Chee-My Chang

High incidence of clopidogrel-associated gastrointestinal bleeding in patients with previous peptic ulcer disease

Background:  In average‐risk patients, the new anti‐platelet agent, clopidogrel, causes less upper gastrointestinal adverse events than aspirin. However, there are no safety data on the use of clopidogrel in high‐risk patients.

Gastrointestinal bleeding in patients receiving a combination of aspirin, clopidogrel, and enoxaparin in acute coronary syndrome.

BACKGROUND:The combination of aspirin, clopidogrel, and enoxaparin (combination therapy) is the standard treatment for acute coronary syndrome but is associated with gastrointestinal bleeding. However, information in this area is scarce.AIM:This retrospective study aimed to determine the incidence of upper gastrointestinal bleeding in a real-life situation. The effect of proton pump inhibitor (PPI) treatment was also analyzed.METHOD:From January 2002 to December 2006, all patients receiving combination therapy were analyzed. The end point was the occurrence of upper gastrointestinal bleeding during combination therapy or within 7 days of stopping enoxaparin.RESULTS:The patient group consisted of 666 patients (age 72.1 ± 12.6 yr). Gastrointestinal bleeding occurred in 18 (2.7%) patients. The overall hospital mortality was 4.1% (27 patients). A cardiac event was the major cause (N = 24, 3.6%). Only one patient died of massive gastrointestinal bleeding (0.15%). Multiple logistic regression analysis demonstrated that previous peptic ulcer, cardiogenic shock, and the lack of PPI coprescription were significant risk factors for gastrointestinal bleeding. The age-adjusted odds ratio (95% confidence interval) for gastrointestinal bleeding was 5.07 (1.31–16.58) for previous peptic ulcer, 21.41 (2.56–146.68) for cardiogenic shock, and 0.068 (0.010–0.272) for the coprescription with a PPI.CONCLUSION:In real life, the incidence of gastrointestinal bleeding associated with the combination of aspirin, clopidogrel, and enoxaparin therapy was estimated to be 2.7%. Previous peptic ulcer disease or cardiogenic shock were significant independent risk factors. Coprescription with a PPI can significantly reduce the risk.

Upper Gastrointestinal Bleeding in Patients with Aspirin and Clopidogrel Co-Therapy

Introduction: The major complication of aspirin and clopidogrel (A+C) co-therapy is upper gastrointestinal bleeding (UGIB). However, data are unavailable for real-life situations. Furthermore, the treatment effect of antisecretory agents is unknown. Aim: This cohort study aimed to determine the occurrence of UGIB. The treatment effect of H2-receptor antagonist (H2RA) and proton pump inhibitor (PPI) was also analyzed. Method: The records of 987 consecutive patients on A+C co-therapy between January 2001 and September 2006 were analyzed. The follow-up ended on the dates of a first occurrence of UGIB, stopping A+C co-therapy, a change in the antisecretory class, death, or March 2007. Results: After a follow-up of 5.8 ± 6.5 months, UGIB occurred in 39 (4.0%) patients. PPI, H2RA and control were prescribed in 213, 287 and 487 patients respectively. After adjustment for age, dose of aspirin, previous UGIB and duration of treatment, the risk was marginally reduced by H2RA (OR = 0.43, 95% CI 0.18–0.91, p = 0.04) and significantly reduced by PPI (OR = 0.04, 95% CI 0.002–0.21, p = 0.002), as compared to control. Conclusion: The occurrence of UGIB associated with A+C co-therapy for a median of 5.8 months was 4.0%. Co-prescription with PPI was associated with a lower risk.

Clopidogrel plus omeprazole compared with aspirin plus omeprazole for aspirin-induced symptomatic peptic ulcers/erosions with low to moderate bleeding/re-bleeding risk: a single-blind, randomized controlled study

Background : Clopidogrel causes significantly less symptomatic peptic ulcer disease and gastrointestinal bleeding than low‐dose aspirin in average‐risk patients. The gastrotoxicity of clopidogrel in patients with active peptic ulcer disease is unknown.

Cytomegalovirus colitis in individuals without apparent cause of immunodeficiency.

Cytomegalovirus infection is usually reported inimmunocompromised patients. In this study, apparentlyimmunocompetent patients with cytomegaloviral colitiswere reviewed. Records with a diagnosis ofcytomegaloviral colitis from January 1989 to June 1996 wereretrieved for analysis. Ten patients were included(median age 70 yr). The major presenting symptoms werediarrhea and hematochezia. Ulceration was the mainmacroscopic finding. Rectal bleeding was mostlyself-limiting. Three patients developed localcomplications (rectovaginal fistula in two; rectalstricture in one). In the two patients with rectovaginalfistula, lymphocytes subsets and proliferative response wereentirely normal. In the other patient, low B lymphocytecount and low response to mitogen were demonstrated.However, the immunoglobulins were not suppressed and rectal biopsies revealed noncaseatinggranulomas, suggesting activated cell-mediated immunity.In conclusion, a high index of suspicion is crucial forearly diagnosis of cytomegaloviral colitis in patients with bloody diarrhea, even though obviousevidence of immunodeficiency is lacking.

N-hexane neuropathy in offset printers.

In an offset printing factory with 56 workers, 20 (36%) developed symptomatic peripheral neuropathy due to exposure to n-hexane. Another 26 workers (46%) were found to have subclinical neuropathy. The initial change in the nerve conduction study was reduced amplitude of the sensory action potentials, followed by reduced amplitude of the motor action potentials, reduction in motor conduction velocities and increase in distal latencies. These changes indicate primary axonal degeneration with secondary demyelination. Sural nerve biopsy in a severe case showed giant axonal swellings due to accumulation of 10nm neurofilaments, myelin sheath attenuation and widening of nodal gaps. The development of neuropathy bore no direct relationship to the duration of exposure, hence factors such as individual susceptibility may be important. Optic neuropathy and CNS involvement were uncommon and autonomic neuropathy was not encountered.

Herpes zoster and its neurological complications.

Ninety-three Chinese patients with cutaneous herpes zoster were seen during a 4-year period. Thoracic zoster occurred most commonly, followed by ophthalmic, cervical and lumbosacral zoster. Neurological complications were present in eleven patients (11.8%), the commonest being Ramsay-Hunt syndrome and segmental limb paresis. The clinical picture, pathogenesis, treatment and outcome of segmental limb paresis, myelitis and delayed contralateral hemiparesis following zoster ophthalmicus are discussed. Nine immunocompromised patients received intravenous adenine arabinoside (vidarabine) or acycloguanosine (acyclovir), and no cutaneous or visceral spread occurred in these patients.

Encephalopathy and neuropathy following ingestion of a Chinese herbal broth containing podophyllin

Two patients developed podophyllin intoxication following ingestion of a broth of the Chinese herb guijiu. The neurological manifestations are described and the pathology of the peripheral neuropathy is fully documented with ultrastructural and quantitative studies.

Huntington's disease in Chinese: a hypothesis of its origin.

The period prevalence (1984-91) of Huntingtons disease (HD) in Hong Kong Chinese was 3.7 per million population. HD patients in Mainland China and Hong Kong showed similar hereditary pattern, clinical and pathological features as in the West. Chinese HD patients were male predominant with a younger age of onset and death. Their ancestral origin could be traced mostly to the coastal provinces of China. It is proposed that Chinese HD patients may have a European origin and share the same gene pool as their white counterparts.

Cerebral venous thrombosis in Hong Kong.

Cerebral venous thrombosis (CVT) is a ‘relatively uncommon but nonetheless important condition’ [1]. The Chinese are considered less susceptible to venous thrombosis, and CVT in Chinese has not been systemically studied. To date, there is only one abstract reporting a case series from Taiwan [2]. Queen Mary, Ruttonjee and Pamela Youde Nethersole Eastern are the three district hospitals of Hong Kong Island that provide acute services to an urban population of 1.4 million. We reviewed retrospectively 13 consecutive adult patients presenting with CVT over 3 years (October 1995 to September 1998) to explore the clinical relevance of CVT in a Chinese community. Details of the patients are summarized in table 1. Hypercoagulation states were screened for in all cases. Laboratory evidence of type I natural anticoagulant protein deficiency was present in 3 patients. Patient 9 had a persistent thrombocytosis of undetermined cause. Six cases were on oral contraceptive pills (OCP) for various indications. Patient 13 was also taking an unknown herbal preparation for weight reduction. Patients 1 and 8 developed symptoms of CVT 18 and 14 days, respectively, after delivery. Patient 6 was an intravenous narcotic addict with a history of deep venous thrombosis related to selfinjection. She was admitted for septicaemic shock. Meningitis was excluded by lumbar puncture. Patient 11 was on a moderate dose of corticosteroid for suspected bronchiolitis obliterans organizing pneumonia. CT scan demonstrated the cord sign in patients 1 and 9, haemorrhagic infarction in patients 3, 9, 11 and 13, non-haemorrhagic venous infarction in patients 1 and 12, and hydrocephalus in patient 7. Thrombosed dural sinus was confirmed in all patients with MRI.