SUMMARYAim: To test the efficacy of rabeprazole, levofloxacin and rifabutin triple therapy vs. quadruple therapy for the second-line treatment of Helicobacter pylori infection. Methods: One hundred and nine patients who had failed previous H. pylori eradication were randomized to receive: (i) rabeprazole, 20 mg b.d., rifabutin, 300 mg once daily, and levofloxacin, 500 mg once daily, for 7 days (triple therapy); or (ii) rabeprazole, 20 mg b.d., metronidazole, 400 mg t.d.s., bismuth subcitrate, 120 mg q.d.s., and tetracycline, 500 mg q.d.s., for 7 days (quadruple therapy). Endoscopy and culture were performed before treatment. Results:The clarithromycin (79% vs. 21%, P < 0.001) and metronidazole (89% vs. 40%, P < 0.001) resistance rates were significantly higher in patients with previous exposure than in those with no previous exposure. The intention-to-treat and per protocol eradication rates were 91%/91% for the triple therapy group and 91%/92% for the quadruple therapy group. For patients with double resistance to metronidazole and clarithromycin, the eradication rates were 85% (17/20) in the triple therapy group and 87% (13/15) in the quadruple therapy group. Compliance was greater than 95% for both regimens. Conclusion: Rabeprazole, levofloxacin and rifabutinbased triple therapy and quadruple therapy were equally effective as second-line treatments for H. pylori infection.

Background: Different tests are available for diagnosing Helicobacter pylori infection. Aim: To compare the most commonly used tests either alone or in combination in Chinese patients with respect to routine clinical use or research purpose. Methods: A total of 294 consecutive dyspeptic patients without previous H. pylori treatment were recruited. During upper endoscopy, biopsies were taken from the antrum and corpus, for a commercially available CLO‐test, an in‐house rapid urease test, culture, polymerase chain reaction and histological examination. Patients then received a 13C‐urea breath test. The H. pylori status of each patient was determined by a concordance of test results. Results: For routine clinical use, histology (antral plus corpus biopsies) had an accuracy of 100%, whilst the rapid urease test had an accuracy of 99.7%. The 13C‐urea breath test was equally reliable, with an accuracy of 94.5%. Combinations of two tests did not confer additional advantage over the most accurate single test. For research purposes, the accuracy of using the criteria of two positives out of three diagnostic tests was 100% and equivocal results were not found. Conclusion: Histology with or without a rapid urease test was highly accurate for routine clinical use. Alternatively, the 13C‐urea breath test was an equally reliable non‐invasive test. The two positives out of three tests approach was highly reliable in predicting H. pylori status of untreated Chinese patients in a research setting.

Clinical, endoscopic, and laboratory data were collected prospectively in 701 patients with bleeding peptic ulcer. The overall rebleeding rate was 16.1% and increased the risk of a fatal outcome by 17 fold (1.2% versus 20.6%, p less than 0.001). Rebleeding was documented in more than 75% of the group who did not survive following initial conservative management. Rebleeding was more likely (24.1% versus 14.2%, p less than 0.02) when shock was present on admission and the risk of a rebleed was doubled in patients over 60 years of age (22.1% versus 10.9%, p less than 0.001). Ulcers greater than 1 cm in size carried twice the risk of rebleeding (23.9% versus 12.4%, p less than 0.002). Concomitant medical illness had a significant adverse effect on outcome (p less than 0.05). Shock on admission was associated with a doubling of mortality figures (9.5% versus 3.7%, p less than 0.01). The identification of endoscopic stigmata of recent hemorrhage (ESRH) tripled the risk of mortality (7.5% versus 2.4%, p less than 0.002), ESRH were more frequently encountered when ulcer size was larger than 1 cm (61.4% versus 39.8%, p less than 0.001). Respective mortality rates for ulcers less than or equal to 1 cm and greater than 1 cm in size were 1.6% and 12.5% (p less than 0.001), corresponding mortality figures for patients over 60 years of age being 4.4% and 16.4% (p less than 0.002). The risk of a rebleed tripled (6.7% versus 2.6%, p less than 0.02) when ESRH were evident. There was a 6-fold increase in mortality following emergency surgery when compared with conservative management of patients in whom no surgical intervention was necessary (2.6% versus 14.9%, p less than 0.001). In summary, age over 60 years, previous medical illness, shock on admission, large ulcer size, and ESRH were each associated with an increased risk of rebleeding and mortality.

Nerve hydrodissection (HD), a technique used when treating nerve entrapments, involves the injection of an anesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue, fascia, or adjacent structures. Animal models suggest the potential for minimal compression to initiate and perpetuate neuropathic pain. Mechanical benefits of HD may relate to release of nervi nervorum or vasa nervorum compression. Pathologic nerves can be identified by examination or ultrasound visualization. The in-plane technique is the predominant and safest method for nerve HD. Five percent dextrose may be favored as the preferred injectate based on preliminary comparative-injectate literature, but additional research is critical. Literature-based hypotheses for a direct ameliorative effect of dextrose HD on neuropathic pain are presented.

Summary:is generally believed that immunosuppresion enhances viral replication with consequent increase in hepatocyte infection. Withdrawal of cytotoxic or immunosuppressive drugs Hepatitis B reactivation following chemotherapy withdrawal may result in hepatitis, hepatic failure and leads to restoration of immune function, resulting in rapid destruction of infected hepatocytes. This may give rise to death. We studied the clinical outcome and the causes of hepatic events of hepatitis B surface antigen positive a clinical picture of hepatitis and even hepatic failure and death. 6 Bone marrow transplantation (BMT) has become a recipients undergoing bone marrow transplantation. Twenty-four hepatitis B surface antigen patients were standard treatment for various hematological malignancies. 7 During the procedure, intensive chemotherapy with and matched with 24 hepatitis B surface antigen negative patients for age, sex, CMV positive serology, underlying without total body irradiation was required to ablate the recipients' marrow. Furthermore, immunosuppressive hematological disease and type of bone marrow transplantation. Post-BMT, there were 18 patients in the agents have to be administered for at least 6 months after BMT for prevention or treatment of graft-versus-host dishepatitis B surface antigen positive group and four patients in the hepatitis B surface antigen negative ease (GVHD). Therefore, one would anticipate that chemotherapy withdrawal HBV reactivation would be a problem group who suffered from hepatitis (P Ͻ 0.05). Thirteen of the 18 hepatitis were related to HBV reactivation in after bone marrow transplantation. In fact, fatal fulminant hepatitis due to HBV reactivation has been reported in the hepatitis B surface antigen positive group and none of the four hepatitis in the hepatitis B surface antigen HBsAg positive carriers undergoing BMT. 8 The aim of this study was to define the incidence of hepatic events negative group (P = 0.01). The hepatitis B surface antigen positive group also had an increased incidence of (hepatitis and hepatic failure) in the HBsAg positive patients undergoing BMT and the causes of the hepatic acute graft-versus-host disease of liver (6 vs 1, P = 0.03). However, there was no significant increase in the incievents. dence of veno-occlusive disease (10 vs 7, P = 0.40) and persistent hepatitis (3 vs 0, P = 0.07) in the hepatitis B Patients and methods surface antigen positive group. Using the log-rank test, there was no significant difference in survival betweenPatients studied the hepatitis B surface antigen positive and negative recipients.Two hundred and twenty-four patients received a BMT at Keywords: HBV; bone marrow transplantation; hepatitis;Queen Mary Hospital between May 1990 and March 1995. VOD; GVHD; HBV reactivation All of them were screened before BMT for hepatitis serology (HBsAg/Ab, HBeAg/Ab, anti-HCV (EIA II), anti-HDV). Twenty-five patients were HBsAg positive and among them one was also HCV Ab positive (EIA II). Chronic hepatitis B infection is endemic in ...

A 67-year-old woman with diabetes mellitus, chronic renal insufficiency, and recurrent urinary tract infections experienced encephalopathy and myoclonus while receiving cefepime. The adverse drug event was accompanied by elevated cefepime levels and abnormal electroencephalograms. This syndrome resolved after discontinuation of cefepime. Neurotoxicity is a known but possibly underreported adverse event associated with cefepime in patients with renal impairment who receive relatively excessive doses. Most cases reverse on drug cessation. In patients with renal disease, the maintenance dosage should be reduced and the patient monitored for neurotoxicity. Cefepime toxicity should be suspected whenever a patient receiving the drug experiences a change in mental status or myoclonus.

Deep nerve hydrodissection uses fluid injection under pressure to purposely separate nerves from areas of suspected fascial compression, which are increasingly viewed as potential perpetuating factors in recalcitrant neuropathic pain/complex regional pain. The usage of 5% dextrose water (D5W) as a primary injectate for hydrodissection, with or without low dose anesthetic, could limit anesthetic-related toxicity. An analgesic effect of 5% dextrose water (D5W) upon perineural injection in patients with chronic neuropathic pain has recently been described. Here we describe ultrasound-guided methods for hydrodissection of deep nerve structures in the upper torso, including the stellate ganglion, brachial plexus, cervical nerve roots, and paravertebral spaces. We retrospectively reviewed the outcomes of 100 hydrodissection treatments in 26 consecutive cases with a neuropathic pain duration of 16 ± 12.2 months and the mean Numeric Pain Rating Scale (NPRS) 0–10 pain level of 8.3 ± 1.3. The mean percentage of analgesia during each treatment session involving D5W injection without anesthetic was 88.1%  ±  9.8%. The pretreatment Numeric Pain Rating Scale score of 8.3 ± 1.3 improved to 1.9 ± 0.9 at 2 months after the last treatment. Patients received 3.8 ± 2.6 treatments over 9.7 ± 7.8 months from the first treatment to the 2-month posttreatment follow-up. Pain improvement exceeded 50% in all cases and 75% in half. Our results confirm the analgesic effect of D5W injection and suggest that hydrodissection using D5W provides cumulative pain reduction.

Background/Aims: Helicobacter pylori induces the apoptosis of gastric epithelial cells in vivo and in vitro. However, the molecular mechanism has not been clarified. The aim of this study was to investigate the effect of H pylori on the apoptosis of gastric epithelial cells and the expression of apoptosis related genes in vitro. Methods: Human gastric adenocarcinoma SGC-7901 cells were co-cultured with a cytotoxic H pylori strain, NCTC 11637, at various densities ranging from 3.2 × 10 4 to 1.0 × 10 8 colony forming units (CFU)/ml for 48 hours. Apoptosis in gastric cells was determined by transmission electron microscopy, Hoechst 33258 fluorochrome staining, and flow cytometry. The expression of apoptosis related proteins, Bcl-2, Bax, and c-Myc, was measured by an immunohistochemical method, and c-Myc mRNA expression was determined by the reverse transcription-polymerase chain reaction. Results: Helicobacter pylori induces morphological changes typical of apoptosis. Both fluorochrome staining and flow cytometry showed that the apoptotic index began to increase when H pylori were at a density of > 1.6 × 10 4 CFU/ml, and in a density dependent manner (p < 0.01; one way ANOVA). The expression of the Bax and c-Myc proteins and of c-Myc mRNA was increased, whereas Bcl-2 expression was decreased after co-culture for 48 hours. Conclusions: Helicobacter pylori induced apoptosis in gastric epithelial cells is mediated by altered expression of the products of the Bcl-2, Bax, and c-Myc genes.