Development of Gastroesophageal Varices and Risk of Variceal Bleeding in Patients With Cirrhosis

Abstract: We studied the relationships between portal pressure measured using the portal venous pressure gradient, the development of gastroesophageal varices, and the risk of variceal bleeding in 56 patients with cirrhosis. Portal pressure was higher in patients with varices than in those without (P>0.01), and 11 mmHg was the lowest portal pressure measured in the patients with varices. The size of the varices was not associated with the portal pressure. There was no difference in the value of portal pressure measurements for the patients with variceal bleeding and those without and there was no linear-relationship between the degree of portal hypertension and the rate of variceal bleeding. 12 mmHg was the lowest portal pressure measured in the patients with variceal bleeding. The size of the varices was related to the rate of variceal bleeding (P>0.05). We conclude that (a) a portal pressure of 11 mmHg is necessary for the formation of varices, (b) 12 mmHg of portal pressure is necessary for variceal bleeding to occur but the degree of portal hypertension has no predictive value for the risk of variceal bleeding, and (c) the size of the varices does not depend on the degree of portal hypertension but is associated with the risk of variceal bleeding.     

Clonal and non-clonal karyotypically abnormal cells in haemophagocytic lymphohistiocytosis

We studied chromosomes in bone marrow (BM) or peripheral blood cells of nine patients with haemophagocytic lymphohistiocytosis (HLH); three of them had a family history of HLH and four others underwent concurrent Epstein-Barr virus (EBV) infection. In addition to a large population of normal mitotic cells, karyotypically abnormal clonal cells were found in two patients, abnormal clonal cells and a nonclonal (single) abnormal cell in one, and nonclonal abnormal cells in three. All the six patients with chromosome abnormalities died of progressive disease; one of them also had EBV infection and EBV-associated clonal proliferation. Two of three patients with EBV infection and only normal mitotic cells in BM completely recovered from the disease.
Although HLH did not show histological and/or haema-tological evidence of a neoplastic disease, clonal chromosome abnormalities and the fatal clinical outcome found in some of the patients suggest that the disease may be heterogenous and include malignancy. HLH patients with karyotypically abnormal clonal cells in BM should warrant more intensive chemotherapy than that presently being applied to them and should be considered as candidates for BM transplantation.     

Heart Rate Turbulence as a Predictor of Cardiac Mortality and Arrhythmic Events in Patients with Dilated Cardiomyopathy: A Prospective Study

Background: Few studies have described the clinical usefulness of heart rate turbulence (HRT), an autonomic predictor of mortality, in stratifying patients with dilated cardiomyopathy (DCM) at risk of cardiac mortality and arrhythmic events. We prospectively assessed the utility of HRT for risk stratification in patients with ischemic or nonischemic DCM.
Methods: We enrolled 375 consecutive patients with DCM including ischemic (n = 241) and nonischemic causes (n = 134). HRT was measured using an algorithm based on routine 24-hour Holter electrocardiograms, assessing 2 parameters: turbulence onset (TO) and turbulence slope (TS). HRT was considered positive when both TO was ≥0% and TS was ≤ 2.5 ms/R-R interval. The primary endpoint was defined as cardiac mortality and the secondary endpoint as occurrence of hemodynamically stable sustained ventricular tachyarrhythmias.
Results: Of patients enrolled, 83 patients (22.1%) were not utilized for HRT assessment because there were too few ventricular premature beats, or for other reasons. Eighty-one of 292 patients (27.7%) were HRT-positive. During follow-up of 445 ± 216 days, 30 patients (10.3%) reached the primary endpoint and 17 patients, the secondary endpoint. The hazard ratio (HR) of patients with an HRT-positive outcome was 6.4 (95%CI, 3.0–14.1; P < 0.0001) for the primary endpoint and 5.1 (95%CI, 2.8–9.3; P < 0.0001) for combined endpoints. On subanalysis, HRT positivity was significantly associated in both the ischemic and nonischemic DCM patients with both the primary endpoint (HR = 4.9, P = 0.0006 and HR = 12.3, P = 0.002, respectively) and with combined endpoints.
Conclusions: HRT is a powerful risk stratification marker for cardiac mortality and arrhythmic events in patients with DCM whether ischemia is present or not.     

Effect of prior administration of succinylcholine on duration of action of vecuronium during enflurane anaesthesia

The effects of succinylcholine, which was given to facilitate tracheal intubation on the duration of action of subsequently administered vecuronium bromide, were evaluated in 54 adult patients who underwent abdominal surgeries under enflurane anaesthesia. The electromyographic response to train–of–four ulnar nerve stimulation was measured. Twenty–seven patients received 1 mg–kg^-1 of succinylcholine, followed by 0.15 mg kg^-1 of vecuronium when the electromyographic response recovered to 50% of control after succinylcholine–induced neuromuscular blockade. The other 27 patients served as the control group, receiving 0.15 mg kg^-1 of vecuronium without prior administration of succinylcholine. In both groups, administration of supplemental 0.04 mg kg^-1 of vecuronium was repeated whenever the electromyographic response recovered to 25% of control during surgical procedures. The duration of blockade induced by the initial 0.15 mg kg^-1 of vecuronium was 56.5 ± 12.8 (mean ± s.d.) min for the group with succinylcholine, and 58.5 ± 21.5 min for the control group. In both groups, the average duration of four consecutive supplemental doses of vecuronium was approximately 35 min. No significant differences between groups were found in the duration of neuromuscular blockade induced by initial and supplemental doses of vecuronium.     

Response of pial vessel diameter and regional cerebral blood flow to CO2 during midazolam administration in cats

Midazolam has been demonstrated to preserve the response of cerebral blood flow to CO2. However, the responsiveness of cerebral vessels or microcirculation during midazolam administration related to alteration of cerebral blood flow has not been explored. The purpose of this study was to examine the effects of midazolam on cerebral microcirculation. Nine cats were paralyzed and mechanically ventilated under nitrous oxide/oxygen anaesthesia. Using the closed cranial window technique and laser Doppler flowmetry, diameter of pial vessels and regional cerebral blood flow (rCBF) were examined on the surface of the cerebral cortex which was perfused by the middle cerebral artery. Before midazolam administration, haemodynamic variables, blood gases, rCBF, and diameter of pial vessels were determined as a control under normocapnia, hypocapnia, and hypercapnia conditions. After midazolam administration, given initially at 0.8 mg kg^-1·min^-1 for 10 min and subsequently at 0.04 mg kg^-1 min"¹ (total dose 10 mg kg^-1'), the same variables were again analyzed. With regard to CO2 responsiveness, an 8.85% increase in rCBF was demonstrated for a Paco2 elevation of 1 kPa before midazolam administration, compared with a 7.47% increase after midazolam administration. With regard to the correlation between C02 response and vessel diameter, arterioles less than 50 μm in diameter were more sensitive than those more than 50 μm in diameter, although there were no significant differences before or after midazolam administration. We conclude that CO2 responsiveness is preserved in terms of rCBF and vessel diameter after high doses of midazolam (10 mg·kg^-1) in cats.     

A pilot study to evaluate a new combination therapy for gastric ulcer: Helicobacter pylori eradication therapy followed by gastroprotective treatment with rebamipide

Background and Aim: Controversies remain over the need for antiulcer treatment following 1‐week eradication triple therapy for Helicobacter pylori‐positive peptic ulcers. The usefulness of combination therapy for gastric ulcers in Japanese patients, which consists of H. pylori eradication followed by gastroprotective therapy with rebamipide, was therefore evaluated. Methods: The study was conducted in 52 H. pylori‐positive patients with an endoscopically‐proven open gastric ulcer. All patients received 1‐week triple therapy (lansoprazole, amoxicillin and clarithromycin) followed by 7‐week rebamipide therapy. After completion of the combination therapy, all patients underwent evaluation of ulcer healing by endoscopy, gastric ulcer symptoms and H. pylori eradication by rapid urease test and ¹³C‐urea breath test. Results: The ulcer healing rates were 85.7% (36/42) at 8 weeks, 83.3% (30/36) in eradicated patients and 100% (6/6) in non‐eradicated patients. The overall gastrointestinal symptom‐free rate improved from 19.0% at baseline to 88.1% at 8 weeks. H. pylori was effectively eradicated in 85.7% (36/42) of patients. Conclusions: The results suggested that the combination therapy for open gastric ulcer was safe, well‐tolerated and effective. However, data from a double‐blind placebo‐controlled study is necessary to confirm these findings.     

Endoscopic Findings of Acute Intestinal Graft-versus-host Disease after Bone Marrow Transplantation

Abstract: To clarify the endoscopic findings of intestinal graft-versus-host disease (GVHD), we reviewed the endoscopic findings of 19 patients who underwent colonoscopy because of abdominal pain, watery diarrhea or bloody stool among 196 bone marrow transplant (BMT) recipients between 1986 and 1997. BMT had been performed for treatment of various hematopoietic disorders. Eleven patients were diagnosed as having intestinal GVHD, based on the pathological findings of biopsy specimens. Although the grade of inflammation differed among cases, the terminal ileum was most vulnerable to GVHD, based on our observations. Compared to the ileum, findings in the colon tended to be mild. Therefore, evaluation of intestinal GVHD requires observation of the terminal ileum when the colorectal findings are mild. The findings consisted of shallow ulcerations, erythema and easy bleeding. However, there were very few specific endoscopic findings of intestinal GVHD. Since intestinal GVHD and cytomegalovirus (CMV) enterocolitis share several clinical characteristics, including preferential involvement of the ileum, biopsy is indispensable for the final diagnosis.     

Age changes in the rat temporomandibular joint articular disc: a biochemical study on glycosaminoglycan content

SUMMARY The temporomandibular joint (TMJ) articular discs were removed from female Sprague-Dawley rats 3, 5, 10, 32, 90 and 130 weeks of age. Glycosaminoglycans (GAGS) were extracted from the discs by heat treatment, alkali treatment and digestion with Pronase E, and purified by precipitation with cetylpyridinium chloride and ethanol. The concentration of total GAG was highest in the 3 week extracts and tended to decrease with age. Dermatan sulphate was the predominant GAG detected in all age groups along with chondroitin sulphate, hyaluronic acid and heparan sulphate. The disaccharides obtained from chondroitin sulphate were ΔDi-4S, ΔDi-6S and ΔDi-OS, with ADi-4S being the predominant isomer followed by ADi-6S for all ages of all the GAG examined. The concentration of chondroitin sulphate showed a decrease with age. Quantitative changes of GAG with age may be related to functional changes in TMJ discs.