Cheng-Hung Chien

Efficacy and safety of ribavirin plus pegylated interferon alfa in geriatric patients with chronic hepatitis C

Limited data are available on the efficacy and safety of antiviral therapy in geriatric patients with chronic hepatitis C virus (HCV) infection.

Predictors of Changes in Hemoglobin Levels in Patients with Chronic Hepatitis C Treated with Ribavirin Plus Pegylated Interferon-α

Background: Combination therapy with pegylated interferon (pegIFN)-α and ribavirin (RBV) for chronic hepatitis C virus (HCV) infection is associated with reduction in hemoglobin (Hb) concentrations and anemia. The aim of this study was to evaluate the magnitude and frequency of change in Hb and determine the predictive risk factors for Hb decrease during this therapy. Methods: We enrolled 308 patients with chronic HCV infection who were receiving weekly subcutaneous pegIFN injection in combination with body weight-based oral RBV for 24 weeks. Clinical and virological characteristics were used for studying the predictors of decrease in Hb. Results: The majority (95%) of patients showed reduction in Hb concentration of at least 1 g/dL during pegIFN and RBV combination therapy. The mean and median maximal decrease in Hb level of the study patients was 3.9 g/dL (range −0.3 to 8.2 g/dL; interquartile range 2.8–5.0 g/dL). Of all patients, 49.4% showed a reduction in Hb level of more than 4 g/dL; a higher number of male patients than female patients showed an Hb decrease of >4 g/dL. Multivariate analysis of our data showed that older age, high baseline Hb concentration, high HCV RNA viral load, low estimated glomerular filtration rate (eGFR), and low platelet count were independent predictors of significant decline in Hb levels. Conclusions: Patients with low eGFR before antiviral therapy may have an increased risk of RBV-related anemia and should be closely monitored. Clinician should consider the potential risk of significant reduction in Hb level according to eGFR while deciding the RBV dose.

Carbon dioxide insufflation during colonoscopy can significantly decrease post‐interventional abdominal discomfort in deeply sedated patients: A prospective, randomized, double‐blinded, controlled trial

CO2 has been reported to be absorbed from the bowel more rapidly than air, resulting in a discomfort reduction after colonoscopy. Its role in deeply sedated patients is limited. This study was designed to investigate the efficacy and safety of CO2 insufflation during colonoscopy in patients deeply sedated with propofol.

The Associations Between Helicobacter pylori Infection, Serum Vitamin D, and Metabolic Syndrome: A Community-Based Study.

AbstractThe associations between Helicobacter pylori infection, serum vitamin D level, and metabolic syndrome (MS) are controversial. The present community-based study aimed to investigate the effect of H pylori infection and serum vitamin D deficiency on MS development.Individuals from the northeastern region of Taiwan were enrolled in a community-based study from March, 2014 to August, 2015. All participants completed a demographic survey and underwent the urea breath test (UBT) to detect H pylori infection as well as blood tests to determine levels of vitamin D, adiponectin, leptin, and high-sensitivity C-reactive protein. The ATP III criteria for MS were used in this study.A total of 792 men and 1321 women were enrolled. The mean age was 56.4 ± 13.0 years. After adjusting for age and sex, the estimated odds of MS development for a UBT-positive subject were 1.503 (95% confidence interval [CI]: 1.206–1.872, P < 0.001) when compared to a UBT-negative subject. For participants with vitamin D deficiency (<20 ng/mL), the odds of MS development were 1.423 (95% CI: 1.029–1.967, P = 0.033) when compared to those with sufficient vitamin D level (>30 ng/mL). For participants with both H pylori infection and vitamin D deficiency, the odds of MS development were 2.140 (95% CI: 1.348–3.398, P = 0.001) when compared to subjects without H pylori infection and with sufficient vitamin D levels.H pylori infection and vitamin D deficiency could be predictors of MS. For individuals with both H pylori infection and vitamin D deficiency, the odds of MS development were 2.140 when compared to individuals without H pylori infection and with sufficient vitamin D levels.

Unawareness of Hepatitis B Virus Infection confers on Higher Rate of Metabolic Syndrome: A Community-based Study

The objective of this study was to determine whether awareness of hepatitis B virus (HBV) serostatus was discordant with metabolic syndrome (MetS) among people with chronic HBV infection. We conducted a community-based study in four Taiwanese districts. A total of 3493 adult participants were recruited. Participants who were hepatitis B surface antigen (HBsAg) seropositive and had self-reported HBV infection were considered aware of hepatitis B (aHB); those who denied a history of HBV infection were considered unaware of hepatitis B (uaHB). Among the 454 participants who were HBsAg seropositive, 275 (60.6%) were aHB and 179 (39.3%) were uaHB. Hypertriglyceridemia showed significant inverse association with HBsAg seropositive, especially among those who were aHB. Insulin resistance was significantly, positively associated with HBsAg seropositive, especially among participants who were uaHB. Those who were uaHB had a higher risk of central obesity, hyperglycemia, insulin resistance, and MetS than those who were aHB (odds ratio = 2.33, 1.64, 2.15, 1.85, respectively, all p < 0.05). The association among the prevalence of MetS, its individual components and HBsAg seropositivity varies according to awareness of HBV infection. It is important to recognize an individual’s risk for MetS, especially who were unaware of HBV infection.

A community-based study on the association between Helicobacter pylori Infection and obesity

Helicobacter pylori (H. pylori) infection can induce chronic inflammation and is associated with insulin resistance, metabolic syndrome and body mass index (BMI, kg/m2) changes. This study aimed to evaluate the association between H. pylori infection and overweight/obesity. This research was a cross-sectional study conducted from March 2014 to November 2016, using data from the three districts in the northeastern region of Taiwan. The inclusion criteria were an age >30 years and the absence of pregnancy. Ultimately, 2686 subjects (1713 women) were included in this study. Among the subjects aged less than 50 years, the subjects with H. pylori infection had higher mean BMI values than those without H. pylori infection (40–49 years: 25.7 ± 4.4 vs. 24.7 ± 3.8, P = 0.025; 30–39 years: 24.9 ± 4.4 vs. 24.0 ± 4.1, P = 0.063). H. pylori infection increased the risk of being obese 2 (BMI ≥30) (odds ratio, OR = 1.836, 95% CI = 1.079–3.125, P = 0.025) with adjustments for demographic factors in subjects aged less than 50 years. In conclusions, subjects with H. pylori infection and age less than 50 years may increase a risk of being obesity (BMI ≥30) compared to those without this type of infection.

Cervical esophageal perforation during endoscopic ultrasonography: A retrospective evaluation of frequency, outcome, and patient management

To analyze the indications and complications of diagnostic endoscopic ultrasonography (EUS) within a 12‐year period in our hospital. We retrospectively reviewed all patients who received upper gastrointestinal EUS at Keelung Chang Gung Memorial Hospital from January 2002 to December 2013. The examination was performed using a radial scanning echo endoscope (Olympus GF‐UMQ 240 before August 2011; Olympus GF‐UE 260‐AL5 after September 2011). The indications as well as complications were reviewed. A total of 839 patients underwent a total of 1036 procedures. Mean age of the patients was 59 years (range, 16‐102 years); 56.3% of patients were men. The indications for EUS were: evaluation of gastric submucosal tumors in 425 patients (41%), esophageal cancer staging in 247 patients (23.8%), evaluation of esophageal submucosal tumors in 91 patients (8.8%), evaluation of pancreatic lesions in 66 patients (6.4%), gastric cancer staging in 66 patients (6.4%), and evaluation of biliary lesions in 53 patients (5.1%). Only one patient (0.096%) developed a major complication (cervical esophageal perforation). Fortunately, the patient recovered smoothly after a surgical repair and felt well at 5‐year follow up. Cervical esophageal perforation is a rare but catastrophic complication of EUS. Advanced age, history of difficult intubation, cervical osteophytes, and less experienced doctors are documented to be the risk factors for perforation. In addition, surgeons should pay more attention to those who have a history of thyroidectomy. Immediate recognition of the perforation and urgent primary surgical repair results in a favorable outcome.

Thrombocytopenia as a Strong Indicator of Liver Fibrosis in Chronic Liver Disease Patients from Areas Hyperendemic for Hepatitis B and C Virus Infection

Background and Aims: Thrombocytopenia is likely the most common hematological abnormality diagnosed in patients with significant liver fibrosis or cirrhosis. The objective of this study was to investigate the relationship between peripheral platelet count and degree of fibrosis in patients with chronic liver disease in a hyperendemic area for hepatitis B and C virus infection.Materials and Methods: We studied 337 consecutive patients who underwent percutaneous liver biopsy. Clinical, laboratory, and histological features were measured and correlated with peripheral platelet counts.Results: Thrombocytopenia was common and peripheral platelet count was significantly decreased in patients with significant liver fibrosis or cirrhosis. Univariate and multivariate regression analyses revealed that a high liver fibrosis score (odds ratio [OR], -8.983; 95% confidence interval [95% CI], -13.641 to -4.324), advanced age (OR, -1.362 ; 95% CI, -2.058 to -0.667), absence of fatty liver (OR, 6.995; 95% CI, 0.125 to 13.866), presence of splenomegaly (OR, -2.647; 95% CI, -3.682 to -1.613), and a low serum WBC count are independently associated with decreased platelet count. Notably, because of a significant inverse correlation between platelet count and stage of liver fibrosis, significant liver fibrosis and cirrhosis could be predicted by a peripheral platelet count below 189,500 and 149,500 cells/μL, with 0.644 and 0.807 accuracy, respectively.Conclusions: Thrombocytopenia is common and severe in patients with significant liver fibrosis or cirrhosis. Therefore, we advocate close monitoring of platelet count to prevent the risk of bleeding, especially in patients with advanced age, without fatty liver, with splenomegaly, and with a low serum WBC count.

The Therapeutic Efficacy of Percutaneous Transhepatic Gallbladder Drainage in Acute Cholecystitis

Introduction: Acute cholecystitis is an acute inflammation of the gallbladder. In 96% of patients, the cystic duct is obstructed with gallstones. This results in a high risk of mortality and morbidity in debilitated and elderly patients. Percutaneous transhepatic gallbladder drainage (PTGBD) combined with intensive antibiotic treatment may allow the patients to receive elective surgery in a better clinical condition. The aim of the present study was to investigate the therapeutic efficacy of PTGBD in debilitated and elderly patients with acute cholecystitis.Patients and Methods: A total of 496 patients with acute cholecystitis were enrolled in this study. Patients who received conservative treatment and who had common bile duct (CBD) stones (evidenced by endoscopic retrograde cholangiopancreatography [ERCP] or magnetic resonance cholangiopancreatography [MRCP]) and Mirizzis syndrome were excluded. PTGBD was performed under ultrasound or computed tomography (CT) guidance in 65 patients. The clinical features, biochemical data, and outcomes were analyzed.Results: Among the 65 patients, 27 patients underwent cholecystectomy after PTGBD and 18 patients (67%) underwent surgery within 28 days. Fourteen (22%) patients died during follow up; they had significantly higher levels of total bilirubin, aspartate amminotransferase (AST), and alkaline phosphatase (ALP), and a higher incidence of sepsis. The clinical and laboratory features were similar between patients with and without surgery after PTGBD. However, patients without surgery had higher rates of sepsis and mortality, which was associated with more comorbidities.Conclusion: Elective surgery after PTGBD may be necessary for debilitated patients with acute cholecystitis. PTGBD together with antibiotics can convert a septic into a non-septic cholecystitis, particularly in elderly and debilitated patients. Surgery alone has a lower mortality rate and may be a better treatment choice for patients with acute cholecystitis who are younger and have fewer comorbidities.

Non-variceal Upper Gastrointestinal Bleeding in the Elderly Patients-A Comparison with Younger Patients

Background: The in-hospital complications and mortality rates of patients with non-variceal upper gastrointestinal bleeding have been reported to be higher in elderly than in younger patients. However, the mortality, the need for surgery and the rebleeding rates of elderly compared with younger patients in the era of therapeutic endoscopy and proton pump inhibitor are unclear.Aim: This study aims to investigate and compare the clinical outcomes of the non-variceal upper gastrointestinal bleeding in the elderly patients with those of the younger patients.Materials and Methods: A total of 205 consecutive patients who were diagnosed with non-variceal upper gastrointestinal bleeding according to chart review from June 2008 to March 2010 were enrolled in this study, including 112 elderly patients (age ≧ 70) and 93 younger patients (age ＜ 70).Result: The frequencies of cardiovascular diseases (40% vs. 14%, P＜0.001), hypertension (68% vs. 39%, P＜0.001), diabetes mellitus (30% vs. 17%, P=0.003 ), ulcerogenic drug use (42% vs.23% P=0.003) and gastric ulcer (66 % vs. 46%, P=0.004) were greater among elderly patients. There was no significant difference in the proportion of high-risk stigmata of recent hemorrhage, amount of blood transfused, rebleeding rate, endoscopy sessions, the need for surgery, or mortality rate between two groups of patients. The length of hospital stay was significantly longer in the elderly patients.Conclusion: Peptic ulcers account for the majority of the in hospital non-variceal upper gastrointestinal bleedings. Among them, gastric ulcers occur more frequently in the elderly patients due to the use of more ulcerogenic drugs. The rate of rebleeding, surgery, or mortality was not statistically different between both groups of patients although the elderly patients tend to have more mortality risk.