Comparison of metronidazole versus clarithromycin in first-line vonoprazan-based triple therapy for Helicobacter pylori: A multicenter randomized trial in Japan

Background and Aim

To date, no randomized trials have compared the efficacy of 7-day vonoprazan, amoxicillin, and metronidazole triple therapy (VAM) versus 7-day vonoprazan, amoxicillin, and clarithromycin triple therapy (VAC) as a first-line treatment for Helicobacter pylori eradication. This study was performed to compare the efficacy of VAM and VAC as first-line treatments.

Methods

This prospective multicenter randomized trial was performed in Japan and involved 124 H. pylori-positive patients without a history of eradication. Patients without antibiotic resistance testing of H. pylori were eligible. The patients were randomized to receive either VAC (vonoprazan 20 mg + amoxicillin 750 mg + clarithromycin 200 or 400 mg twice a day) or VAM (vonoprazan 20 mg + amoxicillin 750 mg + metronidazole 250 mg twice a day) for 7 days, with stratification by age and sex. Eradication success was evaluated using the 13C-urea breath test. We evaluated safety using patient questionnaires (UMIN000025773).

Results

The intention-to-treat and per-protocol eradication rates of VAM were 91.3% (95% confidence interval [CI], 82.0-96.7%) and 92.6% (95% CI, 83.7-97.6%), respectively, and those of VAC were 89.1% (95% CI, 77.8-95.9%) and 96.1% (95% CI, 86.5-99.5%), respectively. No significant difference was observed between VAM and VAC in either analysis (P = 0.76 and P = 0.70, respectively). Abdominal fullness was more frequent in patients who received VAM than VAC.

Conclusions

These findings suggest that VAM as a first-line treatment in Japan can be categorized as grade B (intention-to-treat cure rate of 90-95%) and have potential as a first-line national insurance -approved regimen.

The usefulness of texture and color enhancement imaging to identify the minor papilla orifice

In clinical cases of pancreas divisum, endoscopic retrograde cholangiopancreatography often necessitates cannulation of the pancreatic duct through the minor papilla. Nevertheless, this procedure can be challenging because of the small size of the minor papilla and the difficulty in visualizing the ductal orifice. A new image-enhanced endoscopy technique called texture and color enhancement imaging (TXI) has been developed, which enhances texture, brightness, and color compared with white-light imaging, resulting in subtle differences in the surface mucosa. Herein, we describe the case of a 73-year-old man with pancreas divisum in whom TXI was useful in identifying the orifice of the minor papilla. He was referred to our hospital with repetitive acute exacerbation of chronic pancreatitis. Since contrast-enhanced computed tomography revealed a pancreatic stone in the main pancreatic duct, endoscopic retrograde cholangoepancreatography was performed as a therapeutic intervention. Despite the initial difficulty in identifying the orifice of the minor papilla on white-light imaging, TXI enhanced its visibility successfully, enabling dorsal pancreatic duct cannulation via the minor papilla. Subsequently, endoscopic pancreatic sphincterotomy was performed and a 6Fr plastic stent was placed. Post-endoscopic therapy, the patient's abdominal pain was relieved. TXI was useful in identifying the minor papilla orifice and led to successful cannulation.

Risk assessment of metachronous gastric cancer after endoscopic submucosal dissection based on endoscopic intestinal metaplasia

Background and Aim

The incidence of metachronous gastric cancer (MGC) after endoscopic treatment for early gastric cancer (EGC) is high, but a method of risk assessment for MGC based on endoscopic findings has not been established. In this study, we focused on endoscopic intestinal metaplasia (IM) and investigated the risk for MGC after endoscopic submucosal dissection (ESD) for EGC.

Methods

This retrospective observational study involved patients who underwent curative ESD for EGC from April 2015 to January 2021. We assessed endoscopic IM using the pretreatment endoscopic examination images. The severity of endoscopic IM was classified into four levels: 0 (none), 1 (mild), 2 (moderate), and 3 (severe). Four different gastric areas were evaluated. We divided the patients into a low-score group and a high-score group, and compared the cumulative incidence of MGC.

Results

In total, 156 patients who met the inclusion criteria were followed up for at least 12 months after ESD, and MGC developed in 14 patients during a mean period oof 41.5 months. The endoscopic IM scores in the lesser curvature of the antrum, lesser curvature of the corpus, and greater curvature of the corpus were higher in patients with MGC than in those without MGC. In the corpus, the 5-year cumulative incidence of MGC was significantly higher in the high-score group than in the low-score group (29.8% vs 10.0%, P = 0.004).

Conclusion

The severity of endoscopic corpus IM was associated with MGC. Thus, patients with severe corpus IM at the time of ESD require careful examination and intensive follow-up.

Prospective Study of Vonoprazan-Based First-Line Triple Therapy with Amoxicillin and Metronidazole for Clarithromycin-Resistant Helicobacter pylori

AIM

This was a prospective, multicenter, single-arm intervention, against historical controls, study of the efficacy of a vonoprazan-based 7-day triple regimen with metronidazole (VPZ-AMPC-MNZ) as a first-line therapy for eradicating clarithromycin-resistant Helicobacter pylori (H. pylori).

METHODS

We enrolled 35 patients positive for clarithromycin-resistant H. pylori, as assessed by culture, without a history of eradication. These 35 patients were prospectively eradicated with VPZ-AMPC-MNZ. As historical controls, we also assessed 98 patients with clarithromycin-resistant H. pylori from our prior prospective studies, who achieved H. pylori eradication with a 7-day triple regimen including clarithromycin (VPZ-AMPC-CAM). A preplanned analysis was performed as a superiority study against the historical controls (VPZ-AMPC-MNZ compared to VPZ-AMPC-CAM). In each regimen, vonoprazan was used at 20 mg bid, amoxicillin at 750 mg bid, metronidazole at 250 mg bid, and clarithromycin at 200 mg or 400 mg bid for 7 days. We assessed the outcome of eradication therapy using a 13C-urea breath test or H. pylori stool antigen test. We evaluated safety using patient questionnaires.

RESULTS

The intention-to-treat (ITT) and per-protocol (PP) eradication rates of VPZ-AMPC-MNZ were both 100% (95% confidence interval (95% CI) 90.0-100%, n = 35). The eradication rates of VPZ-AMPC-CAM were 76.5% (95% CI 66.9-84.5%, n = 98) in the ITT analysis and 77.3% (95% CI 67.7-85.2%, n = 97) in the PP analysis. The eradication rate of VPZ-AMPC-MNZ was significantly higher than that of VPZ-AMPC-CAM in both the ITT (p = 0.00052) and PP (p = 0.00095) analyses.

CONCLUSIONS

The findings suggest that 7-day VPZ-AMPC-MNZ was superior to 7-day VPZ-AMPC-CAM as a first-line regimen for eradicating clarithromycin-resistant H. pylori. We suggest VPZ-AMPC-MNZ as the standard first-line regimen for eradication of clarithromycin-resistant H. pylori in Japan.

Vonoprazan and high-dose amoxicillin dual therapy for Helicobacter pylori first-line eradication: A single-arm, interventional study

Background

To date, no interventional trial has assessed the efficacy and safety of vonoprazan and high-dose (500 mg four times daily, 2000 mg/day) amoxicillin dual therapy in terms of Helicobacter pylori eradication. We explored whether this was an appropriate first-line treatment.

Methods

This prospective, dual-center, single-arm interventional study was performed in Japan. Twenty H. pylori-positive patients lacking any eradication history were treated with vonoprazan 20 mg twice daily and amoxicillin 500 mg four times daily (qid) for 7 days. Eradication was evaluated using a stool H. pylori antigen test. We evaluated safety using patient questionnaires. This study was registered in the jRCT database (jRCT031200128).

Results

The intention-to-treat and per-protocol eradication rates were 90% (95% confidence interval [CI] 68.3-98.8%, n = 20) and 94.4% (95% CI 72.7-99.9%, n = 18) respectively. No significant adverse event was recorded.

Conclusion

Vonoprazan/high-dose amoxicillin dual therapy can be a safe standard first-line therapy. We are now undergoing a randomized controlled trial comparing dual therapy and vonoprazan-based triple therapy.

Is a Potassium-Competitive Acid Blocker Truly Superior to Proton Pump Inhibitors in Terms of Helicobacter pylori Eradication?

Vonoprazan (VPZ), a new potassium-competitive acid blocker, has been approved and used for Helicobacterpylori eradication in Japan. To date, many studies, as well as several systematic reviews and meta-analyses (MAs), have compared VPZ-based 7-day triple therapy with proton pump inhibitor (PPI)-based therapy. An MA of randomized controlled trials (RCTs) comparing first-line VPZ- with PPI-based triple therapy, the latter featuring amoxicillin (AMPC) and clarithromycin (CAM), found that approximately 30% of patients hosted CAM-resistant H. pylori; however, the reliability was poor because of high heterogeneity and a risk of selection bias. VPZ-based triple therapy is superior to PPI-based triple therapy for patients with CAM-resistant H. pylori, but not for those with CAM-susceptible H. pylori. An MA of non-RCTs found that second-line VPZ-based triple therapies were slightly (~2.6%) better than PPI-based triple therapies (with AMPC and metronidazole). However, the reliability of that MA was also low because of selection bias, confounding variables and a risk of publication bias; in addition, it is difficult to generalize the results because of a lack of data on antibiotic resistance. VPZ-based triple therapy (involving AMPC and sitafloxacin) was more effective than PPI-based triple therapy in a third-line setting, but a confirmatory RCT is needed. Non-RCT studies indicated that VPZ-based triple therapy involving CAM and metronidazole may be promising. Any further RCTs must explore the antibiotic-resistance status when evaluating the possible superiority of a potassium-competitive acid blocker.

NAFLD exacerbates cholangitis and promotes cholangiocellular carcinoma in mice

Nonalcoholic fatty liver disease (NAFLD) is an increasingly common condition, affecting up to 25% of the population worldwide. NAFLD has been linked to several conditions, including hepatic inflammation, fibrosis, and hepatocellular carcinoma (HCC), however the role of NAFLD in cholangitis and the development of cholangiocellular carcinoma (CCC) remains poorly understood. This study investigated whether a high-fat diet (HFD) promotes cholangitis and the development of CCC in mice. We used liver-specific E-cadherin gene (CDH1) knockout mice, CDH1^∆Liv , which develop spontaneous inflammation in the portal areas along with periductal onion skin-like fibrosis, similar to that of primary sclerosing cholangitis (PSC). An HFD or normal diet (ND) was fed to CDH1^∆Liv mice for 7 mo. In addition, CDH1^∆Liv mice were crossed with LSL-Kras^G12D mice, fed an HFD, and assessed in terms of liver tumor development. The extent of cholangitis and number of bile ductules significantly increased in mice fed an HFD compared with ND-administered CDH1^∆Liv mice. The numbers of Sox9 and CD44-positive stem cell-like cells were significantly increased in HFD mice. LSL-Kras^G12D /CDH1^∆Liv HFD mice exhibited increased aggressiveness along with the development of numerous HCC and CCC, whereas LSL-Kras^G12D /CDH1^∆Liv ND mice showed several macroscopic tumors with both HCC and CCC components. In conclusion, NAFLD exacerbates cholangitis and promotes the development of both HCC and CCC in mice.

Helicobacter pylori rescue treatment with vonoprazan, metronidazole, and sitafloxacin in the presence of penicillin allergy

Background and Aim

To assess the efficacy and safety of 7‐day Helicobacter pylori rescue treatment consisting of a vonoprazan (VPZ), metronidazole (MNZ), and sitafloxacin (STFX) regimen (VPZ‐MNZ‐STFX therapy) in patients with penicillin allergy.

Methods

This was a registered prospective intervention study. Patients with penicillin allergy who were diagnosed with H. pylori infection and had a history of H. pylori eradication were eligible for inclusion. Seventeen patients were prospectively treated with VPZ 20 mg bid, MNZ 250 mg bid, and STFX 100 mg bid for 7 days. Safety was evaluated using a questionnaire on adverse effects.

Results

The eradication rate of 7‐day VPZ‐MNZ‐SFTX therapy was 88.2% (95% confidence interval: 63.6–98.5%; n = 17) in both intention‐to‐treat and per‐protocol analyses. On the questionnaire, 25% of patients reported experiencing diarrhea, with a score of 2 or 3. All patients undergoing VPZ‐MNZ‐STFX therapy completed 100% of their medication course.

Conclusion

Rescue H. pylori eradication with VPZ‐MNZ‐STFX therapy is effective and well tolerated in patients with penicillin allergy (UMIN000016335, jRCTs031180133).

Loss of Pancreatic E-Cadherin Causes Pancreatitis-Like Changes and Contributes to Carcinogenesis

BACKGROUND & AIMS

E-cadherin (Cdh1) is a key molecule for adherence required for maintenance of structural homeostasis. Loss of E-cadherin leads to poor prognosis and the development of resistance to chemotherapy in pancreatic cancer. Here, we evaluated the physiological and pathologic roles of E-cadherin in the pancreas.

METHODS

We crossbred Ptf1a-Cre mice with Cdh1^f/f mice to examine the physiological roles of E-cadherin in the pancreas. In addition, we crossbred these mice with LSL-Kras^G12D/+ mice (PKC) to investigate the pathologic roles of E-cadherin. We also generated a tamoxifen-inducible system (Ptf1a-Cre^ERT model). Organoids derived from these models using lentiviral transduction were analyzed for immunohistochemical features. Established cell lines from these organoids were analyzed for migratory and invasive activities as well as gene expression by complementary DNA microarray analyses.

RESULTS

None of the Ptf1a-Cre mice crossbred with Cdh1^f/f mice survived for more than 28 days. We observed aberrant epithelial tubules that resembled the structure of acinar-to-ductal metaplasia after postnatal day 6, showing features of pancreatitis. All of the PKC mice died within 10 days. We observed tumorigenicity with increasing stroma-like aggressive tumors. Ptf1a-Cre^ERT models showed that deletion of E-cadherin led to earlier pancreatic intraepithelial neoplasm formation. Cells established from PKC organoids had greater migratory and invasive activities, and these allograft tumors showed a poorly differentiated phenotype. Gene expression analysis indicated that Hdac1 was up-regulated in PKC cell lines and a histone deacetylase 1 inhibitor suppressed PKC cell proliferation.

CONCLUSIONS

Under physiological conditions, E-cadherin is important for maintaining the tissue homeostasis of the pancreas. Under pathologic conditions with mutational Kras activation, E-cadherin plays an important role in tumor formation via the acquisition of tumorigenic activity.

Randomized trial of vonoprazan-based versus proton-pump inhibitor-based third-line triple therapy with sitafloxacin for Helicobacter pylori

BACKGROUND AND AIM

This was a prospective, randomized trial of the efficacy of vonoprazan-based and proton-pump inhibitor-based 7-day triple regimens with amoxicillin and sitafloxacin as a third-line therapy for eradicating Helicobacter pylori after failure of clarithromycin-based and metronidazole-based first-line and second-line therapy.

METHODS

We enrolled 63 patients positive for H. pylori in whom first-line and second-line regimens for eradicating failed. Patients were randomized to the V-AS group (vonoprazan 20-mg bid, amoxicillin 750-mg bid, and sitafloxacin 100-mg bid for 7 days) or PPI-AS group (esomeprazole 20-mg bid, rabeprazole 10-mg bid, or lansoprazole 30-mg bid; amoxicillin 750-mg bid; and sitafloxacin 100-mg bid for 7 days). We assessed the outcome of eradication therapy using the ¹³ C-urea breath test. We evaluated safety using patient questionnaires. This study was registered in the UMIN Clinical Trials Registry (UMIN000016336).

RESULTS

The intention-to-treat and per-protocol eradication rates of V-AS were 75.8% (95% confidence interval [CI]: 57.7-88.9%) and 83.3% (95% CI: 65.3-94.4%), respectively. The respective eradication rates of PPI-AS were 53.3% (95% CI: 34.3-71.7%) and 57.1% (95% CI: 37.2-75.5%). In per-protocol analyses, the eradication rate of the V-AS group was significantly higher than that of the PPI-AS group (P = 0.043); however, no significant differences were observed in intention-to-treat analyses (P = 0.071). Questionnaire scores did not differ significantly between the groups.

CONCLUSIONS

The findings suggest that 7-day triple therapy with vonoprazan, amoxicillin, and sitafloxacin is more effective than proton-pump inhibitor, amoxicillin, and sitafloxacin as a third-line regimen for eradicating H. pylori.

Vonoprazan- vs proton-pump inhibitor-based first-line 7-day triple therapy for clarithromycin-susceptible Helicobacter pylori: A multicenter, prospective, randomized trial

BACKGROUND

The eradication rate of vonoprazan-based first-line triple therapy (combined with clarithromycin and amoxicillin) (V-AC) was reported to be 97.6% in patients with clarithromycin (CAM)-susceptible Helicobacter pylori in a phase III study, whereas our real-world, prospective, multicenter cohort study yielded an eradication rate <90%.

OBJECTIVE

To validate the eradication rate of V-AC using CAM-susceptible testing in a multicenter, prospective, randomized trial.

METHODS

We included 147 treatment-naïve H. pylori-positive patients [41 with CAM-resistant infections and 106 with CAM-susceptible infections]. The CAM-susceptible group patients were randomized to either the V-AC group (vonoprazan 20 mg bid, amoxicillin 750 mg bid, and clarithromycin 200 or 400 mg bid) or PPI-AC group (lansoprazole 30 mg, rabeprazole 10 mg, or esomeprazole 20 mg bid; amoxicillin 750 mg bid; and clarithromycin 200 or 400 mg bid). All CAM-resistant H. pylori were eradicated by V-AC, as measured by the urea breath test around 8 weeks after eradication. Safety was evaluated by patient questionnaires.

RESULTS

The intention-to-treat and per-protocol eradication rates of V-AC in the CAM-susceptible H. pylori-infected patients were 87.3% (95% confidence interval 75.5%-94.7%) and 88.9% (77.4%-95.8%). The respective eradication rates of PPI-AC were 76.5% (62.5%-87.2%) and 86.7% (73.2%-94.9%). No significant difference was observed between the V-AC and PPI-AC regimes in terms of the intention-to-treat (P = .21) or per-protocol (P = .77) analyses. The questionnaire scores did not differ significantly between the groups. Both the intention-to-treat and per-protocol eradication rates of V-AC in the CAM-resistant patients were 82.9% (67.9%-92.8%).

CONCLUSION

The eradication rate of V-AC treatment in the CAM-susceptible H. pylori-infected patients was <90%, as was that by PPI-AC, thus V-AC is not ideal regimen in CAM-susceptible H. pylori. However, the 82.9% eradication rate of V-AC in the CAM-resistant infections may indicate the potential of V-AC with modified dose, dosing interval, and treatment duration. (UMIN000016337).

Helicobacter-induced gastric inflammation alters the properties of gastric tissue stem/progenitor cells

Background

Although Helicobacter-induced gastric inflammation is the major predisposing factor for gastric carcinogenesis, the precise mechanism by which chronic gastritis causes gastric cancer remains unclear. Intestinal and spasmolytic polypeptide-expressing metaplasia (SPEM) is considered as precancerous lesions, changes in epithelial tissue stem/progenitor cells after chronic inflammation has not been clarified yet. In this study, we utilized three-dimensional gastric epithelial cell culture systems that could form organoids, mimicking gastric epithelial layer, and characterized the changes in epithelial cells after chronic Helicobacter felis infection.

Methods

We used three mice model; 1) long-term H. felis infection, 2) H. felis eradication, and 3) MNU chemical carcinogenesis model. We performed cRNA microarray analysis after organoid culture, and analyzed the effects of chronic gastric inflammation on tissue stem cells, by the size of organoid, mRNA expression profile and immunohistochemical analysis.

Results

The number of organoids cultured from gastric epithelial cells was significantly higher in organoids isolated from H. felis-infected mice compared with those from uninfected gastric mucosa. Based on the mRNA expression profile, we found that possible stem cell markers such as Cd44, Dclk1, and genes associated with the intestinal phenotype, such as Villin, were increased in organoids isolated from H. felis-infected mucosa compared with the control. The upregulation of these genes were cancelled after H. felis eradication. In a xenograft model, tumors were generated only from organoids cultured from carcinogen-treated gastric mucosa, not from H. felis infected mucosa or control organoids.

Conclusions

Our results suggested that, as a possible mechanism of gastric carcinogenesis, chronic inflammation induced by H. felis infection increased the number of tissue stem/progenitor cells and the expression of stem cell markers. These findings suggest that chronic inflammation may alter the direction of differentiation toward undifferentiated state and that drawbacks may enable cells to redifferentiate to intestinal metaplasia or neoplasia.

Electronic supplementary material

The online version of this article (10.1186/s12876-017-0706-6) contains supplementary material, which is available to authorized users.

c-Jun N-terminal kinase in pancreatic tumor stroma augments tumor development in mice

Pancreatic ductal adenocarcinoma (PDAC) is a life‐threatening disease and there is an urgent need to develop improved therapeutic approaches. The role of c‐Jun N‐terminal kinase (JNK) in PDAC stroma is not well defined even though dense desmoplastic reactions are characteristic of PDAC histology. We aimed to explore the role of JNK in PDAC stroma in mice. We crossed Ptf1a^Cre/+;Kras^G12D/+ mice with JNK1^−/− mice to generate Ptf1a^Cre/+;Kras^G12D/+;JNK1^−/− (Kras;JNK1^−/−) mice. Tumor weight was significantly lower in Kras;JNK1^−/− mice than in Kras;JNK1^+/− mice, whereas histopathological features were similar. We also transplanted a murine PDAC cell line (mPC) with intact JNK1 s.c. into WT and JNK1^−/− mice. Tumor diameters were significantly smaller in JNK1^−/− mice. Phosphorylated JNK (p‐JNK) was activated in α‐smooth muscle actin (SMA)‐positive cells in tumor stroma, and mPC‐conditioned medium activated p‐JNK in tumor‐associated fibroblasts (TAF) in vitro. Relative expression of Ccl20 was downregulated in stimulated TAF. Ccl20 is an important chemokine that promotes CD8⁺ T‐cell infiltration by recruitment of dendritic cells, and the number of CD8⁺ T cells was decreased in Kras;JNK1^+/− mice compared with Kras;JNK1^−/− mice. These results suggest that the cancer secretome decreases Ccl20 secretion from TAF by activation of JNK, and downregulation of Ccl20 secretion might be correlated with reduction of infiltrating CD8⁺ T cells. Therefore, we concluded that inhibition of activated JNK in pancreatic tumor stroma could be a potential therapeutic target to increase Ccl20 secretion from TAF and induce accumulation of CD8⁺ T cells, which would be expected to enhance antitumor immunity.

The Superiority of Vonoprazan-based First-line Triple Therapy with Clarithromycin: A Prospective Multi-center Cohort Study on Helicobacter pylori Eradication

Objective We evaluated the safety and efficacy of vonoprazan-based amoxicillin and clarithromycin 7-day triple therapy (VAC) in comparison to proton pump inhibitor (PPI)-based (PAC) as a first-line treatment and vonoprazan-based amoxicillin and metronidazole 7-day triple therapy (VAM) in comparison to PPI-based (PAM) as a second-line treatment for the eradication of Helicobacter pylori in Japan. Methods We performed a non-randomized, multi-center, parallel-group study to compare first-line VAC to PAC and second-line VAM to PAM. A pre-planned subgroup analysis on CAM resistance was also performed. Safety was evaluated with an adverse effects questionnaire (AEQ), which was completed by patients during therapy. Results The first-line eradication rates (ER) in the intention-to-treat (ITT) and per protocol (PP) analyses were 84.9% (95% CI: 81.9-87.6%, n=623) and 86.4% (83.5-89.1%, n=612), respectively, for VAC and 78.8% (75.3-82.0%, n=608) and 79.4% (76.0-82.6%, n=603), respectively, for PAC. The ER of VAC was higher than that of PAC in the ITT (p=0.0061) and PP analyses (p=0.0013). The ERs for VAC in patients with CAM-resistant and CAM-susceptible bacteria were 73.2% (59.7-84.2%, n=56) and 88.9% (83.4-93.1%, n=180), respectively. PAC was associated with higher AEQ scores for diarrhea, nausea, headache, and general malaise. In the second-line ITT and PP analyses VAM achieved ERs of 80.5% (74.6-85.6%, n=216) and 82.4% (76.6-87.3%, n=211), respectively, while PAM achieved ERs of 81.5% (74.2-87.4%, n=146) and 82.1% (74.8-87.9%, n=145), respectively. No significant differences were observed in the ITT (p=0.89) or PP (p=1.0) analyses. Conclusion The ER of first-line VAC was higher than that of PAC, but still <90%. No difference was observed between second-line VAM and PAM. Vonoprazan-based triple therapy was safe and well tolerated.

Intestine-specific homeobox (ISX) induces intestinal metaplasia and cell proliferation to contribute to gastric carcinogenesis

BACKGROUND

Helicobacter pylori induces chronic inflammation and intestinal metaplasia (IM) through genetic and epigenetic changes and activation of intracellular signaling pathways that contribute to gastric carcinogenesis. However, the precise mechanism of IM in gastric carcinogenesis has not been fully elucidated. We previously found that intestine-specific homeobox (ISX) mRNA expression increased in organoids cultured from Helicobacter-infected mouse mucosa. In this study, we elucidate the role of ISX in the development of IM and gastric carcinogenesis.

METHODS

ISX expression was assessed in Helicobacter-infected mouse and human gastric mucosa. MKN45 gastric cancer cells were co-cultured with H. pylori to determine whether Helicobacter infection induced ISX expression. We established stable MKN45 transfected cells expressing ISX (Stable-ISX MKN45) and performed a spheroid colony formation assay and a xenograft model. We performed ISX immunohistochemistry in cancer and adjacent gastric tissues.

RESULTS

ISX expression was increased in mouse and human gastric mucosa infected with Helicobacter. The presence of IM and H. pylori infection in human stomach was correlated with ISX expression. H. pylori induced ISX mRNA and protein expression. CDX1/2, cyclinD1, and MUC2 were upregulated in Stable-ISX MKN45, whereas MUC5AC was downregulated. Stable-ISX MKN45 cells formed more spheroid colonies, and had high tumorigenic ability. ISX expression in gastric cancer and adjacent mucosa were correlated.

CONCLUSIONS

ISX expression induced by H. pylori infection may lead to IM and hyperproliferation of gastric mucosa through CDX1/2 and cyclinD1 expression, contributing to gastric carcinogenesis.

Case of a tumor comprising gastric cancer and duodenal neuroendocrine tumor

The present report describes a rare case of a tumor composed of early gastric cancer and a duodenal neuroendocrine tumor (NET). A 78-year-old woman underwent esophagogastroduodenoscopy at a local institution for screening of the upper gastrointestinal tract which revealed a protruded tumor through the pyloric ring from the pyloric antrum. The tumor was too large to treat at the facility; consequently, she was referred to our hospital for further management. Esophagogastroduodenoscopy with tumor biopsy of the lesion revealed the diagnosis of early gastric cancer. Endoscopic submucosal dissection was performed with sufficient free margins in both vertical and horizontal directions. Histopathological findings showed NET confined to the submucosal layer and covered by well-differentiated adenocarcinoma. Immunohistochemical stainings showed that the two lesions existed continuously. While the possibility of a collision cancer was considered, it was suggested that the two lesions existed continuously. Finally, the tumor was diagnosed as gastric cancer composed of duodenal NET G1, with a lymphatic invasion of NET component.

Diagnosis of pancreatic lesions collected by endoscopic ultrasound-guided fine-needle aspiration using next-generation sequencing

Endoscopic ultrasound-guided fine-needle aspiration (EUF-FNA) has improved the diagnosis of pancreatic lesions. Next-generation sequencing (NGS) facilitates the production of millions of sequences concurrently. Therefore, in the current study, to improve the detectability of oncogenic mutations in pancreatic lesions, an NGS system was used to diagnose EUS-FNA samples. A total of 38 patients with clinically diagnosed EUS-FNA specimens were analyzed; 27 patients had pancreatic ductal adenocarcinoma (PDAC) and 11 had non-PDAC lesions. DNA samples were isolated and sequenced by NGS using an Ion Personal Genome Machine system. The Cancer Hotspot Panel v2, which includes 50 cancer-related genes and 2,790 COSMIC mutations, was used. A >2% mutation frequency was defined as positive. KRAS mutations were detected in 26 of 27 PDAC aspirates (96%) and 0 of 11 non-PDAC lesions (0%). The G12, G13, and Q61 KRAS mutations were found in 25, 0, and 1 of the 27 PDAC samples, respectively. Mutations were confirmed by TaqMan^® polymerase chain reaction analysis. TP53 mutations were detected in 12 of 27 PDAC aspirates (44%). SMAD4 was observed in 3 PDAC lesions and cyclin-dependent kinase inhibitor 2A in 4 PDAC lesions. Therefore, the current study was successfully able to develop an NGS assay with high clinical sensitivity for EUS-FNA samples.

Patients with recognized psychiatric disorders in trauma surgery: incidence, inpatient length of stay, and cost

BACKGROUND

Although psychiatric disturbances are highly prevalent among traumatically injured inpatients, few investigations have assessed the impact of these disorders on surgical length of stay (LOS) and cost.

METHODS

The authors identified all trauma-registry recorded psychiatric diagnoses among patients admitted to University of California Davis Medical Center between January 1993 and December 1996. Linear and logistic regressions were used to assess the unique effects of psychiatric diagnoses on inpatient LOS and cost.

RESULTS

A total of 29% of patients had one or more registry-recorded psychiatric diagnosis. Patients with alcohol abuse diagnoses demonstrated 10% to 12% decreases in LOS and cost (p < 0.01), whereas patients with stress disorders, delirium, and psychoses demonstrated 46% to 103% increases in LOS and cost (p < 0.01).

CONCLUSION

Patients with recognized psychiatric disorders uniquely impact inpatient trauma surgery LOS and cost. Additional investigations of the processes and outcomes of care could lead to cost-effective performance improvement efforts that target the amelioration of comorbid psychiatric disorders among physically injured trauma survivors.

Implications of test revisions for assessment with Asian Americans

There are serious gaps in knowledge with respect to the use of standardized assessment instruments such as the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III; D. Wechsler, 1997) or the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; J. N. Butcher, W. G. Dahlstrom, J. R. Graham, A. Tellegen, & B. Kaemmer, 1989) with Asian Americans. Issues surrounding the availability, reliability, and validity of assessment instruments must be addressed before extended discussions about the implication of test revisions for this population can take place. The authors review the current status of the WAIS-III and MMPI-2 with Asian Americans with respect to their availability, reliability, and validity, including reasons why Asian Americans have been severely underrepresented in validation studies. The authors argue for the need to collect data on the use of standardized assessment instruments with Asian Americans and conclude with recommendations for the inclusion of this population in future test revision projects.

Culture-specific models of men's sexual aggression: intra- and interpersonal determinants

The role of intra- and interpersonal variables was examined in samples of Asian American (N = 91) and European American (N = 377) men. A path model for Asian American men suggested 2 interpersonal paths and 1 intrapersonal path to sexual aggression. For Asian Americans, concern about social standing is a risk factor among those who hold misogynous beliefs and who use alcohol before sex. Concern about the negative reputational impact of sexual aggression is a protective factor among Asian Americans who do not hold these negative attitudes. A European American model suggested only an intrapersonal path to sexual aggression consisting of misogynous beliefs, with interpersonal variables not being predictive of sexual aggression. These results suggest both individualist and collectivist determinants of Asian American sexual aggression, whereas only individualist determinants were found for European American sexual aggression.

Psychopathology among Asian Americans: a model minority?

The prevalence of psychopathology among Asian Americans has been a source of debate. Some investigators believe that the prevalence rate is quite low, whereas others argue that it is fairly high. A review of the literature suggests that at this time, it is not possible to determine the specific rates of psychopathology. However, evidence does suggest that their rates of mental disorders are not extraordinarily low. Thus, public portrayals of Asian Americans as a well-adjusted group do not reflect reality. Attempts to determine the exact prevalence rates have been hindered by characteristics of the Asian American population, particularly its relatively small size, heterogeneity, and rapid changes in demographics. It is suggested that aggregate research, in which different Asian American groups are combined, is important for policy considerations, broad cultural comparisons, and establishing baseline information. To advance scientific contributions and understanding, studies that examine the correlates and course of disorders within specific Asian American groups are necessary as well.

Severity of disturbance among Asian American outpatients

Although Asian Americans are low utilizers of mental health services, they may suffer from a greater degree of disturbance by the time they are accepted for services. In this study, thousands of Asian and White clients who utilized a large mental health system over a 5-year period were compared on three measures of severity of disturbance: severity of diagnosis, ratings of functioning, and presence of psychotic features. Results for all three indicators supported the hypothesis that Asian Americans show greater disturbance than do Whites. The findings provide convincing evidence of greater disturbance among Asian American clients. It is suggested that for cultural reasons, only the most severely disturbed Asian clients use mental health services.

Science, ethnicity, and bias: Where have we gone wrong?

The quality, quantity, and funding of ethnic minority research have been inadequate. One factor that has contributed to this inadequacy is the practice of scientific psychology. Although principles of psychological science involve internal and external validity, in practice psychology emphasizes internal validity in research studies. Because many psychological principles and measures have not been cross-validated with different populations, those conducting ethnic minority research often have a more difficult time demonstrating rigorous internal validity. Thus, psychology's overemphasis of internal as opposed to external validity has differentially hindered the development of ethnic minority research. To develop stronger research knowledge on ethnic minority groups, it is important that (a) all research studies address external validity issues and explicitly specify the populations to which the findings are applicable; (b) different research approaches, including the use of qualitative and ethnographic methods, be appreciated; and (c) the psychological meaning of ethnicity or race be examined in ethnic comparisons.

Cross-cultural epidemiology

Two issues led me into the area of cross-cultural psychiatric epidemiology in the 1980s. The National Institute of Mental Health funded the Epidemiological Catchment Area Studies. One of them included a study of a Caucasian and Hispanic populations in Los Angeles. Dr Masaaki Kato, then the Director of the National Institute of Mental Health of Japan, was the consultant for a JAICA-funded project in Lima, Peru. He was interested in fostering psychiatric research there, so I suggested an epidemiological study. This study was done in two phases with Drs Shunichiro Hayashi, Kimpei Minobe and Alberto Perales. Because it is extraordinarily expensive to undertake epidemiological studies in the USA, I met with colleagues regarding psychiatric epidemiological studies in Asia, Dr Chung-kyoon Lee at the Seoul National University in Korea, Dr Eng-Kung Yeh of the National Taiwan University in Taipei,Taiwan, Dr Char-nie Chen of the Chinese University of Hong Kong, and Dr Masaaki Kato in Japan. Studies have been completed in Korea, Taiwan, Hong Kong, but not in Japan. In the meantime, very small pilot studies among Asian groups in Los Angeles were performed. The very recent results of the study of Chinese in Los Angeles, California, with the Composite International Diagnostic Interview are now available to compare the prevalence of selected psychiatric disorders among the Chinese in Los Angeles and the data from the National Co-Morbidity Study.

Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese Americans in Los Angeles

OBJECTIVE

The authors' goal was to estimate the lifetime and 12-month rates of major depressive episodes and dysthymia for Chinese Americans who reside in Los Angeles. This effort, the Chinese American Psychiatric Epidemiological Study, is the first large-scale community psychiatric epidemiological study on an Asian American ethnic group that used DSM-III-R criteria for major depressive episodes and dysthymia.

METHOD

A multi-stage sampling design was used to select respondents for participation in the survey. The sample included 1,747 adults, 18-65 years of age, who resided in Los Angeles County and who spoke English, Mandarin, or Cantonese.

RESULTS

Approximately 6.9% of the respondents had experienced an episode of major depression and 5.2% had had dysthymia in their lifetime. The 12-month rates of depressive episode and dysthymia were 3.4% and 0.9%, respectively. The most consistent correlate of lifetime and 12-month depressive episode and dysthymia was social stress, measured by past traumatic events and recent negative life events.

CONCLUSIONS

The Chinese American Psychiatric Epidemiological Study provides a rare opportunity to investigate the heterogeneity within a single Asian American ethnic group, Chinese Americans, and to identify the subgroups among Chinese Americans who may be most at risk for mental health problems.

In search of cultural competence in psychotherapy and counseling

The characteristics involved in cultural competency in psychotherapy and counseling have been difficult to specify. This article describes attempts to study factors associated with cultural competency and addresses 3 questions. First, is ethnic match between therapists and clients associated with treatment outcomes? Second, do clients who use ethnic-specific services exhibit more favorable outcomes than those who use mainstream services? Third, is cognitive match between therapists and clients a predictor of outcomes? The research suggests that match is important in psychotherapy. The cultural competency research has also generated some controversy, and lessons learned from the controversy are discussed. Finally, it is suggested that important and orthogonal ingredients in cultural competency are therapists' scientific mindedness, dynamic-sizing skills, and culture-specific expertise.

In search of cultural competence in psychotherapy and counseling

The characteristics involved in cultural competency in psychotherapy and counseling have been difficult to specify. This article describes attempts to study factors associated with cultural competency and addresses 3 questions. First, is ethnic match between therapists and clients associated with treatment outcomes? Second, do clients who use ethnic-specific services exhibit more favorable outcomes than those who use mainstream services? Third, is cognitive match between therapists and clients a predictor of outcomes? The research suggests that match is important in psychotherapy. The cultural competency research has also generated some controversy, and lessons learned from the controversy are discussed. Finally, it is suggested that important and orthogonal ingredients in cultural competency are therapists' scientific mindedness, dynamic-sizing skills, and culture-specific expertise.

Nucleotide sequence of the psaD gene from the thermophilic cyanobacterium Synechococcus vulcanus

The nucleotide sequence was determined for the psaD gene of a thermophilic cyanobacterium, Synechococcus vulcanus, which encoded the PsaD subunit (Subunit II) of the Photosystem I reaction center complex. Except for some differences in the peripherals, the nucleotide sequence of the gene encoding PsaD was identical to that of another thermophilic cyanobacterium Synechococcus elongatus reported previously. Relationship between these primary structures and thermostability was also discussed.

Return rates and outcomes from ethnicity-specific mental health programs in Los Angeles

OBJECTIVES

The present study compared the return rate, length of treatment, and treatment outcome of ethnic minority adults who received services from ethnicity-specific or mainstream programs.

METHODS

The sample consisted of 1516 African Americans, 1888 Asian Americans, and 1306 Mexican Americans who used 1 of 36 predominantly White (mainstream) or 18 ethnicity-specific mental health centers in Los Angeles County over a 6-year period. Predictor variables included type of program (ethnicity specific vs mainstream), disorder, ethnic match (whether or not clients had a therapist of the same ethnicity), gender, age, and Medi-Cal eligibility. The criterion variables were return after one session, total number of sessions, and treatment outcome.

RESULTS

The study indicated that ethnic clients who attended ethnicity-specific programs had a higher return rate and stayed in the treatment longer than those using mainstream services. The data analyses were less clear cut when treatment outcome was examined.

CONCLUSIONS

The findings support the notion that ethnicity-specific programs seem to increase the continued use of mental health services among ethnic minority groups.

Toward a culturally anchored ecological framework of research in ethnic-cultural communities

Proposed a research framework (the "cube" model) in which community psychologists working in ethnic-cultural communities can make appropriate decisions on conceptual and methodological issues from a culturally anchored, ecological-contextualist perspective. The intent of the model is to articulate ethnic-cultural heterogeneity in community research by elucidating three metamethodological issues: (a) definition of an ethnic-cultural community, (b) applicability of cross-cultural theories and methods to ethnic-cultural community research, and (c) geographical or ecological stability of an ethnic-cultural community. The model posits that ethnic-cultural community research can be conceptualized as a three-dimensional structure that represents an interaction among research questions, methods, and cultural complexity (referring to the extent to which an ethnic-cultural group is defined in a larger ecological context or community both at the individual and collective levels). Future directions for research were discussed in terms of the utility and the limitations of the proposed research model.

Dynamic computed tomography and functional imaging in cerebral arterial occlusive disease: analysis in the chronic phase

Dynamic CT was conducted on 10 patients with internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion or stenosis and 14 controls. All the patients were chronic phase and they only presented small infarctions on CT. Those with ICA or MCA occlusions and insufficient collateral circulations showed delayed mean transit time and peak time of the affected side on functional image and in parameter analysis (P less than 0.01) compared with those of controls. A statistically significant positive coefficient of correlation was noted between the degree of the anterior horn dilatation of lateral ventricle and delay in mean transit time of the affected MCA area (r = 0.62, P less than 0.01).

Community mental health services for ethnic minority groups: a test of the cultural responsiveness hypothesis

This study investigated services received, length of treatment, and outcomes of thousands of Asian-American, African-American, Mexican-American, and White clients using outpatient services in the Los Angeles County mental health system. It tested the hypothesis that therapist-client matches in ethnicity and language are beneficial to clients. Results indicate that Asian Americans and Mexican Americans underutilized, whereas African Americans overutilized, services. African Americans also exhibited less positive treatment outcomes. Furthermore, ethnic match was related to length of treatment for all groups. It was associated with treatment outcomes for Mexican Americans. Among clients who did not speak English as a primary language, ethnic and language match was a predictor of length and outcome of treatment. Thus, the cultural responsiveness hypothesis was partially supported.

[A mechanism of cheiro-oral syndrome due to brainstem lesions, a case of a dissecting aneurysm of the basilar artery]

A 42-year-old woman developed an abrupt onset of severe headache, nausea, vomiting, unstable gait and numbness around the right side of her mouth and in her right hand. Neurological examination revealed bilateral pyramidal tract signs and hypesthesia of her right palmar tip and the right side of her mouth. However, pain and temperature sensibility was preserved. Cerebrospinal fluid was clear and colorless. CT scan showed an enhancing mass in the prepontine cistern compressing the pontine base. Vertebral angiography revealed irregular narrowing of bilateral vertebral arteries (string sign) proximal to a fusiform aneurysm on the entire length of the basilar artery. MRI showed double lumina in the wall of the aneurysm. The medial lemniscus conducts the discriminatory tactile and the deep sensory impulses from the extremities. The ventral ascending tract of the trigeminal nerve conducts the discriminatory tactile sensory impulses from the face. These two tracts lie close together in the pontine tegmentum, which is also a watershed area of the paramedian branches and circumferential branches of the basilar artery. We suggest that in this case the dissecting aneurysm caused ischemia of these two tracts in the left pontine tegmentum, presenting right cheiro-oral syndrome.

Community mental health services for ethnic minority groups: A test of the cultural responsiveness hypothesis

This study investigated services received, length of treatment, and outcomes of thousands of Asian-American, African-American, Mexican-American, and White clients using outpatient services in the Los Angeles County mental health system. It tested the hypothesis that therapist-client matches in ethnicity and language are beneficial to clients. Results indicate that Asian Americans and Mexican Americans underutilized, whereas African Americans overutilized, services. African Americans also exhibited less positive treatment outcomes. Furthermore, ethnic match was related to length of treatment for all groups. It was associated with treatment outcomes for Mexican Americans. Among clients who did not speak English as a primary language, ethnic and language match was a predictor of length and outcome of treatment. Thus, the cultural responsiveness hypothesis was partially supported.

Asian-American educational achievements. A phenomenon in search of an explanation

Considerable attention has been paid to the academic achievements of Asian Americans because there is convergent evidence that this population has attained high educational mobility. In trying to explain the achievement patterns, researchers have largely limited their investigations to one of two contrasting hypotheses involving (a) hereditary differences in intelligence between Asians and Whites and (b) Asian cultural values that promote educational endeavors. Research findings have cast serious doubt over the validity of the genetic hypothesis. Yet, there has been a failure to find strong empirical support for alternative hypothesis concerning cultural values. It is proposed, under the concept of relative functionalism, that Asian Americans perceive, and have experienced, restrictions in upward mobility in careers or jobs that are unrelated to education. Consequently, education assumes importance, above and beyond what can be predicted from cultural values. Research and policy implications of this view are noted.

Asian-American educational achievements: A phenomenon in search of an explanation

Considerable attention has been paid to the academic achievements of Asian Americans because there is convergent evidence that this population has attained high educational mobility. In trying to explain the achievement patterns, researchers have largely limited their investigations to one of two contrasting hypotheses involving (a) hereditary differences in intelligence between Asians and Whites and (b) Asian cultural values that promote educational endeavors. Research findings have cast serious doubt over the validity of the genetic hypothesis. Yet, there has been a failure to find strong empirical support for alternative hypothesis concerning cultural values. It is proposed, under the concept of relative functionalism, that Asian Americans perceive, and have experienced, restrictions in upward mobility in careers or jobs that are unrelated to education. Consequently, education assumes importance, above and beyond what can be predicted from cultural values. Research and policy implications of this view are noted.

Characterization and N-terminal sequence of a 5 kDa polypeptide in the photosystem I core complex from spinach

Photosystem I core complexes were isolated from spinach photosystem I particles after heat treatment in the presence of 50% (v/v) ethylene glycol (heat/EG treatment). The core complex from 58 degrees C/EG-treated particles was composed of polypeptides with apparent molecular masses of 63, 60 and 5 kDA; this complex contained the iron sulfur center Fx but lacked center FA and FB. The core complex obtained from the 70 degrees C/EG-treated preparation lacked FX and contained a lesser amount of the 5 kDa polypeptide. The N-terminal amino acid sequence of the 5 kDa polypeptide did not correspond to the sequence derived from any possible reading frame in the chloroplast DNA of liverwort or tobacco. Twelve of the first 29 N-terminal amino acids were hydrophobic, suggesting that this protein is intrinsic to the photosystem I reaction center.

Ethnic differences in alcohol consumption among Asians and Caucasians in the United States: an investigation of cultural and physiological factors

The present study examined Asian and Caucasian differences in alcohol consumption and the self-reported socio-cultural and physiological correlates of consumption. The subjects were 83 Asian (38 male, 45 female) and 96 Caucasian (48 male, 48 female) students who were asked to complete questionnaires on: (1) demographic information, (2) general attitudes and values, (3) level of alcohol consumption, (4) attitudes toward drinking and (5) physiological reactivity. The results indicated that: (1) Asians self-reported lower levels of alcohol consumption than did Caucasians, and (2) physiological reactivity and attitudes toward drinking rather than general cultural values were significant predictors of ethnic differences in drinking. The results suggest the importance of simultaneously evaluating physiological reactivity and sociocultural factors in alcohol consumption.

Reliability and validity of the Chinese Depression Adjective Check Lists

Presented data on the translation and on the reliability and concurrent validity of the Chinese version of the Depression Adjective Check Lists (DACL). Reliability and validity coefficients are significant and of sufficient magnitude to warrant their use in research (N = 37).

Conceptions of mental illness among Asian and Caucasian-American students

The attitudes and beliefs of 62 Asian American and 81 Caucasian college students toward mental illness were examined. After controlling for demographic and background variables between students, a number of significant ethnic differences emerged. These results were interpreted in the context of Asian subcultural values and implications for psychotherapeutic practice were drawn.

Predictors of the duration of therapy for clients in the community mental health system

Single and multiple correlates for premature termination and duration of treatment were examined for 13,450 clients seem in 17 community mental health facilities. Predictor variables included seven demographic characteristics of clients and five characteristics of service (type of personnel seeing clients, assignment to in- or outpatient programs, diagnosis rendered, assignment to therapy or diagnostic services, and assignment to individual therapy or other services. Results indicated that clients who are members of ethnic groups, who have low educational backgrounds, who are seen by paraprofessional staff, and who are assigned for diagnostic services quickly terminate at community mental health facilities.

Authoritarianism, pretrial publicity, and awareness of bias in simulated jurors

In a simulated jury experiment, 158 university students were asked to render certain decisions as jurors in a criminal case. Subjects were exposed to damaging (to the defendant) pretrial publicity or to neutral pretrial publicity. Subjects were asked if they could remain impartial and also completed the F-scale questionnaire. Results indicated that even when subjects claim they are unbiased by pretrial publicity, their decisions as simulated jurors reveal bias. Their F-scores, however, appeared unrelated to judicial decisions.