Patients with triglyceride levels over 1,000 mg/dl are at high risk of developing acute pancreatitis. This study aimed to determine the effectiveness of plasma exchange (PE) in reducing triglyceride levels during an acute attack of hyperlipidemic pancreatitis (HLP). A total of 17 hypertriglyceridemic patients with the complication of acute pancreatitis received one course of PE treatment for one or two consecutive sessions. The respective mean removal rates during a single PE for triglyceride, cholesterol, amylase, and lipase were 66.3, 62.1, 70.0, and 84.8%, respectively. An additional one exchange increased the removal rate to 83.3, 66.2, 85.5, and 87.0%, respectively. For the two-sessions of treatment, the removal rates were higher for triglyceride (P=0.0015) and amylase with a borderline statistical significance (P=0.0641). Better triglyceride clearance correlated well with lower levels of transmembrane pressure (TMP) at 90 minutes after PE (r2=0.5782, P=0.0010) and shorter plasmapheresis duration (r2=0.2241, P=0.0427). Thirteen of seventeen patients (76.5%) recovered completely, eight patients in a single-session, and five in two-sessions. Two patients developed intra-abdominal abscess, necessitating surgical drainage and two patients died due to both septic shock and multi-organ failure. No significant predictor of clinical outcome was identified. In summary, PE treatment is an effective method to clear lipids and enzymes from plasma in a single session for most HLP patients. A greater extraction of triglyceride would result in a reduced TMP and a shorter duration of PE treatment.

Plasma exchange can not ameliorate the overall mortality or morbidity of hyperlipidemic pancreatitis. The time of plasma exchange might be the critical point. If patients with hyperlipidemic pancreatitis can receive plasma exchange as soon as possible, better result may be predicted. Further study with more cases is needed to clarify the role of plasma exchange in the treatment of hyperlipidemic pancreatitis.

ContributorsGIW wrote and revised the manuscript in response to co-author comments. He finalized all the figures and tables, performed the literature search, and assisted with data interpretation. HJK critically reviewed the manuscript and made important suggestions to improve it. He assisted with data interpretation. IBA performed the data analysis, constructed the figures and tables, and made important suggestions to improve the manuscript. H-CK assisted with the data analysis and also reviewed the manuscript. GRC critically reviewed the manuscript and made important suggestions to improve it. He assisted with data interpretation. All other authors were given the opportunity to review the manuscript and make suggestions which GIW received, either revising the paper or providing explanations. All who are not deceased were involved with approval of the manuscript.

Cholelithiasis patients have a higher risk of gastrointestinal cancer, particularly of gallbladder and extrahepatic bile duct cancer. Post-cholecystectomy patients have a risk of colorectal and stomach cancer within the first 5 years and persisting after 5 years, respectively. This paper proposes strategies for preventing gastrointestinal cancer.

Two techniques for plasmapheresis are used in the treatment of myasthenia gravis (MG): immunoadsorption (IA) and double filtration (DF). This controlled study evaluated the differences between these techniques in clinical effects and serological changes. Five patients with generalized MG (clinical states IIb and III) were enrolled; each patient received IA and DF plasmapheresis on separate occasions. Immunosorba TR-350 with an affinity to acetylcholine receptor antibodies (AchRAb) was used for IA, while Evaflux 4A was used as the plasma fractionator for DF. Each course of treatment consisted of five sessions of apheresis. MG score, titers of AchRAb, immunoglobulins (Ig), and plasma biochemistry were assessed by blinded examiners before and immediately after the entire course of treatment. Both treatments effectively ameliorated symptoms of MG. There were no significant changes in MG score between the two groups (IA vs. DF: 2.2 vs. 2.6, P> 0.5). IA had a higher clearance rate of AchRAb than DF (66 % vs. 54 %, P< 0.05), while DF removed more IgA (72% vs. 21%, P< 0.05) and IgM (89% vs. 57%, P< 0.01) than did IA. Although IA removed AchRAb more effectively than DF, the clinical effects between these two treatments were similar. The titers of AchRAb cannot reflect the clinical severity. Some circulating factors other than AchRAb may contribute to the pathogenesis of MG.

Patients with extremely high triglyceride levels and associated lipemia are at high risk for acute pancreatitis. To evaluate plasmapheresis efficacy for severe hypertriglyceridemia, 18 patients who had not responded to previous therapies were selected for either the plasma-exchange (PE) or double-filtration (DF) treatment variants. After treatment, the mean serum concentrations for triglyceride and cholesterol fell significantly from 1,977.1 and 436.7 mg/dl to 692.6 and 222 mg/dl, respectively. The cholesterol-removal rate was significantly higher for the PE group (P = 0.0082), which also had a lower incidence of hemolysis during the plasmapheresis treatment (P = 0.0430). Improved clearance of serum triglyceride was strongly associated with a lower level of maximal transmembrane pressure (TMP; P = 0.0030), reduced plasmapheresis duration (P = 0.0035), and higher rates of plasma (P = 0.0255) and blood flow (P = 0.0480) during plasmapheresis. In comparison to reports in the literature, the removal rates for serum lipids were lower in our study, possibly as a consequence of early saturation of the plasma separator resulting from blockage caused by the extremely high level of triglyceride-containing lipoproteins. Therefore, PE may be more suitable for the initial treatment of severe hypertriglyceridemia as saturation is prevented. Increasing blood and plasma flow rates, reduction of the TMP level, and reducing effective plasmapheresis duration will improve the clearance of serum lipids during treatment.

Approximately 15% of 1 patients with generalized myasthenia gravis (MG) lack detectable circulating antibodies to the acetylcholine receptor (AChRAb), referred to as seronegative MG (SNMG). During the last 3 years, antibodies against muscle-specific tyrosine kinase (MuSKAb) were found in about 40 to 70% of patients with SNMG. 1-5 We report the first MuSKAb survey among Chinese patients with SNMG and compare the features of MuSKAbpositive patients with those of Caucasian patients.Methods. During last 10 years, we collected data from 774 myasthenic patients (389 with the ocular type and 385 generalized type) at the Shin Kong Wu Ho-Su Memorial Hospital. Among patients with generalized MG, 38 (9.8%) were seronegative for AChRAb. We enrolled 26 of these patients, who had been monitored regularly; 20 were women and 6 were men (table). Twenty patients were in Osserman stage IIa, four were in IIb, and two patients were in stage III. Limb weakness was the most common feature (n ϭ 20). Sixteen patients had ocular muscle weakness, 12 had bulbar weakness, 8 had neck muscle weakness, and 4 had respiratory muscle weakness. All patients had at least one negative result for AChRAb at least 6 months after symptom onset. The diagnosis of MG was based on typical clinical features, positive response to anticholinesterase and immunomodulatory treatment, or abnormal electrophysiologic tests. All patients received anticholinesterase therapy, and 17 of them responded well. Fourteen of all the patients received immunosuppressants, and 10 patients underwent thymectomy. The thymic pathology included hyperplasia in six patients, atrophy in three, and thymoma in one. Ten patients underwent plasmapheresis for relief of their clinical deterioration.MuSKAbs were detected using the immunoprecipitation method. Five microliters of serum was incubated with 50 L of 125 I-MuSK for 4 hours. Further immunoprecipitation was done with 50 L of sheep anti-human IgG for 1 hour. AChRAbs were measured using the standard AChRAb RIA kit (RSR Limited, Cardiff, UK). Five microliters of serum, 50 L of AChR, and 50 L of anti-human IgG were incubated overnight at 4°C.Results. Only 1 of the 26 patients (3.8%) was positive for MuSKAb. This patient's positive sample was confirmed by testing serial dilutions, and the titer was approximately 9.89 nmol of 125 I-MuSK precipitated/L of serum.The MuSKAb-positive patient was a 71-year-old man who developed transient ptosis and diplopia followed by progressive dysphagia at age 67. On examination in November 1999, the motor weakness was distributed in the palate, tongue, and neck flexor. The decremental response of the right trapezius muscle in the repetitive nerve stimulation test was 9%, and the jitter of the right extensor digitorum communis in the stimulated single-fiber electromyography test was 17 microseconds. The AChRAb titer was Ͻ0.2 nmol/L, and the creatine kinase level was within normal limits. No thymic abnormalities were identified on CT. The patient did not respond to pyridostigmine. Because of the progressive wo...

Intensive plasma exchange can transiently alter the hemostatic system. However, the effect of serial double filtration plasmapheresis (DFP) on the hemostatic system has not been adequately described. In this study, we sought to characterize the hemostatic effects of DFP in 32 myasthenia gravis patients who received one course of DFP treatment for five consecutive sessions within 10 days. Platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and serum levels of albumin, globulin, cholesterol, and fibrinogen were measured before and after the course of DFP. Patients were divided into mild hypofibrinogenemia (MH) and severe hypofibrinogenemia (SH) groups based on post-plasmapheresis residual levels of fibrinogen above or below 70 mg/dl. The baseline fibrinogen level was significantly lower in the SH group (P < 0.01). After five sessions of DFP, the fibrinogen level was reduced to below 70 mg/dl in 14 patients (44%). The percentage of excessive prolongation of PT or PTT was significantly higher in the SH group. The SH group also had higher reduction rates of globulin and cholesterol (P < 0.05). Oozing in the punctured site of the central venous catheter occurred in 6 out of 26 patients, with four cases in the MH group and two in the SH group. There was no difference in the overall incidence of bleeding complications between the two groups. Only one episode of clinically overt bleeding occurred during the study after a large-bore femoral catheter was removed soon after the patient had received five consecutive daily treatments. The bleeding stopped after transfusion of 6 units of fresh frozen plasma. In conclusion, despite the obvious reduction of fibrinogen level and the modest decrease in platelet count after an intensive course of DFP treatment, the low incidence of clinically overt bleeding confirmed the safety of DFP.