Use of metformin is associated with a decreased risk of HCC in diabetic patients in a dose-dependent manner, via inhibition of hepatoma cells proliferation and induction of cell cycle arrest at G0/G1 phase.

Our data demonstrate that H pylori infection promotes gastric epithelial cells invasion by activating MMP-9 and VEGF expression. These effects appear to be mediated through a NF-kappaB and COX-2 mediated pathway, as COX-2 or NF-kappaB inhibitor significantly attenuate the invasiveness of gastric cancer cells and the expressions of MMP-9 and VEGF protein.

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Clean and clean-contaminated wounds can be safely showered 48 hours after surgery. Postoperative showering does not increase the risk of surgical site complications. It may increase patients' satisfaction and lower the cost of wound care.

Psychologic factors in functional dyspepsia have been discussed in many previous articles. However, the relationship between depression and functional dyspepsia is still obscure. We investigated the impact of depression on clinical symptoms and gastric dysrhythmia in functional dyspepsia. Thirty-nine patients with functional dyspepsia and 18 healthy subjects were included. Patients were investigated with clinical symptoms assessment, Zung's self-rating depression scale, and electrogastrography. Patients with functional dyspepsia were divided into two groups: 21 patients with depression and 18 patients without depression. The depressed patients had similar total gastrointestinal symptom severity scores compared with the nondepressed patients, but with higher total symptom frequency scores (p < 0.05). With regards to symptoms, the depressed patients had higher abdominal fullness severity and frequency scores and nausea frequency scores. The patients with functional dyspepsia had a lower percentage of normal slow wave in both the fasting and fed states and a higher percentage of bradygastria in the fasting state and tachygastria in the postprandial state (p < 0.05). There was no significant difference in the percentage of bradygastria or tachygastria between the depressed and nondepressed patients. There was no correlation between the specific type of electrogastrographic abnormality and the presence or absence of depression in functional dyspepsia patients.

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We thank Singh et al 1 for their letter 2 commenting on our recent paper. 3 The authors briefly summarised current evidence regarding the chemopreventive effects of statins on hepatocellular carcinoma (HCC) and noted the lack of analyses on the role of statins in HCC in our study.We agree that the use of statins was found to be associated with a reduced risk of HCC according to previous studies. 3 However, not only statins but also nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, thiazolidinediones, antiviral agents, etc, were all reported to be associated with a lower risk of HCC. Sahasrabuddhe et al analysed the National Institutes of Health-AARP Diet and Health Study cohort and reported that aspirin users had significantly reduced risks of HCC (relative risk (RR)=0.59, 95% CI 0.45 to 0.77) and mortality (RR=0.55, 95% CI 0.45 to 0.67) due to chronic liver disease. 4 In the present study, we found that not only metformin but also thiazolidinedions were associated with a lower risk of HCC (HR=0.76, 95% CI 0.70 to 0.81). 1 In our other recent study focused on antiviral therapy and risk of hepatitis B virus (HBV)-related HCC, also based on Taiwan's National Health Insurance Research Database, we found that the use of nucleoside analogues was associated with a lower risk of HCC recurrence among patients with HBV-related HCC after liver resection (HR=0.67, 95% CI 0.55 to 0.81). The use of statins (HR=0.68, 95% CI 0.53 to 0.87) and NSAIDs or aspirin (HR=0.80, 95% CI 0.73 to 0.88) was also found to be an independent protective factor for HCC recurrence. 5 In the present study, we focused on antidiabetic agents because we already had many factors to be controlled, including age, gender, hepatitis B, hepatitis C, cirrhosis, end-stage renal failure, diabetic duration, control of diabetes, and use of other oral antidiabetic agents, thiazolidinediones and insulin. We did not intend to include other non-anti-diabetic agents, such as statins, NSAIDs or aspirin, and antiviral agents in the initial study design of the present study because analysing too many factors in the multivariate model will result in a trade-off with lower power to detect differences. We believe it is for the same reason that Singh et al did not intend to examine the chemopreventive effects of drugs other than statins in their meta-analysis. Even though the roles of metformin, thiazolidinedions, NSAIDs or aspirin, and antiviral agents are not included in their study, this does not hinder the merits of their meta-analysis. 3 REFERENCES 1. Singh S, Singh PP, Singh AG, et al. Statins are associated with a reduced risk of hepatocellular cancer: a systematic review and meta-analysis.