Efficacy and safety of endoscopic submucosal dissection for gastric epithelial neoplasia in elderly patients aged 80 years and older.

BACKGROUND: Endoscopic submucosal dissection (ESD) has been widely used in gastric tumor as a minimally invasive treatment. The efficacy and safety of ESD is still unclear in the elderly who have high frequency comorbidities. The aim of this study is to evaluate the efficacy and safety of ESD for gastric epithelial neoplasia in patients aged 80 years and older. METHODS: Between March 2013 and July 2017, a total of 438 gastric epithelial neoplasia patients treated with ESD were analyzed. Clinical outcomes including en bloc and complete resection rates, adverse events (AE) related procedure and sedation were compared between the elderly group and the non-elderly group. RESULTS: Sex, Body Mass Index, medication history and American Society of Anesthesiologists physical status did not differ between the two groups. Tumor characteristics except size of resected specimen (elderly vs. non-elderly; 36.5 ± 10.5 vs. 32.3 ± 8.7 mm, p < 0.011) did not differ. There were no significant differences in AE-related sedation. En bloc resection (elderly vs. non-elderly; 100% vs. 98.3%, p = 0.454), and complete resection rate (elderly vs. non-elderly; 93.8% vs. 96.3%, p = 0.471) did not differ significantly between the two groups. Procedure time, hospital stay, AE-related procedure and delayed bleeding were also similar between the two groups. However, procedure time of preventive hemostasis (elderly vs. non-elderly; 10.4 ± 7.7 vs. 7.4 ± 5.2 min, p = 0.040) was significantly higher in the elderly group. CONCLUSIONS: ESD for gastric epithelial neoplasia is effective and safe in elderly patients ≥ 80 years as in non-elderly patients.

A Nanoemulsion with A Porphyrin Shell for Cancer Theranostics.

A nanoemulsion with a porphyrin shell (NewPS) was created by the self-assembly of porphyrin salt around an oil core. The NewPS system has excellent colloidal stability, is amenable to different porphyrin salts and oils, and is capable of co-loading with chemotherapeutics. The porphyrin salt shell enables porphyrin-dependent optical tunability. The NewPS consisting of pyropheophorbide a mono-salt has a porphyrin shell of ordered J-aggregates, which produced a narrow, red-shifted Q-band with increased absorbance. Upon nanostructure dissociation, the fluorescence and photodynamic reactivity of the porphyrin monomers are restored. The spectrally distinct photoacoustic imaging (at 715 nm by intact NewPS) and fluorescence increase (at 671 nm by disrupted NewPS) allow the monitoring of NewPS accumulation and disruption in mice bearing KB tumors to guide effective photodynamic therapy. Substituting the oil core with Lipiodol affords additional CT contrast, whereas loading paclitaxel into NewPS facilitates drug delivery.

Learning curve analysis of colorectal endoscopic submucosal dissection (ESD) for laterally spreading tumors by endoscopists experienced in gastric ESD.

BACKGROUND: Endoscopic submucosal dissection (ESD) for various colorectal neoplasms is more technically difficult than gastric ESD. We evaluated treatment outcomes and the learning curve for colorectal ESD of laterally spreading tumors (LSTs) based on the experience of a single endoscopist. METHODS: We included 93 colorectal ESD procedures for colorectal LST that were performed between March 2009 and June 2012 by a single experienced endoscopist who previously performed hundreds of cases of gastric ESD. The cases were grouped chronologically into three periods by multi-dimensional analyses. For procedure time, the learning curve was analyzed using the moving average method, and for complication, the learning curve was analyzed using cumulative sum (cusum) method. RESULTS: The median procedure time for 93 colorectal ESD was 45 min, and the rates of en bloc resection and R0 resection were 89.25 and 83.87 %. When results were compared among three periods in order to determine the learning curve, the procedure time and en bloc resection rates were not significantly different. However, the procedure proficiency (about 0.16 cm(2)/min) was significantly faster during the second period, after about 25 cases of colorectal ESD. In the third period (about 50 cases), the number and rate of en bloc resection (over 90 %) reached the same as that of en bloc R0 resection. When comparing outcomes based on LST subtype, the procedure proficiency of LST-granular type (LST-G) was significantly faster than that of LST-non granular type (LST-NG) (LST-NG, 0.072 cm(2)/min; LST-G, 0.157 cm(2)/min; p = 0.01). CONCLUSION: Endoscopists fully experienced in gastric ESD need a relatively short learning period for colorectal ESD in terms of procedure time and complication. However, approximately 50 cases might be needed to acquire an adequate skill of colorectal ESD for LST in an experienced gastric ESD endoscopist. Colorectal ESD for LST-NG seems to have higher technical difficulty and a longer learning curve than LST-G.

Correlation Between Timed Barium Esophagogram and Esophageal Transit Scintigraphy Results in Achalasia.

BACKGROUND: Timed barium esophagogram (TBE) and esophageal transit scintigraphy (ETS) have been adopted as useful ways to evaluate achalasia patients. TBE has merit as a simple, non-invasive, and convenient method. AIMS: The study sought to compare the results of these two tests and verify their usefulness in evaluating treatment response. In addition, we assessed whether TBE could effectively replace ETS through correlation analysis. METHODS: The medical records of 50 achalasia patients treated between September 2011 and June 2014 were reviewed retrospectively. The height and width of the barium column at 1, 2, and 5 min were measured by TBE. Half-life (T 1/2, min) and R 30 (percentage of remaining radioactivity 30 s after radioisotope ingestion) were measured by ETS. Both tests were performed before and after treatment, and the tests were carried out 1 and 2 days after procedures. And we analyzed the correlation between the parameters from the two tests. RESULTS: The parameters of TBE and ETS were improved after treatment (p < 0.05). Before treatment, the height and width results at 5 min from TBE positively correlated with the T 1/2 parameter from ETS (correlation coefficients of 0.59 and 0.75, respectively). After treatment, the correlation coefficients between the 5-min height and width of the barium column by TBE and T 1/2 by ETS were 0.55 and 0.46, respectively. CONCLUSIONS: Both TBE and ETS are useful modalities in assessing esophageal emptying and response to achalasia treatment. TBE and ETS results have a statistically significant correlation both pre- and post-treatment. We suggest that TBE could effectively replace ETS for the assessment of achalasia.

For patients with primary achalasia the clinical success of pneumatic balloon dilatation can be predicted from the residual fraction of radionuclide during esophageal transit scintigraphy.

BACKGROUND: Esophageal transit scintigraphy (ETS) and esophagography have long been used to evaluate patients with achalasia. The objectives of our study were to evaluate the efficacy of endoscopic pneumatic dilatation (EPD) as treatment for Koreans with achalasia and to determine which findings from ETS and esophagography predict successful treatment of achalasia. METHODS: Patients with achalasia who were treated by EPD between April 2002 and January 2012 were recruited. We defined the success of EPD as 6 months or more of clinical remission without symptoms or a decrease in the Eckardt scores by at least two points and a total Eckardt score not exceeding 3. We reviewed the percentage of maximum scintigraphic activity retained in the esophagus at 30 s (R 30) and the post-PD rate of reduction of R 30 ((Pre R 30 - Post R 30)/Pre R 30 × 100) by ETS. Possible predictive factors determined by ETS and esophagography were analyzed. RESULTS: Our study included 53 eligible patients. The median symptom score (Eckardt score) was 5 (4-8). R 30 and T 1/2 were, respectively, 61.8 % and 38.5 min before EPD and 20 % and 4.19 min after EPD. Successful EPD was achieved for 40 of 53 (75.47 %) patients. Age (≥40, p = 0.027) and post-PD rate of reduction of R 30 (>20 %, p = 0.003) were best prognostic indicators of clinical success. There were no perforations related to EPD. CONCLUSION: Older age and a post-PD rate of reduction of R 30 were strongly associated with better outcomes. Examination with ETS before and after EPD can be used to objectively assess a patient's short-term response to EPD.

Carcinomatosis matters: clinical outcomes and prognostic factors for clinical success of stent placement in malignant gastric outlet obstruction.

BACKGROUND: Although carcinomatosis is not a contraindication to stenting in selected patients with malignant gastric outlet obstruction (GOO), associate factors for clinical success rate of self-expandable metallic stent (SEMS) placement in GOO patients with carcinomatosis have not been fully characterized. METHODS: We analyzed a total 228 patients who were scheduled for SEMS placement for malignant GOO in tertiary-care academic medical center. All patients were treated with an uncovered or covered SEMS by using the over-the-wire placement procedure. We retrospectively evaluated clinical outcomes of SEMS placement. RESULTS: Technical success was achieved in all patients. Patients were categorized into two groups according to the presence of carcinomatosis. Clinical success rates of patients without carcinomatosis group and with carcinomatosis group were 93.9 % (92 of 98) and 80.8 % (105 of 130), respectively (P = 0.004). In subgroup analysis of patients with carcinomatosis, the clinical success rate was lower in patients with ascites (64.8 %) than in those without ascites (92.1 %, P < 0.001). Multivariate logistic regression model revealed that carcinomatosis without ascites did not decrease clinical success rate compared with absence of carcinomatosis; meanwhile, carcinomatosis with ascites showed lower clinical success rates compared with absence of carcinomatosis (adjusted odds ratio 0.163, 95 % confidence interval 0.058-0.461). In addition, poor performance status [Eastern Cooperative Oncology Group (ECOG) status ≥ 3, adjusted odds ratio 0.178, 95 % confidence interval 0.078-0.409] was also an independent poor predictive factor for clinical success of SEMS placement. CONCLUSIONS: In palliation for malignant GOO, the status of carcinomatosis with ascites and poor performance status (ECOG status ≥ 3) are significant predictive factors for poor clinical success of SEMS placement.

Follow-up outcomes of endoscopic resection for early gastric cancer with undifferentiated histology.

BACKGROUND: The application of endoscopic resection (ER) for undifferentiated-type early gastric cancer (UD-EGC) remains controversial. The aim was to examine long-term outcomes of ER for UD-EGC. Furthermore, we investigated whether long-term outcomes of ER differed between poorly differentiated adenocarcinoma (PD) and signet ring cell carcinoma (SRC). METHODS: From 2001 to 2011, 209 lesions in 209 patients with UD-EGC (82 PD; 127 SRC) were treated by ER. We retrospectively assessed the clinical outcomes of ER in 209 patients. The survival rate and disease-free survival rates after ER were evaluated as long-term outcomes. RESULTS: The en bloc resection and curative resection (CR) rates were 91.4 and 55.0 %, respectively. The en bloc and CR rates in PD were 90.2 and 45.1 %, whereas those in SRC were 92.1 and 61.4 %. For patients with PD who underwent non-curative resections, 51.1 % were vertical-cut end-positive and for those with SRC, 63.3 % were lateral-cut end-positive, a statistically significant difference. In those patients where CR was achieved, no case of local recurrence or distant metastasis was observed during the follow-up period (32.7 ± 22.2 months). The 3- and 5-year survival rates were 99.0 and 98.6 %, with no significant difference between CR patients with SRC and PD. CONCLUSIONS: ER may yield good long-term outcomes for UD-EGC if CR is achieved, with no difference between PD and SRC. However, to increase the current CR rate of ER, stricter criteria for performing ER in UD-EGC may be required.

Transcatheter arterial embolization for gastrointestinal bleeding: Clinical outcomes and prognostic factors predicting mortality.

We evaluated clinical outcome and prognostic factors predicting mortality of transcatheter arterial embolization (TAE) for acute gastrointestinal (GI) bleeding. Fifty-nine patients (42 men, 17 women; mean age 66.1 ± 17.0) who underwent 59 TAE procedures for GI bleeding during 2013-2018 were retrospectively evaluated. Clinical outcomes included technical success, adverse events, and rebleeding and mortality rate within 30 days. The technical success rate was 100%. Angiography showed contrast extravasation in 41 (69.5%) patients and indirect signs of bleeding in 16 (27.1%) patients. Two (3.4%) patients underwent prophylactic embolization. TAE-related adverse events occurred in 7 (11.9%) patients; adverse events were more common for mid GI or lower GI bleeding than for upper GI bleeding (22.6% vs 0%, P = 0.007). Rebleeding within 30 days was observed in 22 (37.3%) patients after TAE. Coagulopathy was a prognostic factor for rebleeding (odds ratio [OR] = 3.53, 95% confidence interval 1.07-11.67, P = .038). Mortality within 30 days occurred in 11 (18.6%) patients. Coagulopathy (OR = 24, 95% confidence interval 2.56-225.32, P = .005) was an independent prognostic factor for mortality within 30 days. TAE is an effective, safe, and potentially lifesaving procedure for GI bleeding. If possible, coagulopathy should be corrected before TAE as it may reduce rebleeding and mortality.

Risk Factors for Lymph Node Metastasis and Oncologic Outcomes in Small Rectal Neuroendocrine Tumors with Lymphovascular Invasion.

BACKGROUND/AIMS: Small rectal neuroendocrine tumors (NETs) are often managed with local resection (endoscopic or transanal excision) owing to their low risk of metastasis and recurrence. However, the clinical significance of lymphovascular invasion in resected specimens remains controversial. In this study, we aimed to analyze the frequency of and risk factors for lymph node metastasis proven by histopathologic examination after radical resection. METHODS: We retrospectively reviewed the records of 750 patients diagnosed with a rectal NET at four academic medical centers in South Korea between 2001 and 2019. The frequency of histopathologically proven lymph node metastasis and the associated risk factors were analyzed for small tumors (≤1.5 cm) with lymphovascular invasion. RESULTS: Among 750 patients, 75 had a small tumor (≤1.5 cm) with lymphovascular invasion, of whom 31 patients underwent endoscopic resection only and 44 patients underwent additional radical surgery. Among the 41 patients who underwent surgery and had available data, the rate of regional lymph node metastasis was 48.8% (20/41). In multivariate analysis, the Ki-67 index (odds ratio, 6.279; 95% confidence interval, 1.212 to 32.528; p=0.029) was an independent risk factor for lymph node metastasis. During the mean follow-up period of 37.7 months, only one case of recurrence was detected in the surgery group. The overall survival was not significantly different between radical resection and local resection (p=0.332). CONCLUSIONS: Rectal NETs with lymphovascular invasion showed a significantly high rate of regional lymph node metastasis despite their small size (≤1.5 cm).

Helicobacter pylori infection is associated with elevated low density lipoprotein cholesterol levels in elderly Koreans.

This study was conducted to investigate the association between Helicobacter pylori (H. pylori) infection and the lipid profile among elderly Koreans. A total of 462 subjects (mean age 66.2 ± 7.6 yr, 84% males) who underwent health check-up were investigated. Each subject underwent gastroduodenoscopy with gastric mucosal biopsy, and H. pylori infection was determined by histopathological examination using the updated Sydney System score. The presence of H. pylori infection was significantly associated with the elevated serum levels of total cholesterol and low density lipoprotein (LDL) cholesterol (P < 0.05 for each) in univariate analysis. H. pylori infection was not associated with triglyceride and high density lipoprotein (HDL) cholesterol levels (P > 0.05 for each). After controlling confounders, multiple logistic regression analysis showed that the odds ratio of H. pylori infection for high LDL cholesterol level (> 140 mg/dL) was 3.113 (95% confidence interval, 1.364-7.018; P = 0.007). There were no significant associations between the presence of H. pylori infection and elevated total cholesterol levels (> 200 mg/dL) in this model (P = 0.586). The results of this study demonstrate that H. pylori infection is associated with the elevated serum LDL cholesterol levels in elderly Koreans, supporting the hypothesis that H. pylori plays a role in promoting atherosclerosis by modifying lipid metabolism.

Risk factors associated with surveillance loss after endoscopic submucosal dissection in patients with gastric neoplasm.

BACKGROUND: After endoscopic submucosal dissection of gastric neoplasms, surveillance endoscopy is required for patients with synchronous or metachronous neoplasms. We aimed to evaluate the risk factors associated with surveillance loss in patients who underwent endoscopic submucosal dissection. METHODS: Ninety-five patients treated with endoscopic submucosal dissection for gastric neoplasms between May 2015 and June 2016 were retrospectively reviewed. Clinicopathologic factors, sociodemographic factors, psychiatric measures, and associated risk factors for surveillance loss were evaluated. The chi-square or Fisher exact test, t-test, and logistic regression analysis were used in data analysis. RESULTS: Twenty-five (26.3%) patients were identified as having surveillance loss. Compared to the surveillance group, the surveillance loss group was old and had dysplasia, and a healthy American Society of Anesthesiologists physical status. Similarly, surveillance loss was related to low symptom perception, low incidence of alexithymia, mindful awareness, and high trait forgiveness. Logistic regression analysis showed that dysplasia (odds ratio, 15.23; 95% CI, 1.56-149.09, P=0.019), old age (odds ratio, 7.14; 95% CI, 1.90-26.88, P=0.004), and American Society of Anesthesiologists physical status 1 (odds ratio, 3.99; 95% CI, 1.09-14.60, P=0.037) were associated with surveillance loss. CONCLUSIONS: Dysplasia, old age, and the American Society of Anesthesiologists physical status 1 were associated with surveillance loss in patients who underwent gastric endoscopic submucosal dissection. It could be helpful to proactively monitor patients with such conditions after gastric endoscopic submucosal dissection.

Risk for metabolic syndrome in the population with visceral fat area measured by bioelectrical impedance analysis.

BACKGROUND/AIMS: To investigate whether visceral fat area (VFA) measured by bioelectric impedance analysis (BIA) was associated with metabolic syndrome in subjects with and without obesity. METHODS: A total 23,202 participants who underwent medical check-ups were assessed. Participants were stratified by body mass index (BMI) and VFA. We evaluated six different groups for metabolic syndrome: Group 1 (normal weight and low VFA), Group 2 (normal weight and high VFA), Group 3 (overweight and low VFA), Group 4 (overweight and high VFA), Group 5 (obesity and low VFA), and Group 6 (obesity and high VFA). RESULTS: Metabolic syndrome traits and metabolic syndrome were significantly more prevalent in the high-VFA (≥ 100 cm2 ) subgroup in each BMI group. Adjusted logistic regression analyses revealed that the odds ratio for metabolic syndrome compared with Group 1 was the highest in Group 6 (24.53; 95% confidence interval [CI], 21.77 to 27.64). Notably, the odds ratio of Group 2 was higher than that of Group 3 (2.92; 95% CI, 2.30 to 3.69 vs. 2.57; 95% CI, 2.23 to 2.97). CONCLUSION: Our study demonstrates that the combination of BMI assessment and VFA determination by BIA may be a useful method for predicting the risk of metabolic syndrome. The VFA by BIA may be a useful target for interventions to improve metabolic syndrome.

Risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections: a nationwide population-based study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has rapidly turned into a public health emergency worldwide; however, the risk factors for infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have not been well-described. We aimed to identify the clinical risk factors for SARS-CoV-2 infections in Korea, where social distancing and face masks have been strongly recommended. METHODS: The data of individuals who underwent the reverse transcription polymerase chain reaction test for SARS-CoV-2 between January 3 and May 31, 2020 were retrieved from the Health Insurance Review and Assessment Service dataset. We used multivariable logistic regression models to identify the risk factors for SARS-CoV-2 infections in the population. RESULTS: We retrieved the results of 219,729 SARS-CoV-2 tests, of which 7,333 were positive results. In the multivariable analysis, female sex was associated with a higher risk of testing positive for SARS-CoV-2 [odds ratio (OR) =1.30, 95% confidence interval (CI): 1.24-1.37, P<0.0001]. Additionally, populations living in areas that had large outbreaks of COVID-19 were at an increased risk of testing positive for SARS-CoV-2 (OR =6.87, 95% CI: 6.55-7.21, P<0.0001). The odds of a positive test were greater for the Medical Aid beneficiaries (OR =1.99, 95% CI: 1.82-2.18, P<0.0001) than for the National Health Insurance beneficiaries. Individuals with diabetes mellitus (DM) were more likely to test positive (OR =1.15, 95% CI: 1.07-1.24, P=0.0002). CONCLUSIONS: Women, individuals living in areas with large outbreaks of COVID-19, Medical Aid beneficiaries, and individuals with DM might have greater risks of contracting SARS-CoV-2 infections despite practicing social distancing and using face masks.

Efficacy and Safety of Rebamipide versus Its New Formulation, AD-203, in Patients with Erosive Gastritis: A Randomized, Double-Blind, Active Control, Noninferiority, Multicenter, Phase 3 Study.

Background/Aims: : The mucoprotective drug rebamipide is used to treat gastritis and peptic ulcers. We compared the efficacy of MucostaⓇ (rebamipide 100 mg) and its new formulation, AD-203 (rebamipide 150 mg), in treating erosive gastritis. Methods: This double-blind, active control, noninferiority, multicenter, phase 3 clinical trial randomly assigned 475 patients with endoscopically proven erosive gastritis to two groups: AD-203 twice daily or MucostaⓇ thrice daily for 2 weeks. The intention-to-treat (ITT) analysis included 454 patients (AD-203, n=229; MucostaⓇ, n=225), and the per-protocol (PP) analysis included 439 patients (AD-203, n=224; MucostaⓇ, n=215). The posttreatment assessments included the primary (erosion improvement rate) and secondary endpoints (erosion and edema cure rates; improvement rates of redness, hemorrhage, and gastrointestinal symptoms). Drug-related adverse events were evaluated. Results: According to the ITT analysis, the erosion improvement rates (posttreatment) in AD-203-treated and MucostaⓇ-treated patients were 39.7% and 43.8%, respectively. According to the PP analysis, the erosion improvement rates (posttreatment) in AD-203-treated and MucostaⓇ-treated patients were 39.3% and 43.7%, respectively. The one-sided 97.5% lower limit for the improvement rate difference between the study groups was -4.01% (95% confidence interval [CI], -13.09% to 5.06%) in the ITT analysis and -4.44% (95% CI, -13.65% to 4.78%) in the PP analysis. The groups did not significantly differ in the secondary endpoints in either analysis. Twenty-four AD-203-treated and 20 MucostaⓇ-treated patients reported adverse events but no serious adverse drug reactions; both groups presented similar adverse event rates. Conclusions: The new formulation of rebamipide 150 mg (AD-203) twice daily was not inferior to rebamipide 100 mg (MucostaⓇ) thrice daily. Both formulations showed a similar efficacy in treating erosive gastritis.

Compatibility of endoclips in the gastrointestinal tract with magnetic resonance imaging.

There are no clear guidelines on the compatibility between endoclips that remain in the gastrointestinal (GI) tract and magnetic resonance imaging (MRI). The purpose of this study was to investigate the effect of 3T (T) MRI on endoclips placed in excised pig tissues. Two types of endoclips were assessed: Olympus EZ (HX-610-135L) and QuickClip Pro (HZ-202LR). We assessed tissue damage or perforation and detachment of endoclips under 3T MRI magnetic field. We also evaluated the magnitude of force required to detach the endoclips from the porcine tissue. We measured the magnetic force acting on the Olympus EZ clips. QuickClip Pro clips were used as a control in this study. There was no tissue damage and no detachment of the endoclips (Olympus EZ and QuickClip Pro) during 3T MRI. The force required to detach the Olympus EZ clips ranged from 0.9 to 3.0 N. The translational magnetic force acting on the endoclips was 3.18 × 10-3 N. Ex vivo experiments showed that the magnetic field generated by 3 MRI did not cause tissue damage or perforation and did not detach the endoclips. Olympus EZ clips and QuickClip Pro clips in the GI tract appear to be safe during 3T MRI.

A population-based epidemiology of Wilson's disease in South Korea between 2010 and 2016.

Very few population-based studies have examined the epidemiology of Wilson's disease (WD). We investigated the epidemiology of WD using the National Health Insurance Service (NHIS) database in South Korea. We analyzed not only the statistical variables of WD, but also those of WD-related diseases. WD patients were identified with the relevant International Classification of Diseases-10 code out of 50.5 million people. We used the NHIS database from 2009 to 2016 and analyzed the incidence rate, prevalence, and clinical symptoms of WD. A total of 1,333 patients were identified. The average annual incidence rate was 3.8 per million person-years. The prevalence was 38.7 per million people. The mean diagnostic age was 26.1 ± 17.2 with earlier diagnosis in men (P = 0.0003). Among the patients, 988 (74.1%) had hepatic symptoms, 510 (38.3%) had neurologic symptoms, and 601 (45.1%) had psychiatric symptoms. Before the diagnosis of WD, 350 (26.3%) had neurologic symptoms, and 427 (32%) had psychiatric symptoms. The annual mortality rate was 0.7%. Age, liver cirrhosis, and liver failure correlated with a fatal prognosis (P < 0.05). Many patients showed neurologic and psychiatric symptoms before they were diagnosed with WD. Prognosis correlated with age, liver cirrhosis, and liver failure.

Proton pump inhibitor use is associated with hip fracture development: a nationwide population-based cohort study.

BACKGROUND/AIMS: Effect of proton pump inhibitor (PPI) use on the risk of hip fracture is controversial. This study aimed to clarify the association between PPI use and hip fracture risk using a large cohort. METHODS: This study recruited participants from the nationwide cohort (n = 1,025,340). After exclusion of participants who had hip fractures or were aged less than 40 years during the baseline period (2002 to 2004), 371,806 participants were followed to 2013. Participants prescribed PPIs for more than 90 days during baseline period were defined as users. Fracture cases were defined when participants were hospitalized with claims of a hip fracture. RESULTS: During 4,159,343 person-years of follow-up, fractures developed more often in PPI users than in nonusers (relative risk [RR], 1.787; 95% confidence interval [CI], 1.260 to 2.534; p = 0.002). The results persisted after adjusting for age, sex, and many drugs relevant to osteoporosis or influential in bone health. Furthermore, fracture risk associated with PPI use increased with duration of use (p trend < 0.001). The fully adjusted RRs of hip fracture development were 1.350 (95% CI, 1.203 to 1.515) for 1- to 90-day users, 1.487 (95% CI, 0.957 to 2.311) for 91- to 180-day users, and 1.771 (95% CI, 0.931 to 3.368) for > 180-day users. The positive association between PPI use and fracture was also confirmed in a subgroup with health screening data where further adjustment for body mass index, smoking status, alcohol consumption, and physical activity was available (adjusted RR, 2.025; 95% CI, 1.151 to 3.564, p = 0.014). CONCLUSION: PPI use is associated with hip fracture development.

Associated risk factors for psychological distress in patients with gastric epithelial neoplasm undergoing endoscopic submucosal dissection.

This study aimed to evaluate the psychological distress and associated risk factors for distress among patients with gastric epithelial neoplasm undergoing endoscopic submucosal dissection (ESD).A total of 91 patients treated with ESD for gastric epithelial neoplasm between May 2015 and June 2016 were prospectively enrolled. Sociodemographic factors, psychological distress, anxiety, depression, stress, and associated risk factors for psychological distress were evaluated the day before ESD.Twenty-six (28.6%) patients were identified as patients with psychological distress. The psychological distress group had a higher female ratio and more depression and anxiety symptoms than the non-distress group. Distress was also related to stress level. A multivariate analysis showed that unmarried status (odds ratio [OR], 4.94; 95% confidence interval [CI], 1.13-21.56, P = .034), anxiety (OR, 1.24; 95% CI, 1.12-1.39, P <.001), and stress (OR, 1.06; 95% CI, 1.01-1.12, P = .011) were associated with psychological distress.An unmarried status and a high level of anxiety and stress were associated with more psychological distress in patients undergoing gastric ESD. It could be helpful to screen and proactively monitor patients with such conditions before performing gastric ESD.

A nationwide population-based study of common bile duct stone recurrence after endoscopic stone removal in Korea.

BACKGROUND: There is no consensus whether patients who underwent endoscopic common bile duct (CBD) stone removal should be followed up periodically and whether patients with gallbladder (GB) stones should undergo cholecystectomy. Thus, this study aimed to investigate the recurrence rate of CBD stones and the difference in recurrence rate according to cholecystectomy. METHODS: We conducted a population-based study using the National Health Insurance database. Patients diagnosed with CBD stones and with procedure registry of endoscopic stone removal were included. The primary outcome was the recurrence rate of CBD stones. The secondary outcome was the difference in recurrence rate of CBD stones according to cholecystectomy. RESULTS: A total of 46,181 patients were identified. The mean follow-up was 4.2 years. The first CBD stone recurrence occurred in 5228 (11.3%) patients. The cumulative first recurrence rate was low. However, the second and third recurrence rates were 23.4 and 33.4%, respectively. The cumulative second and third recurrence rates were high and gradually increased with time. The recurrence rate in the non-cholecystectomy group was higher than that in the cholecystectomy group (p < 0.0001). The relative risk for CBD stone recurrence in the non-cholecystectomy group was higher in younger patients, with 3.198 in patients < 50 years, 2.371 in 50-59 years, 1.618 in 60-69 years, and 1.262 in ≥ 70 years (p < 0.0001). CONCLUSIONS: Regular follow-up is not routinely recommended for patients with first-time endoscopic stone removal, but is recommended for patients with recurrent stones. Cholecystectomy is recommended for patients with GB stones who are younger than 70 years.

Real World Experience of Telbivudine Versus Entecavir in Patients with Chronic Hepatitis B, Including Long-Term Outcomes after Treatment Modification.

PURPOSE: To estimate long-term outcomes after treatment modification in patients with chronic hepatitis B (CHB) treated with entecavir (ETV) and telbivudine (LdT). MATERIALS AND METHODS: The study enrolled 131 nucleos(t)ide analogue (NA)-naïve CHB patients treated with ETV or LdT. During the 3-year study, NA treatment history including the incidence, the type of treatment modification, reasons for the modification, and overall complete virologic response (CVR) rate were retrospectively evaluated using the patients' medical records. RESULTS: Among the 131 patients, 84 and 47 were initially treated with ETV and LdT, respectively. During the course of 3-year study, 82 patients in the ETV group (97.6%) maintained initial treatment whereas only 19 in the LdT group (40.4%). In the LdT group, 26 patients (92.9%) switched to another NA and another NA was added in 2 (7.1%) patients. An assessment of the CVR rate at 3 years, including treatment modification, showed that 89.3% and 95.7% of patients in the ETV and LdT groups, respectively, had undetectable serum hepatitis B virus DNA levels (p=0.329). Among LdT patients with treatment modification, the cumulative incidence rate of a CVR for rescue therapy was significantly higher in the tenofovir than in the ETV group (p=0.009). CONCLUSION: During the 3-year study, there were no significant differences in the CVR between the ETV and LdT groups if appropriate rescue therapy was considered.