Two-week bismuth-containing quadruple therapy and concomitant therapy are effective first-line treatments for Helicobacter pylori eradication: A prospective open-label randomized trial.

BACKGROUND: Increasing levels of antibiotic resistance have reduced the Helicobacter pylori (H. pylori) eradication rates afforded by the standard triple therapy. Thus, 2-wk first-line four-drug regimens must be considered. AIM: To analyze the eradication rates of modified bismuth-containing quadruple therapy (mBCQT) and concomitant therapy (CT), the associated adverse events, and compliance. METHODS: Patients infected with H. pylori were prospectively randomized to receive mBCQT or CT for 2 wk. mBCQT featured a proton pump inhibitor (PPI), bismuth, metronidazole, and tetracycline, taken twice daily. CT included a PPI, clarithromycin, metronidazole, and amoxicillin, taken twice daily. The 13C-urea breath test was performed no earlier than 4 wk after therapy concluded to confirm eradication. If either the histological or rapid urease test was positive, H. pylori infection was diagnosed. RESULTS: The demographic characteristics of 68 patients who received mBCQT and 68 who received CT did not differ significantly. On intention-to-treat analysis, the eradication rate was 88.2% (60/68) in the mBCQT group and 79.4% (54/68) in the CT group (P = 0.162). By per-protocol analysis, the respective eradication rates were 98.4% (60/61) and 93.1% (54/58) (P = 0.199). More CT than mBCQT patients experienced adverse events [33.8% (23/68) mBCQT vs 51.5% (35/58) CT patients, respectively, P = 0.037]. All patients showed good compliance [85.3% (58/68) mBCQT vs 82.4% (56/68) CT patients, P = 0.641]. CONCLUSION: The H. pylori eradication rates of the 2-wk mBCQT and CT regimens are high. Most patients show good compliance, and more CT than mBCQT patients experience adverse events.

Primary epiploic appendagitis: compared with diverticulitis and focused on obesity and recurrence.

BACKGROUND/AIMS: There is limited data to compare the clinical characteristics and recurrence rates between left-sided primary epiploic appendagitis (PEA) versus left-sided acute colonic diverticulitis (ACD), and right-sided PEA versus right-sided ACD, respectively. METHODS: We retrospectively reviewed the medical records and radiologic images of the patients who presented with left-sided or right-sided acute abdominal pain and had computer tomography performed at the time of presentation showing radiological signs of PEA or ACD between January 2004 and December 2014. We compared the clinical characteristics of left PEA versus left ACD and right PEA versus right ACD, respectively. RESULTS: Fifty-six patients (left:right = 27:29) and 308 patients (left:right = 24:284) were diagnosed with symptomatic PEA and ACD, respectively. Left-sided PEA were statistically significantly younger (50.2 ± 15.4 years vs. 62.1 ± 15.8 years, P= 0.009), more obese (body mass index [BMI]: 26.3 ± 2.9 kg/m2 vs. 22.3 ± 3.1 kg/m2 , P< 0.001), and had more tendencies with normal or mildly elevated high-sensitivity C-reactive protein (hsCRP) (1.2 ± 1.3 mg/dL vs. 8.4 ± 7.9 mg/dL, P< 0.001) than patients with left-sided ACD. The discriminative function of age, BMI and CRP between left-sided PEA versus left-sided ACD was 0.71 (cutoff: age ≤ 59 years, sensitivity of 66.7%, specificity of 77.8%), 0.83 (cutoff: BMI > 24.5 kg/m2 , sensitivity of 80.0%, specificity of 80.0%) and 0.80 (cutoff: CRP < 1.8 mg/dL, sensitivity of 72.2%, specificity of 85.7%). CONCLUSIONS: If patients with left lower quadrant abdominal pain are less than 60 years, obese (BMI > 24.5 kg/m2 ) with or without normal to mild elevated CRP levels (CRP < 1.8 mg/dL), it might be necessary for clinicians to suspect the diagnosis of PEA rather than ACD.

Refeeding Syndrome as a Possible Cause of Very Early Mortality in Acute Pancreatitis.

Background/Aims: Refeeding syndrome (RFS) is a fatal clinical complication that can occur as a result of fluid and electrolyte shifts during early nutritional rehabilitation for malnourished patients. This study was conducted to determine the clinical implications of RFS in patients with acute pancreatitis (AP). Methods: Between 2006 and 2016, AP patients with very early mortality were retrospectively enrolled from three university hospitals. Results: Among 3,206 patients with AP, 44 patients died within 3 days after diagnosis. The median age was 52.5 years (range, 27 to 92 years), male-to-female ratio was 3:1, and median duration from admission to death was 33 hours (range, 5 to 72 hours). The etiology of AP was alcohol abuse in 32 patients, gallstones in five patients, and hypertriglyceridemia in two patients. Ranson score, bedside index for severity of AP, and acute physiology and chronic health evaluation-II were valuable for predicting very early mortality (median, [range]; 5 [1 to 8], 3 [0 to 5], and 19 [4 to 45]). RFS was diagnosed in nine patients who died of septic shock (n=5), cardiogenic shock (n=2), or cardiac arrhythmia (n=2). In addition, patients with RFS had significant hypophosphatemia compared to non-RFS patients (2.6 mg/dL [1.3 to 5.1] vs 5.8 mg/dL [0.8 to 15.5]; p=0.001). The early AP-related mortality rate within 3 days was approximately 1.4%, and RFS occurred in 20.5% of these patients following sudden nutritional support. Conclusions: The findings of current study emphasize that clinicians should be aware of the possibility of RFS in malnourished AP patients with electrolyte imbalances.

Early experience with Watson for oncology in Korean patients with colorectal cancer.

BACKGROUND: Watson for oncology (WFO) is a cognitive computing system providing decision support. We evaluated the concordance rates between the treatment options determined by WFO and those determined by a multidisciplinary team (MDT). METHODS: We reviewed the medical charts of patients diagnosed with colorectal cancer who visited the MDT at a single tertiary medical center from November 2016 to April 2017. WFO classified the treatment options for specific patients into three categories: 'Recommended', 'For consideration', and 'Not recommended'. Concordance rates between the WFO- and MDT-determined chemotherapy options, and the factors that potentially influence the concordance rate, were analyzed. RESULTS: Sixty-nine patients with colorectal cancer met with the MDT from Nov. 2016 to Feb. 2017. The mean age of the patients was 62 years (range: 34-86 years), and more patients were male (47/69) than female. Of the 69 patients, 51 (73.9%) were diagnosed with colon cancer, of whom 46.4% received the same regimen recommendation from WFO ('Recommended') as they did from the MDT. After inclusion of the 'For consideration' category from WFO, the concordance rate increased to 87.0%. The concordance rate between MDT and NCCN guidelines was 97.1%, and that between the WFO and NCCN guidelines was 88.4%. The concordance rates between WFO and MDT were significantly lower in patients with stage II, IIIC, or IV disease (P<0.001), and the colorectal cancer stage was the only statistically significant factor discriminating between WFO and MDT. CONCLUSIONS: The concordance rate between chemotherapy regimens for colorectal cancer determined by MDT versus WFO recommendations was 46.4%. After including the 'For consideration' category from WFO, the concordance rate increased to 88.4%. Further modification and improvement of the WFO prioritizing algorithm used to recommend treatment may increase the usefulness of WFO in the clinic.

Drug-induced eosinophilic pneumonia in a patient with Crohn's disease: diagnosis and treatment using fraction of exhaled nitric oxide.

Oral 5-aminosalicylic acid agents (mesalazine and sulfasalazine) and azathioprine are the mainstays of treatment for inflammatory bowel disease. Reports of pulmonary toxicity induced by oral 5-aminosalicylic acid agents or azathioprine in patients with inflammatory bowel disease are very rare; to date, only 38 cases have been reported worldwide. We, herein, report a case involving a 26-year-old man who was diagnosed with eosinophilic pneumonia after using mesalazine and azathioprine for the treatment of Crohn's disease and recovered after treatment. We also found that the fraction of exhaled nitric oxide level was elevated in this patient. After treatment, the fraction of exhaled nitric oxide level decreased and the symptoms improved. The present case shows that fraction of exhaled nitric oxide is related to the disease activity and treatment effectiveness of druginduced eosinophilic pneumonia.

DA-9701 improves colonic transit time and symptoms in patients with functional constipation: A prospective study.

BACKGROUND AND AIM: DA-9701, a newly developed prokinetic agent formulated with Pharbitis Semen and Corydalis Tuber, has been shown to effectively treat functional dyspepsia. Recently, it has also been suspected to improve gastrointestinal motor function. The aims of this study were to assess the effect of DA-9701 on colonic transit time (CTT) and symptoms of functional constipation. METHODS: Thirty-three patients with functional constipation based on the Rome III criteria were prospectively enrolled. The patients received 30-mg DA-9701 three times a day for 24 days. CTT was estimated initially and at the end of treatment. Symptoms such as spontaneous bowel movements, straining, stool form, feeling of incomplete emptying and anorectal blockage, abdominal discomfort and pain, overall defecation satisfaction, and incidence of adverse events were also analyzed. RESULTS: Twenty-seven patients completed the study. DA-9701 was associated with a significantly reduced CTT from 34.9 ± 17.6 to 23.7 ± 19.1 h (P = 0.001). Segmental CTT also significantly decreased after treatment (right CTT: from 16.8 [0.0-28.8] to 6.0 [0.0-25.2] hours, P < 0.001; rectosigmoid transit time: from 13.2 [0.0-38.4] to 6.0 [0.0-33.6] hours, P = 0.021). In addition, all constipation-related subjective symptoms, including spontaneous bowel movement frequency, significantly improved compared with those before treatment. Serious adverse events did not occur. CONCLUSIONS: DA-9701 accelerates colonic transit and safely improves symptoms in patients with functional constipation. Therefore, we suggest that this novel agent could help to treat patients with this condition.

Risk Factors for Metachronous Recurrence after Endoscopic Submucosal Dissection of Early Gastric Cancer.

Although endoscopic submucosal dissection (ESD) is widely accepted as a curative treatment method for early gastric cancer (EGC) worldwide, metachronous recurrence often occurs after ESD for EGC. However, there are insufficient data about the role of Helicobacter pylori (H. pylori) infection and other risk factors for recurrence. We aimed to compare the metachronous lesion in the H. pylori persistent group and the eradicated group, and to identify risk factors for metachronous lesion. We retrospectively analyzed 782 patients who underwent ESD between January 2008 and December 2013. We excluded patients with dysplasia or patients who were not tested for H. pylori infection. One hundred eighty-five patients were enrolled. We studied risk factors for recurrence, and used survival analysis to test. There were 24 patients with metachronous recurrence after ESD for EGC among the group. The incidence of metachronous gastric lesions after ESD for EGC developed more in the over 70-year-old group (P = 0.025) and more in the H. pylori persistent group (P = 0.008). In conclusion, H. pylori infection and old age are independent risk factors for metachronous gastric lesions after ESD in EGC.

Spontaneous peeled ileal giant lipoma caused by lower gastrointestinal bleeding: A case report.

RATIONALE: Gastrointestinal subepithelial tumors (SETs) with endoscopic features such as ulceration, a red color change, a peeled mucosal layer, and spontaneous bleeding could have malignant potential. However, we encountered a case of a lipoma that presented features different from the generally known features of gastrointestinal SETs. Therefore, we report an interesting rare case of a terminal ileal giant lipoma with a unique feature of spontaneous peeled ulceration on the surface on endoscopy that caused gastrointestinal bleeding. PATIENT: An 82-year-old woman with a 1-week history of abdominal pain and hematochezia presented to our hospital. DIAGNOSES: Ileocolonoscopy revealed a SET with a peeled surface and erythematous and ulcerative mucosal changes as well as exposed a submucosal mass at the terminal ileum. Macroscopically, the lesion appeared as a yellowish pedunculated polypoid mass measuring 3 × 2 cm with a peeled mucosal ulceration. Histopathological findings revealed a submucosal lipoma of the terminal ileum. INTERVENTION: We thought that the endoscopic finding indicated malignant SETs or those with malignant potential rather than benign SETs. Therefore, the patient underwent an elective laparoscopic ileocecectomy. LESSONS: We encountered a lipoma that did not present with the typical features of gastrointestinal SETs. Our findings suggest that clinicians should consider that benign SETs in the terminal ileum may present with various endoscopic findings similar to those of malignant SETs, which can cause fatal symptoms and signs.

Randomized Phase II Study of Pemetrexed Versus Gefitinib in Previously Treated Patients with Advanced Non-small Cell Lung Cancer.

PURPOSE: This study aimed to evaluate the efficacy and safety of pemetrexed versus gefitinib in patients with advanced non-small cell lung cancer (NSCLC) previously treated with chemotherapy. MATERIALS AND METHODS: Patients with advanced (stage IIIB or IV) or recurrent NSCLC were randomly assigned to receive either 500 mg/m² of pemetrexed intravenously every 3 weeks or gefitinib 250 mg/day orally. The primary end point was progression-free survival (PFS) at 6 months. RESULTS: A total of 95 patients were enrolled (47 for pemetrexed and 48 for gefitinib). Most patients were male (72%) and current/ex-smokers (69%), and 80% had non-squamous cell carcinoma. The epidermal growth factor receptor (EGFR) mutation status was determined in 38 patients (40%); one patient per each arm was positive for EGFR mutation. The 6-month PFS rates were 22% and 15% for pemetrexed and gefitinib, respectively (p=0.35). Both arms showed an identical median PFS of 2.0 months and a median overall survival (OS) of 8.5 months. In EGFR wild-type patients, higher response rate (RR) and longer PFS as well as OS were achieved via pemetrexed compared with gefitinib, although there were no significant differences (RR: 39% vs. 9%, p=0.07; median PFS: 6.6 months vs. 3.1 months, p=0.45; median OS: 29.6 months vs. 12.9 months, p=0.62). Toxicities were mild in both treatment arms. Frequently reported toxicities were anemia and fatigue for pemetrexed, and skin rash and anorexia for gefitinib. CONCLUSION: Both pemetrexed and gefitinib had similar efficacy with good tolerability as second-line treatment in unselected patients with advanced NSCLC. However, pemetrexed is considered more effective than gefitinib for EGFR wild-type patients.

Oxaliplatin-Induced Immune-Mediated Thrombocytopenia: A Case Report.

Oxaliplatin is a third-generation platinum derivative used for metastatic or advanced colorectal cancer treatment. Although myelosuppression is the most common cause of oxaliplatin-induced thrombocytopenia, rare cases of oxaliplatin-induced immune-mediated thrombocytopenia are reported. We report a case of a 57-year-old woman with colon cancer who developed gum bleeding and petechiae after oxaliplatin infusion. Laboratory tests revealed grade 4 thrombocytopenia and grade 4 neutropenia. She recovered from the thrombocytopenia and accompanying neutropenia within 4 days with no recurrence following discontinuation of oxaliplatin. Physicians need to be aware of the risk of severe acute thrombocytopenia following oxaliplatin administration.

Epidermal growth factor receptor (EGFR) exon 20 mutations in non-small-cell lung cancer and resistance to EGFR-tyrosine kinase inhibitors.

INTRODUCTION: In patients with non-small cell lung cancer (NSCLC), the predictive value of rare epidermal growth factor receptor (EGFR) exon 20 mutations in determining a patient's response to EGFR tyrosine kinase inhibitor (TKI) treatment is unclear. PATIENTS AND METHODS: We reviewed data for NSCLC patients harboring EGFR exon 20 mutations from two hospitals in Korea. EGFR mutations were analyzed using directional sequencing. RESULTS: We identified eight patients carrying EGFR exon 20 mutations, seven of whom had insertional mutations. Three patients carried previously unreported insertional mutations. Among six patients who were treated with EGFR TKI, one showed stable disease and three showed primary resistance. Response evaluations were not performed for the other two patients because of their clinical deterioration. CONCLUSIONS: EGFR exon 20 insertional mutations, including three that were previously unreported, were associated with the poor response of patients to TKI treatment.