Efficacy of Vonoprazan, a Novel Potassium-Competitive Acid Blocker, in Patients with Proton Pump Inhibitor-Refractory Acid Reflux

BACKGROUND/AIM

We evaluated the efficacy of vonoprazan (VPZ), a novel potassium-competitive acid blocker, in patients with proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD), exhibiting continued pathological esophageal acid exposure (EAE).

METHODS

Despite ≥8 weeks of appropriate PPI therapy, patients with -persistent reflux symptoms and pathological EAE times (EAETs ≥4%) were invited to switch to VPZ treatment. After an 8-week-course of once-daily VPZ (20 mg), multichannel intraluminal impedance-pH (MII-pH) monitoring was repeated to compare gastric acid exposure times (GAETs), EAETs, and other reflux parameters relative to the baseline values. Before each MII-pH study, reflux symptom severities were scored using the Gastrointestinal Symptom Rating Scale; erosive esophagitis and fasting plasma gastrin levels were also assessed.

RESULTS

From among the 124 patients undergoing MII-pH monitoring, 13 patients (median age, 69 years; females, 64%) were monitored at baseline (while on PPI therapy) and after VPZ therapy. The median GAET associated with VPZ treatment (23.8%) was less than that for PPI treatment (41.1%; p = 0.01), including both daytime and nighttime measurements. VPZ therapy resulted in better median EAET values (4.5%) than did PPI therapy (10.6%) during the 24-h monitoring period (p = 0.055). EAE normalization was achieved in 46% of VPZ-treated patients and was associated with complete gastric acid suppression (p = 0.005). After switching to VPZ, reflux symptoms (p < 0.01) and erosive esophagitis (p = 0.01) improved.

CONCLUSION

In patients with PPI-refractory GERD, VPZ provides more potent gastric acid suppression, more effective EAE control, enhanced symptom improvement, and better esophagitis healing than PPIs.

Next endoscopic approach for acute lower gastrointestinal bleeding without an identified source on colonoscopy: upper or capsule endoscopy?

Background and study aims  We evaluated the utility of esophagogastroduodenoscopy (EGD) or capsule endoscopy (CE) as the next diagnostic approach after negative colonoscopy (CS) results in acute-onset hematochezia. Patients and methods  We retrospectively analyzed 401 patients emergently hospitalized for acute hematochezia who underwent CS within 48 hours of arriving at two large emergency hospitals and in whom a definitive bleeding source was not identified. The positive endoscopic findings, requirement for additional therapeutic procedures, and 30-day rebleeding rates were compared among three strategies: EGD following CS (CS-EGD), CE following CS (CS-CE), and CS alone. Predictors of positive endoscopic findings in the CS-EGD strategy were determined. Results  The rates of positive endoscopic findings and requirement for additional therapeutic procedures were 22 % and 16 %, respectively, in CS-EGD and 50 % and 28 % in CS-CE. The 30-day rebleeding rate did not significantly decrease in CS-EGD (8 %) or CS-CE (11 %) compared with CS alone (12 %). The rate of additional endoscopic therapies was lower in patients with a colonic diverticulum than in those without (CS-EGD: 3 % vs. 33 %, P  = 0.007; CS-CE: 11 % vs. 44 %, P  = 0.147). A history of syncope, low blood pressure, blood urea nitrogen/creatinine ratio of ≥ 30, and low albumin level significantly predicted EGD findings after negative CS results ( P  < 0.05). Conclusions  When the definitive bleeding source is not identified by colonoscopy in patients with acute hematochezia, adjunctive endoscopy helps to identify the etiology and enables subsequent therapy, especially for patients without a colonic diverticulum. Upper gastrointestinal endoscopy is indicated for severe bleeding; other patients may be candidates for capsule endoscopy.

78 Evaluation of the genomic estimated breeding value of carcass traits in blastocyst-stage embryos derived from Japanese Black cattle

Genomic selection based on a high-throughput microarray for genotyping single nucleotide polymorphism (SNP) is expected to accelerate genetic improvement in cattle. Recently, a genomic evaluation system for carcass traits, such as carcass weight and marbling score, is being established in Japanese Black cattle. To further increase genetic improvement efficiency in this breed, establishing a genomic evaluation system for pre-implantation embryos before embryo transfer (ET) is required. Here, we examined the correlation between genomic estimated breeding value (GEBV) of carcass traits calculated from embryonic (blastocyst) biopsy cells and from a corresponding calf produced by ET (Experiment 1); we also evaluated the pregnancy rate following ET of GEBV-evaluated blastocysts (GEBV blastocysts) preserved by vitrification (Experiment 2). In total, 16 Japanese Black dams and cryopreserved semen from 6 Japanese Black sires were used for producing in vivo blastocysts (Day 7-8). In Experiment 1, four blastocysts (IETS code 1) were divided into biopsy cells (15-20 cells) and biopsied embryos using a micromanipulator equipped with a micro blade. Biopsy cells were processed for DNA extraction and whole-genome amplification. Freshly biopsied embryos were transferred to recipient cows, and DNA was extracted from the blood or ear cells of the resulting 4 calves. Then SNP genotyping was performed using Illumina bovine LD BeadChip (Illumina, San Diego, CA, USA). The GEBV of 6 carcass traits (carcass weight, ribeye area, rib thickness, subcutaneous fat thickness, estimated yield percent, and marbling score) were calculated using phenotypic and genotypic data from 4,311 Japanese Black steers, and these were compared between biopsy cells and the corresponding calf. In Experiment 2, 134 blastocysts (IETS code 1 and 2) in total were biopsied (10-20 cells), and the biopsied embryos were vitrified by the cryotop method. Biopsy cells were processed for SNP genotyping as in Experiment 1, and the samples in which the call rate was more than 85% were used for GEBV calculation. Based on GEBV records, 24 vitrified GEBV blastocysts were warmed, cultured for 3 to 5h, and 22 GEBV blastocysts that survived (re-expanded) post-culture were transferred to recipient cows. Pregnancy in these cows was diagnosed using ultrasonography during Day 55 to 60 of gestation. In Experiment 1, the SNP call rates of the biopsy cells and corresponding calf were 98.5 to 99.3% and 99.7 to 99.8%, respectively. The GEBV of 6 carcass traits from biopsy cells and from the corresponding calf had almost the same values. In Experiment 2, the SNP call rates of the biopsy cells were ranged from 26.1 to 99.3%. The GEBV of 6 carcass traits varied among full-sib embryos. The pregnancy rate following ET of vitrified GEBV blastocysts was 40.9% (9/22). These results suggest the possible application of a genomic evaluation system for carcass traits at the blastocyst stage in Japanese Black cattle. Further large-scale assessment of pregnancy rates following ET of cryopreserved GEBV blastocysts is required for practical application of the evaluation system.

Contrast-enhanced CT for Colonic Diverticular Bleeding before Colonoscopy: A Prospective Multicenter Study

Purpose To demonstrate the usefulness of precolonoscopy intravenous contrast material-enhanced CT for colonic diverticular bleeding (CDB). Materials and Methods A prospective, multicenter, observational study was performed. Patients with acute-onset hematochezia who were admitted to hospital were included, and those without CDB were excluded. CT was performed before colonoscopy. A Mann-Whitney U test, χ² test, and multivariable logistic regression analysis were performed to determine the accuracy of CT before colonoscopy. Results A total of 442 patients (mean age, 71.2 years; 302 male patients; 68.3% men) were included between January 2014 and December 2015, and 202 patients were diagnosed as having CDB. The positive extravasation rate during CT was 50 of 202 (24.7%) among all patients and five of nine (55.6%) among patients who underwent CT within 1 hour of the last hematochezia. At multivariable analysis, the interval from the last hematochezia until CT was a predictor of extravasation (beta coefficient, -.0038 ± 0.0014 [standard deviation]). Extravasation at CT had a sensitivity of 38 of 66 (57.6%; 95% confidence interval: 44.8%, 69.7%) and a specificity of 124 of 136 (91.2%; 95% confidence interval: 85.1%, 95.4%) for the prediction of stigmata of recent hemorrhage of diverticula during colonoscopy. The sensitivity was higher in patients who underwent CT examination within 4 hours of hematochezia, compared with those examined after 4 hours (64.7% [33 of 51] vs 33.3% [five of 15]; P < .01). Conclusion Extravasation findings for CT with intravenous contrast material had high specificity for the prediction of stigmata of recent hemorrhage of diverticula during colonoscopy, regardless of the timing of the CT examination. Although the sensitivity was relatively low, it was higher when the CT examination was performed within 4 hours after the last hematochezia. Therefore, urgent precolonoscopy CT may contribute to decision making regarding whether an urgent colonoscopy should be performed.

New predictive model for acute gastrointestinal bleeding in patients taking oral anticoagulants: A cohort study

BACKGROUND AND AIM

The study developed a predictive model of long-term gastrointestinal (GI) bleeding risk in patients receiving oral anticoagulants and compared it with the HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratios, Elderly, Drugs/alcohol concomitantly) score.

METHODS

The study periodically followed a cohort of 508 patients taking oral anticoagulants (66 direct oral anticoagulants users and 442 warfarin users). Absence of GI bleeding at an initial examination and any subsequent GI bleeding were confirmed endoscopically. The bleeding model was developed by multivariate survival analysis and evaluated by Harrell's c-index.

RESULTS

During a median follow-up of 31.4 months, 42 GI bleeds (8.3%) occurred: 42.8% in the upper GI tract, 50.0% in the lower GI tract, and 7.1% in the middle GI tract. The cumulative 5 and 10-year probability of GI bleeding was 12.6% and 18.5%, respectively. Patients who bled had a significantly higher cumulative incidence of all-cause mortality (hazard ratio 2.9, P < 0.001). Multivariate analysis revealed that absence of proton pump inhibitor therapy, chronic kidney disease, chronic obstructive pulmonary disease, history of peptic ulcer disease, and liver cirrhosis predicted GI bleeding. The c-statistic for the new predictive model using these five factors was 0.65 (P < 0.001), higher than the HAS-BLED score of 0.57 (P = 0.145).

CONCLUSIONS

Gastrointestinal bleeding increased the risk of subsequent mortality during follow-up of anticoagulated patients, highlighting the importance of prevention. The study developed a new scoring model for acute GI bleeding risk based on five factors (no-proton pump inhibitor use, chronic kidney disease, chronic obstructive pulmonary disease, history of peptic ulcer disease, and liver cirrhosis), which was superior to the HAS-BLED score.

Acute Severe Gastrointestinal Tract Bleeding Is Associated With an Increased Risk of Thromboembolism and Death

BACKGROUND & AIMS

We performed a retrospective cohort study of patients with and without gastrointestinal bleeding (GIB) to determine whether GIB increases the risks of thromboembolism and death.

METHODS

We collected data from 522 patients with acute severe GIB and 1044 patients without GIB (control subjects, matched for age, sex, year of diagnosis, history of thromboembolism, and use of antithrombotic drugs) who underwent endoscopy at the National Center for Global Health and Medicine in Japan from January 2009 through December 2014. Hazard ratios of GIB for thromboembolism and mortality risk were estimated, adjusting for confounders. We also compared standardized mortality ratios between the GIB cohort and the age- and sex-matched general population in Japan.

RESULTS

During a mean follow up of 23.7 months, thromboembolism was identified in 11.5% of patients with GIB and 2.4% of control subjects (hazard ratio, 5.3; 95% confidence interval, 3.3-8.5; P < .001). Multivariate analysis revealed GIB as a risk factor for all-thromboembolic events, cerebrovascular events, and cardiovascular events. During a mean follow-up of 24.6 months, 15.9% of patients with GIB and 8.6% of control subjects died (hazard ratio, 2.1; 95% confidence interval, 1.6-2.9; P < .001). Multivariate analysis revealed GIB as a risk factor for all-cause mortality. Compared with the general population, patients with GIB were at increased risk of death (standardized mortality ratio, 12.0).

CONCLUSIONS

In a retrospective analysis of patients undergoing endoscopy in Japan, we identified acute GIB was a significant risk factor for late thromboembolism and death, compared with patients without GIB. GIB also increased risk of death compared with the general population.

Impact of INR monitoring, reversal agent use, heparin bridging, and anticoagulant interruption on rebleeding and thromboembolism in acute gastrointestinal bleeding

Background

Anticoagulant management of acute gastrointestinal bleeding (GIB) during the pre-endoscopic period has not been fully addressed in American, European, or Asian guidelines. This study sought to evaluate the risks of rebleeding and thromboembolism in anticoagulated patients with acute GIB.

Methods

Baseline, endoscopy, and outcome data were reviewed for 314 patients with acute GIB: 157 anticoagulant users and 157 age-, sex-, and important risk-matched non-users. Data were also compared between direct oral anticoagulants (DOACs) and warfarin users.

Results

Between anticoagulant users and non-users, of whom 70% underwent early endoscopy, no endoscopy-related adverse events or significant differences were found in the rate of endoscopic therapy need, transfusion need, rebleeding, or thromboembolism. Rebleeding was associated with shock, comorbidities, low platelet count and albumin level, and low-dose aspirin use but not HAS-BLED score, any endoscopic results, heparin bridge, or international normalized ratio (INR) ≥ 2.5. Risks for thromboembolism were INR ≥ 2.5, difference in onset and pre-endoscopic INR, reversal agent use, and anticoagulant interruption but not CHA2DS2-VASc score, any endoscopic results, or heparin bridge. In patients without reversal agent use, heparin bridge, or anticoagulant interruption, there was only one rebleeding event and no thromboembolic events. Warfarin users had a significantly higher transfusion need than DOACs users.

Conclusion

Endoscopy appears to be safe for anticoagulant users with acute GIB compared with non-users. Patient background factors were associated with rebleeding, whereas anticoagulant management factors (e.g. INR correction, reversal agent use, and drug interruption) were associated with thromboembolism. Early intervention without reversal agent use, heparin bridge, or anticoagulant interruption may be warranted for acute GIB.

Development and Validation of a Risk Scoring System for Severe Acute Lower Gastrointestinal Bleeding

BACKGROUND & AIMS

We aimed to develop and validate a risk scoring system to determine the risk of severe lower gastrointestinal bleeding (LGIB) and predict patient outcomes.

METHODS

We first performed a retrospective analysis of data from 439 patients emergently hospitalized for acute LGIB at the National Center for Global Health and Medicine in Japan, from January 2009 through December 2013. We used data on comorbidities, medication, presenting symptoms, and vital signs, and laboratory test results to develop a scoring system for severe LGIB (defined as continuous and/or recurrent bleeding). We validated the risk score in a prospective study of 161 patients with acute LGIB admitted to the same center from April 2014 through April 2015. We assessed the system's accuracy in predicting patient outcome using area under the receiver operating characteristics curve (AUC) analysis. All patients underwent colonoscopy.

RESULTS

In the first study, 29% of the patients developed severe LGIB. We devised a risk scoring system based on nonsteroidal anti-inflammatory drugs use, no diarrhea, no abdominal tenderness, blood pressure of 100 mm Hg or lower, antiplatelet drugs use, albumin level less than 3.0 g/dL, disease scores of 2 or higher, and syncope (NOBLADS), which all were independent correlates of severe LGIB. Severe LGIB developed in 75.7% of patients with scores of 5 or higher compared with 2% of patients without any of the factors correlated with severe LGIB (P < .001). The NOBLADS score determined the severity of LGIB with an AUC value of 0.77. In the validation (second) study, severe LGIB developed in 35% of patients; the NOBLADS score predicted the severity of LGIB with an AUC value of 0.76. Higher NOBLADS scores were associated with a requirement for blood transfusion, longer hospital stay, and intervention (P < .05 for trend).

CONCLUSIONS

We developed and validated a scoring system for risk of severe LGIB based on 8 factors (NOBLADS score). The system also determined the risk for blood transfusion, longer hospital stay, and intervention. It might be used in decision making regarding intervention and management.

Safety and Effectiveness of Early Colonoscopy in Management of Acute Lower Gastrointestinal Bleeding on the Basis of Propensity Score Matching Analysis

BACKGROUND & AIMS

We investigated the safety and effectiveness of early colonoscopy (performed within 24 hours of hospital admission) for acute lower gastrointestinal bleeding (LGIB) vs elective colonoscopy (performed 24 hours after admission).

METHODS

We conducted a retrospective study by using a database of endoscopies performed at the National Center for Global Health and Medicine in Tokyo, Japan from January 2009 through December 2014. We analyzed data from 538 patients emergently hospitalized for acute LGIB. We used propensity score matching to adjust for differences between patients who underwent early colonoscopy vs elective colonoscopy. Outcomes included rates of adverse events during bowel preparation and colonoscopy procedures, stigmata of recent hemorrhage, endoscopic therapy, blood transfusion requirement, 30-day rebleeding and mortality, and length of hospital stay.

RESULTS

We selected 163 pairs of patients for analysis on the basis of propensity matching. We observed no significant differences between the early and elective colonoscopy groups in bowel preparation-related rates of adverse events (1.8% vs 1.2%, P = .652), colonoscopy-related rates of adverse events (none in either group), blood transfusion requirement (27.6% vs 27.6%, P = 1.000), or mortality (1.2% vs 0, P = .156). The early colonoscopy group had higher rates than the elective group for stigmata of recent hemorrhage (26.4% vs 9.2%, P < .001) and endoscopic therapy (25.8% vs 8.6%, P < .001), including clipping (17.8% vs 4.9%, P < .001), band ligation (6.1% vs 1.8%, P = .048), and rebleeding (13.5% vs 7.4%, P = .070). Patients in the early colonoscopy group stayed in the hospital for a shorter mean time (10 days) than patients in the elective colonoscopy group (13 days) (P < .001).

CONCLUSIONS

Early colonoscopy for patients with acute LGIB is safe, allows for endoscopic therapy because it identifies the bleeding source, and reduces hospital stay. However, compared with elective colonoscopy, early colonoscopy does not reduce mortality and may increase the risk for rebleeding.

141 EXPRESSION STATUS OF AQUAPORINS 3, 7, AND 9 IN BOVINE PRE-IMPLANTATION EMBRYOS

The aquaporins (AQP) are a family of small integral membrane proteins that work as channels for rapid water transport. In mouse embryos, AQP3, AQP7, and AQP9 were found to play important roles in the pre-implantation development or adaptive cellular response to osmotic stress. In addition, because AQP3, AQP7, and AQP9 permeate not only water but also cryoprotectant, such as glycerol, these AQP thought to be involved in the process of cryopreservation. However, little information is available for AQP in bovine embryos. The understanding of the mechanisms mediated by AQP that embryos utilise to survive during culture and the process of cryopreservation will contribute to development of in vitro culture systems and cryopreservation procedures for bovine embryos. The aims of present study were to clarify the expression status of AQP3, AQP7, and AQP9 in bovine pre-implantation embryos, and to evaluate the expression level of AQP3 in in vivo-derived (IVD) and IVF bovine embryos. For production of IVF embryos, cumulus-oocyte complexes (COC) were aspirated from ovaries collected at a local slaughterhouse. The COC were in vitro matured, fertilized, and then cultured for 7 days. The IVD embryos at early blastocyst (EB) and blastocyst (BC) stage were obtained from donor cows treated with superovulation and AI. In experiment 1, in order to clarify the expression of AQP3, AQP7, and AQP9 mRNA in bovine pre-implantation embryos, total RNA was extracted from pools of 30 IVM oocytes, pools of 15 IVF embryos at 2- to 4-cell, 8- to 16-cell, compaction morula (CM), EB, BC, and expanded blastocyst (ExBC) stage, and RT-PCR was performed followed by agarose gel electrophoresis. In experiment 2, in order to clarify the expression status of AQP3, AQP7, and AQP9 during bovine pre-implantation development after zygotic gene activation, total RNA was extracted from pools of 15 IVF embryos at 8- to 16-cell, CM, EB, BC and ExBC stage (n = 5), and relative quantifications of AQP mRNA were performed using real-time RT-PCR. Data were analysed by Scheffé’s method. In experiment 3, AQP3 transcript levels in single IVD and IVF embryos at EB and BC stages (n = 10) was evaluated by real-time RT-PCR. Data were analysed by Mann-Whitney’s U test. In experiment 1, AQP3 and AQP7 transcripts were detected in IVM oocytes and all stages of embryos. AQP9 mRNA was detected in IVM oocytes and in 2- to 4-cell, 8- to 16 cell, CM, and EB stage embryos, but was not detected in BC and ExBC stage embryos. In experiment 2, AQP3 and AQP7 transcript levels were significantly increased from 8- to 16-cell to CM and EB stage, and significantly decreased from EB to BC and ExBC stages (P < 0.05). AQP9 transcript level was significantly decreased from 8- to 16-cell to CM and EB stage (P < 0.05). In experiment 3, AQP3 transcript level in IVF embryos was significantly lower than that in in vivo embryos at the BC stage (P < 0.05). Our results indicate that AQP3 and AQP7 may have specific roles at morula and EB stage in bovine embryos. In addition, AQP3 expression is influenced by developmental condition of bovine embryos.

Role of urgent contrast-enhanced multidetector computed tomography for acute lower gastrointestinal bleeding in patients undergoing early colonoscopy

BACKGROUND

The clinical significance of performing computed tomography (CT) for acute lower gastrointestinal bleeding (LGIB) remains unknown. This study aimed to evaluate the role of urgent CT in acute LGIB settings.

METHODS

The cohort comprised 223 patients emergently hospitalized for LGIB who underwent early colonoscopy within 24 h of arriving at the hospital, including 126 who underwent CT within 3 h of arrival. We compared the bleeding source rate between two strategies: early colonoscopy following urgent CT or early colonoscopy alone.

RESULTS

No significant differences in age, sex, comorbidities, vital signs, or laboratory data were observed between the strategies. The detection rate was higher with colonoscopy following CT for vascular lesions (35.7 vs. 20.6%, p = 0.01), leading to more endoscopic therapies (34.9 vs. 13.4%, p < 0.01). Of the 126 who underwent colonoscopy following CT, 26 (20.6%) had extravasation and 34 (27.0%) had nonvascular findings. The sensitivity and specificity of CT extravasation and nonvascular findings for predicting vascular lesions and inflammation or tumors were 37.8 and 88.9 and 81.3 and 80.9%, respectively. A high κ agreement (0.83, p < 0.01) for active bleeding locations was found between CT and subsequent colonoscopy. There were no cases of contrast-induced nephropathy after 1 week of CT.

CONCLUSIONS

Urgent CT before colonoscopy had about 15% additional value for detecting vascular lesion compared to colonoscopy alone and thus enabled subsequent endoscopic therapies. Contrast-enhanced CT in acute LGIB settings was safe and correctly identified the presence and location of active bleeding, as well as severe inflammation or tumor stenosis, facilitating decision making.

Effect of proton-pump inhibitors on the risk of lower gastrointestinal bleeding associated with NSAIDs, aspirin, clopidogrel, and warfarin

BACKGROUND

We investigated the effects of proton-pump inhibitors (PPIs) on lower gastrointestinal bleeding (LGIB) and of their interactions with nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin, clopidogrel, and warfarin on LGIB risk.

METHODS

We prospectively studied 355 patients emergently hospitalized for LGIB and 8,221 nonbleeding patients. All patients underwent colonoscopy. Smoking, alcohol drinking, drug exposure, and the Charlson comorbidity index score were assessed before colonoscopy. Adjusted odds ratios (AOR) of LGIB were estimated.

RESULTS

LGIB was significantly associated with older age, higher comorbidity index, and NSAID, aspirin, clopidogrel, or warfarin use. PPI use was significantly associated with older age, male sex, being a current alcohol drinker, higher comorbidity index, and NSAID, aspirin, clopidogrel, warfarin, acetaminophen, or corticosteroid use. Multivariate analysis adjusted by the confounding factors revealed LGIB was not significantly associated with PPI use (AOR 0.87; 95 % confidence interval 0.68-1.13; p = 0.311), or specifically with omeprazole (AOR 1.18; p = 0.408), esomeprazole (AOR 0.76; p = 0.432), lansoprazole (AOR 0.93; p = 0.669), or rabeprazole (AOR 0.63; p = 0.140). In the interaction model, no significant interactions were observed between PPIs and NSAIDs (AOR 1.40; p = 0.293), aspirin (AOR 1.09; p = 0.767), clopidogrel (AOR 0.99, p = 0.985), or warfarin (AOR 1.52; p = 0.398).

CONCLUSIONS

This large case-control study demonstrated that PPI use did not lead to an increased risk of LGIB, regardless of the type of PPI used. Further, LGIB risk was not affected by PPI use, irrespective of concomitant therapy with NSAIDs, low-dose aspirin, clopidogrel, or warfarin.

Risk factors for adverse in-hospital outcomes in acute colonic diverticular hemorrhage

AIM: To investigate the factors associated with transfusion, further bleeding, and prolonged length of stay.

METHODS: In total, 153 patients emergently hospitalized for diverticular bleeding who were examined by colonoscopy were prospectively enrolled. Patients in whom the bleeding source was identified received endoscopic treatment such as clipping or endoscopic ligation. After spontaneous cessation of bleeding with conservative treatment or hemostasis with endoscopic treatment, all patients were started on a liquid food diet and gradually progressed to a solid diet over 3 d, and were discharged. At enrollment, we assessed smoking, alcohol, medications [non-steroidal anti-inflammatory drugs (NSAIDs)], low-dose aspirin, and other antiplatelets, warfarin, acetaminophen, and oral corticosteroids), and co-morbidities [hypertension, diabetes mellitus, dyslipidemia, cerebro-cardiovascular disease, chronic liver disease, and chronic kidney disease (CKD)]. The in-hospital outcomes were need for transfusion, further bleeding after spontaneous cessation of hemorrhage, and length of hospital stay. The odds ratio (OR) for transfusion need, further bleeding, and prolonged length of stay were estimated by logistic regression analysis.

RESULTS: No patients required angiographic embolization or surgery. Stigmata of bleeding occurred in 18% of patients (27/153) and was treated by endoscopic procedures. During hospitalization, 40 patients (26%) received a median of 6 units of packed red blood cells. Multivariate analysis revealed that female sex (OR = 2.5, P = 0.02), warfarin use (OR = 9.3, P < 0.01), and CKD (OR = 5.9, P < 0.01) were independent risk factors for transfusion need. During hospitalization, 6 patients (3.9%) experienced further bleeding, and NSAID use (OR = 5.9, P = 0.04) and stigmata of bleeding (OR = 11, P < 0.01) were significant risk factors. Median length of hospital stay was 8 d. Multivariate analysis revealed that age > 70 years (OR = 2.1, P = 0.04) and NSAID use (OR = 2.7, P = 0.03) were independent risk factors for prolonged hospitalization (≥ 8 d).

CONCLUSION: In colonic diverticular bleeding, female sex, warfarin, and CKD increased the risk of transfusion requirement, while advanced age and NSAID increased the risk of prolonged hospitalization.

Adverse Events during Bowel Preparation and Colonoscopy in Patients with Acute Lower Gastrointestinal Bleeding Compared with Elective Non-Gastrointestinal Bleeding

BACKGROUND

There are limited data on the safety of colonoscopy in patients with lower gastrointestinal bleeding (LGIB). We examined the various adverse events associated with colonoscopy in acute LGIB compared with non-GIB patients.

METHODS

Emergency hospitalized LGIB patients (n = 161) and age- and gender-matched non-GIB controls (n = 161) were selected. Primary outcomes were any adverse events during preparation and colonoscopy procedure. Secondary outcomes were five bowel preparation-related adverse events--hypotension, systolic blood pressure <100 mmHg, volume overload, vomiting, aspiration pneumonia and loss of consciousness--and four colonoscopy-related adverse events--including hypotension, perforation, cerebrocardiovascular events and sepsis.

RESULTS

During bowel preparation, 16 (9%) LGIB patients experienced an adverse event. None of the LGIB patients experienced volume overload, aspiration pneumonia or loss of consciousness; however, 12 (7%) had hypotension and 4 (2%) vomited. There were no significant differences in the five bowel preparation-related adverse events between LGIB and non-GIB patients. During colonoscopy, 25 (15%) LGIB patients experienced an adverse event. None LGIB patient had perforation or sepsis; however, 23 (14%) had hypotension and 2 (1%) experienced a cerebrocardiovascular event. There was no significant difference in the four colonoscopy-related adverse events between LGIB and non-GIB patients. In addition, no significant difference in any of the nine adverse events was found among subgroups: patients aged ≥65 years, those with comorbidities, and those with antithrombotic drug use.

CONCLUSIONS

Adverse events in bowel preparation and colonoscopy among acute LGIB patients were low. No significant difference was found in adverse events between LGIB and non-GIB patients. These adverse events were also low in elderly LGIB patients, as well as in those with co-morbidities and antithrombotic drug use, suggesting that colonoscopy performed during acute LGIB did not increase adverse events.

84 GENE EXPRESSION DURING BLASTOCYST-TO-ELONGATED STAGE IN BOVINE EMBRYOS DERIVED FROM SOMATIC CELL NUCLEAR TRANSFER

Epigenetic modification is an important factor in the development of embryos and the production of normal offspring derived from somatic cell nuclear transfer (NTSC). Several investigators have reported aberrant gene transcription in bovine NTSC embryos at the blastocyst (BC) stage. The objectives of this study were to evaluate the gene expression in NTSC embryos, which had developed to the elongated (EL) stage, and clarify differential levels of gene transcription in the embryo disc (ED) and trophectoderm (TE) of EL embryos. Five specific mRNAs [octamer-binding transcription factor (OCT-4), interferon-τ (IFN-τ), fibroblast growth factor receptor 2 (FGF-R2), and fibroblast growth factors 2 and 4 (FGF-2 and FGF-4)] were selected. Bovine BC embryos were obtained from NTSC using calf fibroblast cells or the uterus of donor cows after AI (Vivo). Some BC embryos were transferred to recipient cows at Day 7 (Day 0 = estrus), and then EL embryos were collected by uterine flushing at Day 16. Total RNA in single BC, ED, and TE were reverse-transcribed for PCR. Quantification of mRNA abundance was performed by real-time PCR. The expression of each mRNA was normalized to the abundance of GAPDH. A total of 15 (BC) and 7 (ED and TE) samples were used in each group to analyze the gene expression. Data on mRNA expression levels were analyzed using a Kruskal–Wallis test followed by multiple pair-wise comparisons using the Scheffe method. Most embryos (87–100%) gave positive signals of OCT-4, IFN-τ, and FGF-R2, regardless of the origin and stage of the embryos. Transcript signals of FGF-4 in BC embryos derived from Vivo (100%) and NTSC (70%) were detected with higher frequencies. At the EL stage, the FGF-4 signal was detected in only ED. The transcript of FGF-2 was detected with lower frequencies (20–27%) in BC embryos, but was consistently (71–86%) detected in ED of both groups. The relative abundance of OCT-4 expression in NTSC was higher (P &lt; 0.05) than in Vivo embryos at the BC stage. In contrast, the transcript of FGF-4 at the BC stage was lower (P &lt; 0.01) in NTSC than in Vivo embryos. Transcript levels of IFN-�, FGF-R2, and FGF-2 were not significantly different in both groups at the BC stage. The amount of OCT-4, FGF-4, and FGF-2 transcripts in ED were significantly (P &lt; 0.05) higher than in TE. Transcript levels of these genes did not differ between NTSC and Vivo embryos. FGF-R2 levels were not significantly different in origins and tissue of EL embryos. In Vivo embryos, the IFN-τ level of TE was significantly (P &lt; 0.05) higher than in ED. However, the difference in the IFN-τ transcription was not observed between ED and TE in NTSC embryos. The results of an analysis of mRNA transcripts at 2 different stages of development demonstrate that bovine NTSC embryos at the BC stage show deviations in expression patterns with respect to several genes which have important roles in cell differentiation, implantation, and embryo development, but these expressions, except for IFN-τ, were modified to a normal level according to the embryo development and differentiation.

42 PREPARTUM HORMONAL CHANGES IN RECIPIENT COWS FOR SOMATIC CELL CLONED FETUSES

Placental estrogens are associated with fetal growth and development, and play important roles in the initiation of the parturition process. In the delivery of somatic cell-cloned (SC) calves, recipient cows show a weak and unclear symptom of parturition, although large offspring syndrome (LOS) frequently occurs. The mortality of calves by dystocia decreases the efficiency of SC cattle production. In this study, we examined peripheral estrone (E1), estradiol-17� (E2), estrone sulfate (E1S), and progesterone (P4) levels during preparturition in recipients of SC and in vivo calves. Recipients were administered 20 mg dexamethasone (DEX) at Days 276-288 of pregnancy, followed by 0.75-1 mg cloprostenol (PG) and 20 mg estriol 24 h later. Calves (Japanese black cattle) were delivered 2 or 3 days after the DEX administration. SC calves were delivered by cesarean section (C-sec) when LOS was suspected by rectal palpation. Blood samples of recipients [vaginal delivery of SC (Vag): n = 13; C-sec of SC: n = 8; vaginal delivery of in vivo calves (Control): n = 4] were taken at Days 257 and 271 of pregnancy, and just before DEX (-2P), PG (-1P), and parturition (0P). Blood samples of calves were taken just after delivery to analyze cortisol level. The statistical significance was analyzed by the Steel-Dwass test. Birth weight of calves was the heaviest (P &lt; 0.05) in C-sec (62 � 3 kg; n = 12); Vag calves (43 � 2 kg; n = 19) were also heavier (P &lt; 0.05) than Control calves (29 � 2 kg; n = 9). E1 levels in Control calves remained low (&lt;629 � 111 pg mL-1) until Day 271 and then increased progressively (&gt;2156 � 599 pg mL-1). E1 levels tended to be lower in Vag (&lt;1968 � 299 pg mL-1) and C-sec (&lt;1268 � 385 pg mL-1) calves at -2P, -1P, and 0P; E1 levels in C-sec calves were significantly lower (P &lt; 0.05) than in Control calves at -2P (512 � 85 pg/mL-1) and -1P (725 � 91 pg mL-1). The E2 level in Control calves increased and reached a plateau at -2P. Vag and C-sec calves showed lower E2 levels, except that the Vag level at 0P was similar to that in Control calves. The E2 level of C-sec calves (61.8 � 25.3 pg mL-1) at 0P was significantly lower (P &lt; 0.05) than that of Control calves (247.5 � 102.8 pg mL-1). E1S levels in Vag and C-sec calves increased progressively from -2P to 0P, whereas the E1S level in Control calves increased at 0P. The E1S level in Vag calves (41.1 � 4.1 ng mL-1) was significantly higher (P &lt; 0.05) than in Control calves (19.4 � 5.1 ng mL-1) at -1P. P4 levels decreased from -2P in Vag and Control calves, and from -1P in C-sec calves. The cortisol level in C-sec calves (60.1 � 19.1 ng mL-1) tended to be low compared with that in Vag (104.4 � 23.1 ng mL-1) and Control (93.4 � 15.0 ng mL-1) calves. This study revealed fetoplacental dysfunction of estrogen synthesis in the SC fetus during preparturition. Elevated E1S levels in recipients of the SC fetus, which correlated with high birth weight and agreed with previous reports for normal or plural pregnancy, might cause the reduction of E1 level. The comparable level of cortisol in Vag and Control calves indicated that SC calves had normal adrenal cortex function. Further analysis on placental estrogen synthesis and cortisol secretion in the SC fetus is necessary to clarify the cause of the prolonged gestation.

167 EXPRESSION OF INTERFERON τ IN BOVINE EMBRYOS DERIVED FROM PARTHENOGENETIC ACTIVATION

Parthenogenetic activation (PA) is a useful technique for reproductive technologies such as somatic cell nuclear transfer. Furthermore, there is a possibility of embryonic stem cell establishment deriving from PA embryos (Cibelli et al. 2002 Science 295, 819). Understanding of the ability of development and differentiation in PA embryos is important for the application. This study was designed to assess the gene expression of octamer-binding transcription factor (OCT-4) and interferon τ (IFNτ) in bovine PA embryos at the blastocyst (BC) and elongated (EL) stages, and the protein secretion of IFNτ at the EL stage. PA embryos were produced from oocytes matured in vitro (24 h), activated with Ca-ionophore (5 min) and electric pulse, and then treated with cytochalasin B and cycloheximide (5 h). In vivo-produced (Vivo) embryos were obtained non-surgically at Day 8 (Day 0 = estrus) from superovulated donor cows. PA or Vivo embryos were transferred to recipient cows (PA: 10 embryos/cow; Vivo: 1 embryo/cow) at Day 8, and then recovered non-surgically with uterine flushings at Day 16. Total RNA in single BC and EL embryos were reverse transcribed for PCR. Quantification of mRNA abundance was performed by real-time PCR. The expression of each mRNA was normalized to the abundance of GAPDH. IFNτ secretion of uterine flushings was estimated by RIA (Takahashi et al. 2005 Theriogenology 63, 1050–1060). The cleavage and blastocyst developmental rates of PA oocytes were 65.8 and 29.7%, respectively. Most embryos had positive signals of OCT-4 and IFNτ regardless of the origin and stage of embryos. The relative abundance (mean � SEM) of OCT-4 expression in PA and Vivo embryos dropped to its lowest level (1.78 � 0.32 and 1.14 � 0.45, respectively) at the EL stage, and it was significantly lower than that at the BC stage (1018.87 � 148.69 and 696.29 � 151.80, respectively; P &lt; 0.05). The transcript level of OCT-4 was not significantly different between PA and Vivo embryos at both stages. Although the transcript level of IFNτ in PA and Vivo embryos increased significantly at the EL stage (0.36 � 0.06 and 7.68 � 2.01, respectively) from the BC stage (0.03 � 0.01 and 0.01 � 0.004, respectively; P &lt; 0.05), that in PA embryos was significantly lower than that in Vivo embryos at the EL stage (P &lt; 0.01). The total amount (mean � SEM) of IFNτ in uterine flushings from cows with transferred PA embryos was 3.38 � 0.35 �g (the number of embryos in each uterine flushing was unknown), and it was low compared with that from cows with Vivo embryos (13.40 � 3.03 �g). Our results indicate that bovine PA embryos have the ability to secrete IFNτ in the uteri of recipient cows at the EL stage, and there is a similar expression pattern of OCT-4 for Vivo embryos.

170 EXPRESSION PROFILE AND PROTEIN SECRETION OF BOVINE INTERFERON τ ON DAYS 12 TO 28 IN EARLY PREGNANCY

Bovine interferon (bIFN) τ has been implicated as a mediator of maternal recognition of pregnancy in cattle. Ovine (o) and bIFNτ expression show temporal patterns until implantation begins (Farin et al. 1990 Biol. Reprod. 43, 210–218); therefore, the expression peaks of bIFNτ are not well understood. This study aimed to investigate the expression profile of mRNA and protein secretion of bIFNτ in conceptuses obtained from cows on Days 12 to 28 in early pregnancy. Induction of superovulation and recipient synchronization were achieved by previously reported methods (Hirayama et al. 2004 Theriogenology 62, 887–896). Embryos were recovered non-surgically on Day 8 (Day 0 = estrus). Subsequently, recovered embryos were singly transferred to recipients immediately upon evaluation. Bovine conceptuses and uterine flushings were collected non-surgically from embryo-transferred cows on Days 12 (n = 2), 14 (n = 6), 16 (n = 5), 18 (n = 4), and 20 (n = 5) with MEM. On Days 22 (n = 3), 24 (n = 5), and 28 (n = 2), bovine conceptuses were recovered within 30 min after slaughter by flushing the uterus with PBS supplemented with 0.1% BSA. Uterine flushings were also collected from 6 cows in the control group on Day 16 of the estrous cycle. Conceptuses for collection of RNA were processed individually and stored at -80�C until analysis. The flushing was centrifuged at 1800g and 4�C for 30 min to remove cellular debris, and stored at -30�C for subsequent measurement of bIFNτ. Total RNA in conceptuses were reverse transcribed for PCR. Quantification of mRNA abundance was performed by real-time PCR. The expression of each mRNA concentration was normalized to the abundance of GAPDH. BIFNτ contents of the uterine flushings were measured by RIA (Takahashi et al. 2005 Theriogenology 63, 1050–1060). Intra-assay and inter-assay CVs were 11.0 and 8.5%, respectively. Transcripts of bIFNτ were detected in all samples from Days 12 to 28; the expression of mRNA increased remarkably from Day 16 (mean � SEM, 2.15 � 0.66) to Day 18 (9.62 � 4.09), and then declined on Day 20 (3.42 � 0.86). Protein detected on Day 16 was 13.3 � 3.02 �g. An increase of bIFNτ secretion was observed between Day 18 (39.8 � 20.62 �g) and Day 20 (71.9 � 17.36 �g); thereafter it decreased on Day 22 (27.2 � 2.83 �g). BIFNτ displayed a pattern of expression similar to that of oIFNτ, with mRNA expression peaking around Day 18 (ovine, Days 12/13) and protein secretion on Day 20 (ovine, Days 15/16), thereby reflecting the comparatively later time frame of maternal recognition of pregnancy in cattle. These results indicate that the expression and secretion profiles of bIFNτ show temporal and spatial patterns in early pregnancy.

204 RELATIONSHIP BETWEEN RESPIRATORY ACTIVITY AND THE PREGNANCY RATE OF BISECTED BOVINE EMBRYOS IN VIVO

Oxygen consumption is an important indicator of the metabolic activity of living cells, which may provide valuable information for evaluating embryo quality. We have found that the bovine embryos with high oxygen consumption possess stronger potential for further development. However, the relationship between respiratory activity and the pregnancy rate of embryos is still unclear. In this study, we investigated the respiration rates of bisected bovine embryos and the pregnancy rates of demi-embryos after embryo transfer. Compact morula-stage embryos were bisected evenly by micro glass needle. One hundred bisected embryos were incubated for 24 h in embryo culture medium (IVD101; Research Institute for the Functional Peptides, Yamagata, Japan) at 39�C under 5% CO2, 5% O2, 90% N2. After the incubation, demi-embryos were classified into 2 groups: blastocoel-formed (BC) and blastocoel-not-formed (CM) embryos. Oxygen consumption rates of demi-embryos were measured by scanning electrochemical microscopy (SECM; Hokuto Denko Corporation, Tokyo, Japan). Within 3 h after the measurement, 80 demi-embryos were transferred into recipient cows (one demi-embryo/one recipient) at 7–8 days after estrus. Recipient cows were diagnosed for pregnancy by ultrasonography approximately 40 days after estrus. Statistical difference was analyzed by Tukey's post-hoc test and chi-square test. A total of 27 recipient cows became pregnant; the pregnancy rates for cows with CM and BC demi-embryos were 40.6% (13/32) and 29.2% (14/48), respectively. Mean oxygen consumption rates (� 10-14 mol s-1) in pregnant and non-pregnant cows were 0.47 and 0.39 for CM demi-embryos and 0.63 and 0.52 for BC demi-embryos, respectively. Retrospective analysis showed that the respiratory activity of demi-embryos in the pregnant group was higher than those in the non-pregnant group. In particular, the pregnancy rates for demi-embryos with respiratory activity higher than 0.35 in CM and 0.40 in BC groups were 52.0% (13/25) and 35.9% (14/39), respectively. On the other hand, cows with demi-embryos having an oxygen consumption rate under 0.35 in CM (n = 7) and 0.40 in BC (n = 9) groups did not become pregnant. These results demonstrated that bovine demi-embryos with higher respiratory activity showed a high pregnancy rate after embryo transfer. It is generally known that the pregnancy rate after the transfer of bisected embryos is lower than that of whole embryos. The measurement of oxygen consumption by SECM procedures is a useful tool to assess the quality of pre-implantation embryos and may contribute to the improvement of the success rate for bisected embryo transfer.

Mechanism of protection by zinc against mercuric chloride toxicity in rats: effects of zinc and mercury on glutathionine metabolism

To investigate the mechanism by which zinc suppresses mercury toxicity, the effects of zinc and mercury on glutathione (GSH) metabolism in the rat kidney were studied. When the time course of GSH level in the rat kidney was examined at 2, 6, and 12 h after treatment of rats with both metals, an increase of GSH was found and was apparently related to the activation of some GSH-associated enzymes. In the kidney of rats treated with both metals, the response of the protective function involving GSH and GSH-associated enzymes depended on the magnitude of mercury toxicity but appeared to be independent of the zinc dosage. The administration of diethyl maleate (DEM), which depletes GSH, increased lipid peroxidation and mercury toxicity concomitantly with a decrease of GSH level in the kidney of rats treated with zinc and mercury. In conclusion, the data suggest that an increased GSH level in the kidney resulting from the activation of GSH-associated enzymes plays a role in the protective effect of zinc against mercury toxicity.