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Quinolone has the disadvantage of easily acquired drug resistance. It is important to prescribe it wisely for a high eradication rate. The current study aimed to determine the clinical and bacteriological factors for optimal levofloxacin-containing triple therapies in second-line H. pylori eradication. We enrolled a total of 158 H. pylori-infected patients who failed H. pylori eradication using the 7-day standard triple therapy (proton-pump inhibitor [PPI] twice daily, 500 mg clarithromycin twice daily, and 1 g amoxicillin twice daily). They were prescribed with either a 10-day (group A) or 14-day (group B) levofloxacin-containing triple therapy group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily for 10 days) by their clinicians. Follow-up studies to assess treatment responses were carried out 8 weeks later. The eradication rates attained by groups A and B were 73.6% (95% confidence interval [CI] = 63.9–85.3%) and 90.5% (95% CI = 84.5–98.1%), respectively in the per protocol analysis (P = 0.008 in the per protocol analysis) and 67.1% (95% CI = 56.6–78.5%) and 84.8% (95% CI = 76.8–93.4%), respectively, in the intention-to-treat analysis (P = 0.009). The subgroup analysis revealed that H. pylori eradication rates for group A patients with levofloxacin-susceptible strains were 92.9% (13/14) but it dropped to 12.5% (1/8) when levofloxacin-resistant strains existed. H. pylori was eradicated among all the group B patients with levofloxacin-susceptible strains, but only half of patients with levofloxacin-resistant strains were successfully eradicated. In conclusion, this study confirms the effectiveness of 14-day treatment. Importantly, the results imply that 10-day treatment duration should be optimal if a culture can be performed to confirm the existence of susceptible strains. The duration of H. pylori eradication and levofloxacin resistance were the influencing factors for successful treatment. This study suggests that tailored levofloxacin-containing therapy should be administered only for patients with susceptible strains because it can achieve >90% success rates. [ABSTRACT FROM AUTHOR]

Background and Aims: Prospective, long-term reports and predictors of outcome of endoscope-guided pneumatic dilation are lacking in the literature. The aim of this prospective 7-year follow-up study is to report the efficacy of endoscope-guided pneumatic dilation and determine the possible confounding factors related to remission.Methods: Between January 1998 and June 2004, 32 patients were enrolled. Each patient was treated with endoscope-guided pneumatic dilation and followed-up at regular intervals for a median of 4.5 years. Remission was determined with the use of a structured interview and a previously described symptom score. Cumulative remission rate was analyzed by using the Kaplan-Meier method with assessment of symptom scores between grades before and after PD at 6 weeks, 6 months, 1 year, and then every year after. Possible confounding factors related to the remissions were analyzed by Cox's proportional hazard model.Results: Complete follow-up until August 2007 was obtained in 100% of all patients. Cumulative remissions were 1 year (86.7%), 2 years (86.7%), 3 years (80.0%), 4 years (76.5%), 5 years (72.9%), 6 years (61.7%), and 7 years (61.7%), respectively. Age is a relevant confounding factor to the remissions showing a worse outcome for those under 45 (p = 0.046). One esophageal perforation occurred (3.3%).Conclusions: Endoscope-guided PD itself is safe and modestly effective for up to 7 years investigations in current study. Older patients (>45 years) have favorable overall clinical remissions. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background and Aims: Colonoscopic polypectomy in end‐stage renal disease (ESRD) patients are at risks of post‐polypectomy bleeding and perforation, but evidences are limited. This study aimed to determine the incident polypectomy complications among ESRD patients. Methods: In the nationwide ESRD cohort, a propensity score matched case–control study design was conducted to assess risk associated with post‐polypectomy bleeding and perforation using the Taiwanese National Health Insurance Research Database from 1997 to 2013 for adults aged 40 years and older; 7011 ESRD and 19 118 non‐ESRD patients met the study criteria. A total of 5302 patients in each group were matched for further analyses. The primary endpoint was post‐polypectomy bleeding or bowel perforation in 30 days. The secondary endpoint was mortality and length of hospital stay for the bleeding complications requiring hospitalization. Results: Overall incidences of post‐polypectomy bleeding or perforation in patients with ESRD was higher than the non‐ESRD group (5.83% vs 1.78%, P < 0.0001) in the matched cohort. High risk of adverse outcomes was associated with ESRD (adjusted odds ratio [aOR], 2.38, 95% confidence interval [CI], 1.85–3.05), female patient (aOR, 1.7, 95% CI, 1.37–2.11), history of acute myocardial infarction (aOR, 1.91, 95% CI, 1.1–3.32), liver disease (aOR, 1.79, 95% CI, 1.37–2.34), diabetes (aOR, 1.45, 95% CI, 1.16–1.82), cancer (aOR, 1.4, 95% CI, 1.09–1.81), inpatient setting (aOR, 13.19, 95% CI, 9.73–17.88), and prior use of clopidogrel (aOR, 1.61, 95% CI, 1.03–2.52) and warfarin (aOR, 2.03, 95% CI, 1.21–3.41). Conclusions: End‐stage renal disease was associated with approximately twofold higher risk of colonoscopic post‐polypectomy bleeding or perforation and should be cautiously performed in this special population cohort. [ABSTRACT FROM AUTHOR]

Background: Gastroesophageal reflux disease (GERD) affects a significant proportion of individuals, with life stress being a contributing factor. This study aimed to investigate the correlation between psychosomatic evaluations, heart rate variability (HRV), and GERD in a cohort of individuals. Additionally, the study aimed to analyze the sequencing changes following proton pump inhibitor (PPI) treatment and identify predictive factors associated with refractory GERD. Methods: A prospective cohort of 105 individuals with reflux esophagitis and a control group of 50 participants without acid reflux symptoms were enrolled. Psychosomatic evaluations, including GERDQ, GERDQLQ, RSI, BAI, BDI, and SSS-8, were assessed at baseline and during treatment. HRV parameters were also evaluated. Multivariate analysis was used to identify predictive factors for refractory GERD. PPIs were administered regularly for the initial 2 months and then used on-demand. Refractory GERD was defined as less than 50% improvement in symptom relief or GERDQLQ score ≥ 20 after 8 weeks of PPI treatment. Results: The GERD group had higher scores in all psychosomatic evaluations compared to the control group (all p-values < 0.001). There were no significant changes in any parameters of HRV before and after treatment in the GERD group. Strong and consistent correlations were observed between GERD symptoms and psychological scores (BAI, BDI, and SSS-8) across all time points (W0, W4, and W8). Sequential reductions in GERD symptom scores and psychosomatic evaluations were observed during the initial eight weeks of treatment. Higher GERDQ (≥10) and SSS-8 (≥12) scores were predictive of refractory GERD (p = 0.004 and p = 0.009, respectively). Conclusions: This study emphasizes the importance of considering physiological and psychological factors in the management of GERD. Psychosomatic evaluations provide valuable insights for assessing and treating GERD patients. Integrating stress management and comprehensive assessments into personalized treatment strategies is crucial. [ABSTRACT FROM AUTHOR]

Background & Aims There is disagreement over the ideal duration of initial proton pump inhibitor (PPI) therapy for gastroesophageal reflux disease, and whether prolonged therapy increases healing of the esophagitis and prevents symptom relapse. We performed a multicenter, prospective, randomized, controlled study to compare the efficacies of 4 weeks vs 8 weeks of PPI therapy in reducing reflux symptoms and preventing symptom relapse in patients with Los Angeles grade A or B erosive esophagitis. Methods Consecutive patients with symptomatic Los Angeles grade A or B erosive esophagitis were assigned randomly to groups given daily esomeprazole (40 mg) for 4 weeks (n = 207) or 8 weeks (n = 201) as their initial treatment. Patients with complete symptom resolution were switched to on-demand therapy until the end of week 20. All patients underwent follow-up endoscopy at the end of week 20. Symptom relapse was defined as 2 or more episodes of troublesome reflux symptoms per week or ingestion of PPI for more than 7 days within 4 weeks, owing to reflux symptoms. Results The 4-week and 8-week groups had comparable rates of complete symptom resolution (77.9% vs 82.1%). However, the cumulative 12-week incidence of symptom relapse was higher for the 4-week group than for the 8-week group (62.5% vs 47.8%; difference, 14.7%; 95% confidence interval, 3.7%–25.7%; P = .009). No significant difference was observed between groups in the proportions of patients with sustained healing at the end of week 20 (49.6% vs 40.9%; P = .160). Conclusions Prolonging PPI therapy from 4 weeks to 8 weeks does not appear to increase the rate of complete symptom resolution in patients with mild erosive esophagitis. However, 8 weeks of PPI therapy reduces symptom relapse, compared with 4 weeks, in patients with Los Angeles grade A or B erosive esophagitis. ClinicalTrials.gov number: NCT01874535 . [ABSTRACT FROM AUTHOR]

• Eccentric problems are revisited by using the boundary integral equation free of singular integrals. • The fundamental solution is expanded by using the degenerate kernel in terms of bipolar coordinates for the study. • BIE is nothing more than the linear algebra since ln(r) is expanded by using the degenerate kernel. Boundary value problems including a source and no source for an eccentric annular domain are both revisited in this paper. Instead of using complex variables, the null-field boundary integral equation in conjunction with the degenerate kernel is employed to analytically solve the problem. Due to the geometry of the eccentric domain, the fundamental solution is expanded to the degenerate kernel under the bipolar coordinates. Once the degenerate kernel is found, the boundary integral equation is nothing more than a linear algebraic system. The solutions derived by using the present method have been compared with those done by using the complex variables. The potential field of the problems are plotted to show the validity of the present method. [ABSTRACT FROM AUTHOR]

Background and aims: Endoscopic submucosal dissection (ESD) as an advanced endoscopic procedure can be considered for the removal of colorectal lesions with high suspicion of limited submucosal invasion or cannot be optimally removed by snare-based techniques. We aimed to analyze the clinical outcomes of ESD for colorectal neoplasms in our hospital. Methods: We retrospectively enrolled 230 patients with 244 colorectal neoplasms who received ESD procedures from April 2012 to October 2020 at Kaohsiung Chang Gung Memorial Hospital. Clinicopathological data were collected by chart review. We also recorded ESD-related complications and clinical outcomes. Results: The average age was 64 years old, with a mean follow-up time of 22.59 months. There was a loss of follow-up in 34 lesions. Most lesions were lateral spreading tumors of the non-granular type. The average ESD time was 51.9 minutes. Nine cases (3.7%) had procedure-related complications, including two intra-procedure perforations (0.8%) and seven delayed bleeding (2.9%) without procedure-related mortality. 241 lesions (98.8%) achieved en-bloc resection, while 207 lesions (84.8%) achieved R0 resection. Most lesions were tubulo-(villous) adenoma. Malignancy included 35 adenocarcinomas and 5 neuroendocrine tumors. No local recurrence was developed during follow-up. Multivariate analysis for long ESD time revealed significance in size ≥ 10 cm2 and endoscopist's experience < 3 years. Pre-ESD endoscopic ultrasound revealed good prediction in discrimination of mucosal (sensitivity: 0.90) and submucosal lesion (specificity: 0.67). Conclusions: ESD for colorectal neoplasms is an effective and safe technique. Size ≥ 10 cm2 and endoscopist's experience < 3 years were significantly associated with long procedure time. Pre-ESD EUS provided a good prediction for colorectal neoplasms in invasion depth. [ABSTRACT FROM AUTHOR]

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 < 0.01), but not for that of IKPS (0.02% vs. 0.03%, 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. [ABSTRACT FROM AUTHOR]

Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients. [ABSTRACT FROM AUTHOR]

Background & Aims Liver stiffness measurement ( LSM) using transient elastography is useful in prediction of significant portal hypertension ( PHT). To evaluate the usefulness of baseline and serial LSM in predicting clinical disease progression ( CDP) for patients with compensated hepatic cirrhosis. Methods Consecutive patients with compensated cirrhosis and without hepatocellular carcinoma ( HCC) were prospectively enrolled. Baseline LSM was assessed at enrolment, then at a 6- to 12-month interval. Esophagogastroduodenoscopy and ultrasonography were performed regularly for surveillance of varices and HCC, while CDP including HCC development and PHT progression was recorded. Results Two hundred and twenty patients were enrolled. In a median follow-up of 36.9 months, CDP were detected in 49 patients including 30 PHT progression and 19 HCC developments. The cumulative incidence of CDP, PHT progression and HCC development at 3 years was 20.7%, 12.8% and 9.1% respectively. Multivariate analyses showed that baseline LSM was an independent predictor of PHT progression and CDP, however, not of HCC occurrence. The performance of baseline LSM in predicting PHT progression, varices growth/development and hepatic decompensation was 0.744, 0.638 and 0.929. With 17, 12 and 21.1 kPa as the cut-off, the negative predictive value was 92, 94 and 99% respectively. Patients with baseline LSM ≧17 kPa without serial changes had higher risk of PHT progression. Conclusion For patients with compensated cirrhosis, LSM was an independent predictor of PHT progression and CDP, but not of HCC occurrence. Baseline LSM was useful to exclude PHT progression. Patients with baseline and serial LSM ≧17 kPa had higher risk of PHT progression. [ABSTRACT FROM AUTHOR]

Background and Aim: Transient elastography (TE) has been useful in esophageal varices (EV) diagnosis for chronic hepatitis C patients. In the present study, we evaluate the usefulness of TE and simple blood markers in the EV diagnosis of patients with hepatitis B virus (HBV)-related cirrhosis, prospectively. Methods: Consecutive patients with compensated cirrhosis and positive HBV surface antigen were enrolled, prospectively. At enrollment, the aspartate aminotransferase (AST) to alanine aminotransferase ratio (AAR) and the AST to platelet ratio index (APRI) were recorded, and TE was performed. Two experienced endoscopists assessed EV independently. High-risk EV was defined as small size with a red color sign, and medium or large in size. The diagnostic performances, optimal cut-offs, and the validities of TE, APRI, platelet count (PLT), and AAR in EV diagnosis were assessed. Results: A total of 126 patients (male/female: 93/33; mean age: 54.5 years) with reliable TE results were analyzed. There was good agreement between two endoscopists in assessing the presence of EV and high-risk EV (kappa value: 0.82 and 0.96). Forty-eight (38.1%) patients had EV (small: 35; high risk: 13). There was correlation between TE result and EV size (r = 0.515, P < 0.001). TE, APRI, and PLT were similar; however, superior to AAR in the diagnostic accuracies for EV and high-risk EV. In high-risk EV prediction, the negative predictive value (NPV) was 97%, 98%, and 98%, with cut-offs of 21 kPa, 1.24, and 110 (× 109/L) for TE, APRI, and PLT, respectively. Conclusions: For compensated patients with HBV-related cirrhosis, TE, APRI, and PLT are useful in excluding high-risk EV with high NPV. [ABSTRACT FROM AUTHOR]

Background: Classical second-line anti- Helicobacter pylori includes proton-pump inhibitor, tetracycline, metronidazole, and bismuth salts, but alternative therapies are required owing to the restricted availability of the latter. Levofloxacin-containing triple therapy is recommended but is expensive. Besides, quinolone resistance in an endemic tuberculosis infection area like Taiwan is concerned. The low in vitro antibiotic resistance to amoxicillin and tetracycline in Taiwanese H. pylori strains implies that in vivo esomeprazole/amoxicillin/tetracycline (EAT) second-line rescue therapy may be effective. This study compared the efficacy of esomeprazole/amoxicillin/levofloxacin (EAL) and EAT second-line eradication therapies and determines the clinical factors influencing the efficacy of salvage regimens. Materials and methods: One hundred and twenty-eight patients who failed H. pylori eradication using the standard triple therapy for 7 days are randomly assigned to either EAL group (esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, and levofloxacin 500 mg once daily) for 7 days or EAT group (esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, tetracycline 500 mg four times daily) for 14 days. Follow-up endoscopy or urea breath test was performed 8 weeks later to assess treatment response. Results: The eradication rates of EAL and EAT groups were 78.1 versus 75.0%, p = .676 (in intention-to-treat analysis) and 80.3 versus 80%, p = .0964 (per-protocol analysis). Both groups exhibited similar drug compliance (95.3 vs 96.9%, p = .952) but more adverse events in the EAT group (6.3 vs 12.5%, p = .225). Conclusions: Despite low in vitro drug resistances to amoxicillin and tetracycline, the efficacy of 14-day EAT regimens attained an unacceptable report card of 75% eradication rates in intention-to-treat analysis and was not even superior to the 7-day EAL regimen. Drug-drug interaction between combined antibiotics should be considered other than in vivo drug resistances. [ABSTRACT FROM AUTHOR]

Eur J Clin Invest 2012; 42 (4): 427-431 Abstract Background Inadequate reprocessing of double-balloon enteroscopy (DBE) or of endoscopic accessories may result in iatrogenic infections and present a risk to public health. Aim To use microbiological surveillance culture monitoring (SCM) to assess the adequacy of high-level disinfection (HLD) with standard reprocessing procedures of DBE. Materials and methods We performed a prospective study on cultures collected from DBEs that had been treated by HLD by an automated endoscope washing machine (AEWM) decontamination cycle. This study included 42 cases with 57 cultures, which were collected consecutively between October 2009 and December 2010. In 31 cases, 31 cultures were collected from oral route DBE (mean patient age, 68·9 years), and in 23 cases, 26 cultures were collected from anal route DBE (mean patient age, 67·9 years). The results obtained were compared with those of our previous study of SCM on gastroscopy (GS) and colonoscopy (CS). The samples were collected by flushing 50 mL sterile distilled water into the suction channel and collecting the flow-through in a sterile container. The samples were then incubated at 37 °C and examined for bacterial growth. Results Before HLD, the positive culture rate was 83·9% (26/31) for the oral route DBE and 100% (26/26) for the anal route DBE ( P = 0·0406). After HLD, the positive culture rate was 12·9% (4/31) for the oral route DBE and 19·2% (5/26) for the anal route DBE ( P > 0·05). A linear trend relationship was found between positive SCM and the length and category of diagnostic instruments - GS, CS, oral route DBE and anal route DBE. Conclusions Surveillance culture monitoring is a useful method to assess the effectiveness of HLD reprocessing of DBE. Machine washing may not achieve complete disinfection. Using AEWM regularly is mandatory to minimize cross-contamination and to ensure quality assurance. Additional procedures are necessary to employ for the longer and anal route DBE. [ABSTRACT FROM AUTHOR]

Aspirin possesses anti-bacterial activity that may prevent recurrence of Klebsiella pneumoniae pyogenic liver abscess (KP-PLA). In ex-vivo study, aspirin was administered before bactericidal assay against serotype K1 K. pneumoniae. We identified 5,912 patients with PLA who had no known pre-existing hepatobiliary diseases or malignancy in Taiwan from 1999 to 2013 from nationwide cohort study. Multivariate Cox proportional hazards regression models was used to estimate the hazard ratios [HR] for the association between aspirin use and recurrent PLA. The PLA recurrence rate in patients taking aspirin daily for 30 or more days, from 90 days before to 90 days after the first PLA episode (aspirin users), and aspirin non-users was 42.5 and 74.6 per 1,000 person-years of follow-up, respectively. The population-based study showed a HR for PLA recurrence in aspirin users of 0.50 (95% confidence interval, 0.35–0.69), relative to that in non-users, after adjustments for confounders. An ex-vivo study indicated that aspirin was able to significantly enhance bacterial killing by leukocytes, whether collected from diabetic patients with KP-PLA recurrence or from healthy volunteers. Our results suggest that aspirin is associated with reduced risk for PLA recurrence among Taiwanese with PLA who had no preexisting hepatobiliary diseases or malignancy. [ABSTRACT FROM AUTHOR]

Background: The removal of large bile duct stones (> 15 mm) by conventional endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) can be challenging, requiring mechanical lithotripsy (ML) in addition to EST or EPBD. The primary complication of ML is basket and stone impaction, which can lead to complications such as pancreatitis and cholangitis. The present study aims to investigate the efficacy of limited EST plus endoscopic papillary large balloon dilation (EST-EPLBD) for large bile duct stone extraction with an extent of cutting < 1/2 the length of the papillary mound.Methods: We enrolled 185 patients with ≥15 mm bile duct stones who received EST, EPLBD and limited EST-EPLBD treatment from January 1, 2010 to February 28, 2018, at Kaohsiung Chang Gung Memorial Hospital (Kaohsiung, Taiwan). All patients were categorized into three groups: EST group (n = 31), EPLBD group (n = 96), and limited EST-EPLBD group (n = 58). The primary outcome variables were the success rate of complete stone removal and complications.Results: The limited EST-EPLBD group exhibited a higher success rate of the first-session treatment compared with the EST and EPLBD groups (98.3% vs. 83.9% vs. 86.5%; P = 0.032) but required a longer procedure time (32 (12-61) min vs. 23.5 (17-68) min vs. 25.0 (14-60) min; P = 0.001). The need for ML during the procedure was 4 (12.9%) in the EST group, 10 (10.4%) in the EPLBD group and 2 (3.4%) in the limited EST-EPLBD group. Post-procedure bleeding in the EST group was more common than that in the limited EST-EPLBD group (9.7% vs. 0%; P = 0.038). Furthermore, dilated bile duct was the only risk factor for bile duct stone recurrence in the limited EST-EPLBD group.Conclusions: Limited EST-EPLBD exhibits a higher success rate but requires marginally longer procedure time for the first-session treatment. Furthermore, dilated bile duct is the only risk factor for bile duct stone recurrence in patients undergoing limited EST-EPLBD. [ABSTRACT FROM AUTHOR]

Background/purpose: Limited studies have addressed the exacerbation of symptoms and long COVID in inflammatory bowel disease (IBD) patients following non-severe COVID-19 infection, particularly with post-COVID-19 vaccination. We aim to investigate factors associated with exacerbated gastrointestinal symptoms (EGS) and long COVID in IBD patients with non-severe COVID-19, which is most common situation in daily practice., Methods: This is an observational study by multiple centers in Taiwan from May 2020 to March 2023. We collected clinical manifestation, data, and medication information from IBD patients with non-severe COVID-19. EGS was defined as increased frequency of diarrhea, bloody stool, and abdomen pain within 14 days after SARS-COV-2 infection. Long COVID was defined following the guidelines of the World Health Organization., Results: Out of 90 patients, most of them (88.9%) received at least standard two doses of COVID-19 vaccination and the majority (87.8%) were mild diseases of COVID-19.30% of patients experienced EGS during COVID-19 with higher ESR levels serving as a predictive factor (Odds ratio: 3.6, 95% confidence interval: 1.2-10.5, P = 0.02). 38.1% of those patients developed long COVID. The patients who experienced EGS during COVID-19 and with a history of longer IBD duration showed a significant association with long COVID (p = 0.03 and p = 0.02)., Conclusion: Our study revealed that EGS and long COVID occurred in one third of IBD patients with non-severe COVID-19, even though most of them had received the standard plus booster vaccination. We identified associated factors for EGS and long COVID, emphasizing the importance of post-COVID-19 follow-up in IBD patients., Competing Interests: Declaration of competing interest A conflict of interest occurs when an individual's objectivity is potentially compromised by a desire for financial gain, prominence, professional advancement or a successful outcome. JFMA Editors strive to ensure that what is published in the Journal is as balanced, objective and evidence-based as possible. Since it can be difficult to distinguish between an actual conflict of interest and a perceived conflict of interest, the Journal requires authors to disclose all and any potential conflicts of interest., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: High-dose dual therapy (HDDT) using proton-pump inhibitors (PPI) and amoxicillin attracted attention for its simplicity and lower adverse event profile. Besides, vonoprazan is not available worldwide. This real-world study aims to compare the efficacy of esomeprazole-based and rabeprazole-based HDDT regimens and to identify clinical factors influencing outcomes., Methods: A retrospective study enrolled 346 Helicobacter pylori-infected naïve patients from January 2016 to August 2023. Patients were assigned to either a 14-day esomeprazole-based HDDT (EA-14; esomeprazole 40 mg t.i.d. and amoxicillin 750 mg q.i.d. for 14 days, n = 173) or a 14-day rabeprazole-based HDDT (RA-14; rabeprazole 20 mg and amoxicillin 750 mg q.i.d. for 14 days, n = 173)., Results: Five patients from the EA-14 group and 10 from the RA-14 group were lost to follow-up, resulting in 168 and 163 patients for the per-protocol (PP) analysis, respectively. Eradication rates for the EA-14 and RA-14 groups were 90.2% and 80.9% (P = 0.014) in intention-to-treat (ITT) analysis; and 92.9% and 85.9% (P = 0.039) in PP analysis. Adverse event rates were similar between the two groups (11.9% vs 11.7%, P = 0.944). In multiple logistic regression analysis, age≧60 was associated with eradication failure (P = 0.046) and a trend of significance for smoking (P = 0.060) in the EA-14 group but not in the RA-14 group. A trend of significance was also observed for eradication regimens (EA-14 vs RA-14) (P = 0.071). The antibiotic resistance rates were amoxicillin (2.3%), clarithromycin (14.7%), metronidazole (40.3%), and dual resistance to clarithromycin and metronidazole (7.0%)., Conclusions: Esomeprazole-based HDDT achieved over 90% eradication rates but rabeprazole-based HDDT, which failed., Competing Interests: Declaration of competing interest All authors declared there was no conflict of interests., (Copyright © 2024. Published by Elsevier B.V.)

Reprocessing of gastrointestinal (GI) endoscopes and accessories is an essential part of patient safety and quality control in GI endoscopy centers. However, current endoscopic reprocessing guidelines or procedures are not adequate to ensure patient-safe endoscopy. Approximately 5.4 % of the clinically used duodenoscopes remain contaminated with high-concern microorganisms. Thus, the Digestive Endoscopy Society of Taiwan (DEST) sets standards for the reprocessing of GI endoscopes and accessories in endoscopy centers. DEST organized a task force working group using the guideline-revision process. These guidelines contain principles and instructions of step-by-step for endoscope reprocessing. The updated guidelines were established after a thorough review of the existing global and local guidelines, systematic reviews, and health technology assessments of clinical effectiveness. This guideline aims to provide detailed recommendations for endoscope reprocessing to ensure adequate quality control in endoscopy centers., Competing Interests: Conflicts of interest All authors declare that they have no relevant conflicts of interest related to this article., (Copyright © 2023. Published by Elsevier B.V.)

Background: Early-stage esophageal cancer is treated using endoscopic submucosal dissection and esophagectomy. Field cancerization in patients with early-stage esophageal cancer affects treatment outcomes and causes synchronous or metachronous head and neck cancers. We hypothesized that esophagectomy could provide better overall and relapse-free survivals in patients with esophageal cancer and synchronous or metachronous head and neck cancer., Methods: We retrospectively identified patients with early esophageal squamous cell carcinoma and synchronous or metachronous head and neck cancers. We separated the patients into endoscopic submucosal dissection and esophagectomy groups to compare overall and relapse-free survivals., Results: The study included 106 patients, 25 of whom underwent endoscopic submucosal dissection and 81 underwent esophagectomy. Overall and relapse-free survivals did not show significant differences between the two groups for both synchronous and metachronous head and neck cancers., Conclusions: Endoscopic submucosal dissection could provide similar overall and relapse-free survivals in patients with esophageal cancer and synchronous or metachronous head and neck cancer., (© 2024. The Author(s).)

Background: This nationwide prospective registry study investigated the real-world effectiveness, safety, and persistence of vedolizumab (VDZ) in inflammatory bowel disease (IBD) patients in Taiwan. Disease relapse rates after VDZ discontinuation due to reimbursement restriction were assessed., Methods: Data were collected prospectively (January 2018 to May 2020) from the Taiwan Society of IBD registry., Results: Overall, 274 patients (147 ulcerative colitis [UC] patients, 127 Crohn's disease [CD] patients) were included. Among them, 70.7% with UC and 50.4% with CD were biologic-naïve. At 1 year, 76.0%, 58.0%, 35.0%, and 62.2% of UC patients and 57.1%, 71.4%, 33.3%, and 30.0% of CD patients achieved clinical response, clinical remission, steroid-free remission, and mucosal healing, respectively. All patients underwent hepatitis B and tuberculosis screening before initiating biologics, and prophylaxis was recommended when necessary. One hepatitis B carrier, without antiviral prophylaxis due to economic barriers, had hepatitis B reactivation during steroid tapering and increasing azathioprine dosage, which was controlled with an antiviral agent. No tuberculosis reactivation was noted. At 12 months, non-reimbursement-related treatment persistence rates were 94.0% and 82.5% in UC and CD patients, respectively. Moreover, 75.3% of IBD patients discontinued VDZ due to mandatory drug holiday. Relapse rates after VDZ discontinuation at 6 and 12 months were 36.7% and 64.3% in CD patients and 42.9% and 52.4% in UC patients, respectively., Conclusions: The findings demonstrated VDZ effectiveness in IBD patients in Taiwan, with high treatment persistence rates and favorable safety profiles. A substantial IBD relapse rate was observed in patients who had mandatory drug holiday., (© The Author(s) 2023. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The coronavirus disease 2019 (COVID-19) pandemic had a great impact on healthcare system and patients. This study aimed to evaluate the effect of the COVID-19 pandemic on the perceptions of patients with inflammatory bowel disease (IBD)., Methods: This prospective multicenter study was conducted between July 2021 and December 2021. Patients with IBD answered a structured questionnaire, and their degree of anxiety was assessed using a visual analogue scale (VAS) before and after reading educational materials., Results: A total of 225 (47.67%) patients with Crohn's disease, 244 (51.69%) with ulcerative colitis and 3 (0.64%) with indeterminate colitis were enrolled. Common concerns were adverse events from vaccination (20.34%), and higher risks of developing severe COVID-19 (19.28%) and COVID-19 infection (16.31%) than the general population. Medications deemed by the patients to increase the risk of COVID-19 were immunomodulators (16.10%), anti-tumor necrosis factor-α antagonists (9.96%), and corticosteroids (9.32%). Thirty-five (7.42%) patients self-discontinued IBD medication, of whom 12 (34.28%) had worse symptoms. Older age (>50 years) (OR 1.10, 95% CI 1.01-1.19, p = 0.03), IBD-related complications (OR 1.16, 95% CI 1.04-1.28, p = 0.01), education status below senior high school (OR 1.22, 95% CI 1.08-1.37, p = 0.001), and residing in north-central Taiwan (OR 1.21, 95% CI 1.10-1.34, p < 0.001) were associated with more anxiety. None of the enrolled patients contracted COVID-19. The anxiety VAS score (mean ± SD) improved after reading the educational materials (3.84 ± 2.33 vs. 2.81 ± 1.96, p < 0.001)., Conclusion: The medical behavior of IBD patients was influenced by the COVID-19 pandemic, and their anxiety could be mitigated after education., (Copyright © 2023 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: Endoscopic Retrograde Cholangiopancreatography (ERCP), used for choledocholithiasis treatment, carries a risk of pyogenic liver abscess (PLA) due to communication between the biliary system and bowel contents. However, limited data exists on this issue. This study aims to identify the risk factors pertaining to liver abscesses following ERCP lithotomy., Methods: We conducted a retrospective case series across multiple centers to evaluate patients who developed PLA after ERCP for choledocholithiasis. Data was obtained from the Chung Gung Research Database (January 2001 to December 2018). Out of 220 enrolled patients, 195 were categorized in the endoscopic sphincterotomy (ES) group, while 25 were in the non-ES group for further analysis., Results: The non-ES group had significantly higher total bilirubin levels compared to the ES group (4.3 ± 5.8 vs 1.9 ± 2.0, p<0.001). Abscess size, location, and distribution (single or multiple) were similar between the two groups. The most common pathogens were Klebsiella pneumoniae and Escherichia coli . Pseudomonas infection was significantly less prevalent in the ES group compared to the non-ES group (3.6% vs 16.7%, p=0.007). Patients with concurrent malignancies (HR: 9.529, 95% CI: 2.667-34.048, p=0.001), elevated total bilirubin levels (HR: 1.246, 95% CI: 1.062-1.461, p=0.007), multiple abscess lesions (HR: 5.146, 95% CI: 1.777-14.903, p=0.003), and growth of enterococcus pathogens (HR: 4.518, 95% CI: 1.290-15.823, p=0.001) faced a significantly higher risk of in-hospital mortality., Conclusion: PLA incidence was higher in the ES group compared to the non-ES group following ERCP for choledocholithiasis. Attention should be given to significant risk factors, including concurrent malignancies, elevated total bilirubin levels, multiple abscess lesions, and growth of enterococcus pathogens, to reduce in-hospital mortality., Competing Interests: The authors declared that they have no conflicts of interest in this work. All authors have no commercial association, such as consultancies, stock ownership or other equity interests or patent-licensing arrangements., (© 2023 Liu et al.)

A standard bismuth quadruple therapy, a fluoroquinolone-containing triple (or quadruple) therapy or a proton pump inhibitor (PPI)-amoxicillin high-dose dual therapy has been recommended as a second-line treatment for Helicobacter pylori infection by the Maastricht VI/Florence Consensus Report. The major shortcoming of levofloxacin-amoxicillin triple therapy is low cure rate for eradicating levofloxacin-resistant strains. With the rising prevalence of levofloxacin-resistant strains, levofloxacin-amoxicillin triple therapy cannot reliably achieve a high eradication rate for second-line treatment of H. pylori infection in most countries now. The present article aims to review current second-line eradication regimens with a per-protocol eradication rate exceeding 85% in most geographic areas. Recently, a novel tetracycline-levofloxacin quadruple therapy consisting of a PPI, bismuth, tetracycline, and levofloxacin for rescue treatment of H. pylori infection has been developed. The new therapy achieved a higher per-protocol eradication rate than levofloxacin-amoxicillin triple treatment in a randomized controlled trial (98% versus 69%). Additionally, the tetracycline-levofloxacin quadruple therapy also exhibits a higher eradication rate than amoxicillin-levofloxacin quadruple therapy. High-dose dual PPI-amoxicillin therapy is another novel second-line treatment for H. pylori infection. The new therapy can achieve an eradication rate of 89% by per-protocol analysis for the second-line treatment in Taiwan. Recently, levofloxacin-based sequential quadruple therapy and potassium-competitive acid blocker have also been applied in the second-line treatment of H. pylori infection. A meta-analysis revealed that a vonoprazan-based regimen has significant superiority over a PPI-based regimen for second-line H. pylori eradication therapy. In conclusion, the eradication rate of levofloxacin-amoxicillin triple therapy is suboptimal in the second-line treatment of H. pylori infection now. Currently, a standard bismuth quadruple therapy (tetracycline-metronidazole quadruple therapy), a tetracycline-levofloxacin quadruple therapy, an amoxicillin-levofloxacin quadruple therapy, a levofloxacin-based sequential quadruple therapy or a high-dose PPI-amoxicillin dual therapy is recommended for the second-line treatment of H. pylori infection., Competing Interests: The authors declare that there is no conflict of interest., (© The Author(s), 2023.)

Introduction: The study aimed to compare the efficacies and safety of 14-day hybrid therapy, 14-day high-dose dual therapy, and 10-day bismuth quadruple therapy in the first-line treatment of Helicobacter pylori infections., Methods: In this multicenter, open-label, randomized trial, we recruited adult H. pylori -infected patients from 9 centers in Taiwan. Subjects were randomly assigned (1:1:1) to 14-day hybrid therapy, 14-day high-dose dual therapy, or 10-day bismuth quadruple therapy. Eradication status was determined by the 13 C-urea breath test. The primary outcome was the eradication rate of H. pylori assessed in the intention-to-treat population., Results: Between August 1, 2018, and December 2021, 918 patients were randomly assigned in this study. The intention-to-treat eradication rates were 91.5% (280/306; 95% confidence interval [CI] 88.4%-94.6%) for 14-day hybrid therapy, 83.3% (255/306; 95% CI 87.8%-95.0%) for 14-day high-dose dual therapy, and 90.2% (276/306; 95% CI 87.8%-95.0%) for 10-day bismuth quadruple therapy. Both hybrid therapy (difference 8.2%; 95% CI 4.5%-11.9%; P = 0.002) and bismuth quadruple therapy (difference 6.9%; 95% CI 1.6%-12.2%; P = 0.012) were superior to high-dose dual therapy and were similar to one another. The frequency of adverse events was 27% (81/303) with 14-day hybrid therapy, 13% (40/305) with 14-day high-dose dual therapy, and 32% (96/303) with 10-day bismuth quadruple therapy. Patients receiving high-dose dual therapy had the fewest adverse events (both P < 0.001)., Discussion: Fourteen-day hybrid therapy and 10-day bismuth quadruple therapy are more effective than 14-day high-dose dual therapy in the first-line treatment of H. pylori infection in Taiwan. However, high-dose dual therapy has fewer adverse effects than hybrid bismuth quadruple therapies., (Copyright © 2023 by The American College of Gastroenterology.)

Introduction: High-dose dual therapy (HDDT) can attain acceptable eradication rates provided that the optimal doses, timing and treatment duration are applied. The existing evidence still shows inconsistent reports (< 90%) on HDDT therapy except in some Asian countries. We aimed to assess and compare the efficacy of 14-day HDDT by comparing it to 14-day rabeprazole-containing hybrid therapy (HT) and to investigate the host and bacterial factors predicting the treatment outcomes of eradication therapies., Methods: In this open-label, randomized controlled trial, we recruited 243 naïve Helicobacter pylori-infected patients from September 1, 2018, to November 30, 2021. They were randomly allocated (1:1) to the HDDT group (rabeprazole 20 mg and amoxicillin 750 mg q.i.d for 14 days, n = 122) and the HT group (rabeprazole 20 mg and amoxicillin 1 g b.i.d. for 7 days, followed by rabeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg and metronidazole 500 mg b.i.d. for 7 days, n = 121). Twelve patients were absent during follow-up in the HDDT group and 4 in the HT group, resulting in 110 for the HDDT group and 117 for HT group in the per protocol (PP) study. The outcome was determined by urea breath tests 8 weeks later., Results: The eradication rates for the HDDT and HT groups were 77.0% (95% confidence interval [CI]: 68.5% to 84.1%) and 94.2% (95% CI: 88.4% to 97.6%) (P < 0.001) in intention-to-treat analysis; 85.5% (95% CI: 77.5% to 91.5%) and 97.4% [95% CI: 92.6% to 99.5%] (P = 0.001) in per protocol analysis. The adverse event rates were 7.3% in the HDDT group and 14.5% in the HT group (P = 0.081). The habit of coffee drinking was the dependent factor for eradication failure in the HDDT group (88.2% vs. 68.8%, P = 0.040), but had no influence in the HT group (97.9% versus 95.0%, P = 0.449) in the univariate analysis., Conclusion: This study demonstrated that 14-day rabeprazole-containing HDDT did not achieve > 90% eradication rates for first-line H. pylori eradication as 14-day rabeprazole-containing HT did. HDDT is a potentially beneficial combination, which involves only two drugs with mild adverse effects; more precise studies are urged to find answers regarding these failures. This clinical trial was registered retrospectively on 28 November, 2021, as ClinicalTrials.gov identifier: NCT05152004., (© 2023. The Author(s).)

The electrostatics of two cylinders charged to the symmetrical or anti-symmetrical potential is investigated by using the null-field boundary integral equation (BIE) in conjunction with the degenerate kernel of the bipolar coordinates. The undetermined coefficient is obtained according to the Fredholm alternative theorem. The uniqueness of solution, infinite solution, and no solution are examined therein. A single cylinder (circle or ellipse) is also provided for comparison. The link to the general solution space is also done. The condition at infinity is also correspondingly examined. The flux equilibrium along circular boundaries and the infinite boundary is also checked as well as the contribution of the boundary integral (single and double layer potential) at infinity in the BIE is addressed. Ordinary and degenerate scales in the BIE are both discussed. Furthermore, the solution space represented by the BIE is explained after comparing it with the general solution. The present finding is compared to those of Darevski [2] and Lekner [4] for identity.

Background: Aging may affect the efficacy of Helicobacter pylori eradication. The aim of our study was to assess the efficacy and safety of 7-day non-bismuth concomitant quadruple therapy as a first-line H. pylori infection eradication regimen in elderly individuals., Methods: We retrospectively analyzed a cohort with prospectively collected data from January 2013 to December 2019 at Chang Gung Memorial Hospital in Kaohsiung. There were 408 naive infected subjects aged 20 years or older who were treated with 7 days of concomitant therapy as a first-line H. pylori eradication regimen. We divided the patients into an elderly group (aged ≥ 65 years) and a control group (aged < 65 years). Two patients were lost during follow-up in the elderly group and 29 patients were lost in the control group, resulting in 56 in the ≥ 65-year age group and 321 in the control group. The patients were asked to perform urea breath tests 8 weeks later., Results: The eradication rates for the elderly and control groups were 93.1% (95% confidence interval (CI): 83.3-98.1) and 84.0% (95% CI 79.7-87.7) (p = 0.070), respectively, in the intention-to-treat analysis, and 96.4% (95% CI 87.6-99.6) and 91.6% (95% CI 88.0-94.4) (p = 0.210), respectively, in the per-protocol (PP) analysis. The adverse event rates were 8.9% in the elderly group and 12.8% in the control group (p = 0.417). The compliance was 100% in both groups. No significant difference was seen in antibiotic resistance in either group. Multivariate analysis revealed that metronidazole resistance (odds ratio (OR) 6.870, 95% CI 1.182-39.919, p = 0.032) and dual-therapy resistance (OR 7.188, 95% CI 1.326-38.952, p = 0.022) were independent factors for eradication failure., Conclusions: The efficacy of non-bismuth concomitant quadruple therapy in the elderly cohort was comparable with that in the non-elderly cohort for first-line H. pylori eradication with acceptable adverse effects., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: The use of biologic agents has become the cornerstone of therapy for moderate to severe IBD. Few studies have investigated the efficacy of vedolizumab (VDZ) induction for ulcerative colitis (UC) in Asian patients in a real practice setting., Aims: To evaluate the efficacy and safety of VDZ induction therapy for moderate to severe UC in Taiwan., Methods: This was a retrospective and observational study. Selected moderate to severe UC patients received VZD 300 mg i.v. at weeks 0, 2, and 6 as induction therapy. Mayo scores were calculated to evaluate the efficacy., Results: A total of 37 patients with UC who received VDZ and completed the induction therapy at Chang Gung Memorial Hospital (2017/10-2021/5) were included. The mean age was 46.5 year-old and the male to female ratio was 1:1 (19/18). 81.8% of the patients were biologic-naive. At weeks 8-10, a clinical response, clinical remission and endoscopic remission with VDZ induction therapy were achieved in 56.8% (21/37), 32.4% (12/37) and 58.3% (7/12) of the patients, respectively. 54.1% (20/37) were able to taper off at week 8. Overall, only 10.8% (4/37) of the patients were primary non-responders during induction therapy. No obvious VDZ-related severe adverse events were noted. Overall, 58.9% (11/19) of the patients relapsed after stopping VDZ, and the relapse rate after VDZ discontinuation was 42.1% (8/19) within first 6 months and 52.6% (10/19) within the first year., Conclusion: In real-world experience, induction therapy with VDZ showed promising clinical benefits and safety profile for patients with UC., Competing Interests: Declaration of competing interest There was no any financial interests or connections, direct or indirect, or other situations that might raise the question of bias in the work reported or the conclusions, implications, or opinions stated – including pertinent commercial or other sources of funding for the individual authors or for the associated departments or organizations, personal relationships, or direct academic competition., (Copyright © 2021 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

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., Competing Interests: Conflicts of interest All the authors have no conflicts of interest related to the manuscript., (Copyright © 2020 Chang Gung University. Published by Elsevier B.V. All rights reserved.)

Background 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., Competing Interests: The authors declared that they have no conflicts of interest., (© 2021 Wu et al.)

Purpose: Non-bismuth concomitant quadruple therapy is commonly administered in Taiwan, achieving an acceptable efficacy as a first-line anti -Helicobacter pylori treatment. This study compared the eradication rates between esomeprazole- and lansoprazole-based non-bismuth concomitant quadruple therapy for first-line anti- H. pylori treatment., Patients and Methods: This study included 206 H. pylori -infected naïve patients between July 2016 and February 2019. The patients were prescribed with either a 7-day non-bismuth containing quadruple therapy (esomeprazole, 40 mg twice daily; amoxicillin, 1 g twice daily; and metronidazole, 500 mg twice daily; and clarithromycin, 500 mg twice daily for 7 days [EACM group]; lansoprazole, 30 mg twice daily; amoxicillin, 1 g twice daily; metronidazole, 500 mg twice daily; and clarithromycin, 500 mg twice daily [LACM group]). Then, the patients were asked to perform urea breath tests 8 weeks later., Results: The eradication rates in the EACM group were 86.1% (95% confidence interval [CI], 77.8%-92.2%) and 90.6% (95% CI, 82.9%-95.6%) in the intention-to-treat (ITT) and the per-protocol (PP) analyses, respectively. Moreover, the eradication rates in the LACM group were 90.1% (95% CI, 82.6%-95.2%) and 92.6% (95% CI, 85.5%-96.9%) in the ITT and the PP analyses, respectively. Consequently, the LACM group exhibited more diarrhea patients than the EACM group (7.1% versus 1.0%, p = 0.029), but all symptoms were mild. Univariate analysis in this study showed that metronidazole-resistant strains were the clinical factor affecting the eradications (95.3% versus 78.9%, p = 0.044). Moreover, a trend was observed in dual clarithromycin- and metronidazole-resistant strains (91.5% versus 66.7%, p = 0.155)., Conclusion: The eradication rates between esomeprazole and lansoprazole-based non-bismuth concomitant quadruple therapy for first-line H. pylori treatment were similar in this study. Both could achieve a > 90% report card in the PP analysis., Competing Interests: The authors report no conflicts of interest exist in this work., (© 2021 Hung et al.)

Background: Antibiotic resistance plays a crucial role in the treatment failure of Helicobacter pylori (H. pylori) infection. This study aimed to determine the trend of changes in the primary, secondary and tertiary antibiotic resistance of H. pylori in Taiwan over the last 7 years., Methods: We retrospectively analysed H. pylori -infected isolates from patients with primary resistance ( n  = 1369), secondary resistance ( n  = 196) and tertiary resistance ( n  = 184) from January 2013 to December 2019. The H. pylori strains were tested for susceptibility to amoxicillin, clarithromycin, levofloxacin, metronidazole and tetracycline using the Epsilometer test method., Results: A progressively higher primary resistance rate was observed for clarithromycin (11.8-20.4%, p  = 0.039 in χ 2 test for linear trend), levofloxacin (17.3-38.8%, p  < 0.001) and metronidazole (25.6-42.3%, p  < 0.001) among naïve patients who received first-line eradication therapy. The dual primary resistance to clarithromycin and metronidazole also progressively increased in a linear trend (2.4-10.4%, p  = 0.009). For secondary resistance, an increase was observed for levofloxacin (30.5-64.7%, p  = 0.006) and metronidazole (40.5-77.4%, p  < 0.001). For tertiary resistance, the observed increase was even more significant for levofloxacin (65.9-100.0%, p  = 0.106) and metronidazole (44.4-88.2%, p  < 0.001). The resistance to amoxicillin and tetracycline remained very low in Taiwan regardless of primary, secondary and tertiary resistance., Conclusion: Primary, secondary and tertiary antibiotic resistance to clarithromycin, levofloxacin and metronidazole for H. pylori has been increasing in Taiwan since 2013. Treatment should be targeted for eradication success rates of more than 90%. Third-line treatment should be based on antibiotic susceptibility., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2020.)

To investigate the epidemiology of eye-related emergency department (ED) visits and to determine if visual acuity (VA) could be an indicator for determining the timing for managing ocular emergencies, we have conducted the retrospective study which included patients visited the ED for eye-related reasons and had received ophthalmology consultations at a referral center in Taiwan in 2015. Among 46,514 consultations, 5,493 were ophthalmology consultations (11.8%). After exclusion, 5,422 were eligible for analysis. Among them, 1,165 (21.5%) had not likely emergent diagnoses, 4,048 (74.7%) had likely emergent diagnoses, and 209 patients (3.9%) could not be determined. The logMAR VA was 0.31 ± 0.48, 0.66 ± 0.78, and 1.00 ± 0.94 in groups with not likely emergent, likely emergent, and undetermined diagnoses, respectively. Among all eye-related ED visits, 10.3% of patients received ophthalmologic intervention or were admitted to the ophthalmology ward. A LogMAR VA score of 0.45 (decimal equivalent of 0.4) had the highest discrimination power for identifying whether a patient needed ophthalmology intervention or admission to ophthalmology ward (area under the curve: 0.802, sensitivity: 0.800, specificity: 0.672). In our study, we found VA could be an indicator for determining the priority and time of ocular emergencies requiring ophthalmic intervention in patients visiting the ED for eye-related reasons.

Background and Objectives : Non-selective β-blockers (NSBB) could prevent decompensation and hepatocellular carcinoma (HCC) in cirrhotic patients with clinically significant portal hypertension (CSPH), but remained uncertain for compensated cirrhotic patients without major complications. We aimed to compare the clinical outcomes between propranolol users and non-users of a CC group without major complications. Material and Methods : We conducted this population-based cohort study by using the Taiwanese Longitudinal Health Insurance Database 2000. Propranolol users (classified as cumulative defined daily dose (cDDD)) and non-PPL users were matched with a 1:1 propensity score in both cohorts. Results : This study comprised 6896 propranolol users and 6896 non-propranolol users. There was no significant impact on the development of spontaneous bacterial peritonitis between the two groups (aHR: 1.24, 95% confidence interval (CI): 0.88~1.75; p = 0.2111). Male gender, aged condition, and non-liver related diseases (peripheral vascular disease, cerebrovascular disease, dementia, pulmonary disease, and renal disease) were the independent risk factors of mortality. PPL users had significantly lower incidence of HCC development than non-users (aHR: 0.81, p = 0.0580; aHR: 0.80, p = 0.1588; and aHR: 0.49, p < 0.0001 in the groups of 1-28, 29-90, and >90 cDDD, respectively). Conclusion : The current study suggested that high cumulative doses of propranolol could decrease the risk of hepatocellular carcinoma among compensated cirrhotic patients without major complications. Further large-scale prospective studies are still required to confirm the findings in this study. Results : It remained uncertain whether non-selective β-blockers (NSBB) could prevent decompensation and hepatocellular carcinoma (HCC) in compensatory cirrhotic patients without major complications. This study aimed to compare the clinical outcomes between propranolol users and non-users of the CC group without major complications.

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., Competing Interests: The authors report no conflicts of interest exist in this work., (© 2019 Tai et al.)

Purpose: To assess the difference of the first-line therapy for Helicobacter pylori in patients with or without type 2 diabetes (DM) and to investigate the clinical factors influencing treatment outcomes. Patients and methods: In total, 719 patients with H. pylori infection were treated with 7-day standard first-line triple therapy, of whom 182 did and 537 did not have DM. Propensity score matched at a 1:2 ratio - for age, sex and body mass index was performed for the two groups, yielding a DM group with 147 patients and a non-DM group with 249 matched controls for analysis. Urea breath test was performed 6-8 weeks after treatment. Clinical and laboratory parameters were collected for identifying factors associated with failed eradication. Results: H . Pylori was eradicated in 74.1% (95% confidence interval [CI] =66.2-81.0) of the DM group and 85.3% (95% CI =80.8-89.4) of the non-DM group ( p =0.005). Of 51 gastric biopsy samples cultured for H. pylori , 41 were positive. In the DM group, the rates of resistance to amoxicillin, clarithromycin, levofloxacin, and tetracycline were 0%, 50.0%, 50.0% and 0%, respectively. In the non-DM group, the comparable proportions were 2.9%, 17.1%, 22.9%, and 0%, respectively. Univariate analysis revealed that DM (Odds ratio [OR], 1.771, 95% CI, 1.167-2.668, p =0.006), clarithromycin resistance (OR, 15.273; 95% CI, 1.687-138.269; p =0.015), and amoxicillin resistance (OR, 4.672; 95% CI, 2.431-8.979; p <0.001) were independently associated with failure to eradicate H. pylori . Multivariate analysis showed that clarithromycin resistance was the major factor independently associated with failure of eradication (OR, 25.472; 95% CI, 1.549-418.956; p =0.023). Conclusions: First-line H. pylori eradication rates in patients with DM were significantly lower than in those without DM, although neither group achieved >90% eradication., Competing Interests: The authors report no conflicts of interest in this work.

Antiplatelet therapy is a key component in the treatment of acute coronary syndrome (ACS). The management of ACS has evolved considerably over recent years with the development of new and more potent antiplatelet agents. Clinical trials on ACS have demonstrated that potent antiplatelet agents can more effectively reduce cardiovascular events. However, there is a tipping point between safety and efficacy, beyond which the risk of bleeding and other adverse effects can outweigh the benefits of antiplatelet therapy. Striking a balance between safety and efficacy remains a major challenge. A consensus meeting of an expert panel composed of Taiwanese experts was held to provide recommendations for the management of adverse effects in patients with ACS receiving antiplatelet therapy. The common adverse effects of antiplatelet therapy include upper gastrointestinal bleeding, ecchymosis, hematuria, epistaxis and ticagrelor-related dyspnea. In this study, a literature review of these adverse events was performed and recommendations for the management were made.

Background: Although current guidelines recommended surveillance of hepatocellular carcinoma, prognosis in patients undergoing enhanced follow-up has yet to be evaluated., Aims: Examine outcomes of hepatocellular carcinoma diagnosed during enhanced follow-up., Methods: During 2010-2012, 194 patients underwent ultrasonography surveillance were diagnosed with hepatocellular carcinoma and divided into: (A) immediate diagnosis (N=105, 54.1%) after positive ultrasonography, (B) enhanced follow-up: (N=38, 19.6%) for initial negative recall procedures, (C) late call back: (N=28, 14.4%) recall procedures were deferred after positive ultrasonography, and (D) beyond ultrasonography: (N=23, 11.9%) surveillance ultrasonography had been negative., Results: Median time from positive ultrasonography to confirmation of hepatocellular carcinoma were 9.5 months (2-67) in the Group B and 6.5 months (3-44) in the Group C. Stage distribution and 3-year survival rates were similar amongst all Groups. Surveillance intervals longer than 6 months were associated with the non-curative stage (3.7% vs. 12.5%, p=0.04). Nine (4.6%) patients underwent surveillance were diagnosed as Barcelona-Clinic Liver Cancer stage C., Conclusion: Enhanced follow-up by current guidelines is appropriate that treatment can be deferred until a definite diagnosis. Despite optimal surveillance interval and recall policies, few non-curative stage diagnoses seemed inevitable under current standard of care., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aim: To determine changes in the antibiotic resistance of Helicobacter pylori (H. pylori) in southern Taiwan after failure of first-line standard triple therapy., Methods: We analyzed 137 H. pylori-infected isolates from patients who experienced eradication failure after standard first-line triple therapy from January 2010 to December 2014. The H. pylori strains were tested for susceptibility to amoxicillin, clarithromycin, levofloxacin, metronidazole and tetracycline using the E-test method. The minimal inhibitory concentration (MIC) was determined by the agar dilution test. MIC values of ≥ 0.5, ≥ 1, ≥ 1, ≥ 4 and ≥ 8 mg/L were considered to be the resistance breakpoints for amoxicillin, clarithromycin, levofloxacin, tetracycline and metronidazole, respectively., Results: A high resistance rate was found for clarithromycin (65%-75%) and metronidazole (30%-40%) among patients who failed first-line standard therapy. The resistance levels to amoxicillin and tetracycline remained very low; however, levofloxacin resistance was as high as 37.5% in 2010 but did not increase any further during the past 5 years. The rates of resistance to these antibiotics did not show a statistically significant upward or downward trend., Conclusion: Antibiotic resistance of H. pylori remains a problem for the effective eradication of this pathogen and its associated diseases in Taiwan. High clarithromycin resistance indicated that this antibiotic should not be prescribed as a second-line H. pylori eradication therapy. Moreover, levofloxacin-based second-line therapy should be used cautiously, and the local resistance rates should be carefully monitored.

Patients with cancer are at high risk for thrombotic events, which are known collectively as Trousseau's syndrome. Herein, we report a 66-year-old male patient who was diagnosed with terminal stage gastric cancer and liver metastasis and who had an initial clinical presentation of upper gastrointestinal bleeding. Acute ischemia of the left lower leg that resulted in gangrenous changes occurred during admission. Subsequent angiography of the left lower limb was then performed. This procedure revealed arterial thrombosis of the left common iliac artery with extension to the external iliac artery, the left common iliac artery, the posterior tibial artery, and the peroneal artery, which were occluded by thrombi. Aspiration of the thrombi demonstrated that these were not tumor thrombi. The interesting aspect of our case was that the disease it presented as arterial thrombotic events, which may correlate with gastric adenocarcinoma. In summary, we suggested that the unexplained thrombotic events might be one of the initial presentations of occult malignancy and that thromboprophylaxis should always be considered.

Background: Quinolone-containing triple therapy is recommended as an option for non-bismuth containing second-line Helicobacter pylori eradication. Current available Taiwanese reports in the literature used 7-day quinolone-containing triple therapy. As a result, some physicians still prescribe 7-day regimens in real-world practice in Taiwan. This study aimed to further assess the appropriateness of 7-day levofloxacin-containing triple therapy as second-line therapy., Methods: We enrolled 61 patients who failed H. pylori eradication using the standard triple therapy for 7 days and were prescribed levofloxacin-containing second-line triple therapy (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily). Routine follow-up with either endoscopy or urea breath test was done 8 weeks later to assess treatment response., Results: The eradication rates were 78.7% in the intention-to-treat analysis and 81% in the per-protocol analysis. The incidence of adverse events was 6.6%. Drug compliance was 95.1%. Antibiotic resistance showed the following results: Amoxicillin (0%), levofloxacin (23.5%), clarythromycin (35.3%), metronidazole (17.6%), and tetracycline (0%)., Conclusion: The 7-day levofloxacin-containing triple therapy provides an unacceptable per-protocol report card as the second-line treatment for anti-H. pylori eradication in Taiwan and should be modified by either extending the duration to 10-14 days or seeking other regimens.

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy (POEM). The first multicenter randomized, controlled, 2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy (LHM) was not superior to pneumatic dilations (PD). Publications on the long-term success of laparoscopic surgery continue to emerge. In addition, laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication. The optimal treatment option is an ongoing matter of debate. In this review, we provide an update of the current progress in the treatment of esophageal achalasia. Unless new conclusive data prove otherwise, LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications. However, PD is the first choice for non-surgical treatment and is more cost-effective. Repeated PD according to an "on-demand" strategy based on symptom recurrence can achieve long-term remission. Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options. POEM has shown promise but its long-term efficacy and safety need to be assessed further.

Background/aims: The difficulty in establishing early definitive diagnosis and treatment of primary small bowel malignancy (PSBM) is a challenge for clinicians. This study aimed to analyze the symptomatology, diagnosis and outcomes of PSBM., Methodology: A retrospective chart review study was conducted on 49 patients who underwent surgical treatment for PSBM at a tertiary hospital between May 2000 and January 2010., Results: The patients with PSBM had non-specific clinical symptoms. Major diagnostic tools in the current study were computed tomography (CT) (n=40), gastrointestinal series radiography (n=10), angiography (n=5), double-balloon enteroscopy (n=3), gastroduodenoscopy (n=2), magnetic resonance imaging (n=1) and exploratory laparotomy (n=8). Gastrointestinal stromal tumor (GIST) was the most common PSBM (n=21), followed by lymphoma (n=14), adenocarcinoma (n=8), leiomyosarcoma (n=3) and sarcoma (n=3). The overall 5-year cumulative survival rate of the patients with PSBM was 57.1% with a mean survival time of 31.8±7.8 months. The 5-year cumulative survival rates for the different PSBMs were 79.1%, 46.9% and 33.2% for GIST, adenocarcinomas and lymphomas, respectively (p=0.087)., Conclusions: CT is very useful in detecting PSBM. Poor prognosis in PSBM patients detected by CT or angiography could be the result of delayed diagnosis prior to the procedure.

Purpose: All previous studies reported the benefit of antibiotic prophylaxis in cirrhotic patients with either a mixture of nonvariceal and variceal bleeding or variceal bleeding alone. Reports on sole peptic ulcers bleeding are lacking. We aimed to assess the effect of antibiotic prophylaxis in cirrhotic patients with peptic ulcer bleeding after endoscopic interventions and the risk factors associated with recurrent bleeding., Methods: A cross-sectional retrospective chart review study was conducted on 148 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures. Patients who received prophylactic intravenous ceftriaxone were classified as group A (n = 38) and those who did not receive antibiotics were classified as group B (n = 110). The outcomes were prevention of infection, length of hospital stay, time of rebleeding, and death., Results: More patients suffered from recurrent bleeding and infection in group B than those in group A (28.2 vs. 5.3 %; p = 0.003, and 26.4 vs. 10.5 %; p = 0.043, respectively). The risk factors associated with recurrent bleeding were being male (OR = 3.4; p = 0.024), those with advanced stage of cirrhosis with Child-Pugh's class C (OR = 3.8; p < 0.001), and those without antibiotic prophylaxis (OR = 8.9; p = 0.003). The observed 30-day survival was virtually identical for both groups (p = 0.279)., Conclusions: Antibiotic prophylaxis in cirrhotic patients after endoscopic interventions for acute peptic ulcer hemorrhage reduced infections and decreased rebleeding. Male gender, cirrhosis Child-Pugh's class C, and no antibiotic prophylaxis were independent predictors of recurrent bleeding. Further studies should be directed to explore ways to improve the overall outcome of these patients.

Background and Study Aims. The association between Helicobacter pylori (H. pylori) and chronic spontaneous urticaria (CSU) remains controversial. This study explored the role of H. pylori in CSU among different virulent genotypes patients. Patients and Methods. Patients infected by H. pylori were sorted into two groups as group A (with CSU) and group B (without CSU). The tissue materials were taken via endoscopy for polymerase chain reaction study to determine virulence factors. After H. pylori eradication therapy, the eradication rate and response of urticaria were evaluated by using C(13)-UBT and a three-point scale (complete remission, partial remission, or no improvement). Results. The results were comparable between patients of groups A and B in terms of H. pylori infection rates and eradication rate. Longitudinal follow-up of 23.5 months showed complete remission of urticaria in 63.6% but no improvement in 36.4% of the patients after H. pylori eradication. H. pylori infected patients with different virulence factors such as cytotoxin-associated gene A, vacuolating cytotoxin gene A signal region and middle region have similar remission rates for CSU. Conclusions. Current study suggests that H. pylori may play a role in the development and disease course of CSU but may be irrelevant to different virulent genotypes.