Airway pH monitoring in patients with suspected obstructive sleep apnoea using the Dx-pH oropharyngeal probe: preliminary report of a prospective cohort study.

OBJECTIVES: To investigate the laryngopharyngeal reflux (LPR) episodes and pH values in patients with suspected obstructive sleep apnoea (OSA) using the Dx-pH oropharyngeal probe. DESIGN: Prospective cohort study. SETTING: Tertiary medical centre. PARTICIPANTS: Forty patients with complaint of snoring or suspected OSA were prospectively enrolled to receive full nocturnal polysomnography (PSG). The patients were divided into 2 groups: a simple snorers group if the Respiratory Disturbance Index (RDI) was < 5 and an OSA group if the RDI was ≥ 5. MAIN OUTCOME MEASURES: The patients simultaneously received Dx-pH oropharyngeal probe monitoring for 12 h from about 6 pm to 6 am of the next day. The number of LPR events was recorded if the nadir of rapid pH drops was below pH 5.0 and 5.5. The difference of LPR events between the two groups and the difference of LPR events between awake and sleep periods in each group were analysed, respectively. RESULTS: There were 18 (45%) patients diagnosed as OSA with a mean RDI of 28.7, and 22 patients (55%) diagnosed as simple snorers. Between 2 groups, there were no significant differences in the LPR events and pH values during the awake period, sleep period or overall recording period. Comparison of the LPR events and minimum pH values between the awake period and the sleep period revealed there were no significant differences in either group. CONCLUSION: Using the new sensitive Dx-pH oropharyngeal probe with PSG, we found that OSA does not correlate with a higher incidence of LPR episodes.

Lack of efficacy to systemic chemotherapy for treatment of metaplastic carcinoma of the breast in the modern era.

Metaplastic carcinoma of the breast (MCB) is a rare subtype of breast cancer. Anecdotal reports are available regarding its response to systemic chemotherapy. We reviewed the records of patients diagnosed with MCB at National Taiwan University Hospital between 1988 and 2009. A total of 46 MCB cases were identified from 8,695 breast tumor patients who underwent biopsy or resection. About 11 of 25 patients with initial bulky disease (T3-4) received neoadjuvant chemotherapy before surgery, and 2 (18.2%) exhibited a partial response. About 12 of 18 patients who developed distant metastasis received palliative systemic chemotherapy. Of them, only 1 (8.3%), 1 (10%), and none (0%) responded to first-, second-, or third- and beyond line chemotherapy, respectively. None of the patients who received anthracyline- (n = 13), vinorelbine- (n = 7), or cyclophosphamide-based (n = 18) chemotherapy responded, whereas 3 (17.6%) of 17 patients who received taxane-based chemotherapy exhibited a partial response. Tumor response to systemic chemotherapy remains generally poor for MCB patients. Taxanes may have modest activity, but need to be validated in further studies.

Classical reflux symptoms, hiatus hernia and overweight independently predict pharyngeal acid exposure in patients with suspected reflux laryngitis.

BACKGROUND: Gastro-oesophageal reflux disease (GERD) has been associated with reflux laryngitis. AIMS: To investigate the risk factors and the predictors of pharyngeal acid reflux (PAR) in Taiwanese patients with suspected reflux laryngitis. METHODS: With referral from ENT physicians, 104 patients with symptoms and signs suggestive of reflux laryngitis completed a validated symptom questionnaire, an upper endoscopy exam and ambulatory 24-h pH tests with three sensors located at the hypopharynx, proximal and distal oesophagus. Patients with one or more episodes of PAR were considered abnormal. RESULTS: Pharyngeal acid reflux was identified in 17% (18/104) of patients. In multivariate logistic regression analysis, PAR was independently associated with classical reflux symptoms [adjusted odds ratio (aOR) = 3.5, 95% confidence interval (CI): 1.0-12.8], hiatus hernia (aOR = 6.7, 95% CI: 1.5-30.2) and overweight (aOR = 3.4, 95% CI: 1.0-11.0). In predicting PAR, classical reflux symptoms had a sensitivity of 78% and hiatus hernia had a specificity of 95%. With all three factors, the positive predictive value for PAR was 80%. Classical reflux symptoms included heartburn, chest pain, dyspepsia and acid regurgitation. CONCLUSIONS: Classical reflux symptoms, hiatus hernia and overweight are independent risk factors that may predict pharyngeal acid reflux in patients with suspected reflux laryngitis.

Varying postprandial abdominovagal and cardiovagal activity in normal subjects.

BACKGROUND: Several studies have supported the hypothesis of different presentations in the autonomic nervous system (ANS) between cardiac and gastric vagal activity. Due to the regionality of the ANS, different responses among different organ systems to the same stimulation (such as a meal) are quite possible. METHODS: In this study we monitored the postprandial changes of heart rate variability (HRV) and gastrointestinal (GI) hormones to determine whether both responded in a similar pattern. Twenty-two healthy volunteers (6 males and 16 females) were enrolled. After recording a baseline ECG rhythm, further recordings were made at 20 min intervals for 120 min after a test meal. Serum human pancreatic polypeptide (PP), leptin, and total and active ghrelin levels were measured. KEY RESULTS: After the meal, HR increased significantly from baseline at each time point, except for 20 min after the meal. The high frequency (HF) power decreased significantly from 40 min to 120 min after the meal. In addition, the low frequency (LF) power also decreased significantly from 60 min to 120 min. However, the LF:HF ratio increased significantly from 20 min to 120 min. There was a marked increase (>2 fold) of PP at 20 min after the meal, and the increase was sustained throughout the test period. CONCLUSIONS & INFERENCES: These findings suggest that HRV reflects cardiac, but not equivalently, abdominovagal activity. Therefore, HRV as an abdominovagal activity measurement in patients with GI functional problems should be used with caution, and other markers such as PP should be included.

Differential expression of glucocorticoid receptor in carcinomas of the human digestive system.

AIMS: To investigate the in situ expression profile of glucocorticoid receptor (GR) in normal and carcinomatous tissues of the human digestive system. METHODS AND RESULTS: Specimens from 306 carcinomas of the human digestive tract were assayed for the expression of GR by immunohistochemistry. GR expression was strong in oesophageal squamous epithelia, pancreatic islet cells and hepatocytes, but generally weak or negative in non-squamous epithelia. Consistently, GR expression was found in a high percentage of oesophageal squamous cell carcinomas (SCC) (98.1%) and hepatocellular carcinomas (HCC) (92.9%), but rarely in gastric adenocarcinomas (7.4%) and not at all in colorectal adenocarcinomas (0%). Dexamethasone (DEX) was found to confer chemoresistance in oesophageal SCC and HCC cells, suggesting that GR expression may be biologically important in some GR-expressing carcinomas. CONCLUSIONS: Distribution of GR expression is markedly diverse among tissues of the human digestive system. The general lack of GR in adenocarcinomas contrasts with the high percentage of SCCs and HCCs expressing GR, and, along with the generation of chemoresistance by DEX, warrants prospective study of the effects of steroids on these cancers.

Molecular signatures of metaplastic carcinoma of the breast by large-scale transcriptional profiling: identification of genes potentially related to epithelial-mesenchymal transition.

Metaplastic carcinoma of the breast (MCB) is a poorly understood subtype of breast cancer. It is generally characterized by the coexistence of ductal carcinomatous and transdifferentiated sarcomatous components, but the underlying molecular alterations, possibly related to epithelial-mesenchymal transition (EMT), remain elusive. We performed transcriptional profiling using half-a-genome oligonucleotide microarrays to elucidate genetic profiles of MCBs and their differences to those of ductal carcinoma of breasts (DCBs) using discarded specimens of four MCBs and 34 DCBs. Unsupervised clustering disclosed distinctive expression profiles between MCBs and DCBs. Supervised analysis identified gene signatures discriminating MCBs from DCBs and between MCB subclasses. Notably, many of the discriminator genes were associated with downregulation of epithelial phenotypes and with synthesis, remodeling and adhesion of extracellular matrix, with some of them have known or inferred roles related to EMT. Importantly, several of the discriminator genes were upregulated in a mutant Snail-transfected MCF7 cell known to exhibit features of EMT, thereby indicating a crucial role for EMT in the pathogenesis of MCBs. Finally, the identification of SPARC and vimentin as poor prognostic factors reinforced the role of EMT in cancer progression. These data advance our understanding of MCB and offer clues to the molecular alterations underlying EMT.

Improvement of tissue-adhesive obliteration of bleeding gastric varices using adjuvant hypertonic glucose injection: a prospective randomized trial.

BACKGROUND AND STUDY AIMS: Rebleeding can occur after endoscopic injection of gastric varices with tissue adhesive. The aim of this study was to evaluate whether adjuvant hypertonic glucose solution injections enhance the effects of Histoacryl after successful initial variceal obliteration. PATIENTS AND METHODS: A total of 67 patients (37 men, 30 women; mean age +/- standard deviation [SD] 60 +/- 17 years) with initially successful Histoacryl obliteration of bleeding gastric varices were included in the study and randomly divided into two groups: a "combined" group of patients who had adjuvant injection of hypertonic glucose solutions in cases of residual gastric varices (F1 or less) and a "control" group of patients who did not receive such therapy. End points were either variceal recurrence/progression (F2 or more) requiring Histoacryl reinjection or rebleeding. RESULTS: Residual small varices were found in 56% of patients in the combined group and in 60% of patients in the control group. Adjuvant therapy was only performed in the combined group. During the follow-up period (mean duration +/- SD 37.9 +/- 18.5 months, range 19-56 months), two patients in the combined group showed gastric variceal progression, compared with nine patients showing progression in the control group, with two cases of rebleeding, both occurring in the control group. Two years after the first Histoacryl injection, the cumulative proportion of patients who did not have gastric variceal progression was significantly higher in the combined group than it was in the control group (92.8% vs. 71.4%, P = 0.029). There was no significant difference between the two groups with respect to their survival curves (P = 0.12). No marked immediate or delayed symptoms or complications were observed in the patients given hypertonic glucose injections. CONCLUSIONS: Adjuvant treatment with hypertonic glucose solution for residual small gastric varices is a safe and simple method. It helps reduce the recurrence or progression of gastric varices after tissue adhesive injections and can therefore reduce the risk of rebleeding.

Differential expression of glucocorticoid receptor in human breast tissues and related neoplasms.

Glucocorticoid receptor (GR) is a steroid hormone receptor that has been shown to play important roles in mammary development and differentiation, and has been implicated in breast tumourigenesis, but its precise biological significance in mammary pathophysiology remains unclear. In order to generate a comprehensive expression profile for GR in normal versus neoplastic breast tissues, GR expression was investigated in situ in 400 human breast tissue samples, comprising normal tissue and a range of benign, pre-invasive, and invasive lesions, using immunohistochemical assays. The novel expression of GR in myoepithelium, not observed in luminal epithelium, not only demonstrates expression patterns exclusive to the alpha form of oestrogen receptor and progesterone receptor and suggests distinctive functions between GR and these two important steroid hormone receptors in the breast, but may also indicate unique physiological and perhaps pathological roles for the myoepithelium in mediating the effects of glucocorticoid hormones in the breast. The strong expression of GR in metaplastic carcinomas (94.4%) and malignant phyllodes tumours (92.3%) suggests a pathogenetic role for GR, and implies that targeting GR in these tumours may have potential therapeutic application. However, studies on the roles of GR in mammary carcinogenesis should be interpreted with great caution, based on the lack of GR expression in cancer cells in the great majority (98.2%) of non-metaplastic carcinomas, which has gone unnoticed in previous studies. This marked discrepancy warrants a re-examination of the biological roles of GR in the pathophysiology of breast malignancy. The lack of methylation in the promoter region of the GR gene in all 118 non-metaplastic carcinomas, as demonstrated by methylation-specific PCR and bisulphite DNA sequencing analysis, indicates that methylation is less likely to play a role in the reduction of GR expression in non-metaplastic carcinoma of the breast.

Predictive factors of the long-term outcome in reflux esophagitis in a low-prevalence gastroesophageal reflux disease region.

BACKGROUND: There are no data concerning the long-term outcome of patients with reflux esophagitis in Taiwan. In this study the outcome and the specific prognostic indicators associated with outcome in patients were assessed retrospectively, 7 years after diagnosis of esophagitis. METHODS: The study comprised a total of 128 patients with endoscopic esophagitis, diagnosed between January and June 1995, at Taichung Veterans' General Hospital. The outcome at 7 years after diagnosis was assessed by outpatient or telephone interview. Factors associated with requiring long-term acid suppression therapy were analyzed. RESULTS: In all, 105 patients were eligible for analysis: 61 patients (58.1%) with LA (Los Angeles classification) grade A, 29 patients (27.6%) with grade B, 11 patients (10.5%) with grade C and 4 patients (3.5%) with grade D esophagitis. Seven years after diagnosis, there were 52 patients (49.5%) with no or occasional reflux symptoms, 8 patients (7.6%) with occasional symptoms requiring treatment with histamine-2 receptor antagonists (H2RAs), 12 patients (11.4%) with occasional symptoms requiring treatment with proton pump inhibitors (PPIs), as needed, and 33 patients (31.3%) with sustained symptoms needing daily maintenance with PPIs. CONCLUSION: Nearly 50% of patients in Taiwan with endoscopic esophagitis still required treatment 7 years after diagnosis. Approximately 31% of patients still required daily acid suppression therapy. Presence of hiatal hernia and the severity of esophagitis at initial endoscopy independently were predictive of those who would require long-term acid suppression therapy.

Nizatidine enhances the gastrocolonic response and the colonic peristaltic reflex in humans.

Animal studies demonstrate that nizatidine, an H2-receptor inhibitor, may enhance colonic activity independent of its effect on acid secretion. The effect of nizatidine on human colonic motility is unknown. We evaluated the potential prokinetic property of nizatidine in 12 healthy subjects (10 men and 2 women, age 21-46 years). Each subject received either nizatidine (600 mg), famotidine (80 mg, a H2-receptor inhibitor used as a control), or a placebo, on separate days in randomized order at least 3 days apart. Following an overnight fast, a three-lumen catheter fitted with a stimulus balloon and two barostat bags was placed in the descending colon. The gastrocolonic response was tested by antral balloon inflation and the colonic peristaltic reflex was evaluated by colonic distension. Changes in colonic motility were assessed by volume changes in the barostat bags. Antral distension evoked volume-dependent increases in colonic motility, maximal at a 300-ml inflation, as demonstrated by a reduced bag volume. Nizatidine enhanced colonic motility in response to antral distension at 200 and 300 ml, compared with famotidine and placebo. Colonic distension evoked volume-dependent increases in colonic motility proximal to the stimulus balloon. Compared with famotidine and placebo, nizatidine enhanced the ascending and descending contractile limbs of the peristaltic reflex but did not affect relaxation distal to the balloon. In conclusion, nizatidine enhanced the gastrocolonic response and the colonic peristaltic reflex in healthy subjects. Further research on the prokinetic action of nizatidine in the colon may lead to novel treatments for idiopathic constipation.

Predominant Th2/Tc2 polarity of tumor-infiltrating lymphocytes in human cervical cancer.

Cytotoxic T lymphocytes (Tc) play a central role in cellular immunity against cancers. The cytotoxic potential of freshly isolated tumor-infiltrating lymphocytes (TILs) is usually not expressed. This suggests the possible existence of as yet unspecified and perhaps complex immunosuppressive factors or cytokines that affect the anti-tumor capacity of these TILs in the tumor milieu. In the present study, we demonstrated for the first time that TILs derived from human cervical cancer tissue consist mainly of Th2/Tc2 phenotypes. In vitro kinetic assays further revealed that cancer cells could direct the tumor-encountered T cells toward the Th2/Tc2 polarity. Cancer cells promote the production of IL-4 and down-regulate the production of IFN-gamma in cancer-encountered T cells. The regulatory effects of cervical cancer cells are mediated mainly by IL-10, and TGF-beta plays only a synergistic role. The cancer-derived effects can be reversed by neutralizing anti-IL-10 and anti-TGF-beta Abs. IL-10 and TGF-beta are present in cancer tissue and weakly expressed in precancerous tissue, but not in normal cervical epithelial cells. Our study strongly suggests important regulatory roles of IL-10 and TGF-beta in cancer-mediated immunosuppression.

Colonoscopic manifestations of primary colorectal lymphoma.

BACKGROUND AND STUDY AIMS: Little is known about the colonoscopic manifestation of colorectal lymphoma. This article describes the use of colonoscopy for diagnosis of primary colorectal lymphoma. PATIENTS AND METHODS: We analyzed colonoscopic findings in 13 retrospectively collected cases of primary colorectal lymphoma diagnosed between 1990 and 1999 at our hospital. RESULTS: The primary colorectal tymphomas were distinguished into three colonoscopic types: a) the mucosal type, which included six lymphomas (46%), which were classified into two subtypes, erosive (two lymphomas) and ulcerative (four tymphomas); b) the polypoid type, which included three tymphomas (23%); and c) the massive type, which included four (31%). The proportion of patients with T-cell lineage lymphoma (5 of 12, 42%) was higher than in previous studies. Three cases were diagnosed as enteropathy-associated T-cell (EAT)-like lymphoma: one presenting with multicentric ulcerations, one as a massive type and another as a polypoid type. Of those with B-cell lineage lymphoma (7 of 12, 58%), three presented as massive type, two as polypoid type and two as erosive subtype. CONCLUSIONS: Based on the analysis of colonoscopic records, we have proposed three main types of primary colorectal lymphoma. An unusually high proportion of T-cell lineage lymphomas was noted, but as the number of cases was low, further study is still needed for confirmation.

The effect of jejunal meal feeding on gastroesophageal reflux.

BACKGROUND: Postprandial gastric distention is frequently associated with transient lower esophageal sphincter relaxation and gastroesophageal reflux (GER). Since the role of nutrient perfusion into the jejunum in inducing GER is not well understood, we studied the effect of jejunal feeding on GER through a percutaneous gastrojejunal tube in patients with and without reflux esophagitis. METHODS: Nine stroke patients with reflux esophagitis were fed through a percutaneous gastrojejunal tube with either a liquid meal (2 kcal/2 ml/min) or saline for 2 h randomly on 2 separate days. An esophageal pH probe was placed 5 cm above the gastroesophageal junction to detect acid reflux. Six stroke patients without esophagitis were enrolled as controls. RESULTS: In both the patients with esophagitis and the controls, esophageal acid exposure (15.3% (4.9%-28.2%) versus 2.7% (0.0%-10.8%), P=0.003; 5.9% (0.5%-6.7%) versus 0.0% (0.0%-1.5%), P = 0.01) and events of acid reflux (5 (1-16) versus 2 (0-8), P = 0.02; 12 (3-17) versus 1 (0-4), P = 0.02) were significantly greater during jejunal meal feeding than during saline infusion. Furthermore, in the reflux patients, but not in the controls, acid clearance time was also greater during jejunal meal feeding than during saline infusion (2.9 min (0.5-9.6 min) versus 0.7 min (0.0-4.3 min), P = 0.04). CONCLUSIONS: We therefore conclude that jejunal nutrient infusion without gastric distention can induce GER in both patients with reflux esophagitis and controls. This implies that GER induced by jejununal nutrients may in part explain the incapability of jejunal tube feeding to prevent gastropulmonary aspiration in patients at risk.

A novel role of metalloproteinase in cancer-mediated immunosuppression.

Depressed immune responses have been observed frequently in cancer patients. In a variety of human malignancies, the expression of interleukin-2 receptor alpha (IL-2R alpha) on activated tumor-infiltrating lymphocytes was down-regulated. Because IL-2R alpha plays a pivotal role in the development and propagation of functional T cells, its depressed expression may result in poor function of tumor-reactive cytotoxic lymphocytes. For elucidating the mechanism responsible for down-regulation of IL-2R alpha, a coculture model of in vitro mixed autologous lymphocytes and tumor cells was established. Kinetic analysis showed that cervical cancer cells down-regulated IL-2R alpha expression on encountered T cells. The amount of IL-2R alpha mRNA in tumor-infiltrating lymphocytes-derived CD8+ T cells was compatible with that in the corresponding activated CD8+ T cells. Additional evidence showed that cervical cancer cells could induce the release of soluble IL-2R alpha expression on encountered T cells. By using protease inhibition assays we demonstrated that tissue inhibitors of metalloproteinase abrogated the cancer-mediated IL-2R alpha proteolytic process and restored the T-cell proliferation function. Immunohistochemical stainings further revealed prominent metalloproteinase (MMP) expressions, including MMP-1, MMP-2, and MMP-9, in cervical cancer tissues. Additional in vitro studies showed that MMP-9 mediates cleavage of IL-2R alpha and down-regulates the proliferative capability of cancer-encountered T cells. Our findings suggest a new role of MMPs in tumor-mediated immunosuppression and provide a possible therapeutic potential for patients with cervical cancer.

Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety.

BACKGROUND: The long-term efficacy and safety of the endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) were evaluated to define its role as the initial treatment for bleeding gastric varices. METHODS: Ninety patients with bleeding gastric varices underwent endoscopic injections of Histoacryl for hemostasis within a 6-year period. Histoacryl was injected intravariceally as a 1:1 mixture with Lipiodol. Among the 90 patients, 5 had active bleeding and 85 had recent bleeding. Most of the varices were large (F2 or F3, 85 cases). The most common locations were the fundus and the posterior wall of the proximal body (94.4%). After Histoacryl injection, patients were followed endoscopically with retreatment as necessary. RESULTS: The rate of hemostasis at 1 week was 94.4%. Recurrent bleeding occurred in 23.3% of the patients from 3 days to 16 months after the initial injection. Recurrent bleeding was stopped with reinjections of Histoacryl in 16.7% of the patients. The rate of definitive hemostasis was 93.3% (84 of 90). The treatment failure-related mortality rate was 2.2% (2 of 90). To date, 35 patients have died, mostly as a result of malignancy or liver failure, and 55 are still alive. The determining factor for long-term survival was the underlying disease leading to portal hypertension. There were few long-term complications except for Histoacryl cast extrusion-related mucosal defects. CONCLUSIONS: Endoscopic injection of Histoacryl is highly effective for the treatment of bleeding gastric varices, with rare complications both acutely and long term. This treatment modality is appropriate as the first choice for bleeding gastric varices.

Expression of cyclin-dependent kinase 6 (cdk6) and frequent loss of CD44 in nasal-nasopharyngeal NK/T-cell lymphomas: comparison with CD56-negative peripheral T-cell lymphomas.

Lymphomas involving the nasal and nasopharyngeal region mainly include CD56-positive natural killer (NK)/T-cell lymphomas, CD56-negative peripheral T-cell lymphomas (PTL), and B-cell lymphomas. Among these, the CD56-positive lymphoma, presumably of an NK/T-cell nature, is frequently seen in Asian, Mexican, and South American patients. NK cells are proposed to be closer developmentally to T cells than to other lymphoid cells, because bipotential common progenitor cells of NK/T-cell lineage have been isolated. In this study, we collected 47 cases of nasal lymphoma and investigated the phenotypic difference between NK/T-cell lymphoma and PTL by examining the pattern of the developmentally differentially expressed molecules cdk6 (cyclin-dependent kinase 6), CD44, CD117, and by examining the rearrangement of the T-cell receptor gene (TcR-GR). cdk6, an essential regulator of the cell cycle in G1 progression, was over-expressed in a subset of cortical thymocytes, but absent in mature thymocytes. In contrast, CD44, a glycosylated adhesion molecule, was absent in cortical thymocytes, but present in mature thymocytes and peripheral activated T cells. We found both over-expression of nuclear cdk6 (n-cdk6) and frequent absence of CD44 in nasal CD56-positive NK/T-cell lymphomas, in contrast to most nasal CD56-negative PTL, which were CD44-immunoreactive with weak or no expression of n-cdk6. Almost all tested cases of NK/T-cell lymphoma displayed a germ-line configuration of TcR, without evidence of gene rearrangement. Thus, there seems to be a useful distinction between the classical NK/T type of nasal lymphoma (CD56+/n-cdk6+/CD44-/TcR-GR-) and PTL (CD56-/n-cdk6-/CD44+/TcR-GR+) involving the nasal region. The presence of Epstein-Barr virus does not seem to be a good marker for distinguishing between NK/T lymphoma and PTL involving the nasal region.

Wavelet-based histogram equalization enhancement of gastric sonogram images.

The gray levels of gastric sonogram images are usually concentrated at the zero end of the spectrum, making the image too low in contrast and too dark for the naked eye. Though histogram equalization can enhance the contrast by redistributing the gray levels, it has the drawback that it reduces the information in the processed image. In this paper, a wavelet-based enhancement algorithm post-processor is used to further enhance the image and compensate for the information loss during histogram equalization. Experimental results show that the wavelet-based enhancement algorithm can enhance the contrast and significantly increase the informational entropy of the image. Because the combination of the histogram equalization and wavelet approach can dramatically increase the contrast and maintain information rate in gastric sonograms, it has the potential to improve clinical diagnosis and research.

Can percutaneous endoscopic jejunostomy prevent gastroesophageal reflux in patients with preexisting esophagitis?

OBJECTIVE: Percutaneous endoscopic jejunostomy has been used for preventing pulmonary aspiration arising from gastric contents by concomitant jejunal feeding and gastric decompression in susceptible patients. Our objective was to evaluate gastroesophageal reflux in patients with percutaneous endoscopic jejunostomy tube feeding. METHODS: Eight cerebrovascular accident patients with percutaneous endoscopic jejunostomy tube placement caused by reflux esophagitis with hematemesis, food regurgitation or vomiting, and/or recurrent aspiration pneumonia were tested for gastroesophageal reflux using 24-h esophageal pH monitoring during continuous jejunal liquid meal or saline infusion with concomitant gastric decompression. Twenty-four hour pH monitoring was also performed during intragastric feeding on a different day. RESULTS: During the liquid meal feeding period, percutaneous endoscopic jejunostomy feeding reduced esophageal acid exposure 46% [12.9% (4.9-28.2%) versus 24.0% (19.0-40.6%), p = 0.01], compared to intragastric feeding. However, in the period of the jejunal tube infusion, esophageal acid exposure was significantly lower during saline infusion than during meal infusion [3.2 (0.0%-10.8%) versus 12.9% (4.9-28.2%), p = 0.008]. CONCLUSION: Percutaneous endoscopic jejunostomy feeding reduced but did not eliminate gastroesophageal reflux, compared to intragastric feeding in patients with severe gastroesophageal reflux. However, gastroesophageal reflux during percutaneous jejunal feeding was associated with meal infusion. This might, in part, explain the failure of percutaneous endoscopic jejunostomy tube placement to prevent pulmonary aspiration.

The effect of intragastric acidity on Helicobacter pylori eradication with bismuth-metronidazole-amoxicillin.

BACKGROUND/AIMS: Adding an acid secretion inhibitor to anti-H. pylori regimens may be potentially valuable for enhancing the effectiveness of antimicrobials that exhibit markedly reduced activity at low pH. This study was conducted to evaluate intragastric acidity as a factor in H. pylori eradication with bismuth-based triple therapy. METHODOLOGY: Forty patients with duodenal ulcer and H. pylori infection were included. The patients were divided into 2 groups--normacid (n = 20) and hyperacid (n = 20)--based on the amount of time that 24-hour intragastric pH took to reach the level pH > or = 3. All patients received bismuth subsalicylate (600 mg 3 times daily), metronidazole (500 mg 3 times daily) and amoxicillin (500 mg 3 times daily) for 2 weeks. Then, all patients continued treatment with ranitidine (150 mg twice daily) for 8 weeks prior to the follow-up examination. Blood samples were collected before treatment for measurement of fasting gastrin and pepsinogen-I. RESULTS: Nine patients (45%) in the normacid group and 8 patients (40%) in the hyperacid group reported side effects. However, there were only 2 patients (10%) in each group who withdrew from the study due to intolerance of side-effects. There was no difference in the H. pylori eradication rate between the normacid and hyperacid groups (16/18, 88.9% vs. 15/18, 83.3%). CONCLUSIONS: Without co-administration of anti-secretary agents, intragastric acid is not a significant factor in the effectiveness of H. pylori eradication with bismuth-based triple therapy.