K.‐L. Goh

Transarterial embolisation of hepatocellular carcinoma with doxorubicin-eluting beads: single centre early experience

Purpose: This is a retrospective study to evaluate the results of our early experience of using doxorubicin eluting beads (DEB) to treat patients with early and intermediate hepatocellular carcinoma (HCC). Material and methods: A cohort of 19 patients (84.2% male; 15.8% female; mean age 59.2 years ± 11.0; range, 32-80 years) with documented HCC of size 1.8-10cm (mean, 4.0cm ± 1.8 ) undergoing DEB transarterial chembolisation (TACE) was reviewed. All patients had at least one image examination (multiphase computed tomography or magnetic resonance imaging) after embolisation. Results: A total of 32 procedures were performed. The objective response according to the European Association for the Study of the Liver criteria was 57.9% at 1-month, 42.8% at 6-month and 50.0% at 1-year follow up. There were 4 (21.1%) treatment-related complications (1 liver abscess, 2 pancreatitis and 1 tumour rupture) which resulted in 2 deaths. One death occurred 3 weeks after second embolisation, due to ruptured pancreatic pseudocyst, giving a 5.3% 30-day mortality rate. Another patient died 2 months after embolisation caused by tumour rupture. Eight patients received radiofrequency ablation after embolisation for residual or recurrent tumours. The 1-year survival rate in the DEB TACE only group was 80% while the 1- and 2-year survival rate in the group that received radiofrequency after DEB TACE was 85.7% and 100% respectively. Conclusion: DEB TACE is safe and effective in select group of patients. Survival may be improved when combined with other treatment modality.

Letter: enteral nutrition in advanced cirrhosis – a case of missing the boat?

SIRS, Thank you for giving us the opportunity to respond to the letter from Raza and Shata concerning our article. After careful consideration, we believe that the data discussed in the letter and the conclusions made have some important caveats. First, the authors use the Harvey-Bradshaw index, an abbreviated form of the Crohn’s disease activity index, to evaluate both Crohn’s disease (CD) and ulcerative colitis (UC) clinical symptoms. The Harvey-Bradshaw index includes parameters, such as the presence of fistulae or abdominal mass that apply to CD, but not UC, whereas it does not account for rectal bleeding – a good indicator of disease severity in UC. More importantly, Raza and Shata make the assumption that anti-IL-17 (or anti-IL-17R) therapy may have failed in CD due to, according to their data, a lack of production of IL-17 in these patients, whereas they hypothesise that it may work in UC. It is important to emphasise that increased production of IL-17 in active UC and CD patients has been documented by several groups (apart from us) and it is well-known that clinical and endoscopic activity in both UC (measured using the Mayo score) and CD patients is accompanied by increased production of IL-17. Moreover, anti-IL-17 therapy appears to worsen disease in some patients suggesting that, as it has been seen in different animal models, lack of IL-17 may have deleterious effects to intestinal homeostasis. Given the evidence, we believe that the assumption that anti-IL-17 may be beneficial in UC, based on the data the authors provide in the letter, is misleading.

Letter: East-West differences in the economic impact of functional dyspepsia.

SIRS, We read with interest the recent article by Lacy et al., which estimates the direct and indirect costs of functional dyspepsia (FD) at US

Clinical features and treatment of nonalcoholic fatty liver disease across the Asia Pacific region-the GO ASIA initiative

18.4 billion for the entire US population or US

Letter: dyspepsia, anxiety and depression

80 000 per 1000 US population for the year 2009. Although the study is limited by a selection bias of FD patients attending a tertiary centre and is not population-based, it provides current economic information using an internationally accepted Rome criteria. Having said that, the economic data reported in this study, and from other recent US-based studies, may have little global relevance. FD is equally prevalent in the East, but economic data remains sparse. A recent population-based study in South East Asia reported an estimated annual cost for uninvestigated dyspepsia of US

Letter: prompt endoscopy in Asians with uninvestigated dyspepsia.

14 816.00 and US

NOD2/CARD15 variants in Malaysian patients with sporadic colorectal cancer.

59 282.20 per 1000 population in a rural and urban setting respectively. FD is the most common cause of dyspepsia in this region, and as the Rome criteria was used to identify study subjects, this Asian study suggests significant differences in the economic impact of FD in the East. Although healthcare systems in Asia and the West are known to differ, other factors may be responsible for the variation in the economic impact of FD. Self-medication practices and lower healthcare consultation rates among rural Asians, coupled with more aggressive management by clinicians in the US (40% had CT abdominal scans and 23% had surgery in Lacy et al.’s study), may lead to greater direct costs for FD in the West. Furthermore, socioeconomic differences between employees (81% in the US study vs. 27.7% in the Malaysian study with >US

Commentary: rabeprazole improves symptoms in patients with functional dyspepsia in Japan

10 000 annual income) are an obvious factor when considering indirect costs for FD due to work absenteeism. In short, the economic impact of FD appears to vary globally and it is likely that cultural, sociodemographic and clinical factors may be responsible for this difference.

Commentary: adherence and detection rates in colorectal cancer screening.

The Gut and Obesity Asia (GO ASIA) workgroup was formed to study the relationships between obesity and gastrointestinal diseases in the Asia Pacific region.

Commentary: changing aetiology of peptic ulcers

1 year following PLA diagnosis in both sexes, which is comparable with our study. Furthermore, over half (64.5%) of CRC cases were detected within 5 years after PLA diagnosis. In our study, PLA patients had significantly higher risks of overall cancers, especially liver cancer, biliary tract cancer and CRC. The highest risks occurred within 90 days after the diagnosis of PLA. Hence, it is reasonable to consider PLA as the herald of CRC. Nevertheless, the risk of cancer remained elevated even 5 years after the diagnosis of PLA. Previous studies demonstrate that the incidences of PLA are higher in patients with diabetes mellitus and Klebsiella pneumonia is the most common pathogen, which are also the important risk factors for developing CRC. Consequently, patients with PLA had persistent higher risks of developing CRC even in the long-term follow-up period due to their underlying diseases. Based on Lai et al. and our study, patients with PLA should receive colonoscopy for the detection of CRC both in the early and in the long-term follow-up periods. ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.