Chemiluminescence assay of mucosal reactive oxygen species in gastric cancer, ulcer and antral mucosa.

BACKGROUND/AIMS: Reactive oxygen species (ROS) have been implicated in inflammatory and cancerous illness, including that of the gastrointestinal tract. The oxidative damage incurred during human gastric ulcer or cancer mucosa may be related to acumination of ROS. In this study, we aimed to demonstrate oxidative stress of gastric ulcer and cancer mucosa compared to gastric antral mucosa. PATIENTS: Thirty-four patients with gastric ulcer and gastric cancer were enrolled in this study. Gastric mucosa specimens, taken from upper GI endoscopic biopsy, from the lesion (ulcer or cancer) and antrum were sent for the activity of O2- or H2O2 determined by chemiluminescence assay. Protein concentrations in the tissue homogenates were determined by Bio-Red protein assay. The production of O2- or H2O2 per unit of protein was calculated by dividing the tissue CL level by the protein content of a tissue. RESULTS: The oxidative stress metabolites O2- and H2O2 of mucosa were evaluated by chemiluminescence assay in gastric lesions (27 ulcers and 7 cancers) and gastric antrum. Gastric lesion showed significantly increased O2- than antral mucosa (18.77 +/- 45.18 (counts/sec x microg), 95% CI 3.01, 34.53 vs. 3.58 +/- 6.89 (counts/sec x microg), 95% CI 1.18, 5.98, p < 0.05). There was also significantly greater expression of H2O2 in gastric lesion than gastric antral mucosa (76.06 +/- 148.36 (counts/sec x microg), 95% CI 24.30, 127.83 vs. 912.41 +/- 20.22 (counts/sec x microg), 95% CI 5.35, 19.46, p = 0.008). Differences of mucosal O2- and H2O2 between gastric ulcer and cancer were not significant. There was significant correlation of O2- and H2O2 generation in gastric lesion mucosa. CONCLUSIONS: Oxidative stress is now thought to make a significant contribution to inflammatory disease and malignancy. The reason that overproduction of free radicals is a feature of such a broad spectrum of diseases derived from the fact that oxidative metabolism is a necessary part of every cell's metabolism. In this study, we demonstrated increased ROS production in gastric ulceration and cancer compared with gastric antral mucosa.

Successful treatment with a combination of endoscopic injection and irrigation with coca cola for gastric bezoar-induced gastric outlet obstruction.

We report a case of gastric bezoar-induced gastric outlet obstruction that was successfully treated with a combination of endoscopic injection and irrigation with Coca Cola. A 73-year-old diabetic woman had a history of perforated peptic ulcer and had received pyloroplasty more than 20 years previously. She had been ingesting Pho Pu Zi (Cordia dichotoma Forst. f.) as an appetizer for 1 month. She presented with epigastric pain, nausea, and vomiting. Upper gastrointestinal endoscopy, performed at a local hospital, showed 2 gastric bezoars in the stomach, and 1 of them impacted at the pylorus. She was referred to our emergency department for removal of the gastric bezoars that were suspected to be causing gastric outlet obstruction. All attempts at endoscopic removal using a polypectomy snare, biopsy forceps and Dormia basket failed. We then injected Coca Cola directly into the bezoar mass, followed by irrigation with Coca Cola. Follow-up endoscopy was performed the next day, which revealed that the gastric bezoars had dissolved spontaneously.

The prevalence and significance of hypoalbuminemia in non-variceal upper gastrointestinal bleeding.

BACKGROUND/AIMS: Hypoalbuminemia occurs in a variety of disease states and is associated with an increased rate of complications during hospitalization, resulting in an increased length of stay. However, there are no data about hypoalbuminemia in patients with non-variceal upper gastrointestinal bleeding. The purpose of this study is to evaluate the prevalence of hypoalbuminemia in patients with non-variceal upper gastrointestinal bleeding and to examine its significance in relation to severity and outcome of bleeding. METHODOLOGY: This is a retrospective analysis of data collected prospectively on consecutive patients admitted to the Emergency Department of Taichung Veterans General Hospital with upper GI bleeding, and variceal bleeding was excluded. Hypoalbuminemia is defined as serum albumin < 3.5 g/dL. The outcome assessments in the hypoalbuminemia and normal albumin groups were compared. RESULTS: There were three hundred and twenty-nine patients with non-variceal upper GI bleeding identified from July 2000 to January 2001. Two hundred and fifty were male, and 79 were female. Their ages ranged from 21 to 90 (64.60 +/- 14.84) years. Of these 329 patients eligible for the study, hypoalbuminemia was seen in 204 (62.0%). When compared to patients with normal serum albumin, the hypoalbuminemia group was older (66.81 +/- 13.45 vs. 60.98 +/- 16.29 years, P < 0.01), had more associated with underlying diseases (78.4% vs. 57.6%, P < 0.01), and had more leukocytosis (47.5% vs. 35.2%, P < 0.05), had lower hemoglobin (71.1% vs. 29.6% P < 0.01), and elevated BUN (85.3% vs. 72.8%, P < 0.01) at admission. In addition, these patients had longer hospital stay (6.82 +/- 9.45 vs. 2.38 +/- 3.48 days, P < 0.01), greater requirements of blood transfusion (5.76 +/- 7.43 vs. 1.38 +/- 2.20 units, P < 0.01), need of therapeutic endoscopy (41.7% vs. 16.0%, P < 0.01), with higher rebleeding rate (13.2% vs. 0%, P < 0.01), surgery rate (5.4% us. 0.8% P < 0.05), and mortality rate (9.3% vs. 0%, P < 0.01). CONCLUSIONS: Hypoalbuminemia is common in patients with non-variceal upper GI bleeding, appears to reflect the severity of the bleeding episode, and is associated with a more complicated course.

Case report: the clinical toxicity of dimethylamine borane.

CONTEXT: Dimethylamine borane (DMAB) is a reducing agent used in nonelectric plating of semiconductors. Exposures are usually through occupational contact. We report here four cases of people who suffered from work-related exposure to DMAB. CASE PRESENTATION: Three patients exposed to DMAB decontaminated immediately by drinking a lot of water; they reported dizziness, nausea, diarrhea 6-8 hr later. The other patient did not decontaminate at once, and he suffered from more severe symptoms, including dizziness, nausea, limb numbness, slurred speech, irritable mood, and ataxia 13 hr later. Magnetic resonance imaging showed symmetric lesions with hyperintensity on T2WI and FLAIR in bilateral cerebellar dantate nuclei. This patient was readmitted to the hospital due to difficulty in walking and climbing 18 days after exposure. Lower leg weakness and drop foot were found bilaterally. A nerve conduction study revealed polyneuropathy with motor-predominant axonal degeneration. This patient receives regular outpatient followups and still walks with a clumsy gait and has difficulty with hand-grasping activity. DISCUSSION: This case study demonstrates that DMAB is highly toxic to humans through any route of exposure, and dermal absorption is the major route of neurotoxicity. DMAB induces acute cortical and cerebellar injuries and delayed peripheral neuropathy. RELEVANCE: Further investigation of the toxic mechanism of DMAB is warranted. Early decontamination with copious water is the best current treatment for exposure to DMAB.

Extremely high levels of alkaline phosphatase in adult patients as a manifestation of bacteremia.

BACKGROUND/AIMS: Jaundice resulting from severe bacterial infection is well known, particularly in pediatric literature. Extremely high levels of alkaline phosphatase (ALP) have rarely been emphasized as a manifestation of bacteremia in adults. The aim of this study was to evaluate the characteristics of extremely high levels of ALP in adult patients as a manifestation of bacteremia. METHODOLOGY: Extremely high levels of ALP were defined as being more than 1000 U/L. From April 1998 to May 1999, we retrospectively reviewed those patients' charts who had ALP above 1000 U/L. Sixteen patients that had bacteremia among 96 patients with extremely high levels of ALP at the emergency department of Taichung Veterans General Hospital were included in this study. RESULTS: Sixteen patients had bacteremia with extremely high levels of ALP, including 9 patients with malignant biliary obstruction (MBO), and 7 patients without MBO. The ALP levels ranged from 1002 to 2061 (1430.13+/-353.84) U/L. Ten patients were male, and 6 were female. Their ages ranged from 19 to 83 (56.13+/-16.51) years. A variety of gram-negative, and gram-positive organisms were identified, and Escherichia coli was the most common pathogen. Among the seven patients of bacteremia without MBO, 5 patients had underlying diabetes mellitus as the predisposing factor for development of the bacteremia. The ages of the bacteremia patients with MBO were older than those of patients without MBO (66.3+/-10.1 us. 43.0+/-13.7 years, P=0.0025). CONCLUSIONS: Bacteremia from a variety of organisms is a common cause for extreme elevation of ALP. Escherichia coli is the most common pathogen and presented more often in patients with MBO than those without MBO. In the setting o f extremely high levels of ALP as a manifestation of bacteremia, the patients with MBO are as common as those without MBO. We have demonstrated clinically that hepatic dysfunction during bacteremia may be manifested predominantly by extreme elevation of alkaline phosphatase with little abnormality in serum bilirubin.

Characteristics of hepatocellular carcinoma in hemodialysis patients in hepatitis B endemic area.

BACKGROUND/AIMS: Hepatocellular carcinoma is one of the most common malignancies in Taiwan, a hepatitis B endemic area. In this study, we aimed to evaluate the characteristics of hepatocellular carcinoma in patients receiving hemodialysis, as this patient group is at high risk for malignancy. METHODOLOGY: From October 1991 to September 1997, thirteen patients receiving hemodialysis and diagnosed with hepatocellular carcinoma were enrolled in this retrospective study. Patients' clinical course, laboratory data, image study and treatment were evaluated. RESULTS: Among these 13 patients, hepatitis B virus related in 6 and hepatitis C virus related in 7. There was no statistical significance in serum levels of asparate aminotransferase, alanine aminotransferase, bilirubin and alpha-fetoprotein between hepatitis B virus and hepatitis C virus related hepatocellular carcinoma. Hepatitis B virus related hepatocellular carcinoma had a shorter mean dialysis period (29.67 +/- 22.18 vs. 87.86 +/- 79.90 months, P = 0.25) and mean duration from beginning hemodialysis to diagnosis of hepatocellular carcinoma (17.16 +/- 26.94 vs. 76.08 +/- 65.69 months, P = 0.05), but there was no statistical significance. In the area of treatment, the survival curves of the treatment (hepatic resection and/or transcatheter arterial chemoembolization) group and supportive group were compared by log-rank test and there was no statistical significance for these two groups (P = 0.69). CONCLUSIONS: Both hepatitis B virus and hepatitis C virus are equally important for hepatocellular carcinoma in hemodialysis patients in hepatitis B endemic Taiwan. The acquisition of hepatitis B virus or hepatitis C virus might be not related to hemodialysis. Periodic screening with ultrasonography and serum alpha-fetoprotein is necessary among hemodialysis patients with evidence of hepatitis B virus or hepatitis C virus infection.

Clinical significance and prediction factors of gastric varices in patients with hepatocellular carcinoma.

BACKGROUND/AIMS: Hepatocellular carcinoma is part of the natural history of liver cirrhosis. Gastrointestinal bleeding and hepatic failure are the leading causes of death in hepatocellular carcinoma patients. With gastrointestinal bleeding, variceal bleeding is the most prominent, and most variceal bleeding is of esophageal origin. Gastric varices bleeding is often a massive and severe bleeding episode. The role of gastric varices among patients with hepatocellular carcinoma remains to be clarified. In this study, we aimed to evaluate the prevalence, clinical significance and prediction of gastric varices in patients with hepatocellular carcinoma. METHODOLOGY: From 1998 to 2000, we reviewed 304 patients with hepatocellular carcinoma receiving upper gastrointestinal endoscopic examinations. Patients' clinical characteristics, physical findings, laboratory data, image studies, endoscopic examinations and treatment were reviewed. RESULTS: Among 304 patients with HCC, twenty-one (6.9%) had gastric varices among 304 patients with hepatocellular carcinoma. The location of gastric varices were the posterior wall in 12 (57%), the lesser curvature in 1 (5%), the greater curvature in 4 (19%) and the fundus in 4 (19%). Three (14%) of these 21 patients with hepatocellular carcinoma and gastric varices had clinical evidence of bleeding. One of them died due to uncontrollable bleeding. Child-Pugh classification, hepatic encephalopathy, portal vein or splenic vein dilatation, ascites, splenomegaly, albumin level, prothrombin time and platelet count were significantly different between hepatocellular carcinoma patients with gastric varices and without gastric varices under the univariate analysis. Ascites (Odds ratio: 5.45; 95% confidence interval: 2.12-14.01) and portal vein or splenic vein dilatation (Odds ratio: 4.38; 95% confidence interval: 1.77-10.86) were the two most important predictors under the stepwise logistic regression analysis. CONCLUSIONS: The prevalence of gastric varices in patients with hepatocellular carcinoma is 6.9% and the risk of bleeding is low in this study. The Predictors of gastric varices among hepatocellular carcinoma are related to liver cirrhosis, Child-Pugh classification, hepatic encephalopathy, portal vein or splenic vein dilatation, ascites, splenomegaly, albumin level, prothrombin time and platelet count.

Factors associated with frequent use of emergency services in a medical center.

BACKGROUND AND PURPOSE: Overuse of emergency department (ED) services can result in overcrowding and a substantial increase of health care cost. The purpose of this study was to characterize frequent ED users and to identify the factors associated with frequent ED use in a hospital in Taiwan. METHODS: This retrospective study used Andersen's Behavioral Model of Health Service Use as a framework. Frequent ED users (>/= 4 visits/year) and infrequent ED users (< 4 visits/ year) were selected randomly from patients visiting the adult ED of a medical center in central Taiwan from October 1, 2000 to September 30, 2001. Telephone interviews were completed for 200 frequent users and 600 infrequent users. Logistic regression analysis was performed to identify factors associated with frequent ED use. RESULTS: Frequent ED users comprised 3.5% of total ED patients, accounting for 14.3% of the ED visits. Significant factors associated with frequent ED use were: a regular source of care [odds ratio (OR), 2.79; 95% confidence interval (CI), 1.63 to 4.79], alcoholism (OR, 19.4; 95% CI, 3.84 to 98.0), high outpatient clinic use (OR, 2.66; 95% CI, 1.72 to 4.11), previous hospitalization (OR, 3.06; 95% CI, 1.94 to 4.82), chronic disease (OR, 3.07; 95% CI, 1.78 to 5.29), cancer (OR, 4.16; 95% CI, 1.29 to 13.4), gastrointestinal disease (OR, 6.28; 95% CI, 1.95 to 20.2), cardiovascular disease (OR, 8.41; 95% CI, 2.51 to 28.1), pulmonary disease (OR, 4.21; 95% CI, 1.04 to 17.1), low level of emergency (OR, 5.43; 95% CI, 3.40 to 8.68), and dissatisfaction with treatment outcome (OR, 2.62; 95% CI, 1.32 to 5.20). CONCLUSIONS: Frequent ED users were responsible for a disproportionate number of the total ED visits. Andersen's "need factors" were strongly associated with frequent ED use, while the investigated predisposing factors were not significant. Most patients who visited the ED had a low level of emergency. These findings suggest that implementation of an integrated delivery system may decrease ED use.

Metformin-associated lactic acidosis and acute renal failure in a type 2 diabetic patient.

Metformin belongs to a class of drugs known as the biguanides that are widely used in the treatment of type 2 diabetes mellitus. Its association with lactic acidosis is well established, although rare. Metformin-associated lactic acidosis is recognized as a potentially lethal condition that can occur in patients with contraindications to the drug, such as renal dysfunction, liver diseases, alcoholism, and cardiopulmonary diseases. In these cases, the plasma concentration of metformin is not necessarily abnormally high. We describe a 75-year-old diabetic woman with acute renal failure and life-threatening lactic acidosis due to metformin intoxication. Clinical manifestations included vomiting, diarrhea, hypothermia, hypotension and transitory blindness. Her initial renal function was recovered after hemodialysis and she was discharged 3 months after admission.

Determining factors of patient satisfaction for frequent users of emergency services in a medical center.

BACKGROUND: The present era of a competitive healthcare environment indicates that providers have been convinced that attentiveness to patient satisfaction is integral to care quality and market share. Patient satisfaction is especially critical for frequent users of the emergency department (ED). The aim of this study was to compare satisfaction of overall ED care between frequent and infrequent ED users, and to find out the factors determining satisfaction among the frequent ED users. METHODS: Frequent ED users (> or = 4 visits/per year) and infrequent ED users (< 4 visits/per year) were selected randomly from patients visiting the adult ED of a public tertiary medical center from October 1, 2000 to September 30, 2001. Retrospective telephone interviews were completed for 200 frequent users and 200 infrequent users. Ordinal logistic regression analysis was performed. RESULTS: Infrequent ED users tended to give a higher satisfaction rating than frequent ED users to emergency care (OR = 2.14; 95% CI = 1.40-3.25). The 2 significant determinants associated with satisfaction with emergency care among frequent ED users were discharge instructions (OR = 2.78; 95% CI = 1.27-6.12) and subjective waiting time (OR = 12.6; 95% CI = 4.22-37.8). CONCLUSIONS: The frequent ED users were unique, and their satisfaction with overall emergency care was significantly lower than that of infrequent ED users. Managing waiting time perceptions and providing discharge instructions may be an effective strategy to achieve improved patient satisfaction among frequent ED users.

Analysis of emergency department utilization by elderly patients under National Health Insurance.

Elderly persons are thought to use emergency departments (EDs) disproportionately. This phenomenon has implications for policy-making as the population of the elderly continues to increase. This study aimed to characterize national ED utilization by elderly patients (> or = 65 years old), compared with that by younger patients (15-64 years old). The sample was selected from the National Health Insurance Research Database for the year 2000. There were 519,003 visits to adult EDs in the 12 medical centers sampled. The study used a secondary data analysis and included 14 variables. The elderly accounted for 28.5% of all adult ED visits. Compared with younger patients, a greater proportion of elderly patients were male (61.6% vs. 47.7%, p < 0.001), had chronic diseases (11.9% vs. 8.0%, p < 0.001), were major cases (6.7% vs. 4.1%, p < 0.001), made no co-payment (38.5% vs. 5.8%, p < 0.001), were frequent users of outpatient services (28.4% vs. 9.9%, p < 0.001), were higher-level emergencies (60.0% vs. 43.7%, p < 0.001), had longer stays in the ED (14.0% vs. 4.7%, p < 0.001), and had higher costs per visit (NT dollars 4,814 +/- 6,046 vs. 2,779 +/- 5,533, p < 0.001). In addition, elderly patients used 40.8% of total adult ED costs. Older patients have distinct patterns of ED use, and use emergency services at a higher rate than younger patients. ED staff should be knowledgeable about the unique and complex presentations of older ED patients.

Factors associated with failure of initial endoscopic hemoclip hemostasis for upper gastrointestinal bleeding.

BACKGROUND: Endoscopic hemoclip is widely used for the management of bleeding peptic ulcers. The major difficulty in clinical application of the hemoclip is deployment to the lesion during initial hemostasis. The aim of this study was to define factors associated with the failure of endoscopic hemoclip for initial hemostasis of upper GI bleeding. PATIENTS AND METHODS: From January to December 2003, we prospectively studied 77 randomized patients with clinical evidence of upper GI bleeding due to either active bleeding or a visible vessel identified by upper GI endoscopy in our emergency department. RESULTS: Among the 77 patients, 13 (16.9%) failed treatment (Group 1) and 64 (83.1%) were successfully (Group 2) treated by endoscopic hemoclip for lesions related to upper GI bleeding. There were no differences due to gender, blood pressure, initial heart rate, and hemoglobulin before or after endoscopic treatment, platelet count, serum creatinine, and albumin between groups. The mean age of Group 1 was higher than that of Group 2 (73.31+/-9.38 years vs. 65.41+/-16.45 years, respectively; P=0.083). Most patients who did not achieve initial hemostasis by endoscopic hemoclip had upper GI lesions over the gastric antrum and duodenal bulb. Among the 13 patients who failed to achieve endoscopic hemoclip initial hemostasis, four lesions were located over the posterior wall of the antrum, and four lesions over the lesser curvature side of the duodenal bulb. CONCLUSION: Endoscopic hemoclip is an effective hemostatic method for upper GI bleeding. Age, gastric antrum, and duodenal bulb lesions may be associated with the failure of initial hemostasis by endoscopic hemoclip.

Hyperglycemia with occipital seizures: images and visual evoked potentials.

PURPOSE: Hyperglycemia may rarely be seen with visual seizures. Observation of both visual evoked potentials (VEPs) and magnetic resonance imaging (MRI) in visual status epilepticus (SE) has not been reported. We describe acute and follow-up VEP and MRI findings of a patient with hyperglycemia-related visual SE of occipital origin. METHODS: In a 59-year-old diabetic woman, complex visual hallucinations and illusions developed with < or =10 seizures per hour as an initial manifestation of nonketotic hyperglycemia. RESULTS: Neurologic examination revealed ictal nystagmus to the right and continuous right hemianopsia. Ictal electroencephalography (EEG) and Tc-99m hexamethylpropylene amine oxime (HMPAO) single-photon emission computed tomography (SPECT) revealed an epileptogenic focus in the left occipital lobe. MRI with fluid-attenuated inversion recovery showed focal subcortical hypointensity and gyral hyperintensity. Follow-up MRI showed only minimal gyral hyperintensity at 6 months. The P100 amplitude of VEP was significantly higher at the right occipital area during SE, but slightly higher on the left after the patient had been seizure free for 6 months. CONCLUSIONS: Occipital seizures and hemianopsia can be caused by hyperglycemia and may be accompanied by special MRI and VEP findings.

Anticholinergic poisoning from a large dose of Scopolia extract.

Scopolia extract (SE) contains hyoscyamine and scopolamine, which are both anticholinergic. It is usually used as a patent medicine to treat gastrointestinal disorders, to relieve spasmotic discomfort, or to decrease the secretion of gastric acid. Poisoning by SE presents similar symptoms and signs as other types of anticholinergic poisoning. We report a case of severe anticholinergic poisoning after accidentally drinking 8 ml of SE. The patient presented with acute delirium and was successfully treated with physostigmine.