Management of Helicobacter pylori infection after gastric surgery

The Maastricht IV/Florence Consensus Report and the Second Asia-Pacific Consensus Guidelines strongly recommend eradication of Helicobacter pylori(H.pylori)in patients with previous gastric neoplasia who have undergone gastric surgery.However,the guidelines do not mention optimal timing,eradication regimens,diagnostic tools,and follow-up strategies for patients undergoing gastrectomy and do not indicate if eradication of H.pylori reduces the risk of marginal ulcer or stump cancer in the residual stomach after gastrectomy.The purpose of this review is to provide an update which may help physicians to properly manage H.pylori infection in patients who have undergone gastric surgery.This review focuses on(1)the microenvironment change in the stomach after gastrectomy;(2)the phenomenon of spontaneous clearance of H.pylori after gastrectomy;(3)the effects of H.pylori on gastric atrophy and intestinal metaplasia after gastrectomy;(4)incidence and clinical features of ulcers developing after gastrectomy;(5)does eradication of H.pylori reduce the risk of gastric stump cancer in the residual stomach?(6)does eradication of H.pylori reduce the risk of secondary metachronous gastric cancer in the residual stomach?and(7)optimal timing and regimens for H.pylori eradication,diagnostic tools and follow-up strategies for patients undergoing gastrectomy.

Vertical transmission of hepatitis C virus: Current knowledge and perspectives

Hepatitis C virus(HCV) infection is a major global health issue.Infection by the HCV can cause acute and chronic liver diseases and may lead to cirrhosis,hepatocellular carcinoma or liver failure.The World Health Organization estimates that approximately 3% of the world population have been infected with HCVand the worldwide prevalence is between 1% and 8% in pregnant women and between 0.05% and 5% in children.Following the introduction of blood product screening,vertical transmission becomes the leading cause of childhood HCV infection.The prevalence of pediatric HCV infection varies from 0.05% to 0.36% in developed countries and between 1.8% and 5% in the developing world.All children born to women with antiHCV antibodies should be checked for HCV infection.Though universal screening is controversial,selective antenatal HCV screening on high-risk populations is highly recommended and should be tested probably.Multiple risk factors were shown to increase the possibility of HCV vertical transmission,including coinfections with human immunodeficiency virus,intravenous drug use and elevated maternal HCV viral load,while breastfeeding and HCV genotypes have been studied to have little impact.At present,no clinical intervention has been clearly studied and proved to reduce the HCV vertical transmission risk.Cesarean section should not be recommended as a procedure to prevent vertical transmission,however,breastfeeding is generally not forbidden.The high prevalence of global HCV infection necessitates renewed efforts in primary prevention,including vaccine development,as well as new approaches to reduce the burden of chronic liver disease.Future researches should focus on the interruption of vertical transmission,developments of HCV vaccine and directacting antivirals in infancy and early childhood.

Effects of Helicobacter pylori infection in gastrointestinal tract malignant diseases:From the oral cavity to rectum

Helicobacter pylori(H.pylori)has infected approximately fifty percent of humans for a long period of time.However,improvements in the public health environment have led to a decreased chance of H.pylori infection.However,a high infection rate is noted in populations with a high incidence rate of gastric cancer(GC).The worldwide fraction of GC attributable to H.pylori is greater than 85%,and a high H.pylori prevalence is noted in gastric mucosa-associated lymphoid tissue lymphoma patients.These results indicate that the majority of GC cases can be prevented if H.pylori infection is eliminated.Because H.pylori exhibits oral-oral or fecal-oral transmission,the relationship between this microorganism and other digestive tract malignant diseases has also attracted attention.This review article provides an overview of H.pylori and the condition of the whole gastrointestinal tract environment to further understand the correlation between the pathogen and the host,thus allowing improved realization of disease presentation.

Impact of COVID-19 on liver

The incidence of liver injury after coronavirus disease 2019(COVID-19)infection ranged from 15%-53%.The mechanism includes direct viral cytopathic effect,cytokinesis,and treatment drug-induced liver injury.The symptoms include nausea,vomiting,diarrhea,and loss of appetite.The laboratory results include increased liver enzyme levels,decreased monocyte count,and longer prothrombin time.The most common imaging findings are hepatomegaly on ultrasound,ground-glass opacity on chest computed tomography(CT),and liver hypodensity and pericholecystic fat stranding on abdominal CT.Patients may also have different presentations and poor outcomes of different liver diseases concomitant with COVID-19 infection.Liver function test(LFT)results should be monitored,and all factors known to cause or predispose liver injury should be investigated while managing the patients.The risks of transfer to an intensive care unit,need for mechanical ventilator support,and acute kidney injury is higher in COVID-19 patients with than without abnormal LFTs.Increased mortality and length of hospital stay are both observed.

Antifungal Activities of Commercial Rice Wine Extracts of Taiwan Residents Allium fistulosum

Antifungal activities of the commercial rice wine extracts of Allium fistulosum were analyzed. Antifungal activities were tested against 7 pathogenic fungi by using agar disc diffusion and tube dilution tests. The results show that the commercial rice wine extracts of Allium fistulosum have strong antifungal activity against Aspergillus brasiliensis ATCC 16404, Candida albicans ATCC 10231, Microsporumcanis ATCC 36299, M. gypseum ATCC 24102, Trichophyton mentagrophytes ATCC 9533, T. rubrum ATCC 28188, and T. tonsurans ATCC 28942. The commercial rice wine extracts of different A. fistulosum parts were found to exhibit significant antifungal activities with the minimal inhibitory concentration (MIC) in the range of 0.2 - 1.0 mg/mL. The antifungal activity of the extracts of different A. fistulosum parts was in the order of AFS (stem) > AFI (plant body) > AFL (leaf) > AFR (root).

Benign esophageal lesions: Endoscopic and pathologic features

Benign esophageal lesions have a wide spectrum of clinical and pathologic features. Understanding the endoscopic and pathologic features of esophageal lesions is essential for their detection, differential diagnosis, and management. The purpose of this review is to provide updated features that may help physicians to appropriately manage these esophageal lesions. The endoscopic features of 2997 patients are reviewed. In epithelial lesions, the frequency of occurrence was in the following order: glycogenic acanthosis, heterotopic gastric mucosa, squamous papilloma, hyperplastic polyp, ectopic sebaceous gland and xanthoma. In subepithelial lesions, the order was as follows: hemangioma, leiomyoma, dysphagia aortica and granular cell tumor. Most benign esophageal lesions can be diagnosed according to their endoscopic appearance and findings on routine biopsy, and submucosal lesions, by endoscopic resection. Management is generally based upon the confidence of diagnosis and whether the lesion causes symptoms. We suggest endoscopic resection of all granular cell tumors and squamous papillomas because, while rare, these lesions have malignant potential. Dysphagia aortica should be considered in the differential diagnosis of dysphagia in the elderly.

Using typical endoscopic features to diagnose esophagealsquamous papilloma

AIM: To better understand some of the superficial tiny lesions that are recognized as squamous papilloma of the esophagus(SPE) and receive a different pathological diagnosis.METHODS: All consecutive patients with esophageal polypoid lesions detected by routine endoscopy at our Endoscopy Centre between October 2009 and June 2014 were retrospectively analysed. We enrolled patients with SPE or other superficial lesions to investigate four key endoscopic appearances(whitish color, exophytic growth, wart-like shape, and surface vessels) and used narrow band imaging(NBI) to distinguish their differences. These series endoscopic images of each patient were retrospectively reviewed by three experienced endoscopists with no prior access to the images. All lesion specimens obtained by forceps biopsy were fixed in formalin and processed for pathological examination. The following data were collected from patient medical records: gender, age, indications for esophagogastroduodenoscopy, and endoscopic characteristics including lesion location, number, color, size, surface morphology, surrounding mucosa, and surface vessels under NBI. Clinicopathological features were also compared.RESULTS: During the study period, 41 esophageal polypoid lesions from 5698 endoscopic examinations were identified retrospectively. These included 24 patients with pathologically confirmed SPE, 11 patients with squamous hyperplasia, three patients with glycogenic acanthosis, two patients with ectopic sebaceous glands, and one patient with a xanthoma. In the χ2 test, exophytic growth(P = 0.003), a wartlike shape(P < 0.001), and crossing surface vessels under NBI(P = 0.001) were more frequently observed in SPE than in other lesion types. By contrast, there was no significant difference regarding the appearance of a whitish color between SPE and other lesion types(P = 0.872). The most sensitive characteristic was wart-like projections(81.3%) and the most specific was exophytic growth(87.5%). Promising positive predictive values of 84.2%, 80.8%, and 82.6% were noted for exophytic growth, wart-like projections, and surface vessel crossing on NBI, respectively.CONCLUSION: The use of three key typical endoscopic appearances- exophytic growth, a wart-like shape, and vessel crossing on the lesion surface under NBI- has a promising positive predictive value of 88.2%. This diagnostic triad is useful for the endoscopic diagnosis of SPE.

Refeeding syndrome in Southeastern Taiwan:Our experience with 11 cases

AIM:To present our experience with refeeding syndrome in southeastern Taiwan.METHODS:We conducted a retrospective study during a 2-year period at the Mackay Memorial Hospital,Taitung Branch.We enrolled patients with very little or no nutrition intake for more than 10 d,a high risk group of refeeding syndrome,including those suffering from alcohol abuse,cancerous cachexia,chronic malnutrition,and prolonged starvation.RESULTS:A total of 11 patients(7 males,4 females)with nasogastric feeding were included as having refeeding syndrome.Most of them had the symptoms of diarrhea,lethargy,and leg edema.The initial nutritional supplement was found to be relatively high in calories(1355.1±296.2 kcal/d),high in protein(47.3±10.4 gm/d),low in vitamin B1(2.0±0.5 mg/d),low in potassium(1260.4±297.7 mg/d),and low in phosphorus(660.1±151.8 mg/d).Furthermore,hypophosphatemia(2.4±0.9 mg/dL)was noted during follow-up.Based on the suggestions of a dietician and a gastroenterologist,the clinical disorders of diarrhea,malaise and leg edema were significantly improved.The level of phosphate was also increased(3.3±0.6mg/dL).CONCLUSION:Refeeding syndrome is an overlooked and risky disorder that has some potentially fatal complications.Nasogastric feeding in nursing homes is an important risk factor for patients and deserves greater attention based on the initial results of this study.

Estradiol agonists inhibit human Lo Vo colorectal-cancer cell proliferation and migration through p53

AIM: To investigate the effects of 17β-estradiol via estrogen receptors(ER) or direct administration of ER agonists on human colorectal cancer. METHODS: Lo Vo cells were established from the Bioresource Collection and Research Center and cultured in phenol red-free DMEM(Sigma, United States). To investigate the effects of E2 and/or ER selective agonists on cellular proliferation, Lo Vo colorectal cells were treated with E2 or ER-selective agonists for 24 h and 48 h and subjected to the MTT(Sigma) assay to find the concentration. And investigate the effects of E2 and/or ER selective agonists on cell used western immunoblotting to find out the diversification of signaling pathways. In order to observe motility and migration the wound healing assay and a transwell chamber(Neuro Probe) plate were tased. For a quantitative measure, we counted the number of migrating cells to the wound area post-wounding for 24 h. We further examined the cellular migration-regulating factors urokinase-type plasminogen activator(u-PA), tissue-type plasminogen activator(t-PA) and matrix metalloproteinase(MMP)-9 in human Lo Vo cells so gelatin zymography that we used and gelatinolytic activity was visualized by Coomassie blue staining. And these results are presented as means ± SE, and statistical comparisons were made using Student's t-test.RESULTS: The structure was first compared with E2 and ER agonists. We then treated the Lo Vo cells with E2 and ER agonists(10-8 mol/L) for 24 h and 48 h and subsequently measured the cell viability using MTT assay. Our results showed that treatment with 17β-estradiol and/or ER agonists in human Lo Vo colorectal cancer cells activated p53 and then up-regulated p21 and p27 protein levels, subsequently inhibiting the downstream target gene, cyclin D1, which regulates cell proliferation. Taken together, our findings demonstrate the anti-tumorigenesis effects of 17β-estradiol and/or ER agonists and suggest that these compounds may prove to be a potential alternative therapy in the treatment of human colorectal cancer. These results demonstrate that 17β-estradiol and/or ER agonists downregulate migration-related proteins through the p53 signaling pathway in human Lo Vo colorectal cancer cells. These findings suggest that p53 plays a critical role in the 17β-estradiol and/or ER agonist-mediated protective activity against colorectal cancer progression. In addition, 17β-estradiol and/or ER agonists dramatically inhibited cell migration and reduced the expression of u-PA, t-PA and MMP-9 as well as MMP-2/9 activity in Lo Vo cells, which regulate cell metastasis. Moreover, we observed that pretreatment with a p53 inhibitor significantly blocked the anti-migration effects of E2 and/or ER agonists on Lo Vo cells. That E2 and/or ER agonists may impair Lo Vo cell migration by modulating migration-related factors via the p53 tumor suppressor gene.CONCLUSION: Direct ER treatment may prove to be an attractive alternative therapy in the treatment of human colorectal tumors in the future.

Intracranial hemorrhagic embolus

A febrile and unconscious man was sent to our emergency department. On physical examinations, some dark red ecchymosis/discoloration over the trunk and track mark in the left-sided groin region were seen. Brain CT scan showed septic emboli complicated with hemorrhage. Chest X-ray revealed pulmonary emboli. Aortic valve vegetation was found by echocardiography. Although aggressive treatment and resuscitation were taken, he died of methicillin-sensitiveStaphylococcus aureus sepsis and multiple organ failure. Intravenous drug users are susceptible to right-sided infective endocarditis. In our case, left-sided infective endocarditis with lung and brain embolism resulting in fatality was relatively uncommon. Review of literature was also made for this article.

Surgical intervention for acute pancreatitis in the COVID-19 era

Approximately 15%-19%of patients with severe acute respiratory syndrome coronavirus type 2(SARS-CoV-2)infections develop gastrointestinal symptoms.Acute pancreatitis(AP)has been reported in 0.1%of patients with coronavirus disease 2019(COVID-19).Biliary AP was most common(78.4%)before the COVID-19 pandemic;idiopathic AP is most common in patients with COVID-19(up to 57.1%).The number of emergency department presentations decreased by 23.3%during the pandemic and many governments made national recommendations to delay nonurgent endoscopic procedures,leading to decrements of 22%in combined esophagogastroduodenoscopy(EGD)and colonoscopy and 20%in EGD after the COVID-19 pandemic.The symptoms and signs of COVID-19-related AP are fever(63%),abdominal pain(58%),respiratory symptoms(40%),nausea and vomiting(39%),and headache(4%).Approximately 5-10%of patients develop necrotizing or hemorrhagic AP,and patients who required surgical intervention had a higher mortality risk.Compared to 2019,the rates of elective surgery decreased by 41.8%in 2020;including cholecystectomy(40.1%decrease)and pancreas(111.1%decrease).Surgical volumes also decreased by 18.7%in 2020;device-assisted laparoscopic and robot-assisted procedures reduced by 45.4%and 61.9%during the COVID-19 Lockdown in 2020.

Generalized structural equation modeling:Symptom heterogeneity in attention-deficit/hyperactivity disorder leading to poor treatment efficacy

BACKGROUND Treatment efficacy for attention-deficit/hyperactivity disorder(ADHD)is reported to be poor,possibly due to heterogeneity of ADHD symptoms.Little is known about poor treatment efficacy owing to ADHD heterogeneity.AIM To use generalized structural equation modeling(GSEM)to show how the heterogeneous nature of hyperactivity/impulsivity(H/I)symptoms in ADHD,irritable oppositional defiant disorder(ODD),and the presentation of aggression in children interferes with treatment responses in ADHD.METHODS A total of 231 children and adolescents completed ADHD inattention and H/I tests.ODD scores from the Swanson,Nolan,and Pelham,version IV scale were obtained.The child behavior checklist(CBCL)and parent’s satisfaction questionnaire were completed.The relationships were analyzed by GSEM.RESULTS GSEM revealed that the chance of ADHD remission was lower in children with a combination of H/I symptoms of ADHD,ODD symptoms,and childhood aggressive behavior.ODD directly mediated ADHD symptom severity.The chance of reaching remission based on H/I symptoms of ADHD was reduced by 13.494%[=exp(2.602)]in children with comorbid ADHD and ODD[odds ratio(OR)=2.602,95%confidence interval(CI):1.832-3.373,P=0.000]after adjusting for the effects of other factors.Childhood aggression mediated ODD symptom severity.The chance of reaching remission based on ODD symptoms was lowered by 11.000%[=1-exp(-0.117)]in children with more severe baseline symptoms of aggression based on the CBCL score at study entry[OR=-0.117,95%CI:(-0.190)-(-0.044),P=0.002].CONCLUSION Mediation through ODD symptoms and aggression may influence treatment effects in ADHD after adjusting for the effects of baseline ADHD symptom severity.More attention could be directed to the early recognition of risks leading to ineffective ADHD treatment,e.g.,symptoms of ODD and the presentation of aggressive or delinquent behaviors and thought problems in children with ADHD.