Background Off-hour presentation can affect treatment delay and clinical outcomes in endovascular therapy (EVT) for acute ischemic stroke. We aimed to examine the treatment delays and clinical ...outcomes of EVT between on- and off-hour admission and to evaluate the effect of hospital procedure volume and the number of neurointerventionalists on off-hour EVT. Methods and Results From a multicenter registry, we identified patients who were treated with EVT within 12 hours of symptom. Annual hospital procedure volume was divided as low (<30), medium (30-60), and high (>60). The effect of the number of neurointerventionalists and annual hospital procedure volume on clinical outcome was estimated by the generalized estimation equation. Of the 31 133 stroke patients, 1564 patients met the eligibility criteria (mean age: 69±12 years; median baseline National Institutes of Health stroke scale score, 15 interquartile range, 10-19). Of 1564 patients, 893 (57.1%) arrived during off-hour. The off-hour patients had greater median door-to-puncture time (110 versus 95 minutes;
<0.001) compared with on-hour patients. Despite the treatment delay, the functional outcome at 3 months did not differ between off- and on-hour (odds ratio with 95% CI for 3-month modified Rankin Scale 0-2, 0.99 0.78-1.25;
=0.90). The presence of three neurointerventionalists was significantly associated with favorable outcomes at 3 months during on- and off-hour (2.07 1.53-2.81;
<0.001). The association was not observed for annual hospital procedural volume and the functional outcomes. Conclusions The number of neurointerventionalists was more crucial to effective around-the-clock EVT for acute stroke patients than hospital procedural volume.
Decreasing the time delay for thrombolysis, including intravenous thrombolysis (IVT) with tissue plasminogen activator and intra-arterial thrombectomy (IAT), is critical for decreasing the morbidity ...and mortality of patients experiencing acute stroke. We aimed to decrease the in-hospital delay for both IVT and IAT through a multidisciplinary approach that is feasible 24 h/day.
We implemented the Stroke Alert Team (SAT) on May 2, 2016, which introduced hospital-initiated ambulance prenotification and reorganized in-hospital processes. We compared the patient characteristics, time for each step of the evaluation and thrombolysis, thrombolysis rate, and post-thrombolysis intracranial hemorrhage from January 2014 to August 2016.
A total of 245 patients received thrombolysis (198 before SAT; 47 after SAT). The median door-to-CT, door-to-MRI, and door-to-laboratory times decreased to 13 min, 37.5 min, and 8 min, respectively, after SAT implementation (
<0.001). The median door-to-IVT time decreased from 46 min (interquartile range IQR 36-57 min) to 20.5 min (IQR 15.8-32.5 min;
<0.001). The median door-to-IAT time decreased from 156 min (IQR 124.5-212.5 min) to 86.5 min (IQR 67.5-102.3 min;
<0.001). The thrombolysis rate increased from 9.8% (198/2,012) to 15.8% (47/297;
=0.002), and the post-thrombolysis radiological intracranial hemorrhage rate decreased from 12.6% (25/198) to 2.1% (1/47;
=0.035).
SAT significantly decreased the in-hospital delay for thrombolysis, increased thrombolysis rate, and decreased post-thrombolysis intracranial hemorrhage. Time benefits of SAT were observed for both IVT and IAT and during office hours and after-hours.
Irsogladine maleate, an enhancer of gastric mucosal protective factors, has demonstrated its efficacy for various gastric mucosal injuries. The aim of this study was to evaluate the efficacy and ...safety of irsogladine for prevention of nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin-induced peptic ulcer and gastritis.
In this multicenter, randomized, double-blind, exploratory clinical trial, 100 patients over 50 years of age who needed continuous NSAIDs or aspirin for more than 8 weeks were randomly assigned to either test group (irsogladine maleate 2 mg, twice daily, 39 patients for full analysis) or placebo group (37 patients for full analysis). Primary outcomes were incidence of peptic ulcer and ratio of modified Lanza score (MLS) 2 to 4. Secondary outcome was the number of acute erosions confirmed by endoscopy at 8 weeks. Adverse effects were also compared.
There were no significant differences in gastric protective effects between test and placebo groups. However, two cases of peptic ulcer in the placebo group but none in the test group were observed. These two cases of peptic ulcer were Helicobacter pylori-negative. In addition, H. pylori-negative group showed significant changes in MLS score (p = 0.0247) and edema score (p = 0.0154) after the treatment compared to those before treatment in the test group. There was no significant difference in adverse events between the two groups.
The efficacy of irsogladine maleate was found in H. pylori-negative group, suggesting its potential as a protective agent against NSAIDs or aspirin-induced peptic ulcer and gastritis.
Prokinetics such as mosapride citrate CR (conventional-release; Gasmotin) are commonly used in functional dyspepsia (FD). This study aims to evaluate the efficacy and safety of once-a-day mosapride ...citrate SR (DWJ1252), a sustained-release formulation of mosapride citrate, compared with mosapride citrate CR 3 times a day, in patients with FD.
In this multicenter, randomized, double-blind, active-controlled, non-inferiority study, 119 patients with FD (by the Rome III criteria, 60 for mosapride citrate SR and 59 for mosapride citrate CR) were randomly allocated to mosapride citrate SR once daily or mosapride citrate CR thrice daily for 4 weeks in 16 medical institutions. Primary end point was the change in gastrointestinal symptom (GIS) score from baseline, assessed by GIS questionnaires on 5-point Likert scale after 4-week treatment. Secondary end points and safety profiles were also analyzed.
The study included 51 and 49 subjects in the mosapride citrate SR and mosapride citrate CR groups, respectively. GIS scores at week 4 were significantly reduced in both groups (mean ± SD: -10.04 ± 4.45 and -10.86 ± 5.53 in the mosapride citrate SR and mosapride citrate CR groups, respectively;
< 0.001), and the GIS changes from baseline did not differ between the 2 groups (difference, 0.82 point; 95% CI, -1.17, 2.81;
= 0.643). Changes in GIS at weeks 2 and 4 and quality of life at week 4, and the improvement rates of global assessments at weeks 2 and 4, did not differ between the groups. Adverse events were similar in the 2 groups, and there were no serious adverse events.
In patients with FD, mosapride citrate SR once daily is as effective as mosapride citrate CR thrice daily, with a similar safety profile.
Appropriate interval for performing follow-up endoscopy among dyspeptic patients without abnormal findings on previous endoscopy is unclear. We analyzed the multicenter-collected data from the Korean ...Society of Neurogastroenterology and Motility.
We collected clinical data of the patients who visited the gastroenterology department and underwent 2 or more sessions of upper endoscopy during 2012-2017 at 6 university hospitals in Korea. Patients with endoscopic interval between 90 days and 760 days were included. For those with multiple endoscopic sessions, only the first 2 were analyzed. Positive outcome was defined as adenoma or cancer in the upper gastrointestinal tract. To identify the point of change and estimate the properties of the stochastic process before and after the change, we used Bayesian regression with Metropolis-Hastings algorithm.
There were 1595 patients. Mean age was 58.8 years (standard deviation, 12.8). Median interval of endoscopy was 437 days (standard deviation, 153). On follow-up endoscopy, there were 12 patients (0.75%) who had neoplasia (4 with gastric cancer and 8 with gastric adnoma). As with the prior hypothesis, we presumed the change point (CP) of increase in frequency of organic lesion as 360 days. After random-walk Metropolis-Hastings sampling with Markov-Chain Monte Carlo iterations of 5000, the CP was 560 days (95% credible interval, 139-724). Estimated average of frequency of dysplastic lesions increased by a factor of 4.4 after the estimated CP.
To rule out dysplastic lesions among dyspeptic patients who had previously normal endoscopy, a 2-year interval could be offered as follow-up interval for repeat upper endoscopy.
The area of endoscopic application has been continuously expanded since its introduction in the last century and the frequency of its use also increased stiffly in the last decades. Because ...gastrointestinal endoscopy is naturally exposed to diseased internal organs and contact with pathogenic materials, endoscopy mediated infection or disease transmission becomes a major concern in this field. Gastrointestinal endoscopy is not for single use and the proper reprocessing process is a critical factor for safe and reliable endoscopy procedures. What needed in these circumstances is a practical guideline for reprocessing the endoscope and its accessories which is feasible in the real clinical field to guarantee acceptable prevention of pathogen transmission. This guideline contains principles and instructions of the reprocessing procedure according to the step by step. And it newly includes general information and updated knowledge about endoscopy-mediated infection and disinfection. Multiple societies and working groups participated to revise; Korean Association for the Study of the Liver, the Korean Society of Infectious Diseases, Korean College of Helicobacter and Upper Gastrointestinal Research, the Korean Society of Gastroenterology, Korean Society of Gastrointestinal Cancer, Korean Association for the Study of Intestinal Diseases, Korean Pancreatobiliary Association, the Korean Society of Gastrointestinal Endoscopy Nurses and Associates and Korean Society of Gastrointestinal Endoscopy. Through this cooperation, we enhanced communication and established a better concordance. We still need more researches in this field and fill up the unproven area. And our guidelines will be renewed accordingly.
Between endoscopic sphincterotomy (ES) alone and combined endoscopic sphincterotomy and large balloon dilation (ES-LBD) groups, efficacy and long-term complications, difference in biliary stone ...recurrence rate, and risk factors of stone recurrence were compared.
Medical records of 222 patients who underwent ERCP for biliary stone removal were retrospectively reviewed. Patients with dilated CBD ≥11 mm and follow-up longer than 6 months were included.
There were 101 patients in ES-LBD group and 121 patients in ES group. Mean follow-up duration was 25.0 (6-48) months and 13.0 (6-43) months, respectively (p=0.001). There was no difference in number of ERCP sessions, brown pigment stones, angle between mid and distal common bile duct (CBD angle) <135°, and lithotripsy rate. Complete retrieval success rate was excellent in both groups (100% vs. 99%). Early complication rate of ES-LBD and ES alone group was 4 and 4.1%, respectively (p=1.000). One patient in ES-LBD group died from delayed bleeding. Late complication rate was 5.9 and 3.3%, respectively (p=1.000). Stone recurrence rate was 6.9% and 5.8%, respectively (p=0.984). The only Independent risk factor of stone recurrence was presence of periampullary diverticulum.
Late complication and stone recurrence rates were similar between ES-LBD and ES alone groups.
Advances in endoscopic submucosal dissection (ESD) techniques have led to the development of expanded criteria for endoscopic resection of early gas-tric cancer (EGC). The aim of this study was to ...evaluate the short- and long-term outcomes for ESD using indication cri-teria.
A total of 1,105 patients underwent ESD for EGC at six medical centers. The patients were classified into the following two groups based on the lesion size, presence of ulceration and pathological review an absolute criteria group (n=517) and an expanded criteria group (n=588).
The curative resection rates (91.1% vs 91.3%, p=0.896) were similar in the absolute criteria group and the expanded criteria group. The en bloc resection rates (93.4% and 92.3%, respectively; p=0.488) and complete resection rates (98.3% and 97.4%, respectively; p=0.357) did not differ between the groups. The cumulative disease-free survival rates and the overall survival rates were similar between the groups (p=0.778 and p=0.654, respectively). Independent factors for the curative resection of EGC included tumor lo-cation (upper vs middle and lower, 2.632 1.128-6.144 vs 3.497 1.560-7.842, respectively) and en bloc resection rate 12.576 7.442-21.250.
The expanded criteria for ESD in cases of EGC is comparable with the widely ac-cepted pre-existing criteria. (Gut Liver, 2015;9181-187).
Smoking and alcohol intake are two wellknown risk factors for chronic pancreatitis. However, there are few studies examining the association between smoking and changes in computed tomography (CT) ...findings in chronic pancreatitis. The authors evaluated associations between smoking, drinking and the progression of calcification on CT in chronic pancreatitis.
In this retrospective study, 59 patients with chronic pancreatitis who had undergone initial and follow-up CT between January 2002 and September 2010 were included. Progression of calcification among CT findings was compared according to the amount of alcohol intake and smoking.
The median duration of followup was 51.6 months (range, 17.1 to 112.7 months). At initial CT findings, there was pancreatic calcification in 35 patients (59.3%). In the follow-up CT, progression of calcification was observed in 37 patients (62.7%). Progression of calcification was more common in smokers according to the multivariate analysis (odds ratio OR, 9.987; p=0.006). The amount of smoking was a significant predictor for progression of calcification in the multivariate analysis (OR, 6.051 in less than 1 pack per day smokers; OR, 36.562 in more than 1 pack per day smokers; p=0.008).
Continued smoking accelerates pancreatic calcification, and the amount of smoking is associated with the progression of calcification in chronic pancreatitis.
Background
The endoscopic submucosal dissection (ESD) technique has been gaining popularity, with continued advances in this treatment approach. However, ESD still is associated with potential ...complications such as severe bleeding and perforation.
Methods
This study was performed to compare the clinical outcomes for macro- and microperforations with ESD procedures and to determine the short-term prognosis after ESD. A macroperforation was defined as a gross perforation that occurred during an ESD procedure, and a microperforation was defined by free air observed on simple radiography after the procedure. Immediate closure of macroperforations was performed using endoclips. From July 2003 through May 2008, 1,711 patients underwent ESD for gastric lesions such as dysplasia, early cancer, and subepithelial lesions.
Results
Among 39 perforation cases (2.3%), macroperforations occurred for 26 patients (67%) and microperforations for 13 patients (33%). All the patients except one who underwent emergency surgery because of severe bleeding and perforation during ESD were managed successfully by intravenous antibiotics and no oral intake. The clinical prognosis and endoscopic characteristics of the patients with macroperforations did not differ from those of the patients with microperforations.
Conclusions
Perforations associated with ESD could be managed safely and successfully by nonsurgical methods. The clinical prognoses for macro- and microperforations were favorable and comparable.
PDF
