Double-blind comparison of omeprazole 20 mg om and ranitidine 300 mg NOCTE in duodenal ulcer: A Taiwan multi-centre study

Two hundred and twenty-six patients with endoscopically confirmed duodenal ulcers > or = 5 mm in diameter entered a double-blind randomized trial comparing 20 mg omeprazole administered once daily in the morning with 300 mg ranitidine administered once daily at night. The patients were assessed endoscopically and symptomatically after 2 weeks, and those whose ulcers had healed terminated the study. Patients with unhealed ulcers continued treatment for a total of 4 weeks. Omeprazole produced significantly higher healing rates than ranitidine at both 2 weeks (57 vs 28%, P < 0.0001) and 4 weeks (93 vs 80%, P = 0.006). Similarly, significantly higher 'effective healing rates' (defined on the criteria established by the Japanese Society of Digestive Endoscopy) were observed with omeprazole compared with ranitidine at 2 and 4 weeks. After 2 weeks, there were significantly fewer reports of both day-time and night-time epigastric pain by omeprazole-treated patients compared with ranitidine-treated patients (22 vs 44%, P < 0.0001 for day-time pain; 24 vs 35%, P = 0.025 for night-time pain). Both drugs were well-tolerated and no major adverse effects were recorded during either treatment. In conclusion, 20 mg omeprazole administered once daily was superior to 300 mg ranitidine administered once daily for duodenal ulcer healing and symptom relief.     

Prolonged bleeding time: A new clinical manifestation of hepatocellular carcinoma?

The association between prolonged bleeding time and hepatocellular carcinoma (HCC) has not been well studied. We investigated whether bleeding time is prolonged in cirrhotic patients with HCC and studied the role of clinical characteristics, tumour size, and laboratory data in predicting bleeding time prolongation. After excluding patients that presented with blood dyscrasia and uraemia, 58 cirrhotic patients with HCC, 106 cirrhotic patients without HCC, and 44 age- and sex-matched healthy subjects were included in the study. Bleeding time, imaging studies, clinical characteristics and biochemical data were obtained for every patient. Cirrhotic patients with and without HCC had longer bleeding times (554±68 and 535±32s, respectively) compared with healthy controls (357±13s, P < 0.05). Hepatocellular carcinoma patients with a large tumour burden (> 5 cm in diameter) had a significantly longer bleeding time than those patients without (663±105 vs 376±23s, respectively, P < 0.05). After excluding patients with a platelet count ≤ 80 000/mm³, cirrhotic patients classified as Child-Pugh's grading A and with a large tumour burden had longer bleeding times (580±87s) than patients with a small tumour burden (≤ 5 cm in diameter) and cirrhotic patients without HCC (371±22 and 416±29s, respectively, P < 0.05). In cirrhotic patients with HCC, higher serum bilirubin levels, a Child-Pugh's grading C, and a tumour size > 5 cm in diameter were found to be significant predictors for prolonged bleeding time on univariate analysis. On multivariate analysis, both tumour size > 5 cm in diameter and a Child-Pugh's grading C (odd's ratio, 95% confidence interval and P value were measured as 38.5, 2.8–534.7, < 0.001, and 10.5, 0.9–117.6, 0.02, respectively) were the significant independent predictors. A significant correlation existed between tumour diameter and bleeding time (r= 0.44, P < 0.01). In conclusion, these results suggest that prolonged bleeding time may be categorized as a new clinical manifestation in patients with HCC. In addition to cirrhosis, HCC itself may also participate in the pathogenesis of bleeding time prolongation.     

Transluminal Angioplasty, Thrombolysis, and Stenting for Extracranial and Intracranial Cerebral Vascular Disease

Percutaneous transluminal angioplasty, alone or in conjunction with thrombolysis and/or stenting, is now being performed in selected cases for hemodynamically significant stenosis (> 70%), involving both extracranial and intracranial cerebral vascular lesions. In the majority of cases, atherosclerosis was the major cause for symptomatic narrowing, although other causes included fibromuscular dysplasia, cerebral arteritis, postsurgical intimal hyperplasia, and acute arterial dissection. In some cases, direct intraarterial thrombolysis and angioplasty successfully restored perfusion to completely occluded blood vessels to the brain, and in other cases acute vessel closure or dissection of extracranial vessels was successfully managed with stent deployment. Since 1981, 325 patients, ranging in age from 9–78 years old, have been successfully treated by these techniques: 143 (44%) cases involved the anterior cerebral circulation; and 182 (56%) cases, the posterior cerebral circulation. Complications included 17 (5.2%) strokes (of which 4 [1.2%] died), and 23 (7.1%) cases of transient cerebral ischemia. Radiological follow-up demonstrated 24 (7.4%) cases of restenosis. This study indicates the feasibility of angioplasty as a treatment alternative, in conjunction with thrombolysis and intravascular stenting, for extracranial and intracranial obstructive cerebral vascular disorders and may also provide an interventional pathway in the treatment of acute stroke patients.     

Error correction maintains post-error adjustments after one night of total sleep deprivation

Previous behavioral and electrophysiologic evidence indicates that one night of total sleep deprivation (TSD) impairs error monitoring, including error detection, error correction, and posterror adjustments (PEAs). This study examined the hypothesis that error correction, manifesting as an overtly expressed self-generated performance feedback to errors, can effectively prevent TSD-induced impairment in the PEAs. Sixteen healthy right-handed adults (seven women and nine men) aged 19–23 years were instructed to respond to a target arrow flanked by four distracted arrows and to correct their errors immediately after committing errors. Task performance and electroencephalogram (EEG) data were collected after normal sleep (NS) and after one night of TSD in a counterbalanced repeated-measures design. With the demand of error correction, the participants maintained the same level of PEAs in reducing the error rate for trial N +  1 after TSD as after NS. Corrective behavior further affected the PEAs for trial N +  1 in the omission rate and response speed, which decreased and speeded up following corrected errors, particularly after TSD. These results show that error correction effectively maintains posterror reduction in both committed and omitted errors after TSD. A cerebral mechanism might be involved in the effect of error correction as EEG beta (17–24 Hz) activity was increased after erroneous responses compared to after correct responses. The practical application of error correction to increasing work safety, which can be jeopardized by repeated errors, is suggested for workers who are involved in monotonous but attention-demanding monitoring tasks.     

Ankle brachial index as a predictor for mortality in patients with chronic kidney disease and undergoing haemodialysis

Aim: The ankle brachial index (ABI) is a marker for peripheral artery disease and can predict mortality in advanced chronic kidney disease (CKD) and haemodialysis patients, respectively. However, it is seldom studied in Taiwan, an area with high prevalence of CKD and end‐stage renal disease. The aim of this study was to investigate the predictors for mortality by using ABI value in patients with CKD and undergoing haemodialysis in Taiwan. Methods: One hundred and sixty‐nine patients with CKD stage 3–5 and 231 haemodialysis patients were enrolled in one regional hospital. The mean follow‐up period was 23.3 ± 3.3 months. Patients were stratified into three groups according to ABI value (<0.9, ≥0.9 to <1.3, and ≥1.3). The relative mortality risk was analyzed by Cox‐regression methods. Results: In multivariate analysis, an ABI of 1.3 or more (hazard ratio, 3.846; P = 0.043) and coronary artery disease (P = 0.012) were positively associated with overall mortality, and serum low‐density lipoprotein cholesterol level (P = 0.042) was negatively associated with overall mortality. In addition, an ABI of less than 0.9 (P = 0.049), an ABI of 1.3 or more (P = 0.033), coronary artery disease (P = 0.024) and haemodialysis treatment (P = 0.043) were strong predictors for cardiovascular mortality. Conclusion: Our findings show that an ABI of 1.3 or more predicts for both overall and cardiovascular mortality, and an ABI of less than 0.9 predicts for cardiovascular mortality in CKD and haemodialysis patients. Screening patients with chronic renal failure by means of ABI may help to identify a high‐risk group for increased mortality.     

Effects of acupuncture on post-cesarean section pain

Background Post-operation pain is a very subjective phenomenon. The aim of this study was to find out the effects of acupuncture or electro-acupuncture on post-cesarean pain. Methods Sixty women, who had had spinal anesthesia during cesarean section at the Department of Obstetrics of China Medical University Hospital, were randomly assigned to the control group, the acupuncture group, and the electro-acupuncture group. After the operation, we applied subjects with acupuncture or electro-acupuncture on the bilateral acupuncture point, San Yin Jiao （Sp6）, and the patient controlled analgesia （PCA）. The first time of requesting morphine, the frequency of PCA demands in 24 hours, and the doses of PCA used were recorded double blindly. In addition, monitoring the subjects＇ vital signs, the opioid-related side effects, and the pain scores was done. Results The results showed that the acupuncture group and the electro-acupuncture group could delay the time of requesting morphine up to 10-11 minutes when compared with the control group. The total dose of PCA used within the first 24 hours was 30%-35% less in the acupuncture group and the electro-acupuncture group when compared with the control group, which was indicated in statistical significance. However, there was no significant difference between the acupuncture group and the electro-acupuncture group. The electro-acupuncture group＇s and the acupuncture group＇s pain scores were lower than the control group＇s within the first 2 hours. Both were statistically significant. However, two hours later, there were no significant differences of the visual analogue scale （VAS） scores between either of the treatment groups and the control group. Finally, the incidence of opioid-related side effects, such as dizziness, was less in the acupuncture group and electro-acupuncture group than in the control group. Conclusions This study shows that the application of acupuncture and electro-acupuncture could definitely delay the time of requesting pain relief medication after cesarean section and decrease the PCA doses used within the first 24 hours.     

4＇-Chloro-3,5-dihydroxystilbene, a resveratrol derivative, induces lung cancer cell death

Aim:

To examine the antitumor effect of 4′-chloro-3,5-dihydroxystilbene, a resveratrol derivative, on lung adenocarcinoma A549 cells.

Methods:

The cytotoxic IC₅₀ was determined by direct cell counting. Flow cytometry, monodansylcadaverine (MDC) staining, transfection, Western blot and a proteasome activity assay were used to study the cellular mechanism of 4′-chloro-3,5-dihydroxystilbene. A xenograft nude mouse model was used to analyze the antitumor effect in vivo.

Results:

4′-Chloro-3,5-dihydroxystilbene induced a rapid and persistent increase in the intracellular reactive oxygen species in the cells, but the cell death could not be inhibited by two antioxidant agents. The derivative caused sub-G₁ formation, a decrease in the mitochondria membrane potential and poly (ADP-ribose) polymerase degradation, and the caspase inhibitor Z-VAD-FMK could partially prevent cell death. It also induced a significant increase in intracellular acidic vacuoles, LC3-II formation and intracellular GFP-LC3 aggregation. An autophagic inhibitor partially reversed cell death. Additionally, 4′-chloro-3,5-dihydroxystilbene induced the accumulation of ubiquitinated conjugates and inhibited proteasome activity in cells. In an in vivo study, 4′-chloro-3,5-dihydroxystilbene retarded tumor growth in nude mice.

Conclusion:

These data suggest that the resveratrol derivative 4′-chloro-3,5-dihydroxystilbene could be developed as an anti-tumor compound.     

Comparison of Cooled-Tip Versus 4-mm-Tip Catheter in the Efficacy of Acute Ablative Tissue Injury During Circumferential Pulmonary Vein Isolation

Introduction: Although several studies have reported the benefits of cooled-tip ablation for circumferential pulmonary veins isolation (CPVI), the acute change of substrate property and acute PV reconnection have not been well demonstrated. The aim of this study was to compare the cooled-tip with regular 4-mm-tip catheter in acute substrate change after CPVI and long-term efficacy.
Methods and Results: One hundred and fifty-six patients (115 males, age 53 ± 12 years) who underwent CPVI for treatment of atrial fibrillation (AF) were included. Group A consisted of 52 patients with cooled-tip ablation, and group B consisted of 104 patients with 4-mm-tip catheter ablation. The bipolar voltage of circumferential lesions was obtained using a 3-dimensional (3D) mapping system (NavX) before and after CPVI. The electrical reconnections of 4 PVs were evaluated 30 minutes after CPVI using a circular catheter. Cooled-tip catheter caused more reduction of the electrical voltage in PV antrum, lower incidence of acute PV reconnection, inducibility of AF, and gap-related atrial tachyarrhythmia (AT). Less number of left atrial (LA) ablation line and ablation applications and less procedure time were found in cooled-tip group compared to 4-mm-tip group. No significant difference in the incidence of pain sensation and complication was observed between the 2 groups. At a 14-month follow-up, the recurrence rate in the cooled-tip group was lower than in the 4-mm group (13.5% vs 33.7%, P = 0.009).
Conclusion: Cooled-tip catheter has a superior long-term outcome than the 4-mm-tip catheter in CPVI, which may be associated with the efficacy of transmural block and electrical isolation in PV antrum.     

Efficacy of Additional Ablation of Complex Fractionated Atrial Electrograms for Catheter Ablation of Nonparoxysmal Atrial Fibrillation

Background: The efficacy of ablation of complex fractionated atrial electrograms (CFEs) in the single ablation procedure for nonparoxysmal atrial fibrillation (AF) patients is not well demonstrated. The aim of this study was to compare the ablation strategies of pulmonary vein isolation (PVI) plus linear ablation with and without additional ablation of CFEs in these patients.
Methods: Consecutive 60 patients (49 ± 11 years old, 50 male, 10 female) with nonparoxysmal AF underwent catheter ablation guided by a NavX mapping system. A stepwise approach included a circumferential PVI and left atrial (LA) linear ablation followed by either the additional ablation of continuous CFEs in the LA/coronary sinus (the first 30 patients) or not (the second 30 patients), detected by an automatic algorithm.
Results: There was no difference in the baseline characteristics between the two groups. Complete PVI eliminated some continuous CFEs and altered the distribution of CFEs. Following PVI and linear ablation, the remaining continuous CFEs were identified in 7.9 ± 10% mapping sites of the LA and CS, and were ablated successfully with a procedural AF termination rate of 53%. With a follow-up of 19 ± 11 months, a Kaplan–Meier analysis showed that the patients with additional ablation of the CFEs had a higher rate of sinus rhythm maintenance. Multivariate analysis showed the single procedure success could be predicted by the procedural AF termination and the additional ablation of continuous CFEs in the LA/CS.
Conclusions: Ablation of continuous CFEs after PVI and LA linear ablation had a better long-term efficacy based on the results of single-ablation procedure.     

Factors influencing visibility and diagnostic yield of transbronchial biopsy using endobronchial ultrasound in peripheral pulmonary lesions

Background and objective:   Endobronchial ultrasound (EBUS) has increased the diagnostic yield of bronchoscopic biopsy of peripheral pulmonary lesions (PPL). However, certain lesions cannot be localized by EBUS, and the factors associated with the visibility of PPL by EBUS have not been investigated. This study evaluated the factors predicting the visualization of EBUS in PPL and the diagnostic yield of EBUS-guided transbronchial biopsy (TBB).
Methods:   n 2007, 83 patients with PPL underwent EBUS-guided TBB, and their medical records were reviewed and analysed retrospectively.
Results:   Of the 83 patients examined, EBUS images could not be obtained in 23 patients (28%). Lesion size was a determining factor for the visibility of PPL, with the visualization yield of EBUS in lesions <20 mm being significantly lower than that in lesions ≥20 mm ( P  < 0.001). A definitive diagnosis of PPL localized by EBUS was established using EBUS-guided TBB in 73% of patients. There were no significant differences in diagnostic yield related to underlying disease, lobar distribution, CT scan appearance or presence of complications. Multivariate analysis revealed that the location of PPL on CT scans and position of the probe were independent predictors of the diagnostic yield by EBUS-guided TBB ( P  < 0.001 and P  = 0.001, respectively).
Conclusions:   Lesion size is a significant factor predicting visualization of EBUS for PPL. The location of PPL on CT scans and position of the probe are significantly related to a higher diagnostic yield with EBUS-guided TBB.