Cheng-Tang Chiu

Prevalence of and risk factors for gallbladder polyps detected by ultrasonography among healthy Chinese: Analysis of 34 669 cases

Background and Aim:u2002 Gallbladder (GB) polyps are tumor or tumor‐like projections arising from GB mucosa. Although most polyps are benign, some early GB carcinomas present as polypoid lesions. The diagnosis of GB polyps is relatively easy by ultrasonography. Although numerous studies have investigated GB polyps, few studies have addressed the prevalence of and factors associated with GB polyps for specific ethnic populations. This study analyzes the prevalence and factors associated with GB polyps in a Chinese population who can afford a paid general checkup.

A Strong Association Between Down-Regulation of HLA-DR Expression and the Late Mortality in Patients with Severe Acute Pancreatitis

OBJECTIVES:There is no reliable parameter to predict the late mortality of patients with severe acute pancreatitis though it is an important issue. Recently a proposed parameter for “immunoparalysis,” a down-regulation of Human Leukocytes Antigens-DR (HLA-DR) expression on monocytes, had been detected in patients with severe but not mild acute pancreatitis. However, the relationship between this parameter and late mortality of acute pancreatitis is still unclear. Therefore, we conducted this study in order to elucidate this issue.METHODS:Twenty-five patients of severe acute pancreatitis admitted to Chang-Gung Memorial Hospital were successively enrolled during the period of 1999–2002. The HLA-DR expression, and serum levels of interleukin-10 (IL-10) and tumor necrosis factor-α(TNF-α) at different time points were measured. The HLA-DR expression was evaluated by flow cytometry and the levels of IL-10 and TNF-α were measured by ELISA.RESULTS:In our series, there were 7 (28%) late mortality cases out of 25 patients with severe acute pancreatitis. When analyzing the serial change of HLA-DR expression, it is clear that in survival group the HLA-DR expression was gradually up-regulated and in late mortality group it was persistently down-regulated (p < 0.001). When comparing with other parameters like Acute Physiological and Chronic Health Evaluation II and Ransons score by Cox hazards model, the HLA-DR expression on 10th day (HLA-DR-10) gave the only statistically significant correlation with late mortality (p= 0.001). Furthermore, HLA-DR10 is also a good predictor for late mortality when analyzed by receiver-operating characteristics (ROC) curves with 0.944 area under ROC (AUROC) value. The optimal cutoff value of HLA-DR on 10th day for predicting late mortality was 52.3% with 94.4% sensitivity and 85.7% specificity. As for the serum levels of TNF-α and IL-10, there were significant persistently higher levels in late mortality group than in survival group (p < 0.05). Furthermore, these monocytes from severe acute pancreatitis were with partial restoration of HLA-DR expression but with normal TNF-α and IL-10 secretion ability when stimulated in vitro with LPS.CONCLUSIONS:In severe acute pancreatitis, there was a strong association between the persistent down-regulation of HLA-DR expression and the late mortality. Furthermore, a cutoff value of 52.3% of HLA-DR expressed monocytes on the 10th hospitalization day is a good predictor for late mortality in patients with severe acute pancreatitis.

Activated but not resting regulatory T cells accumulated in tumor microenvironment and correlated with tumor progression in patients with colorectal cancer

Activated T regulatory (Treg) cells are potent suppressors that mediate immune tolerance. We investigated the relationship between activated Treg cells and the progression of human colon cancer. We designed a cross‐sectional study of CD4+Foxp3+ T cells from peripheral blood, primary tumor and nontumor colon tissue of 42 patients with colon cancer and correlated the percentages of different subgroups of Treg cells with colon cancer stage. The phenotypes, cytokine‐release patterns and suppression ability of these Treg cells were analyzed. We found that Treg cells increased significantly in both peripheral blood and cancer tissue. In addition, the Treg cells expressed significantly lower levels of CCR7, CD62L and CD45RA in comparison to normal volunteers. Further dividing Treg cells into subgroups based on Foxp3 and CD45RA expression revealed that both activated Treg cells (Foxp3hiCD45RA−) and nonsuppressive Treg cells (Foxp3loCD45RA−), but not resting Treg cells (Foxp3lowCD45RA+), increased in the peripheral blood and cancer tissue of patients with colon cancer. Only the activated Treg cells expressed significantly higher levels of tumor necrosis factor receptor 2 and cytotoxic T‐cell antigen‐4. Activated Treg cells, however, secreted significantly lower levels of effector cytokines (interleukin‐2, tumor necrosis factor‐α and interferon‐γ) than did resting Treg cells and nonsuppressive cells upon ex vivo stimulation. Activated, but not resting, Treg cells in cancer tissue correlated with tumor metastases. In summary, we confirmed that activated Treg cells are a distinct subgroup with effector memory phenotype and fully functional regulatory activity against human colorectal cancer immunity.

Altered expression patterns of lipid metabolism genes in an animal model of HCV core-related, nonobese, modest hepatic steatosis

BackgroundBecause the gene expression patterns of nonobese hepatic steatosis in affected patients remain unclear, we sought to explore these patterns using an animal model of nonobese hepatic steatosis.MethodsWe developed mice that conditionally express the hepatitis C virus (HCV) core protein regulated by the tetracycline transactivator (tTA). Microarray analyses and reverse-transcription polymerase chain reaction were performed using liver samples of both the double transgenic mice (DTM), which express both the HCV core and tTA, and single transgenic mice (STM), which express tTA alone, at 2 months of age. Functional categories of genes with altered expression were classified using gene ontology programs. Serum glucose, lipid levels, and systemic blood pressure were also measured.ResultsApproximately 20–30% of hepatocytes from the DTM were steatotic. No significant differences were observed in the serum glucose, lipid content, or blood pressure levels between the DTM and STM. Gene expression analyses revealed Sterol-regulatory element-binding protein (SREBP) pathway activation and dysregulation of the following genes involved in lipid metabolism: 3-hydroxy-3-methylglutaryl-coenzyme A synthase 1, Apolipoprotein AII, Apolipoprotein CI, acyl-CoA thioesterase I, and fatty acid binding protein 1; in mitochondrial function: solute carrier family 25 member 25 and cytochrome c oxidase subunit II; in immune reaction: complement component 3, lymphocyte antigen 6 complex, locus A, lymphocyte antigen 6 complex, locus C, lymphocyte antigen 6 complex, locus D, and lymphocyte antigen 6 complex, locus E.ConclusionSome genes of lipid metabolism, mitochondrial function, and immune reaction and the SREBP pathway are involved in HCV core-related, nonobese, modest hepatic steatosis.

Factors that influence cecal intubation rate during colonoscopy in deeply sedated patients.

Background and Aim:u2002 The technical performance of colonoscopy performed in deeply sedated patients differs from that performed without sedation or under minimal to moderate sedation. The aim of this study is to evaluate the factors affecting cecal intubation during colonoscopy performed under deep sedation.

Endoscopic management of suspected esophageal foreign body in adults.

Foreign bodies should not be allowed to remain in the esophagus beyond 24 hours after presentation. However, some patients with esophageal foreign body ingestion do not come to the hospital immediately and may delay medical intervention from the time of ingestion. The aim of this study was to investigate the outcomes of adults with suspected esophageal foreign body ingestion according to the time of ingestion and types of foreign bodies. A total of 326 adult patients (151 men and 175 women) were analyzed, and divided into two groups according to the time period: within or beyond 24 hours from ingestion to endoscopic intervention. A total of 172 patients (52.7%) were found to have ingested foreign bodies; 73.5% were removed smoothly, 10.3% were treated by push technique and 16.0% with failed retrieval received alternative treatments. A higher proportion of patients in the beyond-24 hours group suffered from odynophagia (25.9 vs. 12.9%, P < 0.05). Negative identification of esophageal foreign bodies was more frequent in the beyond-24 hours group (67 vs. 40.2%, P < 0.05), but these patients showed higher proportions of esophageal ulcers (21.1 vs. 7.2%, P < 0.05). The beyond-24 hours group also showed a significantly higher rate of foreign bodies in the lower esophagus (40.0 vs. 15.3%, P < 0.05). Patients with esophageal food bolus impaction had significant delayed endoscopic intervention, longer therapeutic endoscopic time, higher proportions of esophageal cancer, stricture and fewer complications. Endoscopic intervention within 24 hours from the time of ingestion should be considered early in adults, because delaying intervention may produce more symptomatic esophageal ulcerations with odynophagia.

Double Balloon Enteroscopy–The Last Blind-Point of the Gastrointestinal Tract

Technical challenges have obstructed the diagnosis and treatment of small intestine disease. An innovative form of enteroscopy—the double balloon method—permits visualization of the complete small intestine, to-and-fro examination of an area of interest, and biopsy and endoscopic procedures which are safer, faster, and less painful than earlier methods. From October 2003 to May 2004, a total of 10 patients with obscure gastrointestinal bleeding received 12 enteroscopic examinations, 8 per oral and 4 per rectal examinations, while 2 patients received per oral enteroscopy first and further per rectal procedures 2 days later. Two cases with intestinal submucosal tumors were discovered by per oral enteroscopy, one with a 5-cm SMT with reddish mucosa at the jejunum and another with a 4-cm SMT and surface ulceration, in which the biopsy showed GIST. Both patients received an operation later. Four patients were found to have intestinal angiodysplasia in jejunum(per oral) and one in ileum (per rectal), and after local therapy bleeding stopped. Multiple angiodysplasias were observed in a patient who was operated on for active bleeding from the ileum after Indian ink tattooing. The two patients who received per oral and per rectal procedures did not display definite small intestinal lesions. All patients underwent the procedures satisfactorily without any complications, and the examination times varied from 90 to 360 min. Double balloon enteroscopy permits deep insertion of an endoscope into the small intestine without excessive stretching of the intestinal tract. This method can use either an oral or an anal approach. To-and-fro observation of almost the complete small intestine is possible, as are interventions.

MELD score can predict early mortality in patients with rebleeding after band ligation for variceal bleeding

AIMnTo investigate the outcomes, as well as risk factors for 6-wk mortality, in patients with early rebleeding after endoscopic variceal band ligation (EVL) for esophageal variceal hemorrhage (EVH).nnnMETHODSnAmong 817 EVL procedures performed for EVH between January 2007 and December 2008, 128 patients with early rebleeding, defined as rebleeding within 6 wk after EVL, were enrolled for analysis.nnnRESULTnThe rate of early rebleeding after EVL for acute EVH was 15.6% (128/817). The 5-d, 6-wk, 3-mo, and 6-mo mortality rates were 7.8%, 38.3%, 55.5%, and 58.6%, respectively, in these early rebleeding patients. The use of beta-blockers, occurrence of hypovolemic shock, and higher model for end-stage liver disease (MELD) score at the time of rebleeding were independent predictors for 6-wk mortality. A cut-off value of 21.5 for the MELD score was found with an area under ROC curve of 0.862 (P < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value were 77.6%, 81%, 71.7%, and 85.3%, respectively. As for the 6-mo survival rate, patients with a MELD score ≥ 21.5 had a significantly lower survival rate than patients with a MELD score < 21.5 (P < 0.001).nnnCONCLUSIONnThis study demonstrated that the MELD score is an easy and powerful predictor for 6-wk mortality and outcomes of patients with early rebleeding after EVL for EVH.

Randomised clinical trial: sodium alginate oral suspension is non‐inferior to omeprazole in the treatment of patients with non‐erosive gastroesophageal disease

The burden of gastroesophageal reflux disease (GERD) is increasing in the Asia area and the majority of GERD patients have non‐erosive reflux disease (NERD).

Extracorporal liver support with molecular adsorbents recirculating system in patients with hepatitis B-associated fulminant hepatic failure.

Hepatitis B virus (HBV) infection is the most prevalent cause of fulminant hepatic failure (FHF) in the Far East. HBV‐associated FHF is characterised by rapidly progressive end organ dysfunction/failure and a very poor prognosis.