Sun-Sang Wang

Proinflammatory cytokines in early assessment of the prognosis of acute pancreatitis

Objective: Proinflammatory cytokines are involved in the pathogenesis of acute pancreatitis. The value of serum levels of tumor necrosis factor-α, interleukin-1-β, interleukin-6, and interleukin-8 in predicting the outcome of acute pancreatitis was evaluated. Methods: In 50 patients with acute pancreatitis, the serum concentrations of tumor necrosis factor-α, interleukin-1-β, interleukin-6, interleukin-8, and C-reactive protein were determined on days 1, 2, 3, 4, and 7 after admission. Acute Physiology and Chronic Health Evaluation (APACHE II) scores were recorded on days 1, 2, and 3. Results: Serum concentrations of interleukin-1-β, interleukin-6, interleukin-8, and C-reactive protein on days 1–7 were significantly higher in patients with severe pancreatitis than in patients with mild pancreatitis. Patients with severe attacks had significantly elevated serum tumor necrosis factor-α concentrations on days 1–3 compared with those with mild attacks, but not on days 4 and 7. The median peak value of tumor necrosis factor-α, interleukin-1-β, interleukin-6, and interleukin-8 was reached on day 1, in contrast to the median peak of C-reactive protein, which was reached on day 2. Using cutoff levels of 12 pg/ml for tumor necrosis factor-α, 1 pg/ml for interleukin-1-β, 400 pg/ml for interleukin-6, 100 pg/ml for interleukin-8, 12 mg/dl for C-reactive protein, and 10 for the Acute Physiology and Chronic Health Evaluation (APACHE II) score, the accuracy rates for detecting severe pancreatitis were 72%, 82%, 88%, 74%, 80%, and 72%, respectively, on day 1 and 78%, 74%, 80%, 76%, 80%, and 78%, respectively, on day 2. Conclusion: Among the proinflammatory cytokines, interleukin-6 is the most useful parameter for early prediction of the prognosis of acute pancreatitis.

Neuropsychiatric profiles in patients with Alzheimer's disease and vascular dementia

Objective: To explore the neuropsychiatric manifestations in patients with Alzheimer’s disease (AD) and cortical and subcortical vascular dementia (VaD). Methods: We investigated consecutive patients with dementia. All the participants received brain computed tomography. The diagnosis of dementia was confirmed by clinical criteria and the imaging findings. Only patients with probable AD, and subcortical and cortical VaD were included. The Mini Mental State Examination (MMSE) was used to evaluate global cognitive function, and the Neuropsychiatric Inventory (NPI) was used to assess neuropsychiatric symptoms. Results: Of the 536 participants with dementia, 320 (59.7%) had AD, 161 (30%) had subcortical VaD, 35 (6.4%) had cortical VaD, and 16 (2.9%) had mixed cortical and subcortical VaD. Cortical VaD patients had the highest mean composite NPI scores in all domains and AD patients had the lowest composite scores in most domains. The mean composite scores of the apathy and sleep disturbance domains in patients with cortical VaD were significantly higher than those in the patients with AD after controlling for years of education and MMSE score (p<0.01). Conclusions: There were few differences among the patients with AD, subcortical VaD and cortical VaD. The most consistent differences were the high sleep disturbance scores in those with cortical VaD.

Metabolic bone disease of liver cirrhosis: Is it parallel to the clinical severity of cirrhosis?

Metabolic bone disease has long been recognized in chronic liver disease, especially cholestatic or alcoholic liver diseases. The aim of the present study was to investigate the prevalence and severity of osteodystrophy in cirrhotic men and the correlation of its incidence with the clinical severity of cirrhosis in an endemic area of post‐necrotic hepatitis. We measured serum levels of osteocalcin, 25‐hydroxyvitamin D, parathyroid hormone mid‐molecule, calcium and testosterone in 74 cirrhotic men (Child‐Pughs classification grade A n= 30, B n= 21 and C n= 23) and 16 healthy controls. Standard X‐rays and bone mineral densities of lumbar spine were performed in 30 patients with post‐necrotic cirrhosis and 10 healthy controls. Serum levels of osteocalcin, parathyroid hormone and testosterone were significantly lower in patients with cirrhosis than in controls. Changes paralleling an increased severity of cirrhosis were found in the serum levels of 25–hydroxyvitamin D and testosterone, but not in the serum levels of osteocalcin and parathyroid hormone. The lumbar bone mineral density was significantly lower in patients with post‐necrotic cirrhosis than in controls (0.97 ± 0.13 vs 1.07±0.12 g/cm2, P<0.05) and was correlated with serum 25–hydroxyvitamin D levels (r = 0.467; P<0.005). There was no correlation between the bone mineral density and serum osteocalcin or the clinical severity of cirrhosis. The prevalence of spinal osteoporosis, as defined by a lumbar bone mineral density greater than two standard deviations below the mean value of the controls, was 20% in cirrhotic patients compared with 10% in controls. Two (6.7%) patients (both grade C) had spinal compression fractures compared with none in the control group. In conclusion, serum osteocalcin and lumbar bone mineral density were significantly lower in cirrhotic men than in controls. However, they were not correlated with each other or the clinical severity of cirrhosis.

Comparison between portal vein pressure and wedged hepatic vein pressure in hepatitis B-related cirrhosis

Portal vein pressure and wedged hepatic vein pressure were measured simultaneously in 21 patients with hepatitis B-related cirrhosis of the liver and were compared to pressure measured in six patients with idiopathic portal hypertension. No significant difference in the portal venous pressure gradient was found between patients with cirrhosis and those with idiopathic portal hypertension (17.3 +/- 4.3 mmHg (mean +/- S.D.) vs. 19.7 +/- 3.1 mmHg, P greater than 0.05). However, the difference between the portal and the hepatic venous pressure gradient was significantly smaller in patients with cirrhosis than in idiopathic portal hypertension patients (1.3 +/- 1.7 vs. 10.8 +/- 2.1 mmHg, P less than 0.001). An excellent correlation was found between portal vein pressure and wedged hepatic vein pressure in hepatitis B-related cirrhosis (r = 0.94, P less than 0.001). There was no linear relationship between the portal venous pressure gradient and varix size or bleeding episodes. We concluded that a close agreement existed between portal vein pressure and wedged hepatic vein pressure in hepatitis B-related liver cirrhosis. Therefore, measurement of wedged hepatic vein pressure reliably reflects portal vein pressure in these patients.

A randomized controlled trial comparing octreotide and vasopressin in the control of acute esophageal variceal bleeding

This randomized controlled trial was conducted to compare the efficacy of intravenous infusion of octreotide (a synthetic long-acting somatostatin analogue) with vasopressin in 48 cirrhotic patients with endoscopically proven bleeding esophageal varices. Twenty-four patients received a continuous infusion of octreotide 25 micrograms/h for 24 h after an initial bolus of 100 micrograms and another 24 patients received a continuous infusion of vasopressin 0.4 U/min for 24 h. Bleeding was initially controlled after 6 h of drug infusion in 88% (21/24) and 54% (13/24) of the patients treated with octreotide and vasopressin respectively (p = 0.03). Complete control of bleeding after 24 h of drug infusion was achieved in 15 (63%) patients receiving octreotide and in 11 (46%) patients receiving vasopressin (p > 0.05). Side effects during drug infusion such as headache, chest pain and abdominal pain were significantly lower in the octreotide group (3/24) than in the vasopressin group (11/24). Serum gastrin and insulin levels fell significantly following octreotide infusion, but plasma glucose levels remained unchanged. Mortality related to bleeding esophageal varices was no different between the two groups. This report showed that octreotide infusion was more effective and had fewer side effects than vasopressin in initial controlling of acute esophageal variceal bleeding until an elective endoscopic sclerotherapy could be performed.

Bone mineral density in patients with Parkinson's disease measured by dual photon absorptiometry

Bone mineral density (BMD) in 22 patients (three females, 19 males, aged 58–76 years) with idiopathic Parkinsons disease (PD) was measured by dual photon absorptiometry (DPA) using a M&SF Osteo Tech 300 scanner. The BMDs of the 2nd to 4th lumbar vertebrae were measured and the mean density was presented as g cm-2. The BMD of the PD patients was compared with normal BMD values within the same age groups, and the patients were interpreted as normal, suffering mild osteoporosis or severe osteoporosis. The patients were divided into two groups according to (a) the Hoehn and Yahr (H-Y) scale as high or low, or based on (b) the duration of the disease as long or short, for comparison. The prevalence of abnormal BMD in each subgroup of patients was calculated. The results show that the BMD of all the PD patients was lower than those of the normal controls. The PD patients with a high H-Y scalc had a higher prevalence of severe osteoporosis. However, the difference between any two groups, separated by the two criteria, is not significant by Fishers test. We find that PD patients have a higher incidence of severe osteoporosis.

Prevalence and health/social impacts of functional dyspepsia in Taiwan: A study based on the Rome Criteria Questionnaire Survey assisted by endoscopic exclusion among a physical check-up population

Objective Until now, the epidemiology of functional dyspepsia (FD) and its social impact on Asians have been rarely studied. The aims of this study were to determine the prevalence, social impact, and health-seeking behaviors of FD in an apparently healthy Chinese population in Taiwan. Material and methods Based on the questionnaire provided by the Rome II working team, a survey was administered to a Taiwanese population receiving paid physical check-up (n=2865). Esophagoduodenoscopy was performed in each subject to exclude organic dyspepsia. Finally, diagnoses of functional gastrointestinal disorders were obtained by means of a computer-generated algorithm. Results The FD prevalences were 23.8% and 11.8% according to the Rome I and -II criteria, respectively. Nearly 60% of Rome I-defined FD subjects and 18.9% of Rome II-defined FD subjects had overlapping irritable bowel syndrome (IBS). Irrespective of any Rome definition, FD subjects had excessive physician visits, absenteeism, and sleep disturbances compared to dyspepsia-free controls (p<0.01). Moreover, over half of the Rome II FD subjects were “consulters” showing excessive physician visits, absenteeism, and sleep disturbances than “non-consulters”. The dysmotility-like subgroup (74.5%) comprised the majority of FD subjects and showed no differences to their ulcer-like counterparts in terms of major demographic data and social and health impacts. Conclusions FD is a common complaint in Taiwan and also bears an obvious social and medical burden to society. Over half of our FD subjects sought medical help, which may be due to the readily accessible medical care in Taiwan. The newly defined Rome II criteria diminish the chance of co-existence of FD and IBS. Further FD classification by the main symptoms appears of limited clinical usefulness.

Clinical Significance of Ultrasonography, Computed Tomography, and Biochemical Tests in the Rapid Diagnosis of Gallstone-related Pancreatitis: A Prospective Study

Real-time ultrasonography (US), computed tomography (CT), and biochemical tests were prospectively performed to detect gallstones in 88 consecutive patients immediately after the onset of an attack of acute pancreatitis. The sensitivity of biochemical tests was 84.6% when the patients had three or more positives of five parameters [including serum bilirubin, alkaline phosphatase (AP), gamma-glutamyl transpeptidase (GGT), alanine transaminase (ALT), and alanine transaminase-aspartate transaminase (ALT-AST) ratio]. The sensitivity, specificity, and accuracy were 71.8, 98.0, and 86.4% for US, and 52.9%, 100%, and 79.5% for CT. The sensitivity, specificity, and accuracy were improved to 82.1, 100, and 93.2% by the combination of US and CT, and 94.9, 100, and 97.7% by the combination of US and biochemical tests. Adding CT to the combination of US and biochemical tests resulted in only a slight improvement in sensitivity and accuracy. In conclusion, a combination of US and biochemical tests can provide the best noninvasive method in rapidly detecting gallstones as an etiological factor in acute pancreatitis. Computed tomography is not cost-effective. A positive result of biochemical tests despite a negative finding in US calls for an intensive search for gallstones by further investigation with endoscopic retrograde cholangiography or repeated US examinations.

Subdural haematoma in patients with spontaneous intracranial hypotension

The incidence and clinical relevance of subdural haematoma (SDH) in patients with spontaneous intracranial hypotension (SIH) remain undetermined. We reviewed 40 consecutive SIH patients (18 female, 22 male) in a tertiary hospital. Eight (20%) of them had SDH and nine (23%), non-haemorrhagic subdural collections. The presence of SDH was associated with higher frequencies of male gender, recurrence of severe headache and neurological deficits. Outcomes were satisfactory after supportive care or epidural blood patches except for one SDH patient, who developed transtentorial herniation resulting in Duret haemorrhage and infarctions of bilateral posterior cerebral artery territories. In conclusion, subdural fluid collections were common in patients with SIH. SDH was associated with headache worsening or neurological deficits. Patients with SDH generally recovered well; however, serious sequela might occur.

The Prevalence of Anti-Hepatitis C Virus Among Chinese Patients With Hepatocellular Carcinoma

To evaluate the role of hepatitis C virus (HCV) in Chinese patients with hepatocellular carcinoma (HCC), the antibodies to HCV (anti‐HCV) were detected by enzyme immu‐noassay in 41 (12.6%) of the 326 patients with HCC. However, none of 35 patients with metastatic carcinoma of the liver had detectable anti‐HCV. The prevalence of anti‐HCV was significantly higher in patients with hepatitis B surface antigen (HBsAg)‐negative HCC than those with HBsAg‐positive HCC (37.3% versus 4.1%, P < 0.0001). However, the prevalence of anti‐HCV was much higher in patients with HCC with negative results for HBsAg and antibody to hepatitis B core antigen (54.5%). The mean age of patients with HCC with positive results for anti‐HCV was significantly greater than that of patients with HBsAg‐positive HCC (65.1 versus 55.5 years, P < 0.0001). Alpha‐fetoprotein levels greater than 20 ng/ml were found in 70.7% of patients with HCC with positive results for anti‐HCV and in 73.3% of patients with HBsAg‐positive HCC. Of the Chinese patients with HCC, 74.5% had HBsAg‐positive results and 96.6% had positive results for antibody to hepatitis core antigen. These data indicate that, although HCV may play an etiologic role in HCC, hepatitis B virus is still the most important causal agent among most Chinese patients with HCC.