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Introduction The aim of this study is to verify if the shoulder anterior capsular block (SHAC), combined with other nerve blocks, is effective in relieving shoulder pain, avoiding motor block and allowing an early rehabilitation program. Methods Seventy-five consecutive patients with painful shoulder were treated with the SHAC, alone (30 patients) or in combination with a suprascapular nerve block (SSnb: 25 patients) or with pectoralis and serratus plane block (PECS-2: 20 patients). All blocks were performed with 0.2% ropivacaine plus 8 mg dexamethasone. All patients were treated with three-weekly physiotherapy sessions for the following 2 weeks and then with home exercises. Results The post-procedural analgesic effect was strong in all groups, with a mean change in numeric rating scale (NRS) values of −6.05 in group 1, −6.25 in group 2, and −6.19 in group 3 (p

We report the first case of using an anterior scalene plane block at the superior trunk level achieving phrenic nerve blockade to treat intolerable referred shoulder pain after liver Radiofrequency Ablation (RFA) of a diaphragm-abutting liver tumor despite prevention with a full-dose non-steroidal anti-inflammatory drug. The anterior scalene plane block rapidly alleviated pain without significant complications.

Aims To date, there is no distinct principle determining whether to use irrigation under negative-pressure wound therapy (NPWT). We developed a new economical device to manage difficult wounds, employing 1 of 2 techniques depending on the wound condition. Methods This case series study was conducted in 12 patients with difficult wound, from 2017 to 2018. Four patients were treated with Type A bidirectional irrigation system (wound irrigation), while 8 patients were treated with Type B bidirectional irrigation system (wound irrigation combined with NPWT). Results In the Type A device group, inflammatory profiles in case I, case IV, and case VIII were not monitored due to the stability of their wound. The mean recovery period was 3.75 weeks (2-8 weeks), with decreases in 100% healing rate. In the Type B device group, we noted an average of 71% reduction in inflammatory profiles. All patients’ infections were resolved or were healing, and 7 patients recovered satisfactorily. The recovery period ranged from 4 to 17 weeks, with a median value of 7 weeks. Conclusion Bidirectional irrigation system decreases secondary infections and complications, and increases the healing rate in patients with difficult wound.

Patients with severe mental illnesses (SMI) were at high risk of infection during Coronavirus Diseases 2019 (COVID-19) pandemic. This study examined hospitalized SMI patients’ attitude and knowledge towards the COVID-19 infection. A cross-sectional survey was conducted in five psychiatric hospitals located in Gansu province, the most economically underdeveloped area in China. Patients’ attitude towards preventive measures and knowledge of COVID-19 were measured by a self-report questionnaire. A total of 925 hospitalized patients with SMI were recruited. Of them, 84.8% (95%CI: 82.4%–87.1%) had positive attitudes towards preventive measures of the COVID-19 outbreak. Being married (OR: 1.55, 95%CI: 1.05–2.30) and a higher educational level (OR: 1.63, 95%CI: 1.12–2.38) were independently associated with positive attitudes towards COVID-19 preventive measures, whereas higher educational level was associated with better knowledge of the COVID-19 outbreak (β: 0.231, P

Objective In this case report, we describe our experience with a patient who was treated for rectal adenocarcinoma complicated with primary cholangiocarcinoma of the liver and highlight the problems in the diagnosis and treatment of these potentially fatal lesions. Methods In the clinical setting, we often use the concept of “monism” for diagnosis and treatment. In this report, we review the diagnosis and treatment of rectal adenocarcinoma complicated with primary cholangiocarcinoma of the liver. Results Four months after surgery, the patient’s carbohydrate antigen 19-9 level was elevated, and positron emission tomography/computed tomography showed multiple liver metastases. The patient underwent three rounds of transarterial chemoembolisation and two rounds of radiofrequency ablation at our hospital for recurrent hepatocellular carcinoma. The clinical response was poor and indicative of progression of intrahepatic lesions. Conclusion A preoperative multidisciplinary team, rapid intraoperative pathological examination, and active comprehensive postoperative treatment are necessary to improve the prognosis of multiple primary tumours.

The understanding of ergonomics is a vital competency for all peripheral nerve block operators. The essence of physical ergonomics for peripheral nerve block procedures can be summarised into three significant components: brain, musculoskeletal and needling. The first component includes strategies to optimise visuospatial neuroprocessing using equipment configuration. The second component reflects the careful planning of posture and position to improve procedural technique and reduce physical fatigue. The final component focuses on strategies to achieve needle beam alignment for optimal needle visualisation.

Background/purpose: Hepatic encephalopathy (HE), a major neuropsychiatric complication in advanced liver disease, is associated with poor prognosis. Sarcopenia, characterized by a decline in muscle mass, strength, and physical performance, is prevalent in liver cirrhosis. This study aims to explore whether sarcopenia is associated with HE in cirrhotic patients. Methods: PubMed and EMBASE were searched for relevant cohort and case-control studies investigating the association between sarcopenia and HE up to July 2018. Data of patients' characteristics, definition of low muscle mass, and protocols of grading/diagnosing HE were retrieved. The primary outcome was estimated by a pooled odds ratio (OR) and its 95% confidence interval (CI), using a random effect model. Results: The meta-analysis enrolled 6 studies, comprising 1795 patients. Sarcopenia was positively associated with the presence of HE (OR 2.74 with a 95% CI, 1.87 to 4.01). The association was less likely to be influenced by differences in research designs, focused study outcomes, muscle mass measurements, and protocols of grading/diagnosing HE. There was lack of evidence supporting higher serum ammonia levels in patients with sarcopenia. Conclusion: In patients with liver cirrhosis, there is a significant association between sarcopenia and HE. A greater number of prospective studies are necessary to clarify whether the association remains even after adjusting relevant confounders and to suggest effective prevention of HE in patients with coexisting sarcopenia. Keywords: Liver, Malnutrition, Skeletal muscle, Neurology, Ammonia

Background Type 2 diabetes mellitus (T2DM) has been strongly associated with an increased risk of developing cognitive dysfunction and dementia. The mechanisms of diabetes-associated cognitive dysfunction (DACD) have not been fully elucidated to date. Some studies proved lower cerebral blood flow (CBF) in the hippocampus was associated with poor executive function and memory in T2DM. Increasing evidence showed that diabetes leads to abnormal vascular endothelial growth factor (VEGF) expression and CBF changes in humans and animal models. In this study, we hypothesized that DACD was correlated with CBF alteration as measured by three-dimensional (3D) arterial spin labeling (3D-ASL) and VEGF expression in the hippocampus. Aim To assess the correlation between CBF (measured by 3D-ASL and VEGF expression) and DACD in a rat model of T2DM. Methods Forty Sprague-Dawley male rats were divided into control and T2DM groups. The T2DM group was established by feeding rats a high-fat diet and glucose to induce impaired glucose tolerance and then injecting them with streptozotocin to induce T2DM. Cognitive function was assessed using the Morris water maze experiment. The CBF changes were measured by 3D-ASL magnetic resonance imaging. VEGF expression was determined using immunofluorescence. Results The escape latency time significantly reduced 15 wk after streptozotocin injection in the T2DM group. The total distance traveled was longer in the T2DM group; also, the platform was crossed fewer times. The percentage of distance in the target zone significantly decreased. CBF decreased in the bilateral hippocampus in the T2DM group. No difference was found between the right CBF value and the left CBF value in the T2DM group. The VEGF expression level in the hippocampus was lower in the T2DM group and correlated with the CBF value. The escape latency negatively correlated with the CBF value. The number of rats crossing the platform positively correlated with the CBF value. Conclusion Low CBF in the hippocampus and decreased VEGF expression might be crucial in DACD. CBF measured by 3D-ASL might serve as a noninvasive imaging biomarker for cognitive impairment associated with T2DM.

Background: Hepatocellular carcinoma (HCC) has multiple prognostic factors, and there is an increase in knowledge about the body composition and physical status of patients with HCC. The present meta-analysis aimed to explore whether loss of skeletal muscle mass is associated with mortality and tumor recurrence in patients with HCC. Method: A systematic search was conducted for published literature using PubMed, Embase, and Scopus. We included cohort or case-control studies investigating patients with HCC. The primary and secondary outcomes were the associations of loss of skeletal muscle mass with overall survival and tumor recurrence, respectively, expressed by a summary hazard ratio (HR) and 95% confidence interval (CI). Result: A total of 13 studies comprising 3,111 patients were included. The summary HRs calculated by either univariate or multivariate analysis both suggested a significant association between sarcopenia and all-cause mortality (crude HR = 2.04, 95% CI: 1.74-2.38; adjusted HR = 1.95, 95% CI: 1.60-2.37). Similarly, loss of skeletal muscle mass was associated with tumor recurrence (crude HR = 1.85, 95% CI: 1.44-2.37; adjusted HR = 1.76, 95% CI: 1.27-2.45). The stratified analysis showed that treatment types and inclusion of body mass index or body weight in the Cox regression model did not modify both clinical outcomes. With an increase in cut-off values of muscle mass on computed tomography images (especially for male patients), there was an insignificant trend of stronger associations between loss of skeletal muscle mass and all-cause mortality. Conclusion: Loss of skeletal muscle mass is associated with increased all-cause mortality and tumor recurrence in patients with HCC. Further prospective studies incorporating measurements of muscle strength and physical function are warranted to see whether inclusion of both parameters better predicts the outcome than use of muscle mass only.

To describe patient characteristics associated with preoperative anxiety and subsequently assess the relationship between preoperative anxiety and postoperative anxiety, pain, sleep quality, nausea and vomiting.The study collected data from patients undergoing elective operation from 12 hospitals in China. The State-Trait Anxiety Inventory (STAI) and the Athens Insomnia Scale (AIS) were used to assess anxiety and sleep quality before surgery. Evaluations of anxiety, pain, sleep quality, nausea and vomiting were quantified using the Visual Analogue Scale on postoperative days 1 and 2.Data from 997 patients were analyzed. Preoperatively, 258 (25.9%) patients had high anxiety (STAI-State44). Multivariate analyses showed a significant relationship between high anxiety and female gender (OR: 1.66, 95% CI: 1.08-2.57, p = 0.02), highly invasive surgery (OR: 2.29, 95% CI: 1.29-4.06, p = 0.005), higher trait anxiety (OR: 1.24, 95% CI: 1.20-1.28, p 0.001) and insomnia (AIS ≥ 6, OR: 1.79, 95% CI: 1.17-2.76, p = 0.008). Preoperative anxiety demonstrated a negative correlation with postoperative anxiety following highly invasive surgery; this became a positive relationship following less invasive surgery. Preoperative anxiety was also positively related to postoperative pain and poor sleep quality. The correlation between preoperative anxiety and postoperative nausea and vomiting was not statistically significant.Female gender, highly invasive surgery, higher trait anxiety and insomnia are independent risk factors for high preoperative anxiety. Surgical invasiveness influences association between pre- and postoperative anxiety. Higher preoperative anxiety is related to poorer sleep quality and more severe pain postoperatively.

Background The empiric therapies for H. pylori infection in clinical guidelines have been widely used. However, the cure rate is decreasing due to the increase of antibiotic resistance. The importance of antimicrobial susceptibility test (AST) has been documented in many consensuses. However, the effect of tailored therapy remains controversial because the AST is rarely offered in most areas. We compared the evolution of treatment efficacy among tailored therapy and some recommended empiric therapies through a trend survey from 1999 to 2018. Methods This retrospective survey was performed at 2 medical centers and 3 community hospitals in Taiwan. A total of 16,370 treatment naive or failure patients were recruited. Successful H. pylori eradication was defined as a negative 13C-UBT. The empiric first-line regimens include tailored therapy, clarithromycin-containing triple therapy (CLA-TT), sequential therapy (ST), bismuth-containing quadruple therapy (BQT), and high-dose dual therapy (HDDT). The empiric rescue regimens include tailored therapy, levofloxacin-containing triple therapy (LEV-TT), BQT, and HDDT. We divided the 20 years of follow-up time into 4-year periods for evaluating the trend of treatment efficacies. The E-test was performed to evaluate H. pylori resistance. For the tailored therapy, CLA-TT, LEV-TT, BQT, or HDDT was chosen according to the resistance pattern of each patient. Results The efficacies of tailored therapy, BQT, and HDDT maintain a stable and high efficacy in both first-line and rescue treatment during the study period. However, the efficacies of CLA-TT, ST, and LEV-TT are decreasing year by year. The eradication rate of tailored therapy is significantly higher than that of CLA-TT, ST, LEV-TT, and BQT in recent 4-year period. However, there is no significant difference between the efficacy of tailored therapy and HDDT. The prevalence of H. pylori resistance to CLA and LEV increased gradually. In contrast, the resistance rate to amoxicillin and tetracycline remained low. Conclusions Over the past 20 years, we found that the efficacy of tailored therapy remains relatively stable. Of the recommended empiric therapies, HDDT and BQT have stable therapeutic efficacies and are a good choice of empiric treatment currently.

This study sought to determine whether chronic hepatitis B or C would modify the association between insulin analogues and hepatocellular carcinoma (HCC) risks. We conducted a nationwide nested case-control study for HCC cases and matched controls from 2003 to 2013 among newly diagnosed type 2 diabetes patients on any antidiabetic agents in Taiwan before and after exclusion of chronic viral hepatitis, respectively. A total of 5832 and 1237 HCC cases were identified before and after exclusion of chronic viral hepatitis, respectively. Incident HCC risks were positively associated with any use of premixed insulin analogues (adjusted odds ratio (OR), 1.27, 95% CI 1.04 to 1.55) among total participants, especially among current users (adjusted OR, 1.45, 95% CI 1.12 to 1.89). However, the association between HCC occurrence and premixed insulin analogues diminished among participants without chronic viral hepatitis (adjusted OR, 1.35, 95% CI 0.92 to 1.98). We also observed a significant multiplicative interaction between chronic viral hepatitis and premixed insulin analogues on HCC risks (P = 0.010). Conclusions: Chronic viral hepatitis signifies the role of premixed insulin analogues in HCC oncogenesis. We recommend a closer liver surveillance among patients prescribed premixed insulin analogues with concomitant chronic viral hepatitis.

Background. We aimed to evaluate the effectiveness of a suture-fixation mucopexy procedure by comparing with Doppler-guided hemorrhoidal artery ligation (DGHAL) in the management of patients with grade III hemorrhoids.Methods.This was a randomized controlled trial. One hundred patients with grade III hemorrhoids were randomly assigned to receive suture-fixation mucopexy (n=50) or DGHAL (n=50). Outcome assessments were performed at 2 weeks, 12 months, and 24 months. Assessments included resolution of clinical symptoms, postoperative complications, duration of hospitalization, and total costs.Results. At 2 weeks, one (2%) patient in suture-fixation group and four (8%) patients in DGHAL group had persistent prolapsing hemorrhoids. Postoperative bleeding was observed in two patients (4%) in suture-fixation group and one patient in DGHAL group. There was no significant difference in short-term recurrence between groups. Postoperative complications and duration of hospitalization were comparable between the two groups. Rates of recurrence of prolapse or bleeding at 12 months did not differ between groups. However, recurrence of prolapse at 24 months was significantly more common in DGHAL group (19.0% versus 2.3%,p=0.030).Conclusions. Compared with DGHAL, the suture-fixation mucopexy technique had comparable short-term outcomes and favorable long-term outcomes.

A national viral hepatitis therapy program was launched in Taiwan in October 2003. This study aimed to assess the impact of the program on reduction of end-stage liver disease (ESLD) burden. Profiles of national registries of households, cancers, and death certificates were used to derive incidence and mortality of ESLDs from 2000 to 2011. Age-gender–adjusted incidence and mortality rates of hepatocellular carcinoma (HCC) and chronic liver diseases (CLDs) and cirrhosis of adults ages 30-69 years were compared before and after launching the program using Poisson's regression models. A total of 157,570 and 61,823 patients (15%-25% of those eligible for reimbursed treatment) received therapy for chronic hepatitis B and C, respectively, by 2011. There were 42,526 CLDs and cirrhosis deaths, 47,392 HCC deaths, and 74,832 incident HCC cases occurred in 140,814,448 person-years from 2000 to 2011. Male gender and elder age were associated with a significantly increased risk of CLDs and cirrhosis and HCC. Mortality and incidence rates of ESLDs decreased continuously from 2000 to 2003 (before therapy program) through 2004-2007 to 2008-2011 in all age and gender groups. The age-gender–adjusted rate ratio (95% confidence interval; P value) in 2008-2011 was 0.78 (0.76-0.80; P

Background:Liver cirrhosis is a risk factor for the loss of muscle mass, which is associated with numerous adverse health outcomes. This meta-analysis aimed to examine whether loss of muscle mass was a predictor of increased mortality in cirrhotic patients without or before liver transplanta

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease related to metabolic syndrome. This study applied an integrated analysis based on texture, backscattering, and attenuation features in ultrasound imaging with the aim of assessing the severity of NAFLD. Ultrasound radiofrequency data obtained from 394 clinical cases were analyzed to extract three texture features (autocorrelation, sum average, and sum variance), the signal-to-noise ratio (SNR), and the slope of the center-frequency downshift (CFDS slope). The texture, SNR, and CFDS slope were combined to produce a quantitative diagnostic index (QDI) that ranged from 0 to 6. We trained the QDI using training data and then applied it to test data to assess its utility. In training data, the areas (AUCs) under the receiver operating characteristic curves for NAFLD and severe NAFLD were 0.81 and 0.84, respectively. In test data, the AUCs were 0.73 and 0.81 for NAFLD and severe NAFLD, respectively. The QDI was able to distinguish severe NAFLD and a normal liver from mild NAFLD, and it was significantly correlated with metabolic factors. This study explored the potential of using the QDI to supply information on different physical characteristics of liver tissues for advancing the ability to grade NAFLD.

Resection of the cephalic or middle portion of lateral crura of alar cartilages is a method for correcting bulbous nose in which the resected cartilages usually are discarded, resulting in a waste of autologous tissues. A silastic implant usually is used to correct saddle nose in Asian countries, but implant extrusion, a severe complication, sometimes occurs. Cartilage flaps were first reported by Jose to increase the projection of the nasal tip. In this study, the authors used cartilaginous flaps of the lateral crura to wrap the tip of the nasal implant for patients with bulbous and saddle noses. This study aimed to investigate the application of cartilaginous flaps of lateral crura. A flap was created from the cephalic portion of the lateral crus of the alar cartilage, leaving the caudal portion intact. The cartilage flap remained attached at the level of the original domal segment of the middle crura. It was rotated over to wrap the tip of the silastic implant, then sutured to the other side flap. From March 2003, 19 patients were treated with this technique. The results were satisfactory without implant extrusion or any other complications except for nonobvious scars. The cartilage flap can reduce the incidence of implant extrusion and help to reduce the size of the bulbous tip.

Background & Aims : Hepatitis B virus (HBV) genotype C is associated with the development of hepatocellular carcinoma (HCC), compared with genotype B. This study aims to investigate whether HBV genotypes influence the clinicopathologic features and long-term prognosis of patients after curative resection of HCC. Methods : Stored serum samples from 62 patients with HBV-related HCC were tested for HBV genotype using a molecular method. Results : Sixty of 62 patients (96.8%) undergoing curative resection of HCC were infected with genotype B or C. Concomitant cirrhosis was encountered more frequently in patients with genotype C. During a mean follow-up period of 26.3 ± 9.8 months, patients with genotype B had a lower overall tumor recurrence rate than those with genotype C (22% vs. 46%; P = 0.04). Stepwise multiple Cox proportional hazards regression analysis showed that multiplicity of tumor (hazard ratio, 6.84; 95% confidence interval [CI], 1.45–32.2; P = 0.02) was associated with tumor recurrence, whereas genotype C and age were associated with borderline significance (P = 0.06). Stratified analysis showed that genotype C was still associated with tumor recurrence in cirrhotic patients with borderline significance by univariate analysis (hazard ratio, 3.8; 95% CI, 0.84–17.6; P = 0.07). However, cumulative 2-year survival rates were similar between patients with genotype B and C (92% vs. 85%; P = 0.23). Conclusions : Our data suggest that patients with HCC with genotype C have a greater tumor recurrence rate after curative resection of HCC compared with those with genotype B. Prolonged follow-up is needed to clarify the impact of HBV genotype on postoperative outcome.

Inherited predisposition to thrombosis contributes to the initiation and progression of coronary artery disease (CAD). The present study was designed to explore the relationship between genetic variation of coagulation factor V and occurrence of CAD. A total of 141 unrelated patients with CAD and 175 healthy controls were analyzed by polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE) for variation detection in all 25 exons of the factor V gene. Among the study subjects, 55 CAD patients and 73 controls were evaluated at random for response to activated protein C (APC) by Coatest APC resistance test. Polymorphisms in exon 4, 10, 13 and 16 of factor V gene were documented [642G → T(S156), 1628 → A(R485K), 4070A → G(H1299R) and 5380G → A(V1736M), respectively]. The study also identified a novel polymorphism 327A → G in exon 2 which did not alter the amino acid residue. Leiden mutation (R506Q) was not detected in any of our 316 subjects. Among the five polymorphisms, the allele frequency of 1628G → A was significantly different between the CAD patients and the controls (0.36 vs. 0.21, p < 0.05). Subjects homozygous or heterozygous for the A allele of 1628G → A polymorphism had lower normalized APC ratios than those with the GG genotype in the CAD group (1.16 ± 0.13 and 1.18 ± 0.23 vs. 1.36 ± 0.33, p < 0.05) and in the controls, indicating that A 1628 allele was associated with a poor response to APC. We conclude that the 1628G → A (R485K) polymorphism of factor V is associated with a poor response to APC and increased risk for CAD.

The exact mechanism by which troglitazone improves insulin sensitivity is not well understood. Eight 35-week-old male diabetic Otsuka Long-Evans Tokushima Fatty (OLETF) rats were treated with troglitazone (30mg/kg body weight/d) for 20d (OLETF-T). Body composition, glucose tolerance, serum lipid profile and expression of glucose transporter 4 (Glut 4) in OLETF-T were compared with those in 8 male control OLETF rats and in 18 normal Long Evans Tokushima Otsuka (LETO) rats. Body weight, visceral fat weight, and pancreas weight in OLETF-T rats were significantly lower than those in OLETF rats (p

The risk and the predictors of liver disease progression in carriers of inactive hepatitis B virus (HBV) are unclear.Participants in the Risk Evaluation of Viral Load Elevation and Associated Liver Disease/Cancer-Hepatitis B Virus (REVEAL-HBV) study who were seronegative for hepatitis B e antigen; had serum levels of HBV DNA10,000 copies/mL; and did not have cirrhosis, hepatocellular carcinoma, or increased serum levels of alanine aminotransferase were classified as carriers of inactive HBV (n = 1932). Study participants who were seronegative for HB surface antigen and antibodies against hepatitis C virus, yet had similar clinical liver features, were the controls (n = 18,137). Liver-related death and new cases of hepatocellular carcinoma were ascertained through computerized data linkage with National Cancer Registry and Death Certification profiles. The disease progression rates were estimated. The multivariate-adjusted hazard ratios for risk predictors were derived from Cox regression models.There were 20,069 participants, contributing a total of 262,122 person-years, with a mean follow-up of 13.1 years. Annual incidence rates of hepatocellular carcinoma and liver-related death were 0.06% and 0.04%, respectively, for inactive HBV carriers; rates were 0.02%, and 0.02% for controls, respectively. The multivariate-adjusted hazard ratios for carriers of inactive HBV, compared to controls, were 4.6 (95% confidence interval: 2.5-8.3) for hepatocellular carcinoma and 2.1 (95% confidence interval: 1.1-4.1) for liver-related death. Older age and alcohol drinking habits were independent predictors of risk for carriers of inactive HBV to develop hepatocellular carcinoma.Carriers of inactive HBV have a substantial risk of hepatocellular carcinoma and liver-related death compared with individuals not infected with HBV.

Background Gastrointestinal graft versus host disease (GI-GVHD) and cytomegalovirus (CMV) enteritis are important complications following allogeneic haematopoietic stem cell transplantation (allo-HSCT). We explored the role of colonoscopy in the diagnosis of GI-GVHD and CMV enteritis following allo-HSCT to identify the endoscopic manifestations of GI-GVHD and CMV enteritis was made. Methods A retrospective analysis of the colonoscopic manifestations of GI-GVHD, CMV enteritis and GI-GVHD with concurrent CMV enteritis (GconC) and their related clinical issues. Results Forty-seven patients underwent 50 colonoscopies with diagnoses of 32 GI-GVHD, 7 CMV enteritis and 11 GconC. Both GI-GVHD and CMV enteritis had colonic mucosal lesions with various manifestations under colonoscopy. Tortoise shell like changes of the mucosa (12 of 32) and deep ulcers (2 of 7) were specific endoscopic manifestations for GI-GVHD and CMV enteritis, respectively, while mucosal oedema, erythema, congestion, erosion and shallow ulcers could not be used to differentiate GI-GVHD from CMV enteritis. GconC patients were prone to have oozing bleeding of the end ileal mucosa and typhlodicliditis. Of the biopsed specimens for GI-GVHD, CMV enteritis and GconC, 64%, 70% and 44% were taken from the rectum and sigmoid colon respectively. Conclusions Following allo-HSCT, tortoise shell like changes and deep ulcers of the colonic mucosa are characteristic changes for GI-GVHD and CMV enteritis, respectively, while the other lesions are not. Most of the GI-GVHDs and CMV enteritis cases can be diagnosed by left colon examination and tissue biopsy, but total colon examination to the terminal ileum is preferred.

Background & Aims The efficacy of treatment of Helicobacter pylori infection has decreased steadily because of increasing resistance to clarithromycin, metronidazole, and levofloxacin. Resistance to amoxicillin is generally low, and high intragastric pH increases the efficacy of amoxicillin, so we investigated whether a combination of a high-dose proton pump inhibitor and amoxicillin (dual therapy) was more effective than standard first-line or rescue therapies in eradicating H pylori . Methods We performed a large-scale multihospital trial to compare the efficacy of a high-dose dual therapy (HDDT) with that of standard therapies in treatment-naive (n = 450) or treatment-experienced (n = 168) patients with H pylori infection. Treatment-naive patients were randomly assigned to groups given HDDT (rabeprazole 20 mg and amoxicillin 750 mg, 4 times/day for 14 days, group A1), sequential therapy for 10 days (group B1), or clarithromycin-containing triple therapy for 7 days (group C1). Treatment-experienced patients were randomly assigned to groups given HDDT for 14 days (group A2), sequential therapy for 10 days (B2), or levofloxacin-containing triple therapy for 7 days (C2). H pylori infection was detected by using the 13 C-urea breath test. We evaluated factors associated with treatment outcomes. Results In the intention-to-treat analysis, H pylori was eradicated in 95.3% of patients in group A1 (95% confidence interval [CI], 91.9%−98.8%), 85.3% in B1 (95% CI, 79.6%−91.1%), and 80.7% in group C1 (95% CI, 74.3%−87.1%). Infection was eradicated in 89.3% of patients in group A2 (95% CI, 80.9%−97.6%), 51.8% in group B2 (95% CI, 38.3%−65.3%), and 78.6% (95% CI, 67.5%−89.7%) in group C2. The efficacy of HDDT was significantly higher than that of currently recommended regimens, irrespective of CYP2C19 genotype. Bacterial resistance to drugs was associated with treatment failure. There were no significant differences between groups in adverse events or patient adherence. Conclusions HDDT is superior to standard regimens as empirical first-line or rescue therapy for H pylori infection, with similar safety profiles and tolerability. ClinicalTrials.gov number: NCT01163435.

Background: The increased primary and acquired resistance rates of H. pylori to clarithromycin, metronidazole, and levofloxacin have resulted in a significant reduction in the efficacy of various anti-H. pylori regimens. We recently demonstrated that an optimized high-dose dual therapy (HDDT) is superior to the standard triple therapy (TT) or sequential therapy (ST) for H. pylori infection in a large-scale multi-hospital, randomized, comparative study (Clinical Gastro & Hepato, in press). Because the global prevalence of primary and acquired resistance to amoxicillin (AMO) is rare, we hypothesize that HDDT can be used repeatedly and empirically for H. pylori treatment without a reduction of eradication efficacy. Aim: To evaluated the cumulative efficacy of repeated HDDT treatment for first-line and rescue antiH. pylori therapy. Methods: A total of 618 patients with H. pylori infection diagnosed by endoscopy with biopsy for histology examination and bacterial culture were recruited in this multi-hospital study and were randomly allocated to receive HDDT, TT, or ST for therapy. As reported in our previous study, H. pylori was eradicated in 143 out of 150 (95.3%; 95% C.I. 92.9-97.8) treatment-naive patients receiving the first course of HDDT (rabeprazole 20 mg + AMO 750 mg, qid for 14 days). Six patients who failed in the first HDDT treatment received the second course of HDDT. For treatment-experienced patients, 68 out of 84 patients failed in TT and 25 out of 45 patients failed in ST received the first course of HDDT. The second course of HDDT was used again if the first course failed. Four to eight weeks after termination of each treatment, H. pylori infection status was examined by the C13-urea breath test. The E-test was used to evaluate the antibiotics resistances of H. pylori strains before and after failed treatment of repeated HDDT. Results: Five out of 6 treatment-naive patients had successfully H. pylori eradication by a second course of HDDT, resulting in a cumulative eradication rate of 98.7% (148/150; 95% C.I. 97.3-100.0) in the intention-to-treat (ITT) analysis, and 99.3% (148/149; 95% C.I. 98.4-100.3) in perprotocol (PP) analysis. For the treatment-experienced patients, H. pylori was successfully eradicated in 90.3% (84/93; 95% C.I. 85.9-94.7) of patients with first course of HDDT treatment. Seven out of 9 patients who failed in the first HDDT treatment achieved H. pylori eradication with a second course of HDDT. The cumulative eradication rate was 97.8% (91/ 93; 95% C.I. 95.7-100.0) in both ITT and PP analyses. The susceptibility of H. pylori to antibiotics did not significantly impact eradication rates. Conclusion: HDDT consisting of a PPI and AMO given four times daily is highly efficacious when it is used repeatedly for H. pylori eradication. Thus, H. pylori susceptibility testing may be avoided by using HDDT.

Acinar cell carcinoma is an uncommon malignancy with a reported incidence of 1% among exocrine tumors of the pancreas. The case of a 60-year-old Taiwanese man who presented with obstructive jaundice, abdominal pain, and body weight loss is described here. A mixed clinical picture of islet cell tumor and ductal carcinoma of the pancreas was shown to be a hypervascular tumor at the pancreatic head region with an irregular stricture at the common channel of the common bile and pancreatic ducts. The patient had normal levels of plasma carcinoembryonic antigen, carbohydrate antigen 19-9, alpha-fetoprotein, but an increase in plasma levels of insulin and C-peptide. Immunohistochemical stains and electron microscopic examination of the tumor was consistent with acinar cell carcinoma.