Perforated peptic ulcer: a comparison of long term results following partial gastric resection or simple closure

The results of simple closure were compared with those of partial resection in the treatment of perforated peptic ulcer. The investigation was carried out 7-13 years after the primary operation on 126 patients who had been allotted to one of the two treatment methods on the basis of an almost randomized schedule. Better late results were obtained with partial resection than with simple closure in patients in the age range 50-59 years at operation, with short duration of perforation and with a long history of symptoms before perforation. None of the patients treated with partial resection later underwent surgical treatment for recurrence of symptoms. In the simple closure group 27.3 per cent needed further surgery at 3 months to 10 years after perforation.     

Expected survival compared with survival of peptic ulcer patients

In analyses of patient survival it is often desirable to compare observed survival curves with expected survival curves based on information obtained from the general population. However, current methods of calculating expected survival curves are difficult to interpret and are often poorly documented. We discuss an alternative formulation of the so-called direct method which we recommend for general use. By simulation, we show that the expected survival curve obtained from this method represents the expectation of a Kaplan-Meier curve for a set of random population controls. Thus, the term expected survival does not refer to the expectation of patient survival, but rather to the expected survival curve for a random set of controls. The alternative methods are discussed, and we illustrate the methods in an analysis of long time survival of a population-based sample of peptic ulcer patients.     

Current treatment strategies and factors influencing outcome in patients with bacterial brain abscess

We clearly determined the key to managing patients with brain abscess by retrospectively evaluating the factors affecting poor outcome in these patients. This study included 113 patients with brain abscess diagnosed in the CT era. Basic characteristics and therapeutic parameters were estimated as independent predictors of poor outcome by using univariate and multivariate logistic regression analysis. Patients with poor outcomes more frequently had deeply-located abscesses (p < 0.02), IVROBA (intraventricular rupture of brain abscess (p < 0.001) and were in a severely deteriorated neurological state (p < 0.001) than those with good outcomes. Multiple logistic regression analysis predicted that IVROBA (ORs, 24.5; 95% CI, 3.04 to 197.9) and severely deteriorated cases (ORs, 13.7; 95% CI, 2.34 to 80.8) resulting from IVROBA increased the relative risk of poor outcome. Patients with IVROBA more frequently had also deeply-located abscesses (p < 0.005), positively immunocompromised states (p < 0.05) and were in a severely deteriorated condition (p < 0.003) than those without IVROBA. Patients with metastatic abscess had also IVROBA (p < 0.006). Multiple logistic regression analysis anticipated that deeply-located abscess (ORs, 3.90; 95% CI, 1.38 to 11.04), and metastatic abscess (ORs, 12.26; 95% CI, 1.35 to 111.2) increased the relative risk of IVROBA. Patients in an obtunded state and with marked neurological deficit had IVROBA more often than patients in an alert state and/or mild neurological deficit (ORs, 3.23; 95% CI, 1.17 to 8.86, p < 0.03) before treatment. Our findings suggest that IVROBA strongly influences poor outcome in patients with brain abscess. The key to decreasing poor outcomes may be the prevention and management of IVROBA, by evaluating intracranial pressure pathophysiology. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with appropriate intravenous and intrathecial administration of antibiotics.     

Psychosocial factors in peptic ulcer and inflammatory bowel disease.

Over the past decade, while gastroenterologists' interest in mind-body interactions in organic disorders dwindled, stronger evidence has linked psychosocial factors with the incidence and recurrence of peptic ulcer and with the course of inflammatory bowel disease. Psychological-behavioral approaches to treatment continue to be disappointing. Psychosocial factors may affect ulcer by increasing duodenal acid load, altering local circulation or motility, intensifying Helicobacter pylori infection, stimulating corticosteroid secretion, and affecting health risk behaviors; possible mechanisms for inflammatory bowel disease include immune deregulation, gut permeability changes, and poor medication adherence. Both belong to the growing category of diseases thought to have an infectious component: for peptic ulcer the bacterium Helicobacter pylori, for inflammatory bowel disease an exaggerated immune response to gut bacteria. Peptic ulcer and inflammatory bowel disease, which present unique interactions among psychological, immunologic, endocrine, infectious, and behavioral factors, are splendid paradigms of the biopsychosocial model. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The mental status characteristics of patients with peptic ulcer and chronic cholecystitis

Mental status examinations (V. P. Za?tsev's clinical scale. MMPI test modified by F. B. Berezin et al.) were performed in 90 patients with duodenal ulcer (DU) and 142 patients with chronic acalculous cholecystitis (CAC). Mental changes were revealed in 93.3% and 86.6% of DU and CAC patients, respectively, in the disease aggravation. These changes persisted more continuously in CAC patients as they remained after the disease treatment unlike those in DU. Therefore, mental status of CAC patients needs correction.     

Eradication of Helicobacter pylori in peptic ulcer patients

The aim of this study was to compare in an open trial the efficacy of 2 x 500 mg clarithromycin + 2 x 1000 mg amoxicillin + 40 mg pantoprazole/day given for 7 days (I. group, 48 cases), with that of 2 x 500 mg clarithromycin + 2 x 400 mg ranitidine bismuth citrate/day given for 14 days (II. group, 51 cases). The diagnosis of peptic ulcer was established endoscopically. HP infection was confirmed the modified Giemsa stain and rapid urease test. After eradication all patients were given 2 x 150 mg ranitidine for one month. Controls were performed 4-6 weeks after eradication. Peptic ulcer healing was proven in the group I in 93.0% and in the group II in 91.6% (p > 0.05). On intention-to-treat basis, HP was eradicated in 80.3% (confidence interval, CI: 73-92.7%) in the I. and 80.3% (confidence interval: 76-95%) in the II. group (p > 0.05). Per protocol analysis revealed eradication rates of 88.3% (CI: 81-97.6%) and 85.4% (CI: 80-97%) (p > 0.05). Side effects were recorded in 9.5% and 14.5% of the cases. Both regimens were equally effective in the eradication of HP and healing of peptic ulcers.     

Short and long term results of pulmonary balloon valvuloplasty in children

Percutaneous balloon valvuloplasty is an alternative to surgical valvotomy for congenital pulmonary valve stenosis. Between 1985 and 1997, 73 valvuloplasties were performed in 70 patients, age range 1 day to 24.7 years. We reviewed the short- and long-term results in regard to transvalvular gradient and pulmonary insufficiency. The gradient was measured pre- and immediately post-valvuloplasty at catheterization and by Doppler echocardiography, and by echocardiography only at follow-up. Valvuloplasty was successful in 61/70 patients whereas surgical valvotomy was necessary in 9/70 because of a very dysplastic valve. A second valvuloplasty was performed in 3 patients presenting with restenosis. A 60% decrease in the gradient was noted immediately after the procedure, from 78.3 +/- 24.5 to 33.7 +/- 19.7 mm Hg (p < 0.05). A follow-up of more than 2 years (4.2 +/- 2.2 years) was obtained in 35 patients. A further decrease in the gradient was noted, to 20 +/- 12 mm Hg, and the degree of pulmonary insufficiency was mild in all patients except 2 with a moderate leak. The mortality was 0% and only 1 patient had a complication (endocarditis). The short- and long-term results of pulmonary percutaneous balloon valvuloplasty are excellent. It can be considered the therapy of choice. The gradient shows a further decrease during follow-up due to regression of the infundibular muscular stenosis. Failure is attributed to very dysplastic valves and these patients may require, in a second stage, a surgical approach (patch enlargement and/or valvulectomy).     

Prognostic factors affecting long term outcome after liver resection for hepatocellular carcinoma: results in a series of 100 Italian patients

BACKGROUND: Long term results after liver resection for hepatocellular carcinoma (HCC) are disappointing because the disease tends to recur. In this study, the authors assessed prognostic factors affecting long term outcome, in the hope that these factors might be used in selecting HCC patients for surgery. METHODS: During the period 1977-1995, 100 consecutive patients underwent curative liver resection; 78 of 100 had HCC arising on preexisting cirrhosis (53 Child's Class A and 25 Child's Class B). Thirty-five prognostic factors were evaluated for their association with overall survival (OS) and disease free survival (DFS) in univariate and multivariate analysis (Cox proportional hazards model). RESULTS: There were four postoperative deaths. Seven patients died in hospital of hepatorenal failure: six had Child's Class B cirrhosis and had undergone preoperative chemoembolization. Of the remaining 89 patients, 50 developed recurrence. All surviving Child's Class B patients had recurrence. Five-year OS, postoperative deaths included, was 38% (median, 36 months). Five-year DFS, postoperative deaths excluded, was 26% (median, 21 months). Independent prognostic factors for DFS were Child's class, glutamic-oxaloacetic transaminase, gamma-glutamyltransferase, alpha-fetoprotein, number of tumor nodules, width of resection margins, preoperative chemoembolization, and experience of the team that performed the surgery. Factors with an independent effect on OS were Child's class and width of resection margins. CONCLUSIONS: Liver resection can provide long term DFS in HCC patients with normal liver function. In patients with liver function impairment or an inadequate resection margin, recurrences are almost certain to occur. Preoperative chemoembolization significantly prolongs DFS but may increase the risk of postoperative liver failure in patients with liver function impairment.     

Prognostic factors of early sequelae and fatal outcome of Japanese encephalitis

A clinical case control study to identify prognostic factors present at hospital admission associated with early sequelae and fatal outcome of acute Japanese encephalitis (JE) was carried out in Gusi county, Henan Province, central China from June to September 1991. A total of 70 patients with laboratory-confirmed acute JE were studied, of whom 3 cases died and 33 cases had neurological or psychiatric sequelae at the end of three months follow-up. The results showed that acute JE at younger age, with higher body temperature, high white cell count in CSF, and deep coma present at hospital admission were markers for unfavorable outcomes (sequelae or fatal). A history of the vaccination was not correlated with the early sequelae and fatal outcome of the disease. The paper suggests that early diagnosis and treatment and universal JE vaccination for all susceptible populations are keys for decreasing incidence of sequelae and fatal outcome of acute JE.     

Immune status indices during the combined treatment of patients with duodenal peptic ulcer

Indices were studied of the immunological status (cell-mediated, humoral immunity) before and after the multimodality pathogenetic treatment of patients with duodenal ulcer. Noted in the course of the complex treatment were changes in the immunoregulatory index, NK-cells, IgM. The findings obtained suggest that the immune defence may be depressed, with the vascular factor, infection (Helicobacter pylori) having their part in the genesis of duodenal ulcer.     

Risk factors of persistent or recurrent bleeding and mortality in peptic ulcer hemorrhage

The mortality rate of peptic ulcer haemorrhage has remained unchanged, mainly attributed to rebleeding in an increasingly elderly population with more coexisting systemic diseases. The value of clinical factors and endoscopic findings in predicting in-hospital further haemorrhage and death are analysed. Over a 2-year period, 157 consecutive patients were admitted with bleeding from peptic ulcer, 19 died and 37 had further bleeding. The predictive value of each factor was determined by the chi 2 test with a Yates-correction (significant, p < 0.05). Significant predictive factors of further bleeding were shock, a transfusion requirement > 4 units during the first 48 hours and endoscopic stigmata of recent haemorrhage. The combination of these factors was not of better predictive value than shock alone. The number of coexisting illnesses per patient was strongly related to fatality rate. Other significant factors indicative of an increased mortality included steroid, onset of bleeding during a hospital stay, alcohol, further bleeding, and > 4 units transfused over the first 48 hours. Shock remains the most valuable sign in predicting further bleeding and is superior to endoscopic stigmata. The close relationship between the mortality rate and coexisting illnesses underlines the fact that the majority of deaths result from non peptic ulcer disease.     

Different course of reactive arthritis in two HLA-B27 positive brothers with fatal outcome in one

During an outbreak of Yersinia pseudotuberculosis III, one of two HLA-B27 positive brothers developed reactive arthritis (ReA), mild at first, but later severely destructive and ultimately fatal. The reactivation of ReA was possibly triggered by an oral polio vaccine. The cause of death was severe secondary amyloidosis. The other brother was exposed to the same Y. pseudotuberculosis strain but did not develop any disease during or after the outbreak. However, he later developed ReA due to a Salmonella infection, with a benign course.