Basal and residual lower esophageal pressures increase in old age in classic achalasia,but not vigorous achalasia

Background and Aim: The relationship between age and esophageal motility parameters (i.e. basal and residual pressure of the lower esophageal sphincter [LES]) remains to be established in achalasia patients, possibly because most previous studies did not distinguish between classic and vigorous achalasia patients. We investigated the relationship between age and esophageal motility parameters in both classic and vigorous achalasia patients. Methods: A retrospective review of esophageal manometry data in a single center was undertaken. Basal and residual pressure for LES was analyzed. A total of 103 achalasia patients were enrolled, comprising 84 classic and 19 vigorous types. They were subdivided into three different age groups as follows: 21–40 years old (group A), 41–60 years old (group B), and over 60 years old (group C). Results: In classic achalasia patients (M : F = 27:57, mean age = 44 ± 15 years old) the older age group showed a significantly higher basal LES pressure (49.62 ± 19.63 mmHg) than the younger age group (P < 0.0001). Moreover, the older age group also showed significantly high residual LES pressure (20.46 ± 8.61 mmHg) than the younger age group (P = 0.0006). In contrast, in vigorous achalasia patients (M : F = 12:7, mean age: 47 ± 15 years old) there were no difference between age and motility indices (all P > 0.05). Conclusion: In classic achalasia patients there appears to be a correlation between age and esophageal motility indices, especially basal and residual LES pressure. Such correlations do not appear to exist for vigorous achalasia patients.     

Clinical significance of distal colon polyps for the prediction of an advanced proximal neoplasm: the KASID prospective multicenter study

Background/aims The possibility of proximal lesion without distal polyps is a weak point of sigmoidoscopic colon cancer screening, but the clinical significance of distal findings for advanced proximal neoplasm (APN) is uncertain. The aim of this study was to assess the significance of a distal finding as a predictor of APN. Materials and methods Asymptomatic patients ≥50 years old were enrolled from among patients who underwent polypectomy at 11 tertiary medical centers during the Korean Association for the Study of Intestinal Disease prospective study conducted between July 2003 and March 2004. Polyps located distal to the splenic flexure were defined as distal polyps. An advanced neoplasm was defined as a polyp of ≥10 mm in size, and/or with villous features, and/or with high-grade dysplasia, or invasive cancer. Age, gender, and distal polyp size, appearance, and histology were analyzed as risk factors of APN. The sensitivity and positive predictive value of distal polyps for APN were calculated. Results Data from 826 patients were analyzed. Mean patient age was 60.1 years (range 50–86), and 71.3% were men. APN was found in 98 patients, and 45 (45.9%) patients had no distal polyps. Risk factors of APN were a male gender, distal polyp size, and an advanced distal neoplasm. Sensitivities of a distal polyp of ≥10 mm and of an advanced distal neoplasm for APN were both 38.8% with positive predictive values of 13.3 and 14.4%, respectively. Conclusions Although distal colon findings were found to be helpful for predicting APN in asymptomatic patients aged ≥50 years, APN without distal polyps requires careful consideration.     

Hepatocellular carcinoma presenting with bone metastasis: clinical characteristics and prognostic factors

Purpose  The survival of patients with hepatocellular carcinoma (HCC) has been prolonged with improvements in various diagnostic tools and treatment modalities. Consequently, bone metastases from HCC are diagnosed more frequently. We investigated the clinical features, prognosis, treatment outcomes, and prognostic factors of HCC presenting with bone metastasis. Methods  Between June 2000 and April 2007, we recruited 37 consecutive HCC patients presenting with bone metastasis. These patients were divided into an untreated control group (n = 16) and a treated group (n = 21). Results  The mean age of the patients was 61.1 years (male:female, 31:6). The most common cause of HCC was hepatitis B virus infection (56.8%). Twenty-two patients (59.5%) were of Child-Pugh class A and 15 (40.5%) were of Child-Pugh class B. Spinal metastasis was most common and noted in 21 patients (56.7%). The treatment modalities in the treated group included intra-arterial chemotherapy in nine patients (42.8%), systemic chemotherapy in five (23.8%), and both intra-arterial and systemic chemotherapy in seven (33.4%). The median survival of all patients was 6.2 months (range 0.7–46.6); that of untreated control group and the treated group was 2.9 (range 0.7–42.2) and 9.7 (range 0.9–46.6) months, respectively, with no significant difference (log-rank test, P = 0.081). Cox regression analysis revealed that the presence of ascites at the initial presentation was the only prognostic factor (P = 0.016). Conclusion  Although our study showed that locoregional and/or systemic chemotherapy did not provide significant survival prolongation compared to supportive care in patients with HCC initially accompanied by bone metastasis, a more large-scaled randomized study might be required. S. U. Kim and D. Y. Kim have equally contributed to this work.     

Response to interferon-alpha in chronic hepatitis B with and without precore mutant strain detected by mutation site-specific assay

GOALS: We investigated whether the presence of precore mutant (stop codon mutation at codon 28) affects the response to interferon-alpha in patients with chronic hepatitis B. BACKGROUND: Mutations of hepatitis B virus (HBV) may influence the response to treatment. The association of precore mutant with the response to interferon is controversial. STUDY: Thirty-one Japanese patients with hepatitis B e antigen-positive chronic hepatitis were treated with natural interferon-alpha. HBV DNA with the precore mutation was assayed in serum using a mutation site-specific assay before and after treatment. RESULTS: Before treatment, precore mutant was detected in 22 cases (group A) and not detected in 9 cases (group B). Serum HBV DNA level before treatment was not different between the 2 groups. At the end of treatment, serum HBV DNA was decreased to undetectable levels in 13% (4 of 31). Six months after treatment, the percentage of cases with loss of hepatitis B e antigen and a decrease in the transaminase level to within the normal range was significantly higher in group B than in group A (67%, 18%, P = 0.015). CONCLUSIONS: Chronic hepatitis without precore mutant strain before treatment is more responsive to IFN-alpha.     

Emergence of Enterococcus species in the infectious microorganisms cultured from patients with endophthalmitis in South Korea

Purpose

To investigate the microorganisms in culture-proven endophthalmitis and their susceptibilities to antimicrobial agents commonly used in South Korea.

Methods

Medical records of consecutive patients with culture-proven endophthalmitis at eight institutions between 1 January 2004 and 31 July 31 2010 were reviewed. Four categories of endophthalmitis were studied: postoperative, posttraumatic, endogenous, and unspecified. Outcome measures were culture-proven infectious organisms, antimicrobial susceptibilities, and final visual acuity in the patients.

Results

A total of 93 microorganisms were identified from 103 patients during the study period. The positive culture rate was 59.2 % (103/174). The most common organisms identified were Enterococcus faecalis (in 20.8 % of patients, 20/96), Staphylococcus epidermidis (18.8 %, 18/96), other coagulase-negative staphylococci (10.4 %, 10/96), Pseudomonas aeruginosa (6.3 %, 6/96), and Klebsiella pneumoniae (6.3 %, 6/96). Two cases of Enterococcus faecium (2.1 %) were recognized. Overall, 70 of 96 (73.0 %) isolates were Gram-positive bacteria, 22 (23.0 %) were Gram-negative bacteria, and 4 (4.2 %) were fungi. The most common organisms resulting in reduced light perception were E. faecalis and K. pneumoniae.

Conclusions

The emergence of E. faecalis in endophthalmitis is mainly caused by the high incidence of E. faecalis in postoperative endophthalmitis. This increase also impacts the final visual acuity of the patients.     

Prevalence of diabetes and impaired fasting glucose in Korea: Korean National Health and Nutrition Survey 2001

OBJECTIVE: The purpose of this study was to estimate the prevalence of diabetes and impaired fasting glucose (IFG) and their association with risk factors in the Korean population. RESEARCH DESIGN AND METHODS: The Korean National Health and Nutrition Survey 2001 was a nationally representative survey with a stratified multistage sampling design. Data from a comprehensive questionnaire, a physical examination, and blood tests were obtained from 5,844 Korean adults (2,513 men and 3,331 women) aged >20 years. RESULTS: The age-adjusted prevalence of diabetes in this Korean population was 7.6%, and the age-adjusted prevalences of previously diagnosed diabetes and newly diagnosed diabetes were 4.4 and 3.3%, respectively (fasting plasma glucose > or = 7.0 mmol/l). Overall, these results indicate that 8.1% or 1.4 million Korean men and 7.5% or 1.3 million Korean women have diabetes. The age-adjusted prevalence of IFG was 23.9%, using the new American Diabetes Association criteria (fasting plasma glucose 5.6-6.9 mmol/l). Diabetes prevalence increased with age and peaked in the oldest age-group; however, IFG prevalence did not show the same trend. Diabetes was found to be associated with age, BMI, blood pressure, triglyceride, HDL cholesterol, education levels, alcohol consumption, exercise, and a family history of diabetes. CONCLUSIONS: This study shows that diabetes and IFG are common in Korea, and about one-half of diabetes cases remain undiagnosed. These results emphasize the need to develop an urgent public program to improve the detection, prevention, and treatment of diabetes.     

Living donor liver transplantation in hepatocellular carcinoma beyond the Milan criteria

Background/Aims: In patients with hepatocellular carcinoma (HCC) exceeding the Milan criteria, the recurrence rate after liver transplantation is over 50%. We investigated pretransplant factor(s) that could predict recurrence after living donor liver transplantation (LDLT) in patients with HCC exceeding the Milan criteria. Methods: Pre‐operative imaging showed that, of the 111 HCC patients who underwent LDLT between June 1995 and January 2006, 37 exceeded the Milan criteria. Clinical factors before LDLT were evaluated. Results: The 1‐ and 3‐year cumulative recurrence rates were 35 and 55% respectively. Pretransplant risk factors for HCC recurrence were large tumour size (>6 cm, P=0.001), tumour exposed to the liver surface (P=0.014) and progressive disease after pretransplant treatment (P=0.038). The 2‐year HCC recurrence rates in patients with 0, 1, 2 and 3 factors were 0% (0/4), 9% (1/16), 80% (8/10) and 100% (7/7) respectively (P<0.001). The 2‐year survival rate was significantly higher in patients with 0 or 1 factor than in patients with two or more factors (P=0.022). Conclusions: In patients with HCC exceeding the Milan criteria, the three pretransplant factors that may be useful for identifying those with high HCC recurrence potential after LDLT are tumour size >6 cm, progressive disease after pretransplant treatment and tumour exposed to the liver surface.     

Plasma asymmetric dimethylarginine concentrations in newly diagnosed patients with acute myocardial infarction or unstable angina pectoris during two weeks of medical treatment

A high concentration of plasma asymmetric dimethylarginine (ADMA) has been associated with several risk factors for atherosclerosis, and this may increase the risk for acute coronary syndromes (ACSs). We measured plasma ADMA concentrations in patients who had newly diagnosed ACS (n = 48), and we followed the changes in ADMA concentrations during these patients' short-term medical therapy, which included various combination of drugs with or without percutaneous coronary interventions according to the needs of each patient. Concentrations of plasma ADMA were found to be high in patients who had ACS compared with 48 age-matched healthy control subjects (3.13 +/- 0.85 vs 1.57 +/- 0.85 mumol/L, p <0.0001). Follow-up measurements of ADMA showed dramatic decreases in plasma ADMA concentrations over 2 weeks of medical therapy for ACS (from 3.27 +/- 0.87 to 1.52 +/- 0.47 mumol/L, p <0.0001). Plasma ADMA at baseline showed a significant positive correlation with serum C-reactive protein and plasma insulin and a significant negative correlation with serum levels of high-density lipoprotein and plasma alpha-tocopherol. During therapy, changes in plasma ADMA concentrations were significantly correlated with changes in the ratio of total cholesterol to high-density lipoprotein cholesterol and in serum C-reactive protein concentrations but not with changes in insulin levels. This study provides the first evidence that plasma ADMA concentrations are significantly high in patients who have ACS and that ADMA concentrations rapidly decrease after short-term medical therapy.     

Association between aortic calcification and stable obstructive coronary artery disease

Aims

Atrial fibrillation and flutter remain an important cause of morbidity in adults with atrial septal defect (ASD). This study aimed at investigating predictors for late (≥ 1 month after repair) atrial arrhythmia.

Methods

Patients who underwent ASD closure after the age of 18 years, were selected through the databases of three medical centres in Belgium. Preprocedural, periprocedural and follow-up data were extracted. Univariate and multivariate Cox-regression analysis was performed. Kaplan-Meier analysis was performed for any independent predictor of late atrial arrhythmia.

Results

A total of 155 patients (38 men and 117 women) was included. Twenty-four patients (median age 48.3 years, range 19.9-79.8) underwent surgical and 131 (median age 57.6 years, range 18.2-86.9) underwent transcatheter closure. Thirty-nine patients (25.2%) presented with late atrial arrhythmia. Male gender (P = 0.008), creatinine (P = 0.002), atrial arrhythmia before (P < 0.0001) and within 1 month after repair (P = 0.001) and a mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg (P < 0.0001) correlated with late atrial arrhythmia in univariate Cox-regression analysis. Multivariate analysis showed that mPAP ≥ 25 mm Hg (HR 3.72; 95%CI 1.82-7.59; P < 0.0001) and the presence of atrial arrhythmia before (HR 3.22; 95%CI 1.56-6.66; P = 0.002) and within 1 month after repair (HR 2.08; 95%CI 2.08-15.92; P = 0.001) were predictive of late atrial arrhythmia. Kaplan-Meier analysis showed that patients with a mPAP ≥ 25 mm Hg had a higher risk at developing late atrial arrhythmia (P < 0.0001).

Conclusion

In patients with ASD type secundum, a mPAP ≥ 25 mm Hg is an independent predictor of late atrial arrhythmia. The presence of pulmonary hypertension before repair should raise awareness for atrial arrhythmias and may be used to guide therapy.