A one-year follow-up study on the incidence and risk of endophthalmitis after pyogenic liver abscess.

PURPOSE: Although endophthalmitis secondary to pyogenic liver abscess (PLA) is becoming a globally emerging infectious disease, population-based investigations evaluating the relationship between PLA and endogenous endophthalmitis remain scarce. This study aimed to investigate the incidence and risk of endogenous endophthalmitis in patients with PLA compared with unaffected individuals by using a nationwide, population-based dataset. DESIGN: Retrospective, cohort study. PARTICIPANTS AND CONTROLS: This study used data sourced from Taiwan's National Health Insurance Research Database. In total, 12 727 patients with PLA were included in the study group and 63 635 matched subjects were randomly extracted as a comparison group. METHODS: Stratified Cox proportional hazards regressions were performed to assess the effect of PLA on the hazard of developing endogenous endophthalmitis. MAIN OUTCOME MEASURES: The incidence and risk of endogenous endophthalmitis between the study group and comparison group. RESULTS: Of the total sample, 148 subjects (0.10%) were diagnosed with endophthalmitis during the 1-year follow-up period. Endophthalmitis was found in 106 patients (0.84%) with PLA and 42 comparison patients (0.07%). After adjusting for patient monthly income, geographic location, and urbanization level, those suffering from PLA were found to have a greater likelihood of developing endophthalmitis during the 1-year follow-up period than comparison patients (hazard ratio [HR], 12.83; 95% confidence interval, 8.94-18.41). Stratification did not reveal any large differences in the adjusted HRs for endophthalmitis between PLA patients suffering from diabetes and those in whom diabetes was absent. We further analyzed the etiology of cases with endogenous endophthalmitis in this investigation and found Klebsiella pneumonia to be the causative organism among 75.5% of the cases but only 33.4% of the comparison group. CONCLUSIONS: We found that the incidence and risk of developing endophthalmitis was significantly higher among patients with PLA compared with matched controls irrespective of diabetes status.

Reflux esophagitis and the risk of stroke in young adults: a 1-year population-based follow-up study.

BACKGROUND AND PURPOSE: Reflux esophagitis (RE) is the most common manifestation of gastro-esophageal reflux disease with esophageal injury. To the best of our knowledge, there has been no specific study to evaluate the risk of stroke after diagnosis of RE in young adults. This study aims to evaluate the risk of stroke among RE patients aged 18 to 50 years during a 1-year period after diagnosis of RE compared to a cohort of non-RE patients during the same period. METHODS: This study used the Taiwan Longitudinal Health Insurance Database 2005. A total of 2340 RE patients were included as the study cohort and 11 700 non-RE patients were included as the comparison cohort. Each patient was individually tracked for 1 year from the index ambulatory visit to identify those in whom stroke developed. RESULTS: Out of the sample of 14 040 patients, 78 patients (0.56%) had strokes develop during the 1-year follow-up period: 22 from the study cohort (0.94% of the RE patients) and 56 from the comparison cohort (0.48% of patients without RE). Patients with RE were 1.68-times more likely to have strokes develop (95% confidence interval, 1.03-2.76) than patients in the comparison cohort during the follow-up period after adjusting for patients' medical comorbidities, such as hypertension, diabetes, coronary heart disease, renal disease, heart failure, and hyperlipidemia, as well as their demographic differences, such as the level of urbanization of their communities, monthly income, and geographical location. CONCLUSIONS: We conclude that RE is associated with an increased risk of subsequent stroke in young adults.

Ulcerative colitis and pregnancy outcomes in an Asian population.

OBJECTIVES: As the prevalence of ulcerative colitis (UC) is much higher in Western countries than in Asian countries, previous investigations of pregnancy outcomes for women with UC were limited to people of European descent. This study was aimed at examining the risk of adverse pregnancy outcomes (low birth weight (LBW), preterm birth, small for gestational age (SGA), and cesarean section (CS)) among Asian women with UC. METHODS: Using a 3-year nationwide population-based database, we identified a total of 196 women who gave birth from 2001 to 2003, who were diagnosed with UC within 2 years before their index deliveries. A total of 1,568 unaffected pregnant women matched these cases according to age and year of delivery. Conditional logistic regression analyses were performed to estimate risk. RESULTS: There were significant differences between women with and without UC in terms of LBW (12.76% vs. 5.55, P<0.001) and preterm births (11.73% vs. 6.25%, P=0.004). After adjusting for infant gender, parity, maternal age, highest maternal educational level, parental age difference, maternal marital status, hypertension, diabetes, anemia, family monthly income, as well as conditioning on maternal age and year of delivery, the odds of LBW and preterm births for women with UC were 2.36 (95% confidence interval (CI)=1.45-3.82) and 1.90 (95% CI=1.16-3.11) times, respectively, those for unaffected women. CONCLUSIONS: Although UC often follows a milder disease course in Asians than in people of European descent, we demonstrated that Asian women suffering from UC were still at risk of having preterm and LBW babies, compared with unaffected mothers.

Increased risk of low birthweight, infants small for gestational age, and preterm delivery for women with peptic ulcer.

OBJECTIVE: The objective of the study was to determine whether maternal peptic ulcer disease (PUD) is associated with increased risk of adverse pregnancy outcomes, using a nationwide population-based dataset. STUDY DESIGN: We identified a total of 2120 women who gave birth from 2001 to 2003 with a diagnosis of PUD during pregnancy. Then 10,600 unaffected pregnant women were matched with cases in age and year of delivery. Multivariate logistic regression analyses were performed for estimation. RESULTS: We found that PUD was independently associated with a 1.18-fold risk of low birthweight (95% confidence interval [CI], 1.01-1.30), a 1.20-fold risk of preterm delivery (95% CI, 1.02-1.41), and a 1.25-fold (95% CI, 1.11-1.41) higher risk of babies small for gestational age, compared with unaffected mothers, after adjusting for potential confounders. In further examining women with treated PUD, improved effects of PUD medication on the risks of adverse neonate outcomes were not identified. CONCLUSION: We document increased risk of adverse birth outcomes for women with PUD during pregnancy.

Comparative study of conventional colonoscopy, magnifying chromoendoscopy, and magnifying narrow-band imaging systems in the differential diagnosis of small colonic polyps between trainee and experienced endoscopist.

BACKGROUND: Removal of colorectal neoplastic polyps can reduce the incidence of colorectal cancers. It is important to distinguish neoplastic from nonneoplastic polyps. We compared the ability of a trainee and an experienced endoscopist in distinguishing between neoplastic polyps and nonneoplastic polyps by conventional white-light, magnifying narrow-band imaging (NBI), and magnifying chromoendoscopy. MATERIALS AND METHODS: One hundred and sixty-three small colorectal polyps from 104 patients were studied. All polyps were diagnosed by trainees and experienced endoscopists using conventional white-light, magnifying NBI, and magnifying chromoendoscopy. The kappa values of interobserver agreement between trainees and experienced endoscopists were evaluated before this study. Sensitivity, specificity, and diagnostic accuracy were assessed by reference to histopathology. The first 50 polyps were diagnosed by the trainee as the first stage and the rest 113 polyps were diagnosed as the second stage. RESULTS: Magnifying NBI and magnifying chromoendoscopy were significant better than conventional white-light by the experienced endoscopist (diagnostic accuracy: NBI 85.3%, chromoendoscopy 87.7%, conventional view 74.8%). No significant differences were found for the trainee. The kappa values (0.77 approximately 0.85) were good for each endoscopic modality for the experienced endoscopist. However, only NBI and chromoendoscopy had acceptable kappa values (0.40 approximately 0.48) for the trainee. The trainee improved diagnostic accuracy in the second stage, but not yielded the level of the experienced endoscopist. CONCLUSION: Magnifying NBI and magnifying chromoendoscopy had a better interobserver agreement than conventional white-light among trainees and experienced endoscopists. The trainee needs learning time to improve diagnostic ability, even using a new modality such as magnifying NBI.

Optimal dose regimens of esomeprazole for gastric acid suppression with minimal influence of the CYP2C19 polymorphism.

OBJECTIVE: In this pilot study, we attempted to determine the optimal dosage regimens of esomeprazole for treatment of GERD with minimal influence of the CYP2C19 polymorphism through a study of the pharmacokinetics and pharmacodynamics of esomeprazole given at 3 different dosage regimens with the same total daily dose. METHODS: Each of the 3 genotypes of CYP2C19, homozygous extensive metabolizers (homEMs), heterozygous EMS (hetEMs), and poor metabolizers (PMs) were recruited in this clinical trial. Subjects were given a placebo followed by the administration of esomeprazole, at a dose of 40 mg once daily (40QD), 20 mg twice daily (20TD), or 10 mg 4 times daily (10Q4D) for 7 days. Twenty-four-hour and nocturnal intragastric pH and plasma esomeprazole concentrations were all determined on day 7. RESULTS: The pharmacokinetic parameters and dynamic characteristics differed among the 3 CYP2C19 genotype groups. With esomeprazole 40QD, gastric acid suppression was insufficient to achieve a therapeutic effect, while 20TD and 10Q4D were found to be effective in controlling both daytime and nocturnal gastric acidity for all 3 genotype groups. CONCLUSIONS: It was confirmed that intragastric pH values and plasma esomeprazole concentrations potentially depended on the CYP2C19 genotype status for treatment with esomeprazole. Dosage regimens of divided doses of 20TD or 10Q4D esomeprazole yielded improved antisecretory effects with a minimal influence of CYP2C19 polymorphisms.

Hospital case volume and clinical outcomes for peptic ulcer treatment.

BACKGROUND: No study has explored the volume-outcome relationship for peptic ulcer treatment. OBJECTIVE: To investigate the association between peptic ulcer case volume per hospital, on the one hand, and in-hospital mortality and 14-day readmission rates, on the other, using a nationwide population-based dataset. DESIGN: A retrospective cross-sectional study, set in Taiwan. PARTICIPANTS: There were 48,250 peptic ulcer patients included. Each patient was assigned to one of three hospital volume groups: low-volume (< or = 189 case), medium volume (190-410 cases), and high volume (> or = 411 cases). MEASUREMENTS: Logistic regression analysis employing generalized estimating equations was used to examine the adjusted relationship of hospital volume with in-hospital mortality and 14-day readmission. MAIN RESULTS: After adjusting for other factors, results showed that the likelihood of in-hospital mortality for peptic ulcer patients treated by low-volume hospitals (mortality rate = 0.68%) was 1.6 times (p < 0.05) that of those treated in high-volume hospitals (mortality rate = 0.72%) and 1.4 times (p < 0.05) that of those treated in medium-volume hospitals (mortality rate = 0.73%). The adjusted odds ratio of 14-day readmission likewise declined with increasing hospital volume, with the odds of 14-day readmission for those patients treated by low-volume hospitals being 1.5 times (p < 0.001) greater than for high-volume hospitals and 1.3 times (p < 0.01) greater than for medium-volume hospitals. CONCLUSIONS: We found that, after adjusting for other factors, peptic ulcer patients treated in the low-volume hospitals had inferior clinical outcomes compared to those treated in medium-volume or high-volume ones.

Premedication with pronase or N-acetylcysteine improves visibility during gastroendoscopy: an endoscopist-blinded, prospective, randomized study.

AIM: To assess the efficacy of premedicaton with pronase or N-acetylcysteine (NAC) at 20 min before upper gastrointestinal (UGI) endoscopy and to determine whether pronase or NAC pretreatment influences the reliability of the rapid urease test. METHODS: A total of 146 patients were prospectively and randomly assigned into the study groups according to different premedications before endoscopy. One endoscopist assessed mucosal visibility (MV) with scores ranged from 1 to 4 at four sites in the stomach. The sum of the MV scores from these four locations was defined as the total mucosal visibility (TMV) score. Identification of H pylori was performed using CLO test, histology, and serology. RESULTS: The Group with pronase premedication had a significantly lower TMV score than did the groups with gascon and gascon water (P < 0.001 and P < 0.01, respectively). The group with NAC had a significantly lower TMV score than the group with gascon (P < 0.01) and a trend of a lower MV score than the group with gascon water (P = 0.06). The TMV score did not significantly differ between the group with pronase and the group with NAC (P = 0.39 and P = 0.14, respectively). The sensitivity and specificity of the CLO test were 92.5% and 93.9%, respectively, in groups premedicated with pronase and NAC together. CONCLUSION: Premedication with pronase or NAC at 20 min before UGI endoscopy improves the mucosal visibility of the stomach. Neither pronase nor NAC produces any obvious interference with the CLO test for the identification of H pylori infection.

A case of human diphyllobothriasis in northern Taiwan after eating raw fish fillets.

The consumption of raw fish fillets is increasing in Taiwan. A male Taiwanese aged 30 years presented after passing a flat, white noodle-like worm. Strobila examination showed that most proglottids were wider than they were long, with the genital pore located at the posterior edge of the cirrus. Histological and coprological findings confirmed the diagnosis of Diphyllobothrium latum; ova were ellipsoidal with operculate characteristics, and had a small knob in the anti-operculum side. Hematological data, including vitamin B12 levels, were normal, except for a low folate level. The patient was treated with a single dose of praziquantel 600 mg and 196 cm of proglottids were expelled during the 3 days following treatment. Further follow-up was declined. Consumption of raw and undercooked fish (especially salmon) poses a risk of D. latum infection.

Metachronous esophageal cancer and colon cancer treated by endoscopic mucosal resection.

Most cases of esophageal cancer and colorectal cancer in Taiwan are diagnosed in the advanced stage and treated by surgery or concurrent chemoirradiation. The detection rates of early esophageal cancer and early colorectal cancer are still low in Taiwan. Metachronous early esophageal cancer and early colorectal cancer have rarely been reported. Endoscopic mucosal resection (EMR) is a well-established method for treatment of early gastrointestinal cancer in Japan. We report a 77-year-old man with metachronous early esophageal cancer and early colorectal cancer detected by chromoendoscopy with 3% Lugol's iodine and 0.2% indigo carmine, respectively. These two lesions were successfully treated by EMR. Endoscopic mucosal resection of early cancer in the gastrointestinal tract may be considered in patients who are not suitable for open surgery.

Large early gastric cancers treated by endoscopic submucosal dissection with an insulation-tipped diathermic knife.

It is difficult to remove a large early gastric cancer (> or = 3 cm) in one-piece resection using conventional endoscopic mucosal resection. We tried to use an insulation-tipped (IT) diathermic knife to dissect these lesions. IT-endoscopic submucosal dissection (ESD) was performed in four aging patients with gastric malignancy. All lesions could be removed in one-piece resection by IT-ESD, although three of them exhibited remarkable fibrosis and ulceration. Three cases experienced curative treatment with IT-ESD after the pathologic evaluation, but it was not curative in one case because the pathology showed angiolymphatic invasion. This patient refused additional surgery in consideration of existing major systemic diseases. At 3 months to 1 year of follow-up, endoscopy showed no evidence of residual cancer. IT-ESD is effective in the treatment of large early gastric cancer and is an alternative treatment for early gastric cancer patients who are at risk for major operation.

Anti-Helicobacter pylori therapy significantly reduces Helicobacter pylori -induced gastric mucosal damage in Mongolian gerbils.

AIM: To investigate the effectiveness of 4 d' anti-Helicobacter pylori therapy on the H pylori-infected Mongolian gerbils based on physiological and pathological changes. METHODS: We used 6-wk-old male gerbils orally inoculated with H pylori (ATCC43504, 2X10(8) CFU/mL). Seven weeks after H pylori inoculation, the animals of study group received 4 d' anti-H pylori triple therapy (H pylori-eradicated group). Seven days later, all animals of the H pylori-eradicated and control groups (H pylori-infected and H pylori-uninfected groups) were sacrificed. We examined gastric mucosal lesions macroscopically, studied gastritis microscopically and determined the stomach weight ratio, myeloperoxidase (MPO) activity and prostaglandin (PG) E(2) level. RESULTS: The results showed that both macroscopic and histological gastric damages were significantly less in H pylori-eradicated group than H pylori-infected group. Stomach weight ratio, MPO activity and PGE(2) levels were significantly higher in H pylori-infected group than those in the other two groups. CONCLUSION: Four days' anti-H pylori therapy was effective in the improvement of H pylori-induced gastric lesions in Mongolian gerbils.

Eradication of Helicobacter pylori significantly reduced gastric damage in nonsteroidal anti-inflammatory drug-treated Mongolian gerbils.

AIM: To examine the effect of eradication of Helicobacter pylori prior to usage of NSAIDs, by investigating gastric inflammatory activity, myeloperoxidase (MPO) activity, prostaglandin (PG) E2 synthesis in H pylori-infected, and H pylori-eradicated gerbils followed by administration of indomethacin and rofecoxib. METHODS: Six-week-old male gerbils were orally inoculated with H pylori. Seven weeks later, anti-H pylori triple therapy and vehicle were given to gerbils respectively and followed by oral indomethacin (2 mg/kg.d) or rofecoxib (10 mg/kg.d) for 2 wk. We examined the area of lesions, gastric inflammatory activity, PGE2 synthesis and MPO activity in the stomach. RESULTS: In indomethacin and rofecoxib-treated gerbils, the following results were obtained in H pylori-infected group vs H pylori-eradicated group respectively: hyperplasia area of the stomach (mm2): 82.4+/-9.2 vs 13.9+/-3.5 (P<0.05), 30.5+/-5.1 vs 1.3+/-0.6 (P<0.05); erosion and ulcer area (mm2): 14.4+/-4.9 vs 0.86+/-0.5 (P<0.05), 1.3+/-0.6 vs 0.4+/-0.3 (P<0.05); score of gastritis: 7.0+/-0.0 vs 3.6+/-0.5 (P<0.05), 7.0+/-0.0 vs 2.7+/-0.5 (P<0.05); MPO activity (micromol H2O2/min/g tissue): 104.7+/-9.2 vs 9.0+/-2.3 (P<0.05), 133.5+/-15.0 vs 2.9+/-0.7 (P<0.05); PGE2 synthesis (pg/mg wet weight/min): 299.2+/-81.5 vs 102.8+/-26.2 (P<0.05), 321.4+/-30.3 vs 11.9+/-4.8 (P<0.05). CONCLUSION: Eradication of H pylori reduced gastric damage of NSAID-treated Mongolian gerbils. Rofecoxib caused less severe gastric damage than indomethacin in H pylori-eradicated gerbils.

Propofol versus midazolam for upper gastrointestinal endoscopy in cirrhotic patients: a meta-analysis of randomized controlled trials.

BACKGROUND: Sedation during gastrointestinal endoscopy is often achieved using propofol or midazolam in general population. However, impaired protein synthesis, altered drug metabolism, and compromised hepatic blood flow in patients with liver cirrhosis might affect the pharmacokinetics of sedatives, placing cirrhotic patients undergoing endoscopy at a greater risk of adverse events. The objective of this study was to assess comparative efficacies and safety of propofol and midazolam in cirrhotic patients undergoing endoscopy. METHODS: Randomized, controlled trials comparing propofol with midazolam in cirrhotic patients undergoing gastrointestinal endoscopy were selected. We performed the meta-analysis, using a random-effect model, the Review Manager, Version 5.2, statistical software package (Cochrane Collaboration, Oxford, UK) according to the PRISMA guidelines. RESULTS: Five studies between 2003 and 2012, including 433 patients, were included. Propofol provided a shorter time to sedation (weight mean difference: -2.76 min, 95% confidence interval: -3.00 to -2.51) and a shorter recovery time (weight mean difference -6.17 min, 95% confidence interval: -6.81 to -5.54) than midazolam did. No intergroup difference in the incidence of hypotension, bradycardia, or hypoxemia was observed. Midazolam was associated with the deterioration of psychometric scores for a longer period than propofol. CONCLUSION: This meta-analysis suggests that Propofol sedation for endoscopy provides more rapid sedation and recovery than midazolam does. The risk of sedation-related side effects for propofol does not differ significantly from that of midazolam. The efficacy of propofol in cirrhotic patients undergoing endoscopy is superior to those of midazolam.

Acute cholangitis secondary to a common bile duct adenoma.

We report a case of distal common bile duct adenoma presenting with acute cholangitis. A 47-year-old woman suffered from right upper abdominal pain with persistent fever for 4 days. Abdominal ultrasonography showed mild dilatation of common bile duct and bilateral intrahepatic ducts. Endoscopic retrograde cholangiopancreatography disclosed a fixed filling defect in the distal common bile duct. Transpapillary biopsy and brush cytology was performed after sphincterotomy. The biopsy specimen showed adenomatous change with dysplasia and negative stain for p53. No significant regional lymph node enlargement was found on computed tomography. The patient subsequently received exploratory laparotomy and sphincteroplasty with excision of the distal common bile duct tumor. Finally, the tumor was diagnosed as common bile duct tubular adenoma with moderate nuclear dysplasia. Postoperatively, the patient had an uneventful course and has been well at follow-up for 8 months. We encountered a rare case of common bile duct adenoma in which malignant change was hard to rule out. We propose that sphincterotomy with biopsy is crucial before operation and p53 immunohistochemical staining is valuable for determining whether or not malignant change occurs in this borderline tumor.

Hepatic failure related to itraconazole use successfully treated by corticosteroids.

BACKGROUND: Itraconazole is believed to carry a low risk of hepatic toxicity owing to its low affinity for the human P-450 enzyme. Therefore, hepatic failure caused by itraconazole is exceedingly rare. OBJECTIVES: We report the case of a 46-year-old woman who developed hepatic failure related to itraconazole that was administered for the treatment of onychomycosis. Her condition deteriorated after withdrawal of the drug, followed solely by supportive care initially. CASE REPORT: Treatment with corticosteroids was started 10 days after her admission, and her condition gradually improved. Unfortunately, her condition worsened when the dosage of corticosteroids was abruptly decreased. Ultimately, her condition improved with appropriate adjustments of corticosteroid dosage. DISCUSSION: We conclude that corticosteroid therapy may be effective for itraconazole-induced hepatitis, especially in those patients who do not respond to conservative treatment. Notably, any decrease in the dosage should be performed with caution. We also recommend that close monitoring of liver function is mandatory during the use of itraconazole.

Seasonal variation in the incidence of gastroesophageal reflux disease.

BACKGROUND: To examine the seasonal variation in the incidence of gastroesophageal reflux disease (GERD) for different gender and age groups and its association with climatic parameters (ambient temperature, relative humidity, atmospheric pressure, rainfall, and hours of sunshine). METHODS: A total of 76,636 ambulatory care visits for the treatment of GERD between 2001 and 2006 were included. Monthly GERD incidence rates per 10,000 people were calculated over 72 months and categorized by gender and age groupings (19-44, 45-64, and >or=65 years). Seasonality is a general component of time-series patterns. The auto-regressive integrated moving average (ARIMA) regression method was used to evaluate the effects of climatic and monthly factors on GERD incidence rates after adjusting for the time-trend effect. RESULTS: Seasonal trends showed an incidence peak in October to December, followed by a sharp decrease in January, and a trough in February; a fairly similar seasonal pattern of GERD incidence was apparent for gender, age, and combined groups. The ARIMA test for seasonality found a significant association for the total group (P < 0.01), for female (P < 0.05) patients, and for the 45 to 64 years (P < 0.01) and >64 years (P < 0.01) age groups. The ARIMA models also showed that relative humidity was negatively related to monthly GERD incidence rates for men (P < 0.01) and the >64 years (P < 0.01) age group. CONCLUSION: Data showed seasonal variations in GERD incidence. Relative humidity was associated with monthly GERD incidence rates for men and the >64 years age group.