基因型C型HBV感染与肝细胞癌风险增加相关

Background: Identification of risk factors for the development of hepatocellul ar carcinoma (HCC) is important for HCC surveillance in chronic hepatitis B viru s (HBV) infection. Our aim was to study the independent risk factors and effect of HBV genotypes on HCC development in a prospective longitudinal cohort of chro nic hepatitis B patients. Patients and methods: Chronic hepatitis B patients rec ruited since 1997 were prospectively followed up for the development of HCC. HCC was diagnosed by a combination of αfetoprotein, imaging, and histology. Liver cirrhosis was defined as ultrasonic features of cirrhosis together with hyperspl enism, ascites, varices, and/or encephalopathy. Results: In total, 426 patients were followed up for 1664 person years; median 225 (range 12-295) weeks. Forty nine (11%) patients had underlying clinical liver cirrhosis. A total of 242 (57 %) and 179 (42%) patients had HBV genotypes C and B, respectively. Twenty five patients developed HCC in a median follow up of 121 (range 14-236) weeks. The overall incidence of HCC was 1502 cases per 100 000 person years. On multivariat e analysis, clinical liver cirrhosis and HBV genotype C infection were independe ntly associated with HCC development,with an adjusted relative risk of 10.24 (95 %confidence interval (CI) 4.39-23.89; p < 0.001) and 2.84 (95%CI 1.05-7.72; p = 0.040), respectively. Patient age, sex, hepatitis B e antigen (HBeAg) status , alanine aminotransferase (ALT)-levels, and basal core promoter mutations did not predict HCC development. Patients infected with HBV genotype C tended to hav e persistently positive HBeAg or fluctuating HBeAg status and higher ALT levels during the follow up period. Conclusion: Genotype C HBV infection is an independ ent risk factor for HCC development in addition to liver cirrhosis.

一项关于慢性乙型肝炎联合治疗的随机对照试验:聚乙二醇干扰素α-2b联合拉米夫定与单用拉米夫定治疗的比较

Background: Conventional interferon and lamivudine monotherapy are unsatisfac tory in treating hepatitis B virus (HBV) infection. Objective: To evaluate the e fficacy and safety of pegylated interferon- α 2b and lamivudine combination t herapy for chronic hepatitis B. Design: Randomized ,controlled, open- label tri al. Setting: Outpatient clinic in a referral center. Participants: 100 treatment - naive patients with hepatitis B e antigen (HBeAg)- positive chronic hepatiti s B and moderately elevated alanine aminotransferase levels. Measurement: The pr imary end point was sustained virologic response (HBeAg seroconversion and HBV D NA level < 500 000 copies/ml) at 24 weeks after cessation of treatment. Interven tion: A staggered regimen of combination therapy with pegylated interferon- α 2b (1.5 μ g/kg of body weight per week; maximum,100 μ g) given for 32 weeks p lus lamivudine (100 mg daily) given for 52 weeks versus lamivudine (100 mg daily ) monotherapy given for 52 weeks. Of the 100 participants,96% completed treatm ent and 80% completed post- treatment follow- up. Results: The rate of susta ined virologic response was 36% for the combination treatment group and 14% for the lamivudine monotherapy group (absolute difference, 22 percentage points [95% CI, 6 to 38 percentage points]). End- of- treatment outcomes showed tha t, compared with monotherapy, patients receiving combination therapy more often had virologic response (60% vs. 28% [absolute difference, 32 percentage poin ts (CI, 14 to 50 percentage points)]); had more substantial reductions of HBV DN A (3.91 log 10 copies/ml vs. 2.83 log10 copies/ml); and less often had lamivudin e resistant mutants (21% vs. 40% ). The percentages of patients with normaliz ation of alanine aminotransferase levels and histologic improvement did not diff er. Adverse effects, such as transient influenza- like symptoms, alopecia, and local erythematous reactions, were more common with combination therapy. Limitat ions: This study lacked a double- blind design and was conducted at 1 instituti on. Because of the staggered pegylated interferon- lamivudine regimen, patients assigned to combination therapy received treatment for 8 weeks longer than thos e assigned to monotherapy. Conclusions: In patients with HBeAg- positive chroni c hepatitis B, staggered combination treatment with pegylated interferon- α 2b and lamivudine may lead to a higher rate of virologic response than lamivudine monotherapy.

应用氯吡格雷与阿司匹林加艾美拉唑预防复发性溃疡出血的比较研究

BACKGROUND: Concurrent therapy with a proton-pump inhibitor is a standard treatment for patients receiving aspirin who are at risk for ulcer. Current U.S. guidelines also recommend clopidrogel for patients who have major gastrointestinal intolerance of aspirin. We compared clopidogrel with aspirin plus esomeprazole for the prevention of recurrent bleeding from ulcers in high-risk patients. METHODS: We studied patients who took aspirin to prevent vascular diseases and who presented with ulcer bleeding. After the ulcers had healed, we randomly assigned patients who were negative for Helicobacter pylori to receive either 75 mg of clopidogrel daily plus esomeprazole placebo twice daily or 80 mg of aspirin daily plus 20 mg of esomeprazole twice daily for 12 months. The end point was recurrent ulcer bleeding. RESULTS: We enrolled 320 patients (161 patients assigned to receive clopidogrel and 159 to receive aspirin plus esomeprazole). Recurrent ulcer bleeding occurred in 13 patients receiving clopidogrel and 1 receiving aspirin plus esomeprazole. The cumulative incidence of recurrent bleeding during the 12-month period was 8.6 percent (95 percent confidence interval, 4.1 to 13.1 percent) among patients who received clopidogrel and 0.7 percent (95 percent confidence interval, 0 to 2.0 percent) among those who received aspirin plus esomeprazole (difference, 7.9 percentage points; 95 percent confidence interval for the difference, 3.4 to 12.4; P=0.001). CONCLUSIONS: Among patients with a history of aspirin-induced ulcer bleeding whose ulcers had healed before they received the study treatment, aspirin plus esomeprazole was superior to clopidogrel in the prevention of recurrent ulcer bleeding. Our finding does not support the current recommendation that patients with major gastrointestinal intolerance of aspirin be given clopidogrel.

对伴有或不伴有HP感染的良性胃出口梗阻行内镜下球囊扩张术

Background Endoscopic balloon dilation has been used to treat patients with ga stric outlet obstruction caused by peptic stricture.This study assessed the role of endoscopic balloon dilation in patients with gastric outlet obstruction with or without Helicobacter pylori infection. Methods Consecutive patients seen bet ween January 1996 and September 2001 with benign gastric outlet obstruction (def ined as stenosis preventing the passage of a 9-mm diameter endoscope, vomiting, succussion splash, and recent weight loss) were prospectively studied. Exclusio n criteria were the following: refusal to undergo dilation, and gastric outlet o bstruction because of malignancy. At endoscopy, antral biopsy specimens were obt ained for histopathologic evaluation and for a rapid urease test for Helicobacte r pylori infection.Patients then underwent dilation with through-the-scope bal loons.After balloon dilation, patients with Helicobacter pylori infection were t reated to eradicate the infection. Results Fifty one patients (33 men, 18 women; median age 65 years; IQR 44-79 years) were studied; 33 consented to endoscopic balloon dilation. Symptom resolution occurred in 25 patients (14 Helicobacter p ylori positive, 11 Helicobacter pylori negative).During amedian follow-up of 24 months (IQR 16-40 months), 3 of 14 patients in the Helicobacter pylori positiv e group and 6 of 11 in the Helicobacter pylori negative group developed further ulcer complications (p=0.039). Conclusions After endoscopic dilation for gastric outlet obstruction, eradication of Helicobacter pylori infection is associated with fewer ulcer complications.

结肠镜远端附有黏膜切除帽可提高检查的成功率

Background and Study Aims:Although colonoscopy is a welle-stablished procedure,various technical difficulties may cause failure.This report describes experience with cap-assisted colonoscopy(CAC) ,a technique in which a mucosectomy cap is attached to the end of colonoscope in order to improve the success rate.Patients and Methods:From January 2003 to May 2005,CAC was used in consecutive patients with difficult colonoscopy procedures,which were defined firstly as failure to pass through the sigmoid colon after 20 min of examination,or secondly as failure to reach the cecum at the end of the procedure.Patients with prior colonic surgery,poor bowel preparation,distal colonic stricture,or obstructing tumors were excluded.The results with the CAC method were reviewed retrospectively.Results:A total of 100 patients met the criteria for difficult colonos copy during the study period.When CAC was used to repeat the procedure,cecal and terminal ileal intubation could then be achieved in 94 and 70 patients,respectively.In the remaining six patients in whom cecal intubation failed,one failure was due to a tumor obstruction at the splenic flexure.Conclusions:CAC can be used as a rescue method to improve the success rate of colonoscopy when failure is encountered.

弥散加权成像示多发性急性大脑梗死与卒中复发的风险

Multiple acute cerebral infarcts (MACIs) detected by diffu sion weighted ima ging (DWI) may indicate an unstable source of thromboembolism. The authors studi ed 119 consecutive acute ischemic stroke patients within 24 hours of onset with DWI. MACIs were present in 20 patients (16.8%). During the follow up period, t here were 15 recurrent strokes, 3 acute coronary syndromes, and 5 deaths. MACI w as the only significant independent predictor for vascular events and death (odd ratio [OR]= 4.34; p = 0.001) and stroke recurrence (OR = 5.93; p = 0.001).