Correlation between clinical indication for treatment and liver histology in HBeAg‐negative chronic hepatitis B: a novel role of α‐fetoprotein

Background: It is unclear whether clinical indication for antiviral treatment is in agreement with histological indication in HBeAg‐negative chronic hepatitis B (CHB). This study aimed to clarify this relationship and identify factors associated with liver histology. Patients and methods: We investigated 152 consecutive, treatment‐naïve, HBeAg‐negative CHB patients who had undergone liver biopsies at a tertiary medical centre in Taiwan. Clinical indications for treatment included a serum alanine aminotransferase level more than twice the upper limit of normal and an hepatitis B virus DNA level >2000 IU/ml. Factors associated with the histological indication (Ishak's grade ≥7 and/or stage ≥2) were analysed. Results: The association between the clinical and the histological indications was significant (P=0.011). However, the agreement was poor (κ value=0.197). In patients satisfying the clinical indication, age >52 years [odds ratio (OR)=2.669, P=0.042], serum α‐fetoprotein (AFP) level >7 ng/ml (OR=7.070, P<0.001) and platelet count <130 × 10⁹/L (OR=11.720, P=0.025) were identified to be independent factors associated with histological indication. In patients who did not satisfy the clinical indication, multivariate analysis revealed that only an AFP level >7 ng/ml (OR=10.345, P=0.021) was independently associated with histological indication. Combining the clinical indication and/or AFP level >7 ng/ml to predict liver histology, the sensitivity and the negative predictive value could improve from 86 to 94.4% and 66.7 to 81% respectively. Conclusion: AFP level is associated with liver histology in HBeAg‐negative CHB. Serum AFP level can serve as a surrogate indicator to identify patients who need antiviral treatment.     

Gastric cancer: preoperative local staging with 3D multi-detector row CT--correlation with surgical and histopathologic results

PURPOSE: To prospectively evaluate accuracy of multi-detector row computed tomographic (CT) images for preoperative staging of gastric cancer by using surgical and histopathologic results as reference standards. MATERIALS AND METHODS: This study had institutional review board approval; informed consent was obtained from all patients. Multi-detector row CT included acquisition of virtual gastroscopy images after air distention and contrast material-enhanced dynamic transverse and multiplanar reformation (MPR) images after water distention. Fifty-five consecutive patients with gastric cancer (38 men, 17 women; age range, 37-84 years; mean age, 63 years) underwent preoperative CT. All received 6 g of gas-producing crystals before unenhanced CT scanning for gastric distention and virtual gastroscopy. Patients drank 800-1000 mL of tap water to establish a background for dynamic contrast-enhanced CT scans. Images were obtained in late arterial, portal venous, and delayed phases with start delays of 40, 70, and 150 seconds, respectively. All patients underwent surgery. CT findings were compared with surgical and histopathologic results. Differences in accuracy of transverse and MPR images for T and N staging were assessed with the McNemar exact test. Statistical significance was inferred at P < .05. RESULTS: Detection rates of primary tumors with transverse images, MPRs, and combinations of MPR and virtual gastroscopy images were 91% (50 of 55), 96% (53 of 55), and 98% (54 of 55), respectively. Overall accuracy in assessment of tumor invasion of the gastric wall (T stage) was significantly better with MPR images (89% [49 of 55]) than with transverse images (73% [40 of 55]) (P < .01). Overall accuracy for lymph node (N) staging was 78% (43 of 55) with MPR images and 71% (39 of 55) with transverse images. This difference was not significant (P = .103). CONCLUSION: Multi-detector row CT with combined water and air distention can improve the accuracy of preoperative staging of gastric cancer. MPRs yield significantly better overall accuracy than transverse images for tumor staging but not for lymph node staging.     

Myocardial ischemia during endoscopic retrograde cholangiopancreatography: An overlooked issue with significant clinical impact

Background and Aim: The occurrence of peri‐procedural myocardial ischemia with endoscopic retrograde cholangiopancreatography (ERCP) has been documented, but its significance remains controversial. This study aimed to investigate the incidence and risk factors of myocardial ischemia during ERCP procedures and to analyze the potential association between myocardial ischemia and post‐ERCP complications. Methods: Ambulatory 24‐h ST‐segment monitoring from 30 min prior to 24 h after ERCP was obtained on 71 patients from September 2006 to August 2007. Changes in vital signs during ERCP, post‐ERCP complications, and their outcomes were recorded and analyzed. Results: Cardiac ischemia occurred in 13 patients (18.3%) during ERCP and one patient developed myocardial infarction. More patients in the ischemic group (38.5%) than in the non‐ischemic group (5.2%) had ST‐T changes in pre‐ERCP resting electrocardiography (P < 0.01). Hypotension during ERCP was found only in the ischemic group (15.4% vs 0%; P = 0.03). Patients with cardiac ischemia during ERCP had a significantly higher rate of elevated serum amylase and lipase levels (53.8% vs 15.5%; P < 0.01) and post‐ERCP pancreatitis (30.8% vs 6.9%; P = 0.03). Multivariable logistic regression analysis revealed that cardiac ischemia during ERCP (OR: 5.21, P = 0.050) and pancreatic duct cannulation (OR: 5.7, P = 0.036) were independent predictors for post‐ERCP pancreatitis. Conclusions: ST‐T changes on resting electrocardiography and intra‐procedural hypotension are risk factors of myocardial ischemia during ERCP. Post‐ERCP hyperamylasemia, hyperlipasemia, and pancreatitis were associated with myocardial ischemia during ERCP.     

Desflurane potentiates atracurium in humans: A comparative study with isoflurane

Study Objective: (1) To evaluate the neuromuscular effects of desflurane and its interactions with atracurium and (2) to compare desflurane and isoflurane in these effects.

Design: Sequential entry of informed and consenting patients randomly assigned to receive desfurane (n = 25) or isofurane (n = 25).

Setting: Operating suite of a county-university medical center.

Patients: Fifty adults, ASA physical status I, undergoing elective orthopedic surgery.

Interventions: Following establishment of steady desfurane or isofurane anesthesia, at 1.25 minimum alveolar concentration (MAC) exhaled for 15 minutes, a randomly predetermined dose of atracurium (0.05, 0.1, or 0.15 mg/kg) was injected intravenously (IV). At the end of surgery, neostigmine 0.04 mglkg IV was given to reverse the residual block. The neuromuscular effects of desfurane or isofurane alone, and the dose-response relationship, time course, and reversibility of the neuromuscular effects of atracurium with either anesthetic, were examined in detail and compared using electromyographic quantification of the response of the first dorsal interosseous muscle to train-of-four (TOF) stimulation of the ulnar nerve.

Measurements and Main Results: TOF fade and depression of the first response (T₁) of the TOF were measured in response to desfurane or isofurane, atracurium, and neostigmine. Desf urane caused more TOF fade than isofurane prior to atracurium administration. The TOF ratios were 0.91 ± 0.02 and 0.98 ± 0.01, respectively (p < 0.05). For other measured neuromuscular parameters, atracurium-induced depression tended to be greater in the presence of desfurane than in the presence of isofurane, but none of the measured differences reached the statistical significance level of p < 0.05. The ED₅₀, ED₉₅, and 25–75% recovery index of atracurium were 0.038 mg/kg (95% confidence level; range 0.030 to 0.047 mg/kg), 0.11 mg/kg (0.095 to 0.14 mg/kg), and 31 ± 4 minutes (means ± SEM) with desfurane anesthesia, versus 0.043 mg/kg (0.035 to 0.052 mg/kg), 0.13 mg/kg (0.11 to 0.16 mg/kg), and 23 ± 4 minutes with isofurane anesthesia (p = 0.1-0.2). Continuation of either anesthetic at 1.25 MAC prevented complete recovery of neuromuscular functions spontaneously or following neostigmine 0.04 mg/kg.

Conclusion: In ASA physical status I adults, 9% desfurane has neuromuscular effects equal to or slightly in excess of those of 1.6% isofurane.     

The relationship between nickel chloride-induced peroxidation and DNA strand breakage in rat liver.

Inorganic nickel chloride induces hepatic DNA strand breaks, chromosome aberrations, and lipid peroxidation under in vitro and in vivo conditions. The objective of this research was to determine if a relationship exists between NiCl2 genotoxicity and lipid peroxidation in vivo. Male Sprague-Dawley rats (210-250 g) were dosed with 0.56 or 0.75 mmol/kg NiCl2 subcutaneously and euthanized after specific time periods, ranging from 30 min to 24 hr. Livers were perfused and excised for the measurement of nickel content using atomic absorption spectrometry, lipid peroxidation using a thiobarbituric acid assay, and DNA strand breakage using single-stranded DNA extraction and the diaminobenzoic acid assay. The lower dose (0.56 mmol/kg) did not induce lipid peroxidation or strand breakage. The higher dose (0.75 mmol/kg) induced DNA strand breakage at 4 hr and lipid peroxidation at 12 hr in rat liver. Nickel was seen to accumulate in liver nuclei of rats receiving 0.75 mmol/kg. Deferoxamine (1 g/kg, ip, 15 min before the NiCl2 injection) completely inhibited DNA strand breakage at 4 hr but had no effect on lipid peroxidation. This suggests that lipid peroxidation is not causally related to genetic damage. NiCl2-induced DNA strand breakage may be caused by the induction of the Fenton reaction, generating hydroxyl radicals.