Effectiveness of fecal immunochemical testing in reducing colorectal cancer mortality from the One Million Taiwanese Screening Program.

BACKGROUND: The effectiveness of fecal immunochemical testing (FIT) in reducing colorectal cancer (CRC) mortality has not yet been fully assessed in a large, population-based service screening program. METHODS: A prospective cohort study of the follow-up of approximately 5 million Taiwanese from 2004 to 2009 was conducted to compare CRC mortality for an exposed (screened) group and an unexposed (unscreened) group in a population-based CRC screening service targeting community residents of Taiwan who were 50 to 69 years old. Given clinical capacity, this nationwide screening program was first rolled out in 2004. In all, 1,160,895 eligible subjects who were 50 to 69 years old (ie, 21.4% of the 5,417,699 subjects of the underlying population) participated in the biennial nationwide screening program by 2009. RESULTS: The actual effectiveness in reducing CRC mortality attributed to the FIT screening was 62% (relative rate for the screened group vs the unscreened group, 0.38; 95% confidence interval, 0.35-0.42) with a maximum follow-up of 6 years. The 21.4% coverage of the population receiving FIT led to a significant 10% reduction in CRC mortality (relative rate, 0.90; 95% confidence interval, 0.84-0.95) after adjustments for a self-selection bias. CONCLUSIONS: This large, prospective Taiwanese cohort undergoing population-based FIT screening for CRC had the statistical power to demonstrate a significant CRC mortality reduction, although the follow-up time was short. Although such findings are informative for health decision makers, continued follow-up of this large cohort will be required to estimate the long-term impact of FIT screening if the covered population is expanded.

Evaluation of abdominal ultrasonography mass screening for hepatocellular carcinoma in Taiwan.

UNLABELLED: Mass screening with abdominal ultrasonography (AUS) has been suggested as a tool to control adult hepatocellular carcinoma (HCC) in individuals, but its efficacy in reducing HCC mortality has never been demonstrated. This study aimed to assess the effectiveness of reducing HCC mortality by mass AUS screening for HCC based on a program designed and implemented in the Changhua Community-based Integrated Screening (CHCIS) program with an efficient invitation scheme guided by the risk score. We invited 11,114 (27.0%) of 41,219 eligible Taiwanese subjects between 45 and 69 years of age who resided in an HCC high-incidence area to attend a risk score-guided mass AUS screening between 2008 and 2010. The efficacy of reducing HCC mortality was estimated. Of the 8,962 AUS screening attendees (with an 80.6% attendance rate), a total of 16 confirmed HCC cases were identified through community-based ultrasonography screening. Among the 16 screen-detected HCC cases, only two died from HCC, indicating a favorable survival. The cumulative mortality due to HCC (per 100,000) was considerably lower in the invited AUS group (17.26) compared with the uninvited AUS group (42.87) and the historical control group (47.51), yielding age- and gender-adjusted relative mortality rates of 0.69 (95% confidence interval [CI]: 0.56-0.84) and 0.63 (95% CI: 0.52-0.77), respectively. CONCLUSION: The residents invited to community-based AUS screening for HCC, compared with those who were not invited, showed a reduction in HCC mortality by ∼ 31% among subjects aged 45-69 years who had not been included in the nationwide vaccination program against hepatitis B virus infection.

A new insight into fecal hemoglobin concentration-dependent predictor for colorectal neoplasia.

We sought to assess how much of the variation in incidence of colorectal neoplasia is explained by baseline fecal hemoglobin concentration (FHbC) and also to assess the additional predictive value of conventional risk factors. We enrolled subjects aged 40 years and over who attended screening for colorectal cancer with the fecal immunochemical test (FIT) in Keelung community-based integrated screening program. The accelerated failure time model was used to train the clinical weights of covariates in the prediction model. Datasets from two external communities were used for external validation. The area under curve (AUC) for the model containing only FHbC was 83.0% (95% CI: 81.5-84.4%), which was considerably greater than the one containing only conventional risk factors (65.8%, 95% CI: 64.2-67.4%). Adding conventional risk factors did not make significant additional contribution (p = 0.62, AUC = 83.5%, 95% CI: 82.1-84.9%) to the predictive model with FHbC only. Males showed a stronger linear dose-response relationship than females, yielding gender-specific FHbC predictive models. External validation confirms these results. The high predictive ability supported by a dose-dependent relationship between baseline FHbC and the risk of developing colorectal neoplasia suggests that FHbC may be useful for identifying cases requiring closer postdiagnosis clinical surveillance as well as being an early indicator of colorectal neoplasia risk in the general population. Our findings may also make contribution to the development of the FHbC-guided screening policy but its pros and cons in connection with cost and effectiveness of screening should be evaluated before it can be applied to population-based screening for colorectal cancer.

Blockade of reactive oxygen species and Akt activation is critical for anti-inflammation and growth inhibition of metformin in phosphatase and tensin homolog-deficient RAW264.7 cells.

CONTEXT: Metformin is widely used for treatment of type 2 diabetes and has a potential application on the treatment of inflammation and cancer. Phosphatase and tensin homolog (PTEN) plays a critical role in cancer cell growth and inflammation; however, precise mechanisms remain unclear. OBJECTIVE: We aimed to investigate the possible mechanisms of how PTEN regulates metformin against cell growth and inflammation. MATERIALS AND METHODS: We established PTEN knockdown in RAW264.7 murine macrophages (shPTEN cells) to detect inflammatory mediators using commercial kits, production of reactive oxygen species (ROS) by flow cytometry, cell growth by MTT assay and phosphorylated levels of signal molecules by western blot. RESULTS: The shPTEN cells had a significant large amount of inflammatory mediators, such as inducible nitric oxide synthase (iNOS)/nitric oxide (NO) and cyclooxygenase-2 (COX-2)/prostaglandin E(2) (PGE(2)); and also elevated the production of ROS and increased cell proliferation. These effects were accompanied with the activation of Akt and p38 mitogen-activated protein kinase (MAPK), and the inactivation of an AMP-activated protein kinase (AMPK) activator and extracellular signal-regulated kinase 1/2. Pretreatment with metformin not only blocked these inflammatory mediators, but also caused growth inhibition induced by significant apoptosis. Furthermore, inactivation of Akt, blockade of ROS generation and independence of activations of AMPK and MAPK by metformin were also observed. CONCLUSION: Macrophages with PTEN deficiency developed a continuous inflammatory microenvironment, which further aggravated tumor cell growth. Moreover, metformin affected PTEN-deficient cells dependent of inhibition of ROS production and Akt activation against enlarged inflammatory mediators and/or cell growth in shPTEN cells.

Epiphytic microbiota source stimulates the fermentation profile and bacterial community of alfalfa-corn mixed silage.

The epiphytic microbiota source on plants plays a crucial role in the production of high-quality silage. To gain a better understanding of its contribution, the microbiota of alfalfa (M1C0), corn (M0C1) and the resulting mixture (M1C1) was applied in alfalfa-corn mixed silage production system. M1C0 decreased ammonia-N levels in terms of total nitrogen (57.59-118.23 g/kg TN) and pH (3.59-4.40) values (p < 0.01), which increased lactic acid (33.73-61.89 g/kg DM) content (p < 0.01). Consequently, this resulted in higher residual water-soluble carbohydrate (29.13-41.76 g/kg DM) and crude protein (152.54-167.91 g/kg DM) contents, as well as lower NDF (427.27 g/kg DM) and ADF (269.53 g/kg DM) contents in the silage compared to M1C1- and M0C1-treated samples. Moreover, M1C0 silage showed significantly higher bacterial alpha diversity indices (p < 0.05), including the number of observed species and Chao1 and Shannon diversity indices, at the later stages of ensiling. Lactobacillus, Kosakonia and Enterobacter were the dominant bacterial species in silages, with a relative abundance of >80%. However, the abundance of Lactobacillus amylovorus in M0C1- and M1C1-treated silage increased (p < 0.01) in the late stages of ensiling. These findings confirmed that the epiphytic microbiota source exerts competitive effects during anaerobic storage of alfalfa-corn mixed silage.

Potential for volatile fatty acid production via anaerobically-fermenting rice straw pretreated with silage effluent and phenyllactic acid.

To resolve environmental problems associated with rice straw and silage effluent disposal, silage effluent pretreating rice straw for the anaerobic production of volatile fatty acids (VFAs) was investigated. To prevent the lactic acid bacteria in silage effluent from inhibiting anaerobic fermentation, four phenyllactic acid (PLA) levels were set (0, 0.1, 0.3, 0.5 mg/kg). The total VFA yields of treatments pretreated only with silage effluent (CK) were higher than the groups combined with PLA during 15 days fermentation. Compared to PLA treatments, the total VFA of CK increased by 11.4 % ∼ 25.1 % on day 15. The CK showed higher lactic and propionic acid contents and lower pH values (<4.9). The PLA treatments decreased Lactobacillus abundance while increasing bacterial richness and evenness, and acetic and butyric acid contents. These demonstrated silage effluent has the potential to be used as a biological pretreatment for VFA production in anaerobic fermentation.

Contribution of the bacterial community of poorly fermented oat silage to biogas emissions on the Qinghai Tibetan Plateau.

To better utilize poorly fermented oat silage on the Qinghai Tibetan Plateau, 239 samples of this biomass were collected from the plateau temperate zone (PTZ), plateau subboreal zone (PSBZ), and nonplateau climatic zone (NPCZ) in the region and analyzed for microbial community, chemical composition and in vitro gas production. Climatic factors affect the bacterial α-diversity and ß-diversity of poorly fermented oat silage, which led to the NPCZ having the highest relative abundance of Lactiplantibacillus plantarum. Furthermore, the gas production analysis showed that the NPCZ had the highest maximum cumulative gas emissions of methane. Through structural equation modeling analysis, environmental factors (solar radiation) affected methane emissions via the regulation of lactate production by L. plantarum. The enrichment of L. plantarum contributes to lactic acid production and thereby enhances methane emission from poorly fermented oat silage. Notably, there are many lactic acid bacteria detrimental to methane production in the PTZ. This knowledge will be helpful in revealing the mechanisms of environmental factors and microbial relationships influencing the metabolic processes of methane production, thereby providing a reference for the clean utilization of other poorly fermented silage.

CD44/CD24 expression in recurrent gastric cancer: a retrospective analysis.

BACKGROUND: To correlate CD44/CD24 expression with gastric cancer recurrence and prognosis. Gastric cancer is the second leading cause of cancer mortality due to the high recurrence rate, of which the molecular signature has not yet been identified. METHODS: We retrospectively reviewed the hospital records of patients with gastric cancer. Among 500 patients receiving curative resection, 95 patients had recurrence. Twenty patients from the recurrence group (95 patients) and 20 patients from the non-recurrence group (405 patients) were randomly selected and identified as "study" and "control" groups, respectively. We reviewed patients' histological study of CD44/CD24 expression by performing immunohistochemistry and recurrence rate. RESULTS: Study group had higher TNM stage (III-IV) than control group (80% vs. 25%, P = 0.001). Proportion of lymph node metastasis was significantly higher in study group than that in control group (90% vs. 45%, P = 0.002), and proportion of patients with 5 or more metastatic lymph nodes was also significantly higher in study group than in control group (45% vs. 15%, P = 0.007). Univariate analysis revealed no difference in risk of gastric cancer recurrence between CD44+ and CD44- patients (OR = 1.00, 95% CI: 0.29-3.45, P =1.000). CD24+ patients showed no greater significance of gastric cancer recurrence than CD24- patients (OR = 1.86, 95% CI: 0.52-6.61, P = 0.339). After adjusting for other risk factors, the association of CD44 expression (aOR = 0.66, 95% CI: 0.10-4.26, P = 0.658), CD24 expression (aOR = 0.09, 95% CI: 0.01-1.35, P = 0.081) or combined (CD44/CD24) with gastric cancer recurrence were not significant. CONCLUSION: Neither individual expression of CD24 or CD44, nor combined expression of CD44/CD24 was associated with recurrence of gastric carcinoma.

Baseline faecal occult blood concentration as a predictor of incident colorectal neoplasia: longitudinal follow-up of a Taiwanese population-based colorectal cancer screening cohort.

BACKGROUND: Despite widespread use of the immunochemical faecal occult blood test (iFOBT), little is known about the subsequent risk of developing colorectal neoplasia for participants with negative iFOBT results. We investigated whether the concentration of faecal haemoglobin at the first screen is predictive of the subsequent incidence of colorectal neoplasia in those with a negative screening result. METHODS: Between 2001 and 2007, we did a prospective cohort study within the Keelung community-based iFOBT screening programme for residents aged 40-69 years, using a cutoff faecal haemoglobin concentration of 100 ng/mL to classify attendees as negative and positive groups for further clinical investigations. 44,324 participants with negative findings and 1668 with a positive result at the first screen (854 non-referrals who refused colonoscopy and 814 with a false-positive result as assessed by colonoscopy) were followed up to ascertain cases of colorectal neoplasia. We investigated the association between baseline faecal haemoglobin concentration and risk of incident colorectal neoplasia, after adjusting for possible confounders. FINDINGS: Median follow-up was 4·39 years (IQR 2·53-6·12) for all 45 992 participants, during which the incidence of colorectal neoplasia increased from 1·74 per 1000 person-years for those with baseline faecal haemoglobin concentration 1-19 ng/mL, to 7·08 per 1000 person-years for those with a baseline concentration of 80-99 ng/mL. The adjusted hazard ratios (HRs) increased from 1·43 (95% CI 1·08-1·88) for baseline faecal haemoglobin concentration of 20-39 ng/mL, to 3·41 (2·02-5·75) for a baseline concentration of 80-99 ng/mL (trend test p<0·0001), relative to 1-19 ng/mL. These results did not change when we included repeated iFOBT measurements. Non-referrals had the highest risk of incident colorectal neoplasia (adjusted HR 8·46 [6·08-11·76]). INTERPRETATION: Quantitative faecal haemoglobin concentration at first screening predicts subsequent risk of incident colorectal neoplasia. During follow-up, risk stratification based on faecal haemoglobin could help clinicians, with particular attention being paid to those with higher initial faecal haemoglobin concentrations, especially those just under the threshold taken to indicate presence of colorectal neoplasia. FUNDING: None.

Influence of Fermented-Moutai Distillers' Grain on Growth Performance, Meat Quality, and Blood Metabolites of Finishing Cattle.

The present study evaluated the effect of dietary supplementation with fermented-Moutai distillers' grain (FMDG) on the growth performance, meat quality, amino acid composition and blood metabolites of finishing cattle. Thirty cattle (2 years old; 237.55 ± 10.72 kg) were randomly assigned to one of three dietary supplementations: 0% FMDG (control), 15% FMDG (R1) and 30% FMDG (R2) [dry matter (DM) basis]. After 60 days, the inclusion of FMDG had no significant (p > 0.05) effects on the growth performance indices (dry matter intake, average daily gain and feed efficiency), meat quality (cooking yield, shear force, L*, a*, and b* values) or bovine blood biochemical indicators (except albumin and immunoglobulin A). Cattle fed R1 had the lowest (p = 0.001) loin eye area. Supplementation with FMDG significantly (p < 0.05) increased the beef contents of various amino acids (except isoleucine and arginine) compared with the control diet. Specifically, R2 significantly increased (p < 0.05) the total amino acid, essential amino acid, non-essential amino acid and umami amino acid contents in beef, while the difference in bitter amino acid content between different treatments was not significant (p = 0.165). These results suggest that it is feasible to include FMDG at up to 30% DM without affecting the growth performance, meat quality or blood metabolites of finishing cattle.

Role of Lactiplantibacillus paraplantarum during anaerobic storage of ear-removed corn on biogas production.

To optimize the volatile fatty acid production for anaerobic fermentation, the ear-removed corn was ensiled without (control) or with Lactiplantibacillus plantarum (LP), Lacticaseibacillus paracasei (LC) and L. paraplantarum (LpP). Inoculation of LpP increased acetic acid content by 40%, and decreased butyric acid content by 38% in relative to control. Moreover, inoculation of LpP decreased the bacterial alpha diversity indices, while inherent species of Lentilactobacillus buchneri and L. hilgardii dominated the anaerobic fermentation. In particular, inoculation of LpP restricted the growth of yeasts and production of propionic acid at the early stage of storage, but continuously stimulated anaerobic fermentation, resulting in a higher maximal cumulative gas emissions of methane (by about 20 %) than that of LP and LC. Therefore, inoculation of LpP during anaerobic storage was favorable to produce intermediate metabolites (acetic acid) for subsequent biogas production of ear-removed corn.

Effect of lactic acid bacteria, yeast, and their mixture on the chemical composition, fermentation quality, and bacterial community of cellulase-treated Pennisetum sinese silage.

The present study investigated the effects of Lentilactobacillus buchneri, Saccharomyces cerevisiae, and a mixture of the two on the cellulose degradation and microbial community of cellulase-treated Pennisetum sinese (CTPS) during biological pretreatment. The CTPS was stored without additives (CK) or with L. buchneri (L), yeast (Y, S. cerevisiae), and their mixture (LY) under anaerobic conditions for 60 days. All inoculants enhanced the anaerobic fermentation of CTPS. In relative to L, inoculations with Y and LY decreased the cellulose level of fermented-CTPS by 8.90 ~ 17.13%. Inoculation with L inhibited the growth of Weissella cibaria during anaerobic storage. However, inoculations with LY increased the relative abundance of the homofermentative bacterium Lactiplantibacillus plantarum by 6.04%. Therefore, inoculating S. cerevisiae reduced the adverse effects of L. buchneri-stimulated fermentation on cellulose degradation by altering the bacterial community during anaerobic storage of P. sinese. This work provides a new insight for the subsequent anaerobic digestion of P. sinese.

The effects of different oral care protocols on mucosal change in orally intubated patients from an intensive care unit.

AIM: To compare the effectiveness of three different oral care protocols in intubated patients. BACKGROUND: Although oral care is important to improve the oral mucosa integrity in intubated patients, there are few evidence-based nursing protocols to deal with this problem in critical care units. DESIGN: A quasi-experimental design was employed for this study. METHODS: Eighty-one orally intubated patients recruited from the intensive care unit of a medical centre in northern Taiwan were employed in this study. Patients were divided into three treatment groups: a control group (n = 27), green tea group (n = 29) and boiled water group (n = 25). Oral mucosal status was monitored using a rating scale for 14 days. All data were analysed by the sas software (version 8.2; SAS Institute, Cary, NC, USA) using descriptive statistics, the Kruskal-Wallis H test and generalised estimating equation regression models. RESULTS: Severity of mucosal change was significantly less on six subscales (labial mucosa, tongue mucosa, gingival colour, gingivitis, salivary status and amount of dental plaque) in the boiled water group than the control group (p < 0·05). In addition, severity was significantly less on two subscales (salivary status and amount of dental plaque) in the green tea group than the control group (p < 0·05). CONCLUSIONS: Both boiled water and green tea oral care protocols may improve mucosal status of orally intubated patients. Mucosal status was significantly more improved by oral care with boiled water than by oral care with green tea. RELEVANCE TO CLINICAL PRACTICE: Because oral care plays an important role in improving mucosal status, nurses are urged to find new effective oral care methods to further reduce the occurrence of oropharyngeal colonisation and ventilator-associated pneumonia in intubated patients.

Effects of Additives on Silage Fermentation Characteristic and In Vitro Digestibility of Perennial Oat at Different Maturity Stages on the Qinghai Tibetan.

To effectively use local grass resources to cover the winter feed shortage on the Qinghai-Tibetan Plateau, the silage fermentation and in vitro digestibility of perennial oat (Helictotrichonvirescens Henr.) were investigated. Perennial oat was harvested at the heading/flowering stage, wilted under sunny conditions, chopped, vacuumed in small bag silos, and stored at ambient temperatures (5-15 °C) for 60 days. The silages were treated without (CK) or with local lactic acid bacteria (LAB) inoculant (IN1), commercial LAB inoculant (IN2), and sodium benzoate (BL). Control silages of perennial oat at early heading stage showed higher (p < 0.05) lactate and acetate contents and lower (p < 0.05) final pH, butyrate, and ammonia-N contents than those at the flowering stage. High levels of dry matter recovery (DMR) and crude protein (CP) were observed in IN1- and BL-treated silages, with high in vitro gas production and dry matter digestibility. Compared to CK, additives increased (p < 0.05) aerobic stability by inhibiting yeasts, aerobic bacteria, and coliform bacteria during ensiling. In particular, the local LAB inoculant increased (p < 0.05) concentrations of lactate, acetate and propionate, and decreased concentrations of butyrate and ammonia-N in silages. This study confirmed that local LAB inoculant could improve the silage quality of perennial oat, and this could be a potential winter feed for animals such as yaks on the Qinghai Tibetan Plateau.

Cost-effectiveness analysis for determining optimal cut-off of immunochemical faecal occult blood test for population-based colorectal cancer screening (KCIS 16).

OBJECTIVES: We aimed to determine the optimal cut-off of the immunochemical faecal occult blood test (iFOBT) by using cost-effectiveness analysis. METHODS: A total of 22,672 subjects aged 50 years or older were invited to have an uptake of iFOBT. We collected data from screen-detected cases for the cut-off above 100 ng/mL and obtained interval cancers from a nationwide cancer registry for a cut-off below 100 ng/mL. We found a total of 65 colorectal cancer (CRC) cases, including 43 detected by screen and 22 diagnosed between screens (interval cases). The optimal cut-off was first determined by receiver operating characteristics (ROC) curve analysis. Formal economic evaluation was further applied to identifying the optimal cut-off by assessing the minimum incremental cost-effectiveness ratio (ICER), an indicator for cost per life year gained (effectiveness), given a series of cut-offs of iFOBT, ranging from 30 to 200 ng/mL compared with no screening. RESULTS: ROC curve analysis found the optimal cut-off of iFOBT to be 100 ng/mL at which the sensitivity, false-positive and odds of being affected given a positive result were 81.5% (70.2%-89.2%), 5.7% (5.4%-6.0%) and 1.24 (1.19-1.32), respectively. The area under ROC curve was 0.87 (0.81-0.93). In economic appraisal, the screening programme irrespective of any cut-off dominated (less cost and more effectiveness) over the control group. The optimal cut-off (the lowest ICER) was 110 ng/mL at which an average of 0.054 life year was gained and that of 950 ($US) was saved. CONCLUSIONS: We used cost-effectiveness to identify 110 ng/mL as the optimal cut-off of iFOBT in a Taiwanese population-based screening for CRC. Our model provides a useful approach for health policy-makers in designing population-based screening for CRC to determine the optimal cut-off of iFOBT when cost and effectiveness need to be taken into account.

Colorectal cancer screening with faecal occult blood test within a multiple disease screening programme: an experience from Keelung, Taiwan.

BACKGROUND: Given increasing rates of colorectal cancer (CRC) in countries with intermediate incidence rates, the decision to implement population-based screening must consider the trade-off between high costs and a relatively low yield. In Taiwan, we proposed community-based CRC screening using faecal occult blood tests (FOBT) within a multiple disease screening programme. AIMS: Based on early results from the screening programme, we aimed to compare the projected efficacies, in terms of reductions in CRC mortality, achieved with multiple disease screening, single disease screening and no screening programmes. METHODS: Annual FOBT has been included in the Keelung multiple disease screening programme. A total of 26,008 subjects were offered screening. Early indicators have been estimated to assess the potential effectiveness of this programme, including the Dukes' stage distribution of screen-detected cases, the proportionate incidence and the prevalence/incidence ratio. Transition rates according to adenoma size and Dukes' stage have been estimated from an eight-state Markov model. The projected mortality reductions based on this disease natural history have been estimated using Markov Chain Monte Carlo simulation for both multiple screening and single screening. RESULTS: The overall attendance rate was 82% at the first screen and 87% at the second screen. At the first screen, 70% of screen-detected cases were localized (i.e. Dukes' stage A or B). The corresponding figure for the second screen was 80%. Approximately three-quarters of detected adenomas were smaller than 1 cm. The estimated mean transition times from diminutive adenoma to small adenoma, from small adenoma to large adenoma and from large adenoma to pre-clinical Dukes' A or B invasive carcinoma were 14.4, 5.4 and 5.6 years, respectively. Estimated reductions in CRC mortality, based on annual screening, are 23 and 33% for the single and multiple disease screening programmes, respectively. Multiple screening with an annual screening regime may lead to a further 13% reduction in mortality when compared to conventional single screening. CONCLUSION: Early indications suggest that population-based screening for CRC with FOBT, implemented through a multi-disease screening programme, is both feasible and efficacious. Further evaluation of the programme, through longer follow-up and cost-effectiveness analysis, is now required.

Self-expandable metallic stents for malignant biliary obstruction: efficacy on proximal and distal tumors.

AIM: To compare the efficacy of self-expandable metallic stents (EMS) in the treatment of distal and proximal stricture of malignant biliary tumors. METHODS: From March 1995 to June 2004, 61 patients (40 males, 21 females) with malignant biliary obstruction who received self-expandable metallic stent implantation were reviewed retrospectively. The stents were inserted by an endoscopic or percutaneous transhepatic method. We tried to place two stents in the biliary system in T or Y configuration in cases of hilar tumors with bilateral hepatic duct obstruction. The end points of the study were stent occlusion or patient death. RESULTS: The mean time of stent patency was 421 +/- 67 d in the group of proximal stricture (group I) and 168 +/- 18 d in the group of distal stricture (group II). The difference was significant in borderline between the two groups (P = 0.0567). The mean survival time was 574 +/- 76 d in group I and 182 +/- 25 d in group II. There was a significant difference between the two groups (P = 0.0005). CONCLUSION: EMS implantation is a feasible, palliative method for unresectable malignant biliary obstruction. The clinical efficacy of EMS in patients with proximal hilar tumors is better than that in patients with distal tumors.

Evaluation of the role of H pylori infection in pathogenesis of gastric cancer by immunoblot assay.

AIM: To elucidate the different serological reactions to H pylori using the immunoblotting technique for further understanding of its pathogenic role in gastric cancer. METHODS: A total of 54 patients were divided into two groups after upper gastrointestinal endoscopy: normal control group (25 patients) and gastric cancer group (29 patients). Both groups were further divided into H pylori (+) and H pylori (-) subgroups based on the results of CLO test, Giemsa staining and culture. Sera were further analyzed with the immunoblotting technique (HelicoBlot 2.0, Genelabs Diagnostics, Singapore). RESULTS: The positive rate of the immunoblotting test was as high as 88.9% in the H pylori (-) gastric cancer group and only 14.3% in the H pylori (-) normal control group with a statistically significant difference. CONCLUSION: The prevalence of H pylori infection is higher in gastric cancer patients than in the normal controls, suggesting that H pylori may play a role in the pathogenesis of gastric cancer.

Cost-effectiveness analysis of population-based screening of hepatocellular carcinoma: Comparing ultrasonography with two-stage screening.

AIM: To assess the cost-effectiveness of two population-based hepatocellular carcinoma (HCC) screening programs, two-stage biomarker-ultrasound method and mass screening using abdominal ultrasonography (AUS). METHODS: In this study, we applied a Markov decision model with a societal perspective and a lifetime horizon for the general population-based cohorts in an area with high HCC incidence, such as Taiwan. The accuracy of biomarkers and ultrasonography was estimated from published meta-analyses. The costs of surveillance, diagnosis, and treatment were based on a combination of published literature, Medicare payments, and medical expenditure at the National Taiwan University Hospital. The main outcome measure was cost per life-year gained with a 3% annual discount rate. RESULTS: The results show that the mass screening using AUS was associated with an incremental cost-effectiveness ratio of USD39825 per life-year gained, whereas two-stage screening was associated with an incremental cost-effectiveness ratio of USD49733 per life-year gained, as compared with no screening. Screening programs with an initial screening age of 50 years old and biennial screening interval were the most cost-effective. These findings were sensitive to the costs of screening tools and the specificity of biomarker screening. CONCLUSION: Mass screening using AUS is more cost effective than two-stage biomarker-ultrasound screening. The most optimal strategy is an initial screening age at 50 years old with a 2-year inter-screening interval.

Utility of FDG-PET for investigating unexplained serum AFP elevation in patients with suspected hepatocellular carcinoma recurrence.

UNLABELLED: The aim of this study was to evaluate the potential role of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in patients with unexplained rising serum alpha-fetoprotein (AFP) levels after the treatment of hepatocellular carcinoma (HCC). PATIENTS AND METHODS: Thirty-one FDG-PET studies were performed in 26 patients (age range, 45-83; 21 men and 5 women), who had undergone either surgical resection or interventional therapy for HCC, but were subsequently noted to have high AFP serum levels on routine follow-up examinations, although imaging studies and physical examinations were normal. The FDG-PET results were correlated with histological findings, as well as long-term radiological and clinical follow-up (shortest follow-up period after FDG-PET was 6 months). RESULTS: FDG-PET was abnormal in 22 of the 31 studies (71.0%) among the 26 patients. Intrahepatic lesions were detected in 20 of a total 30 lesions (66.7%) in 18 studies of FDG-PET among 26 patients. Ten FDG-PET studies among 9 patients identified one intrahepatic lesion, while 3 studies among 3 patients identified more than one intrahepatic lesion. Extrahepatic metastases were found in 9/31 studies of FDG-PET (29.0%) among 8 patients. These metastatic foci, composed of increased FDG accumulation, were identified in several locations; lung (4 studies among 4 patients), bone (2 studies among 2 patients) and the peritoneum (4 studies among 3 patients). Overall, FDG-PET for detecting HCC recurrence demonstrated 22 true-positives, 8 false-negatives, 1 true-negative and 0 false-positive results., The sensitivity, specificity and accuracy of FDG-PET for detecting HCC recurrence was 73.3%, 100% and 74.2%, respectively. CONCLUSION: When conventional examinations are normal, FDG-PET is a valuable imaging tool in patients who have rising AFP levels after HCC treatment. FDG-PET whole-body scan also provides an important and valuable imaging study for detecting extrahepatic metastasis.