appears to be associated with a low eradication rate [40% (2/5) failure rate and 13.3% (6/45) treatment success rate], supporting its role as a clinically significant point mutation. T2186C (aka T2182C) was found in 71.1% (32/45) and 80% (4/5) of treatment success and failure cases, respectively, suggesting that the mutation is clinically insignificant. The eradication success rate in patients with the novel T2929C mutation was decreased three-fold (6.7%; 3/45) compared with the failure rate (20%; 1/5), suggesting that it may play an important role in clarithromycin resistance, thus warranting further study. Conclusion This study identified multiple known and novel mutations in 23S rRNA domain V through direct sequencing. Molecular detection of clarithromycin resistance directly on biopsies offers an alternative to conventional susceptibility testing.

In this study, we aimed to investigate the impact of aspirin on the risk of pyogenic liver abscess caused by Klebsiella pneumoniae (KP-PLA) and invasive KP-PLA syndrome (IKPS) in diabetic patients. Diabetic patients who were propensity-score matched were retrospectively included from hospital-based database. Kaplan–Meier approach with a log-rank test was used to compare the cumulative incidences of KP-PLA including IKPS between aspirin users and non-users. Totally, 63,500 patients were analyzed after propensity-score matching (1:1). Compared with that of non-users, the incidence of KP-PLA was significantly reduced in aspirin users (0.31% vs. 0.50%, p p = 0.29). Patients taking aspirin for ≥ 90 days had a significantly lower risk for KP-PLA (hazard ratio, 0.67; 95%CI, 0.50–0.90). Females, taking clopidogrel or metformin for ≥ 90 days, and taking H2-blockers or proton pump inhibitors (PPIs) for ≥ 5 days were also associated with a lower risk of KP-PLA. However, cholangitis and a glycated hemoglobin ≥ 8.5% were associated with an increased risk of KP-PLA.

Objectives Melioidosis is associated with extremely high case fatality ratios. The aim of this study was to determine whether detection of abdominal visceral abscesses can facilitate diagnosis of melioidosis in children. Methods We conducted a retrospective analysis of all children who had liver and/or spleen abscesses on abdominal ultrasonography admitted to Bintulu Hospital in Sarawak, Malaysia, from January 2014 until December 2018. Results Fifty-three children had liver and/or spleen abscesses. Spleen abscesses were present in 48 (91%) cases; liver abscesses in 15 (28%). Melioidosis was confirmed by culture in 9 (17%) children; small occult splenic abscesses were present in all cases. In 78% of these cases, the lesions were detected before any positive culture (or serology) results were available. Four (8%) children had bacteriologically-confirmed tuberculosis. Two (4%) had Staphylococcus aureus infection. Of the remaining 38 (72%) culture-negative cases, 36 (95%) had clinical and imaging characteristics similar to that of children with culture-confirmed melioidosis and improved with empirical melioidosis antibiotic therapy. Conclusions A large number of children in Bintulu Hospital in Sarawak, Malaysia, were found to have spleen abscesses. Melioidosis was the most common etiology identified in these children. Abdominal ultrasonography is extremely useful in facilitating the diagnosis of pediatric melioidosis.

The COVID‐19 pandemic, secondary to SARS‐CoV‐2, has resulted in high mortality and morbidity worldwide. As inflammatory bowel disease (IBD) is a chronic disease, and most patients are on long‐term immunosuppressive agents, there is understandable concern, particularly in terms of therapy. In view of this, experts in IBD across the Asia Pacific region were invited to put together recommendations based on their experience and the currently available data. In general, most IBD therapies (with a few exceptions) can be continued safely, and the general consensus is that maintaining disease control should remain the main principle of management. In addition, social distancing measures and the appropriate use of personal protective equipment should be strictly adhered to. During the current pandemic, face‐to‐face clinic follow ups and non‐urgent procedures should be kept to a minimum., This is a concerted effort by the members of the Asian Pacific Association of Gastroenterology Inflammatory Bowel Disease (IBD) Workgroup members to provide guidance on IBD management (all‐in‐one succinct review paper) during the difficult COVID‐19 pandemic.

Introduction The current gold standard for diagnosing interstitial lung disease (ILD) involves an ILD clinic evaluation, followed by discussion in a multidisciplinary meeting (MDM). However, there is a paucity of data on the impact of ILD MDMs on the diagnosis and management of ILDs in Southeast Asia. We studied the clinical impact of the ILD service on the diagnosis and management of ILDs at a university-affiliated tertiary hospital in Singapore. Methods A single-centre retrospective review was done on 97 consecutive patients referred for evaluation to the ILD service from March 2016 to August 2017. Results Mean age of the patients was 67 ± 11 years. Gender distribution was almost equal (52% male), with a majority of never-smokers (63%). Mean forced vital capacity (FVC) was 1.81 ± 0.66 L (66% ± 20% predicted). The three commonest referral diagnoses were ILD of uncertain classification (n = 38, 39%), connective tissue disease-associated ILD (CTD-ILD) (n = 24, 25%) and idiopathic pulmonary fibrosis (IPF) (n = 16, 17%). Following evaluation by the ILD service, there was a change of diagnosis in 60 (62%) patients and a change of management in 71 (73%) patients. The majority of consensus MDM diagnoses were IPF (n = 35, 36%), CTD-ILD (n = 30, 30%) and others (n = 15, 15%). There was a significant prognostic separation between the IPF and non-IPF diagnoses made following evaluation by the ILD service. Conclusion The ILD service allowed for more precise subtyping of various ILDs. This is particularly useful for IPF patients, who can benefit from antifibrotic therapies.

Alteration in the natural history of Crohn’s disease (CD) since the advent of biologic therapy remains to be proven. Our aim was to look at the intestinal surgical rates and the association with biologic therapy over the last two decades. This was a retrospective study in which all CD patients seen in two tertiary referral hospitals in Malaysia were recruited. Patients were stratified into two cohorts; cohort 1 was patients diagnosed from year 1991 to 2000 and cohort 2 was patients diagnosed from year 2001 to 2010. These time cohorts were selected based on initial availability of biologic agents in Malaysia in year 2000. Details of demography, disease location, medications and cumulative surgical rates over 7 years were recorded. A total of 207 patients were recruited: 70 from cohort 1 and 137 from cohort 2. Differences seen in terms of disease location, phenotype, and use of immunomodulatory therapy between the two cohorts were not significant. Patients who were ever exposed to biologics were significantly different between the two cohorts, approximately two times higher at 35.8% (n = 49) in cohort 2, and 18.6% (n = 13) in cohort 1, p = 0.011. There was a significant reduction in the 7-year cumulative intestinal surgical rates between cohort 1 and cohort 2, from 21.4% (n = 15) to 10.2% (n = 14), p = 0.028. However, there was no statistically significant difference in biologic exposure between those who underwent surgery and those who did not. There has been a significant reduction in intestinal surgical rates for Crohn’s disease over the last two decades but does not appear to be associated with the increased use of biologics.

Pregnancy can provide a window of opportunity for healthcare professionals to promote healthy lifestyle choices. Pregnant women often receive inaccurate advice about diet and exercise. GPs have an important role in advocating a healthy lifestyle with dietary advice and the promotion of appropriate physical activity. This article aims to empower healthcare professionals to provide evidence-based advice to patients in pregnancy.

Aim: The aim and objectives of the study were: 1) To assess the knowledge regarding dengue viral infection among undergraduate healthcare professional (HCP) students. 2) To investigate the association of socio-demographic factors towards dengue knowledge among the study participants. 3) To compare the dengue knowledge among the three HCP (Dental, Medical and Pharmacy) students. Study Design: A cross sectional study design was used in the study. Place and Duration of Study: The study was conducted in AIMST University campus, Kedah state, Malaysia between January, 2017 and June, 2017. Methods: The study was conducted among HCP students using pre-validated questionnaire with knowledge as a single dependent variable. The questionnaire was distributed in class room setting after obtaining informed consent forms signed by participants. The summary statistics for categorical variables was used with chi-square test to see if there was any association between the variables. Inferential statistics was done using Spearmans correlation. Results: Among the 636 participants, an overall good knowledge (≈90%) was observed regarding the cause, breeding sites and common clinical symptoms of dengue fever. However, poor knowledge was observed regarding the time of dengue mosquitoes bite (51%, P = .58) and transmission through blood transfusion (59%, P

International audience; Objectives: Relapsing polychondritis is a rare, multi-systemic and inflammatory condition of unknown origin. We currently lack a core set of measures to assess and follow damage in patients suffering from this condition. Our primary aim was to derive a disease-specific damage measuring tool for relapsing polychondritis, the Relapsing Polychondritis Damage Index (RPDAM).Methods: We performed an international 4-round multicenter Delphi study during which experts were asked to rate the relevance of potential damage items for relapsing polychondritis (141 items were obtained from a literature review and 12 from expert suggestion), using a Likert Scale. The selection of items for each subsequent round was based on the median rating of each item.Results: Twenty-four experts from 11 nationalities participated in round 1 and 22 in rounds 2, 3 and 4. From the initial 153 potential damage items, 44 items were selected during round 1, 30 items during round 2 and 16 during round 3. During round 4, we refined the index to a total of 17 items referring to ear nose and throat, eye, respiratory, cardiovascular and hematological systems as well as to treatment-related specific damage items.Conclusion: We have developed by international consensus a scoring system to assess damage in patients with relapsing polychondritis. Following its validation, the RPDAM may contribute to improve the care of patients suffering from this rare condition as well as to standardize data collection for future clinical trials.

— The coronavirus SARS-CoV-2 contributes to morbidity and mortality mainly as a result of immune-pathology in the lungs. Recent data has shown multi-system involvement with widespread viral tropism. Here we present a detailed intestinal protein characterisation of SARS-Cov-2 entry molecules ACE2 and TMPRSS2 in patients with inflammatory bowel disease ([IBD]; ulcerative colitis [UC] and Crohn’s disease [CD]) with age- and sex-matched non-IBD controls, and in those with fatal COVID-19 infection. In our dataset, ACE2 and TMPRSS2 displayed a membrane enterocyte staining in the ileum (due to presence of brush border/microvilli) in contrast to a cytoplasmic pattern in the colon. We also showed a high ACE2/low TMPRSS2 expression pattern in the ileum with a reverse trend in the colon. In UC, colonic ACE2 and TMPRSS2 are cytoplasmic in nature, with significantly higher ACE2 staining intensity compared to non-IBD controls. In inflamed and unaffected IBD mucosa, ileal and colonic enterocyte ACE2 and TMPRSS2 expressions are not modified in the histologic presence of inflammation. We observed immune cells within the lamina propria that expressed ACE2 and TMPRSS2, at higher frequencies in IBD when compared to non-IBD controls. These were identified as plasma cells with multiple myeloma oncogene 1/interferon regulatory factor 4 (MUM1/IRF4) expression. We further analysed the gut histology of six fatal COVID-19 cases, with no difference in colonic and ileal ACE2/TMRPSS2 staining (compared to non-IBD controls) and identified ACE2 + lamina propria plasma cells. Of interest, in this COVID-19 cohort, there was no histologic evidence gut inflammation despite known evidence of viral tropism within the enterocytes. Our data provides evidence for tissue expression of entry molecules ACE2 and TMPRSS2 including a close apposition to plasma cells — both pointing towards a role of the gut in the antecedent immune response to SARS-CoV-2 infection. Supplementary Information The online version contains supplementary material available at 10.1007/s10753-021-01567-z.

Background Cerebellar degeneration is a rare and severe presentation of primary Sjögren syndrome. There are few case reports of cerebellar degeneration associated with different autoimmune diseases, especially with systemic lupus erythematosus and neuro-Behcet’s disease. There are only six patients reported worldwide to be affected by cerebellar atrophy associated with primary Sjögren syndrome. In this report, we describe a patient with primary Sjögren syndrome who presented with ataxia due to cerebellar degeneration. Case presentation We report the case of a 37-year-old Chinese woman with primary Sjögren syndrome who presented with ataxia over 3 months associated with tremor of the limbs. Magnetic resonance imaging of the brain revealed bilateral cerebellar atrophy. Based on the presence of cerebellar signs with magnetic resonance imaging brain findings, she was diagnosed as cerebellar degeneration secondary to primary Sjögren syndrome. She was treated with methylprednisolone, hydroxychloroquine, and two cycles of monthly intravenous cyclophosphamide. Subsequently, she refused further treatment, and her neurological symptoms remained the same upon the last clinic review. Primary cerebellar degeneration is rarely associated with primary Sjögren syndrome. The pathogenesis of the neurological manifestations in primary Sjögren syndrome is unclear. Treatment involves corticosteroids and immunosuppressive agents with no consensus of a specific therapy for the management of primary Sjögren syndrome with central nervous system involvement. Conclusions Cerebellar degeneration is a rare presentation of primary Sjögren syndrome. Early diagnosis and treatment of this condition is needed to ensure a good outcome.

Background The role of favipiravir in preventing disease progression in coronavirus disease 2019 (COVID-19) remains uncertain. We aimed to determine its effect in preventing disease progression from nonhypoxia to hypoxia among high-risk COVID-19 patients. Methods This was an open-label, randomized clinical trial conducted at 14 public hospitals across Malaysia (February–July 2021) among 500 symptomatic, RT-PCR–confirmed COVID-19 patients, aged ≥50 years with ≥1 comorbidity, and hospitalized within first 7 days of illness. Patients were randomized 1:1 to favipiravir plus standard care or standard care alone. Favipiravir was administered at 1800 mg 2×/day on day 1 followed by 800 mg 2×/day until day 5. The primary endpoint was rate of clinical progression from nonhypoxia to hypoxia. Secondary outcomes included rates of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality. Results Of 500 patients randomized (mean [SD] age, 62.5 [8.0] years; 258 women [51.6%]; 251 [50.2%] had COVID-19 pneumonia), 487 (97.4%) patients completed the trial. Clinical progression to hypoxia occurred in 46 (18.4%) patients on favipiravir plus standard care and 37 (14.8%) on standard care alone (OR, 1.30; 95% CI: .81–2.09; P = .28). All 3 prespecified secondary endpoints were similar between both groups. Mechanical ventilation occurred in 6 (2.4%) vs 5 (2.0%) (OR, 1.20; 95% CI: .36–4.23; P = .76), ICU admission in 13 (5.2%) vs 12 (4.8%) (OR, 1.09; 95% CI: .48–2.47; P = .84), and in-hospital mortality in 5 (2.0%) vs 0 (OR, 12.54; 95% CI: .76–207.84; P = .08) patients. Conclusions Among COVID-19 patients at high risk of disease progression, early treatment with oral favipiravir did not prevent their disease progression from nonhypoxia to hypoxia. Clinical Trials Registration ClinicalTrials.gov (NCT04818320).

Objective In the recent months, there have been several case reports and case series on COVID-19 in patients with systemic lupus erythematosus(SLE). We conducted a pooled analysis and systematic review to summarise the findings of these articles. Besides, we aimed to determine the predictors of severe COVID-19 infection in SLE by comparing the mild to moderate cases with the severe to critical ones. Method All case reports and case series pertaining to COVID-19 in SLE were retrieved from Pubmed, Wiley Online Library, Springer Link, Science Direct and Web of Science databases using ‘lupus’, ‘systemic lupus erythematosus’, ‘coronavirus’, ‘SARS-CoV-2’, ‘SLE’ and “Covid-19” as keywords. The following data were extracted from the selected articles: country, age of the patient and the characteristics of SLE such as disease duration, organ or system involved, baseline medications and the severity of the COVID-19 infection. Data extracted from the articles were utilised to perform the pooled analysis. Results A total of 24 articles with 48 patients met the eligibility criteria. The median age at diagnosis of COVID-19 infection was 41 years (IQR: 11–66 years). The median SLE disease duration prior to the diagnosis of COVID-19 was 9 years (IQR: 0–30 years). A total of 22 (45.83%) patients had severe to critical COVID-19. This pooled data did not demonstrate any difference in the baseline medications between the 2 groups. Patients with lupus nephritis were significantly more prone to develop severe to critical disease ( p = 0 .036) with an odds ratio of 5.40 (95% confidence interval of 1.120–26.045). Conclusion We found that lupus nephritis was the only predictor of severe to critical COVID-19 in SLE.

Introduction: Air pollution is associated with adverse health outcomes. However, its impact on emergency health services is less well understood. We investigated the impact of air pollution on nation-wide emergency department (ED) visits and hospital admissions to public hospitals in Singapore. Materials and Methods: Anonymised administrative and clinical data of all ED visits to public hospitals in Singapore from January 2010 to December 2015 were retrieved and analysed. Primary and secondary outcomes were defined as ED visits and hospital admissions, respectively. Conditional Poisson regression was used to model the effect of Pollutant Standards Index (PSI) on each outcome. Both outcomes were stratified according to subgroups defined a priori based on age, diagnosis, gender, patient acuity and time of day. Results: There were 5,791,945 ED visits, of which 1,552,187 resulted in hospital admissions. No significant association between PSI and total ED visits (Relative risk [RR], 1.002; 99.2% confidence interval [CI], 0.995–1.008; P = 0.509) or hospital admissions (RR, 1.005; 99.2% CI, 0.996–1.014; P = 0.112) was found. However, for every 30-unit increase in PSI, significant increases in ED visits (RR, 1.023; 99.2% CI, 1.011–1.036; P = 1.24 × 10˗6) and hospital admissions (RR, 1.027; 99.2% CI, 1.010–1.043; P = 2.02 × 10˗5) for respiratory conditions were found. Conclusion: Increased PSI was not associated with increase in total ED visits and hospital admissions, but was associated with increased ED visits and hospital admissions for respiratory conditions in Singapore. Key words: Epidemiology, Healthcare utilisation, PSI, Public health, Time series

BACKGROUND AND AIM Repeating liver stiffness measurement (LSM) was recently reported to improve accuracy to diagnose fibrosis stage in patients with non-alcoholic fatty liver disease (NAFLD). There are to date no other studies confirming this finding. This aims to evaluate the accuracy of repeating LSM for the diagnosis of fibrosis stage in NAFLD patients. METHODS Retrospective analysis of prospectively collected data on adult NAFLD patients who had two FibroScan examination within 6 months prior to liver biopsy. F3-F4 fibrosis was excluded using LSM cut-off of 7.9 kPa. RESULTS A total of 136 patients were recruited. Eighty-five percent (115/136) of patients had high baseline LSM (≥ 7.9 kPa). Among them, 25% (29/115) had low repeat LSM (

Chest X-ray (CXR) interpretations are conducted in hospitals and medical facilities on daily basis. If the interpretation tasks were performed correctly, various vital medical conditions of patients can be revealed such as pneumonia, pneumothorax, interstitial lung disease, heart failure and bone fracture. The current practices often involve tedious manual processes dependent on the expertise of radiologist or consultant, thus, the execution is easily prone to human errors of being misdiagnosed. With the recent advances of deep learning and increased hardware computational power, researchers are working on various networks and algorithms to develop machines learning that can assists radiologists in their diagnosis and reduce the probability of misdiagnosis. This paper presents a review of deep learning advancements made in the field of chest radiography. It discusses single and multi-level localization and segmentation techniques adopted by researchers for higher accuracy and precision.

Perivascular epithelioid cell (PEC) tumors are rare tumors of mesenchymal origin and can affect many anatomic regions. Although these tumors are usually benign, malignant variants exist. We document for the first time a malignant PEComa arising from the pleura of a 43-year-old Malay woman. The pathology of the tumor as well as differential diagnoses is discussed.

This study aimed to evaluate the anti-ageing effects of different strains of lactobacilli putative probiotics on an ageing rat model as induced by D-galactose and a high fat diet. Male Sprague-Dawley rats were fed with high fat diet (54% kcal fat) and injected with D-galactose daily for 12 weeks to induce ageing. The effects of putative probiotic strains on age-related impairment such as telomere length, plasma lipid peroxidation, hepatic 5’adenosine monophosphate-activated protein kinase (AMPK) expression, as well as endurance performance were evaluated. Administration of statin, Lactobacillus plantarum DR7 (LP-DR7), Lactobacillus fermentum DR9 (LF-DR9), and Lactobacillus reuteri 8513d (LR-8513d) significantly reduced the shortening of telomere and increased the expression of AMPK subunit-α1 (P

To review the available modalities for quantification of liver fat in nonalcoholic fatty liver disease (NAFLD) and their clinical significance. Ultrasonography remains the first line imaging used to diagnose NAFLD as it is widely available and relatively inexpensive. Controlled attenuation parameter can be used as a screening tool for fatty liver as it is reasonably accurate and provides simultaneous estimation of hepatic fibrosis. Magnetic resonance imaging proton density fat fraction and magnetic resonance spectroscopy are the most accurate noninvasive modalities for quantification of hepatic steatosis. Liver biopsy remains the gold standard but is limited by the invasive nature of the procedure, and observer and sampling variability. This may be improved with novel computer-assisted stereological analysis or second harmonic generation microscopy. Understanding the advantages and disadvantages of each of the modalities will help one choose the most suitable method for quantifying hepatic steatosis in NAFLD.

Background and aim Antibiotic prophylaxis should be instituted for cirrhotic patients with upper gastrointestinal bleeding (UGIB), but the benefit on compensated patients remains undetermined. We aimed to compare the clinical outcomes between cirrhotic patients without major complications with UGIB with and without antibiotic prophylaxis. Methods We conducted this population-based cohort study by using Taiwanese Longitudinal Health Insurance Database 2000 (LHID2000, between 1997 to 2013), aged 18 years or older with a hospital discharge diagnosis of cirrhosis (n = 64,506), UGIB (n = 7,784), and endoscopic therapy (n = 2,292). After strict exclusions, 1205 patients were enrolled and were divided into antibiotic exposure (n = 558) and non-exposure (n = 647) groups. The outcomes were rebleeding and mortality. Results After completing the analysis adjusted by death, the rebleeding rates within 4 weeks were significantly lower in patients with antibiotic prophylaxis (3.05% versus 6.03%, P = 0.0142) and those with endoscopic therapy (0.72% vs 3.09%, P = 0.0033) but not significant after 3 months and onwards. Male patients aged > 55, high CCI score ≧ 4, and UGIB of variceal etiologies were benefited from rebleeding. The use of antibiotics did not significantly impact 6-week mortality (adjusted hazard ratio: 1.07, 95%CI: 0.41~2.75; P = 0.8943). Old age, multiple comorbidities, and UGIB of variceal etiologies were risk factors of all-cause mortality. Conclusions The current study suggested that cirrhotic patients without major complications who suffered from UGIB were benefited by the use of antibiotics to prevent rebleeding within 4 weeks after endoscopic treatment of UGIB especially for those with age > 55, high CCI score ≧ 4, and UGIB of variceal etiologies.

Purpose Steadily maintaining high intra-gastric PH is the major factor for successful Helicobacter pylori (H.pylori) eradication. It is important to search for a stronger PPI. Dexlansoprazole MR is a dual delayed release formulation PPI taken once daily which is capable of maintaining longer duration of high intra-gastric PH. It is very effective in treating gastroesophageal disease but reports on H, pylori eradication is very rare. This study sought to compare dexlansoprazole MR-based concomitant treatment and lansoprazole-based concomitant treatment in H. pylori infection and to investigate the factors that affect the eradication rates. Methods Two hundred two participants with H. pylori infection were included and randomly assigned to seven days of dexlansoprazole MR-based concomitant therapy (dexlansoprazole MR 60 mg once daily, clarithromycin 500 mg twice daily, amoxicillin 1 g twice daily and metronidazole 500 mg twice daily; DACM group) or a seven days of lansoprazole-based concomitant therapy (lansoprazole 30 mg twice daily, clarithromycin 500 mg twice daily, amoxicillin 1 g twice daily, and metronidazole 500 mg twice daily; LACM group). The participants were asked to perform urea breath tests eight weeks later. Results The eradication rates in the DACM group were 86.1% [95% confidence interval (CI): 77.8%-92.2%] in the ITT analysis and 90.6% (95% CI: 82.9%-95.6%) in the PP analysis, respectively, as compared with 90.1% (95% CI: 82.6%-95.2%) and 92.6% (95% CI: 85.5%-96.9%) (p=0.384 and p=0.572, respectively) in the LACM group for the same analyses. The adverse event rates were 11.5% in the DACM group and 10.2% in the LACM group (p=0.779). Conclusion As a first-line H. pylori treatment regimen, dexlansoprazole MR-based concomitant therapy attained a successful eradication rate of 90%, which was non inferior to that of lansoprazole-based concomitant treatment. Clinicaltrialsgov identifier NCT03829150.