Chieh-Chang Chen

A Tool to Predict Risk for Gastric Cancer in Patients With Peptic Ulcer Disease on the Basis of a Nationwide Cohort

BACKGROUND & AIMSnPatients with gastric ulcers have significantly higher risk of gastric cancer, especially within 2xa0years after diagnosis. We used data from a national database to develop a personalized risk prediction model for patients with peptic ulcer diseases.nnnMETHODSnWe collected data from Taiwans National Health Insurance Research Database on 278,898 patients admitted for the first time with a primary diagnosis of peptic ulcer disease. We used the data to develop a nomogram, which we validated by discrimination and calibration, and in a test cohort. Cumulative incidences of study subjects predicted by the nomogram were examined.nnnRESULTSnIn total, 1269 subjects developed gastric cancer. Age, sex, peptic ulcer sites, peptic ulcer complications, Helicobacter pylori eradication, nonsteroidal anti-inflammatory drug use, and surveillance endoscopy were independent factors associated with risk of gastric cancer (all Pxa0<xa0.001). The concordance index for the nomogram developed on the basis of these factors was 0.78. Study subjects were divided into quartiles of predicted risk scores; from lowest score quartile to highest, cumulative incidences at 1 year were 7.4/10,000 people, 14.2/10,000 people, 25.5/10,000 people, and 86.6/10,000 people. The cumulative incidences at 2 years were 9.3/10,000 people, 20.9/10,000 people, 38.0/10,000 people, and 135.7/10,000 people for the same quartiles of risk scores. The nomogram was validated in an independent cohort, and similar incidence values were determined.nnnCONCLUSIONSnWe developed and validated a nomogram to predict risk for gastric cancer 1 and 2 years after diagnosis of peptic ulcer disease. The nomogram provides a prognostic tool that can be easily used for individuals and can help physicians explain risk levels to patients.

Ultrasound-guided core biopsy for hypopharyngeal cancer with difficult endoscopic approaches: our experience in eleven patients.

*Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Department of Otolaryngology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan, Graduate Institute of ClinicalMedicine,National TaiwanUniversity College ofMedicine, Taipei, Taiwan, Department of Otolaryngology, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan, and Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan

Endoscopy Timing in Acute Variceal Hemorrhage: Perhaps Not the Sooner the Better, but Delay Not Justified

Endoscopy Timing in Acute Variceal Hemorrhage: Perhaps Not the Sooner the Better, but Delay Not Justified

Upper gastrointestinal bleeding owing to right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy.

C uestion: A 67-year-old man with diabetes mellitus preented to our emergency department with hematemesis. He ad undergone laparoscopic cholecystectomy 2 months reviously. On arrival, his blood pressure was 97/50 mmHg nd his heart rate was 101 bpm. Laboratory tests revealed a emoglobin concentration of 9.3 g/dL (normal, 12.3–18.3), levated urea (29 mg/dL; normal, 8.0–20.0), and normal reatinine (0.9 mg/dL). Liver function tests and prothromin time were within normal limits. He denied taking aspiin or nonsteroid anti-inflammatory analgesics. After resuscitation with fluid, an emergent upper gasrointestinal endoscopy disclosed a protruding lesion ith pulsatile spurting at anterior wall of duodenal bulb nd bleeding stopped after epinephrine injection (Figure ). Abdominal ultrasonography showed a periduodenal esion with turbulent arterial signal (Figure B). What is your diagnosis? See the GASTROENTEROLOGY web site (www. astrojournal.org) for more information on submiting your favorite image to Clinical Challenges and mages in GI. CHIEH-CHANG CHEN, MD Department of Internal Medicine National Taiwan University Hospital Yun-Lin Branch BANG-BIN CHEN, MD Department of Medical Imaging National Taiwan University Hospital Yun-Lin Branch HSIU-PO WANG, MD Department of Internal Medicine National Taiwan University Hospital Yun-Lin Branch and Department of Internal Medicine National Taiwan University Hospital and National Taiwan University College of Medicine Taipei, Taiwan

Systematic Review with Meta-Analysis: Concomitant Therapy vs. Triple Therapy for the First-Line Treatment of Helicobacter pylori Infection

BACKGROUND: Whether concomitant therapy is superior to triple therapy of various treatment lengths for the first‐line treatment of H. pylori remains controversial. The objective of this study is to compare the efficacy of concomitant therapy and triple therapy given for 5‐14 days. METHODS: Randomized control trials (RCTs) comparing the efficacy of concomitant therapy for 5‐14 days and proton pump inhibitor‐amoxicillin‐clarithromycin (PAC)‐based triple therapy for 5‐14 days in the first‐line treatment of adult patients with H. pylori infection published from 1990 to January 2018 were searched from the PubMed, Cochrane Library, and Embase. Abstracts from international annual conferences were also searched. The primary and secondary outcomes were the eradication rate according to the intention‐to‐treat analysis and the adverse effects, respectively. Subgroup analyses were also performed according to treatment length. This study is registered with PROSPERO, number CRD42017081328. RESULTS: Of the 639 articles identified, 23 RCTs including 3305 patients in the concomitant therapy group and 3327 patients in the triple therapy group were eligible. Overall, concomitant therapy was superior to triple therapy [risk ratio (RR): 1.15; 95% confidence interval (CI): 1.09‐1.21; p < 0.001]. However, there were significant heterogeneity (I2 = 74.0%, p < 0.001). In the subgroup analysis, 5‐day concomitant therapy was superior to 5‐day triple therapy (RR: 1.30; 95% CI: 1.04‐1.62; p = 0.02), 5‐ or 7‐day concomitant therapy was superior to 7‐day triple therapy (RR: 1.16; 95% CI: 1.12‐1.21; p < 0.001), and 5‐ or 7‐, or 10‐ or 14‐day concomitant therapy was superior to 10‐day triple therapy (RR: 1.15; 95% CI: 1.08‐1.23; p < 0.001). However, 5‐ or 10‐day concomitant therapy was not superior to 14‐day triple therapy (RR: 1.02; 95% CI: 0.89‐1.16; p = 0.796). The frequency of adverse effects was significantly higher in concomitant therapy than triple therapy (RR: 1.19; 95% CI: 1.06‐1.34; P = 0.004). CONCLUSIONS: Concomitant therapy given for 5 or 10 days was superior to 5‐ or 7‐, or 10‐day PAC‐based triple therapy, but was not superior to 14‐day triple therapy.

14 day sequential therapy versus 10 day bismuth quadruple therapy containing high-dose esomeprazole in the first-line and second-line treatment of Helicobacter pylori: a multicentre, non-inferiority, randomized trial

BackgroundnWhether extending the treatment length and the use of high-dose esomeprazole may optimize the efficacy of Helicobacter pylori eradication remains unknown.nnnObjectivesnTo compare the efficacy and tolerability of optimized 14u2009day sequential therapy and 10u2009day bismuth quadruple therapy containing high-dose esomeprazole in first-line therapy.nnnMethodsnWe recruited 620 adult patients (≥20u2009years of age) with H. pylori infection naive to treatment in this multicentre, open-label, randomized trial. Patients were randomly assigned to receive 14u2009day sequential therapy or 10u2009day bismuth quadruple therapy, both containing esomeprazole 40u2009mg twice daily. Those who failed after 14u2009day sequential therapy received rescue therapy with 10u2009day bismuth quadruple therapy and vice versa. Our primary outcome was the eradication rate in the first-line therapy. Antibiotic susceptibility was determined. ClinicalTrials.gov: NCT03156855.nnnResultsnThe eradication rates of 14u2009day sequential therapy and 10u2009day bismuth quadruple therapy were 91.3% (283 of 310, 95% CI 87.4%-94.1%) and 91.6% (284 of 310, 95% CI 87.8%-94.3%) in the ITT analysis, respectively (difference -0.3%, 95% CI -4.7% to 4.4%, Pu2009=u20090.886). However, the frequencies of adverse effects were significantly higher in patients treated with 10u2009day bismuth quadruple therapy than those treated with 14u2009day sequential therapy (74.4% versus 36.7% Pu2009<u20090.0001). The eradication rate of 14u2009day sequential therapy in strains with and without 23S ribosomal RNA mutation was 80% (24 of 30) and 99% (193 of 195), respectively (Pu2009<u20090.0001).nnnConclusionsnOptimized 14u2009day sequential therapy was non-inferior to, but better tolerated than 10u2009day bismuth quadruple therapy and both may be used in first-line treatment in populations with low to intermediate clarithromycin resistance.

Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection

BACKGROUND & AIMSnWe aimed to compare the efficacy of genotypic resistance-guided therapy vs empirical therapy for eradication of refractory Helicobacter pylori infection in randomized controlled trials.nnnMETHODSnWe performed 2 multicenter, open-label trials of patients with H pylori infection (20 years or older) failed by 2 or more previous treatment regimens, from October 2012 through September 2017 in Taiwan. The patients were randomly assigned to groups given genotypic resistance-guided therapy for 14 days (nxa0= 21 in trial 1, nxa0= 205 in trial 2) or empirical therapy according to medication history for 14 days (nxa0= 20 in trial 1, nxa0= 205 in trial 2). Patients received sequential therapy containing esomeprazole and amoxicillin for the first 7 days, followed by esomeprazole and metronidazole, with levofloxacin, clarithromycin, or tetracycline (doxycycline in trial 1, tetracycline in trial 2) for another 7 days (all given twice daily) based on genotype markers of resistance determined from gastric biopsy specimens (group A) or empirical therapy according to medication history. Resistance-associated mutations in 23S ribosomal RNA or gyrase A were identified by polymerase chain reaction with direct sequencing. Eradication status was determined by 13C-urea breath test. The primary outcome was eradication rate.nnnRESULTSnH pylori infection was eradicated in 17 of 21 (81%) patients receiving genotype resistance-guided therapy and 12 of 20 (60%) patients receiving empirical therapy (Pxa0= .181) in trial 1. This trial was terminated ahead of schedule due to the low rate of eradication in patients given doxycycline sequential therapy (15 of 26 [57.7%]). In trial 2, H pylori infection was eradicated in 160 of 205 (78%) patients receiving genotype resistance-guided therapy and 148 of 205 (72.2%) patients receiving empirical therapy (Pxa0= .170), according to intent to treat analysis. The frequencies of adverse effects and compliance did not differ significantly between groups.nnnCONCLUSIONSnProperly designed empirical therapy, based on medication history, is an acceptable alternative to genotypic resistance-guided therapy for eradication of refractory H pylori infection after consideration of accessibility, cost, and patient preference. ClinicalTrials.gov ID: NCT01725906.

Sa1893 Primary Genotypic Resistance of Helicobacter pylori and Its Relations With Virulence Factors - A Multicenter Surveillance Program in Taiwan

patients (218 without current HP infection and 49 with successful eradication of HP infection) were HP negative status (HP-negative group), 107 patients (19 with failed eradication and 88 with no treatment of HP infection) were HP positive status (HP-positive group). The incidence of metachronous gastric cancer was compared in both groups, and the risk factors associated with the development of metachronous gastric cancer after ER was analyzed. Results: Median follow-up duration after ER was 4.1 years (range 1.0 10.5 years). During the follow-up period, metachronous gastric cancer developed in 16 patients (15.0% [16/ 107]) in the HP-positive group and in 15 patients (5.6% [15/267]) in the HP-negative group. The cumulative incidence of metachronous gastic cancer was significantly different between HP-negative and HP-positive groups (P= .003 by Log-rank test). In a multivariate Coxproportional hazard model, age . 65 years (hazard ratio [HR], 2.88; 95% confidential interval [CI], 1.28 6.49; P= .011), family history of gastric cancer (HR, 2.48; 95% CI, 1.11 5.53; P= .026), and HP-positive status (HR, 2.52; 95% CI, 1.24 5.14; P= .011) were associated with the development ofmetachronous gastric cancer. Conclusions: Persistent H. pylori infection after ER for EGC seems be associated with the development of metachronous gastric cancer during long-term follow-up period.

Plasma indoxyl sulfate concentration predicts progression of chronic kidney disease in dogs and cats

Indoxyl sulfate is a protein-bound uremic toxin that increases as the severity of impaired renal function increases in humans, laboratory animals, dogs and cats. An elevation of indoxyl sulfate is related to prognosis among people with chronic kidney disease. However, whether indoxyl sulfate is able to predict the progression of chronic kidney disease in dogs and cats has not been previously studied. In the present study, 58 cats and 36 dogs with chronic kidney disease were enrolled. Plasma indoxyl sulfate was measured by high performance liquid chromatography. Renal progression was defined as an increase by one International Renal Interest Society (IRIS) stage and/or a rise in serum creatinine concentration of 0.5mg/dL during the same stage within a 3-month period. Compared with the non-progression groups, across different stages of renal failure, the baseline plasma indoxyl sulfate concentration was increased in the renal progression group (P<0.05), especially for IRIS stages 2 and 3 animals. The area under the receiver operator characteristic curves of indoxyl sulfate, when predicting renal progression, was above 0.75 for both dogs and cats. Indoxyl sulfate concentrations were also correlated with the increase of blood urea nitrogen, serum creatinine, and phosphate and the decrease of hematocrit among cats; while in dogs, concentrations were only correlated with the increase of phosphate concentrations. Indoxyl sulfate served as a biomarker of progression risk in dogs and cats with chronic kidney disease.

IDDF2018-ABS-0076 Optimised 14-day levofloxacin sequential versus 10-day bismuth quadruple therapy containing high dose esomeprazole in the second-line and third-line treatment of helicobacter pylori – a multicenter randomised trial

Background We aimed to compare the efficacy of 14u2009day levofloxacin sequential therapy versus 10u2009day bismuth quadruple therapy in the second-line and third-line treatment of Helicobacter pylori (H. pylori) infection. Methods H. pylori infected patients who failed after one treatment were eligible in this open labelled, multicenter, randomised trial, and were randomised to receive (1) levofloxacin sequential therapy (EAML): esomeprazole 40u2009mg and amoxicillin 1u2009g for the first 7 days, followed by esomeprazole 40u2009mg, metronidazole 500u2009mg, and levofloxacin 250u2009mg for another 7 days (all twice daily); or (2) bismuth quadruple therapy (BQ): esomeprazole 40u2009mg twice daily, bismuth tripotassium dicitrate 300u2009mg four times a day, tetracycline 500u2009mg four times a day, and metronidazole 500u2009mg three times a day, for 10 days. The primary end point was the eradication rate in the second-line treatment according to intention to treat (ITT) analysis. The minimum inhibitory concentrations were determined by agar dilution test. Results The results were available for analysis in 398 patients up to Dec, 2017. The preliminary eradication rate in the EAML and BQ groups were 88.9% (169/190) and 91% (172/189), respectively (p=0.505) in the ITT analysis, and were 89.9% (169/188) and 96.1% (172/179) in the PP analyses, respectively (p=0.021) in the second line treatment. The efficacy of levofloxacin sequential therapy, but not bismuth quadruple therapy, appeared to be affected by levofloxacin resistance. In the third-line therapy, the eradication rate of EAML was 60% (3/5) for patients who failed after bismuth quadruple therapy. The eradication rate of BQ was 80% (12/15) for patients who failed after levofloxacin sequential therapy. The cumulative eradication rates were 95.3% (181/190) and 92.6% (175/1189) in the EAML (2nd)-BQ(3rd) and the BQ(2nd)- EAML (3rd) groups (p=0.276). The frequencies of adverse effects were 42.8% (62/145) and 81.9% (118/144) in patients treated with EAML and BQ, respectively (p<0.001). Conclusions Levofloxacin sequential therapy and bismuth quadruple therapy are similarly effective in the second-line treatment for H. pylori infection. (Trial registration number: NCT NCT03148366).