Second-line triple therapy in failures with vonoprazan-based triple therapy for eradication of Helicobacter pylori.

Gastric acid inhibition during treatment is important for the eradication of Helicobacter pylori (H. pylori) infection. A novel potassium-competitive acid blocker, vonoprazan (VPZ), has been demonstrated to achieve high eradication rates; however, the efficacy of second-line treatment in failures of VPZ-based triple therapy has not been well studied. The aim of the current study was to determine the efficacy of VPZ in a first-line regimen for H. pylori eradication, and the efficacy of a second-line regimen using metronidazole (MTZ) in failures with the first-line regimen. Of 580 subjects enrolled in the study, 524 patients completed first-line treatment (275 patients who received VPZ and 249 patients who received LPZ). First-line regimens consisted of a combination of clarithromycin (CAM) 200 or 400 mg twice a day, amoxicillin (AMPC) 750 mg twice a day, and either LPZ 30 mg or VPZ 20 mg twice a day, administered orally for 7 days. CAM and VPZ/LPZ were replaced with metronidazole (MTZ) 250 mg and rabeprazole 10 mg in the second-line regimens. The eradication of H. pylori was assessed by the H. pylori stool antigen test. The overall first-line eradication rate with VPZ was significantly higher than that with LPZ [91.0% (250/275) vs. 84.7% (211/249), respectively, P=0.030]. The dose of CAM (400 vs. 800 mg) did not affect the eradication rate in either the VPZ or LPZ regimens. The overall eradication rates of the second-line regimens with MTZ did not differ significantly between the VPZ-failure and LPZ-failure groups [87.0% (20/23) vs. 87.9% (29/33), respectively, P=0.700]. Therefore, VPZ was significantly more effective than LPZ for first-line treatment. In patients with failure of first-line eradication therapy, successful results of second-line eradication therapy did not differ between the VPZ- and LPZ-failure groups. In conclusion, VPZ-based triple therapy should be recommended for eradication of H. pylori.

Aspartate aminotransferase-immunoglobulin complexes in patients with chronic liver disease.

AIM: To determine the complex of AST and immunoglobulin and to investigate its clinical significance in patients with liver disease. METHODS: The complex of AST and immunoglobulin was determined by encounter immunoelectrophoresis and its clinical significance was investigated in 128 patients with liver disease. RESULTS: AST was bound to immunoglobulin of anti-immunoglobulin A (IgA) class, but any binding to anti-immunoglobulin G and anti-immunoglobulin M classes was not observed. Although the incidence of AST-immunoglobulin complex was 41.8% in chronic hepatitis (CH), the incidences in liver cirrhosis and hepatocellular carcinoma were 62.2 and 90.0%, respectively. In alcoholic liver disease with high level of serum IgA, the incidence of the complex was 66.7%, which was higher than that in CH. The ratio of binding to lambda-chain of IgA was higher than that to kappa-chain of IgA. The serum level of IgA and the ratio of AST/alanine aminotransferase (ALT) were significantly higher in patients with AST-IgA complex than in those without complex. CONCLUSION: These results suggest that AST-IgA complex in patients with progressive liver diseases and alcoholic liver injury can lead to elevation of the ratio of AST/ALT.

Sequential fluctuation pattern of serum des-gamma-carboxy prothrombin levels detected by high-sensitive electrochemiluminescence system as an early predictive marker for hepatocellular carcinoma in patients with cirrhosis.

Serum concentration levels of des-gamma-carboxy prothrombin (DCP), alpha-fetoprotein (AFP) and Lens culinaris agglutinin-reactive fraction (AFP-L3) are useful tumor markers for the diagnosis of hepatocellular carcinoma (HCC). Recently, a novel immunoassay using the electrochemiluminescence (ECLIA) was developed to enable measurement of low-concentration of DCP. This study investigated the usefulness of high-sensitive DCP for the early diagnosis of HCC. The subjects consisted of 90 patients with viral cirrhosis who could be followed for at least 24 months from 1992 to 1997. Fifty-six of these patients developed HCC and 34 patients had not by 1998. We measured the serum levels of high-sensitive DCP, AFP and %AFP-L3 every 3 months during 2 years before the detection of tumor in patients with HCC and during 2 years from 1995 to 97 in patients without HCC. Youden's index was calculated for evaluation of the ideal cut-off levels. The patterns of serial changes during 2 years were divided into two types: fluctuating type and non-fluctuating type. Cut-off levels of 40 mAU/ml for high-sensitive DCP (Youden's index = 0.435), 20 ng/ml for AFP (Youden's index = 0.442) and 10% for %AFP-L3 (Youden's index = 0.364) gave the highest index for each marker. When these markers were combined, the combination of high-sensitive DCP, AFP and %AFP-L3 gave the highest accuracy (sensitivity = 82.1%, specificity = 82.4%, accuracy = 82.2%). Fluctuating type of high-sensitive DCP, AFP and %AFP-L3 levels were found in 15 (17%), 29 (32%) and 11 (12%) patients, respectively. The rate of complication with HCC in the patients who showed the fluctuating type of high-sensitive DCP levels was significantly greater than that in the patients who showed non-fluctuating type (P<0.01). These results suggest that periodic measurement of serum DCP levels using ECLIA method is very useful for HCC screening and predicting the development of HCC.

Detection of precore-mutant hepatitis B virus genome in patients with acute and fulminant hepatitis using mutation site-specific assay (MSSA).

BACKGROUND/AIMS: Precore mutation of hepatitis B virus was recently been suggested to be involved in the pathogenesis of fulminant hepatitis. In this study, we analyzed the occurrence of precore mutants in patients with acute and fulminant hepatitis B using new simple rapid and sensitive MSSA (mutation site-specific assay) and evaluated this method for predicting prognosis. METHODOLOGY: We analyzed HBV-DNA of 10 patients with fulminant hepatitis B, 15 patients with acute self-limited hepatitis, and 4 patients with acute severe hepatitis using MSSA. Precore point mutation (G to A; 83rd base of precore region) was examined using a mutation-trapped oligonucleotide primer, which would yield a polymerase chain reaction amplification product only with precore mutants. RESULTS: We distinguished precore mutants from wild type according to the presence or absence of the band at 203 bp, which was amplified in only precore mutants by polymerase chain reaction. Mutation of the precore region was observed in all 10 patients with fulminant hepatitis, in 3 of the 4 patients with severe hepatitis, and 11 of 15 patients with self-limited hepatitis. Negative pre-C mutants in patients with HBeAg indicates good prognosis of hepatitis. CONCLUSIONS: Precore mutant strains of HBV-DNA play an important role but are not specific for fulminant hepatitis, and the mere presence of precore mutants may not directly lead to fulminant hepatitis or severe hepatitis. However, this method is useful for predicting outcome of patients with acute HBV hepatitis, especially in HBeAg-positive state.

Pneumothorax after diagnostic laparoscopy.

Here we want to call laparoscopist's attention to pneumothorax after diagnostic laparoscopy. Diagnostic laparoscopy has less complications, compared with laparoscopic surgery. In our experience, only one case (0.04%) developed pneumothorax during routine diagnostic laparoscopic procedure. This complication is presented in a 50-year-old female. She complained of dyspnea just after the decrease of intraabdominal pressure and deflation of intraperitoneal gas. The chest roentgenogram showed a right pneumothorax, and a right chest tube was inserted with immediate relief of tension. Pneumothorax during diagnostic laparoscopy is relatively rare but a major complication; Medline literature research showed six reported cases of pneumothorax after diagnostic laparoscopy from 1983 to 1998 including our case. The etiology was idiopathy in 5 and diaphragmatic injury in 1. Hypotension, elevation of inspiratory pressure, dyspnea, a decrease in systemic oxygen saturation, and loss of breath sounds suggest tension pneumothorax. The clinical condition of the patients improved rapidly because of the easy diffusion of the gas used in laparoscopy. Diagnostic laparoscopists should be aware of this complication and treat ventilatory problems.

[Comparison of activities of daily living for a convalescent rehabilitation ward and general ward for stroke patients].

We investigated changes in the Activities of Daily Living (ADL) of stroke patients in a convalescent rehabilitation ward and a general ward using a Functional Independent Measure (FIM). The subjects were 109 patients hospitalized for rehabilitation purposes at the Oyamada Memorial Spa Hospital. The change in FIM at the time of hospitalization and that at 1 week later was investigated in 81 patients in the convalescent rehabilitation group (CRG) and 28 patients in the control group (CG). In addition, the CRG was investigated again after one month. Intensive rehabilitation service based on ADL and worksheets was introduced in the CRG. On the other hand, these were not introduced in the CG. The total score of FIM increased significantly (p<0.01) in the first week after hospitalization in both groups. The FIM-gain after one week in the CRG was high. With regard to each item, a significant improvement was observed in patients' motor skills while eating, grooming, bathing, dressing the upper body, dressing the lower body, toilet, bladder management, transfer bed/chair, toilet and tub, and walking/wheelchair (11/13). Multiple regressions were used to assess the relationships between FIM-gain (one week, one month), age, rehabilitation intensity and other predictive variables. Better rehabilitation outcomes were observed in patients with lower level of dementia and high rehabilitation intensity. It was thought that planned rehabilitation based on ADL was effective in the CRG, and it was suggested that the CRG's system is effective in the rehabilitation of stroke patients.

HBV subtype as a marker of the clinical course of chronic HBV infection in Japanese patients.

Hepatitis B virus (HBV) genotype C is predominant in Japan. However, many HBV subtypes are involved in each genotype, and the clinical manifestations in the patients associated with each subtype remain unknown. Therefore, we investigated the relationship between HBV subtype and clinical aspects of chronic HBV infection. The subtype of 237 patients with chronic HBV infection, including 74 asymptomatic carriers, was determined. The subtypes of 110 HBV carriers undergoing long-term follow-up management were determined twice to detect subtypic changes. The clinical features of the patients were also studied with regard to presence or absence of subtypic change. The subtypic distribution in the 237 HBV carriers was as follows: subtype adr, 161 (68%); subtype adw, 25 (11%); subtype adwr, 12 (5%); subtype ar, 24 (10%); subtype adyr, 4 (2%); and unclassified, 8 (3%). The proportion of asymptomatic carriers in patients with subtype adw was significantly higher than those in patients with subtype adr (56% vs. 28%, P < 0.05). In addition, the proportion of HCC in patients with subtype adwr was significantly higher than those in patients with subtype adr (25% vs. 6%, P < 0.05). The prevalence of subtype adr in 74 asymptomatic carriers tended to decrease with age (82% in carriers aged < or =35 years vs 43% in those aged > or =61 years, P < 0.05). The subtypic change and the course of chronic HBV infection had no significant correlation. These results suggest that HBV subtypes are associated with the clinical course of chronic HBV infection.