Outcome of acute upper gastrointestinal bleeding in patients with coronary artery disease: A matched case-control study.

BACKGROUND/AIM: The risk of upper gastrointestinal bleeding (UGIB) increases in patients with coronary artery disease (CAD) due to the frequent use of antiplatelets. There is some data reporting on treatment outcomes in CAD patients presenting with UGIB. We aim to determine the clinical characteristics and outcomes of UGIB in patients with CAD, compared with non-CAD patients. PATIENTS AND METHODS: We conducted a prospective multi-center cohort study (THAI UGIB-2010) that enrolled 981 consecutive hospitalized patients with acute UGIB. A matched case-control analysis using this database, which was collected from 11 tertiary referral hospitals in Thailand between January 2010 and September 2011, was performed. RESULT: Of 981 hospitalized patients with UGIB, there were 61 CAD patients and 244 gender-matched non-CAD patients (ratio 1:4). UGIB patients with CAD were significantly older, and had more frequently used antiplatelets and warfarin than in non-CAD patients. Compared with non-CAD, the CAD patients had significantly higher Glasgow-Blatchford score, full and pre-endoscopic Rockall score and full. Peptic ulcer in CAD patients was identified more often than in non-CAD patients. UGIB patients with CAD and non-CAD had similar outcomes with regard to mortality rate, re-bleeding, surgery, embolization, and packed erythrocyte transfusion. However, CAD patients had longer duration of hospital stays than non-CAD patients. Two CAD patients died from cardiac arrest after endoscopy, whereas three non-CAD patients died from pneumonia and acute renal failure during their hospitalization. CONCLUSION: In Thailand, patients presenting with UGIB, concomitant CAD did not affect clinical outcome of treatment, compared with non-CAD patients, except for longer hospital stay.

Movement Disorders in Non-Wilsonian Hepatic Cirrhotic Patients: The Subgroup Analysis of Various Phenotypes and Associated Risk Factors.

OBJECTIVE: The aim of this subgroup analysis was to identify the risk factors associated with the development of various movement disorder phenotypes. METHODS: Eighty-three non-Wilsonian cirrhotic patients with abnormal movements were allocated into the following groups: intention tremor, bradykinesia, Parkinsonism, and abnormal ocular movements. These movement types were considered the primary outcomes as there was a sufficient sample size. Researchers took into consideration the gender, etiologies of cirrhosis, cirrhosis-related complications, hepatic encephalopathy, medical illness, and some neurological deficits as potential factors associated with these movement disorders. RESULTS: The male gender (p = 0.002) and alcoholic cirrhosis (p = 0.005) were significant factors for the prevalence of intention tremors. In bradykinesia, hepatic encephalopathy was highly statistically significant (p < 0.001), and females more commonly developed bradykinesia (p = 0.04). The Parkinsonism features in this study were confounded by hyperlipidemia (p = 0.04) and motor or sensory deficits (p = 0.02). Jerky pursuits and a horizontal nystagmus were detected. Jerky pursuits were significantly related to hepatic encephalopathy (p = 0.003) and bradykinesia, but there were no factors associated with the prevalence of nystagmus other than an intention tremor. CONCLUSIONS: The association of alcoholic cirrhosis with the development of intention tremor indicates that the persistent cerebellar malfunction in cirrhotic patients is due to alcohol toxicity. The slowness of finger tapping and jerky pursuit eye movements are significantly associated with hepatic encephalopathy. Thus, further studies are needed to evaluate the diagnostic value of these two signs for an early detection of mild hepatic encephalopathy.

Prospective comparison of three risk scoring systems in non-variceal and variceal upper gastrointestinal bleeding.

BACKGROUND AND AIM: Data regarding the efficacy of the Glasgow Blatchford score (GBS), full Rockall score (FRS) and pre-endoscopic Rockall scores (PRS) in comparing non-variceal and variceal upper gastrointestinal bleeding (UGIB) are limited. Our aim was to determine the performance of these three risk scores in predicting the need for treatment, mortality, and re-bleeding among patients with non-variceal and variceal UGIB. METHODS: During January, 2010 and September, 2011, patients with UGIB from 11 hospitals were prospectively enrolled. The GBS, FRS, and PRS were calculated. Discriminative ability for each score was assessed using the receiver operated characteristics curve (ROC) analysis. RESULTS: A total of 981 patients presented with acute UGIB, 225 patients (22.9%) had variceal UGIB. The areas under the ROC (AUC) of the GBS, FRS, and PRS for predicting the need for treatment were 0.77, 0.69, and 0.61 in non-variceal versus 0.66, 0.66, and 0.59 in variceal UGIB. The AUC for predicting mortality and re-bleeding during admission were 0.66, 0.80, and 0.76 in non-variceal versus 0.63, 0.57, and 0.63 in variceal UGIB. AUC score was not statistically significant for predicting need for therapy and clinical outcome in variceal UGIB. The GBS ≤ 2 and FRS ≤ 1 identified low-risk non-variceal UGIB patients for death and re-bleeding during hospitalization. CONCLUSION: In contrast to non-variceal UGIB, the GBS, FRS, and PRS were not precise scores for assessing the need for therapy, mortality, and re-bleeding during admission in variceal UGIB.

Movement Disorders in Non-Wilsonian Cirrhotic Patients: A Report of the Prevalence and Risk Factors from a Study Done in a Medical School in an Agricultural-Based Community.

OBJECTIVE: Parkinsonism and other movement disorders have previously been reported in the acquired hepatocerebral degeneration associated with portosystemic shunting. However, there is no study to date about their prevalence as has been noted in general practice. METHODS: One hundred and forty-three patients with hepatic cirrhosis from the gastroenterology clinic and internal medicine wards were enrolled. Liver data included the diagnoses, etiologies, assessments of complications, and treatments for cirrhosis. Hepatic encephalopathy was classified with regard to the West Haven criteria for semi-quantitative grading for mental status. Neurological examination results and abnormal involuntary movements were recorded as primary outcomes. Neuro-radiology was used for the detection of severe brain lesions. RESULTS: Alcoholism was the most common cause of liver cirrhosis. Eighty-three patients (58%) presented with movement disorders. Asterixis was found in one of the cases. The most common movement disorder seen was an intentional tremor at 37.1%, which was followed by bradykinesia, Parkinsonism, and postural tremors at 29.4%, 10.5%, and 6.3%, respectively. The prevalence of movement disorders simultaneously increased with a high Child-Turcotte-Pugh score. The hepatic encephalopathy was grade 1 and 2. With the inclusion of age-range adjustments, we found that alcoholic cirrhosis and hepatic encephalopathy are statistically significant factors [p < 0.05, odds ratio (OR) = 6.41, 95% confidence interval (CI) 1.38-29.71 and p < 0.001, OR = 13.65, 95% CI 4.71-39.54] for the development of movement disorders in non-Wilsonian cirrhotic patients. CONCLUSIONS: Intentional tremor is a common abnormal movement. Alcoholic cirrhosis and hepatic encephalopathy are significant risk factors in the development of movement disorders in non-Wilsonian cirrhotic patients.

CTLA-4 and its ligands on the surface of T- and B-lymphocyte subsets in chronic hepatitis B virus infection.

BACKGROUND: During chronic hepatitis B virus (CHB) infection, a number of co-stimulatory, co-inhibitory molecules and theirs ligands play a prominent role in the immune-regulation. OBJECTIVE: To compare the number of peripheral-blood mononuclear cells expressing co-inhibitory marker, cytotoxic T lymphocyte associated antigen-4 (CTLA-4) and program cell death ligand-1 (PD-L1) between CHB infected patients and healthy controls. MATERIAL AND METHOD: Peripheral-blood mononuclear cells (PBMCs) from 19 CHB-infected patients and nine healthy controls were stained with specific combinations of the following monoclonal antibodies: CD3-PE/cy5, CD4-APC, CD8-APC, CD152-PE (CTLA-4), CD19PE/Cy5, CD80-FITC (B7-1), CD86-PE (B7-2) and CD274-FITC (B 7-H1) according to standard protocol. RESULTS: The frequencies of B-lymphocyte expressing B7-1, B7-2 and B7-H1 of CHB-infected patients and healthy controls were not shown any statistical differences. The mean percentage of B-lymphocyte with B7-2 molecule was higher than those with B7-1 molecules in both infected- and non-infected groups. In contrast, the frequencies of T-lymphocyte subsets, CD3+, CD4+ and CD8+ expressing CTLA-4 molecules in CHB-infected patients were significantly higher than those in healthy controls with p = 0.04, 0.01 and 0.04 respectively. CONCLUSION: An increase in percentage of circulating CD4+/CD152+ (T-cell) was observed in CHB-infected patients. A small but significant increase in percentage of CD8+/CD152+ T-cells raises the possibility that CTLA-4 are involved in the development of HBV-specific CD8+ T-cell exhaustion. Overall, CD4+ and CD8+ T-cells presenting CTLA-4 might contribute to the impaired immune response and likely to be a factor influencing in failure of immunological control of the persisting pathogens.

Home-made rapid urease test compared with commercial kit for diagnosis of Helicobacter pylori infection.

OBJECTIVE: To evaluate the sensitivity and specificity of home-made rapid urease test compared with commercial kit for diagnosis of Helicobacter pylori infection. MATERIAL AND METHOD: A cross-sectional study of patients who underwent esophagogastro-duodenoscopy from June 2009 to May 2010 was carried out. Gastric biopsy specimens were taken from antrum and body of the stomach for home-made rapid urease testing, commercial kit (hpfast) urease testing, and histological study. RESULTS: One hundred and ninety nine patients were included in the present study. The sensitivity of home-made rapid urease test and hpfast were 40% and 48.5% at 1 hour and 91.4% and 91.4% at 24 hours. The specificity, positive and negative predictive value and accuracy of home-made rapid urease test vs. hpfast were 100% vs. 100%, 100% vs. 100%, 95.5% vs. 95.5% and 96.9% vs. 96.9% respectively. Furthermore 45.3% of home-made rapid urease test and 54. 7% of hpfast showed positive results within 1 hour CONCLUSION: Home-made rapid urease test has good sensitivity and specificity comparable to commercial kit for the diagnosis of H. pylori infection.

Case report: severe CMV colitis in a patient with follicular lymphoma after chemotherapy.

BACKGROUND: Cytomegalovirus (CMV) can infect immuno-compromised host, especially in HIV and bone marrow transplantation patients. CMV colitis was reported after receiving chemotherapy in a solid tumor and aggressive Non-Hodgkin's lymphoma, but not yet in indolent lymphoma patients. CASE REPORT: In the present report, a 64-year-old woman was re-admitted with watery diarrhea after eight cycles of chemotherapy for Follicular lymphoma. She had hyponatremia, hypokalemia, and hypocalcemia, which were the consequences of severe diarrhea. After two weeks of continuous diarrhea, she was set for colonoscopy, which showed multiple ulcers along the colon. Pathological results were found to be consistent with CMV colitis. Her diarrhea symptom improved after receiving ganciclovir. CONCLUSION: CMV colitis could occur in indolent lymphoma patients who receive R-CVP regimen (rituximab, cyclophosphamide, vincristine, and prednisolone). Patients exhibiting severe and prolonged diarrhea should be investigated for definite diagnosis in order to receive proper treatment.

Prevalence of cirrhosis registered in Nakhon Nayok, Thailand.

OBJECTIVE: To determine population-based prevalence rates of cirrhosis in Nakhon Nayok Province and patterns of the prevalence by sex, age groups and disease type. MATERIAL AND METHOD: A retrospective descriptive study of medical record database was performed in all hospitals in the province of Nakhon Nayok during the year 2007. ICD-10 was used to identify patients with cirrhosis. Patient information was collected, including name, sex, address and age and data of population of Nakhon Nayok Province stratified by 5 year-age groups, sex and district of the province were obtained. Crude and standardised prevalence rates were calculated using WHO (2000) standard population. RESULTS: There were 199 cirrhosis patients comprising 111 males (55.8%) and 88 females (44.2%) with average age of 54.7 years (SD, 13.0). Crude prevalence rate per 100,000 was 86.3 (95% CI: 74.3-98.3) and age standardized prevalence rate was 75.3 (95% CI: 64.8-85.8). Prevalence of alcoholic cirrhosis was 53.6 (95% CI: 44.8-62.5) and 21.7 (95% CI: 16.0-27.4) for non-alcoholic cirrhosis. Alcoholic cirrhosis in male was found in younger age groups than older age. The prevalence rates vary among four districts. DISCUSSION: In this rural area in the central part of Thailand, the standardized prevalence rates is 75.3 per 100,000 and the prevalence is more common in male than female especially for alcoholic cirrhosis. Prevalence of cirrhosis starts to rise from age of 30 to 60 years. Age distributions of non alcoholic cirrhosis in males and females are similar but in alcoholic cirrhosis the magnitude of prevalence in male is higher than female. Alcoholic cirrhosis is 2.6 folds more prevalent than non-alcoholic cirrhosis.

Treatment of eosinophilic meningitis with a combination of albendazole and corticosteroid.

To study the efficacy of the combination of albendazole and prednisolone for the treatment of eosinophilic meningitis, we conducted a pilot study among Thai patients with eosinophilic meningitis. Patients were given a 2-week course of prednisolone, 60 mg/day and albendazole, 15 mg/kg/ day. The primary observation parameter was the number of patients who still had headache after the 2-week course of treatment. Twenty-six patients were enrolled in the study. There were 3 (11.5%) patients who still had headache after the 2-week course of treatment and the median length of time until complete disappearance of headache was 4 days. Serious side effects were not detected. Treatment for 2 weeks with the combination regimen of albendazole and prednisolone is safe and effective for the treatment of eosinophilic meningitis.