Noniatrogenic Meningitis Caused by Streptococcus salivarius Associated with Early Esophageal Cancer and Early Gastric Cancer

Streptococcus salivarius is part of the normal oral cavity and gastrointestinal tract microflora and an unusual cause of acute bacterial meningitis. We herein report an 81-year-old man with S. salivarius meningitis, which led to a diagnosis of early esophageal cancer and early gastric cancer. S. salivarius infection may occur through the gastrointestinal mucosa when it is disrupted in association with early gastrointestinal cancer. To our knowledge, this is the first report describing S. salivarius meningitis associated with multiple early gastrointestinal cancers in the absence of other sources of infection.

Diagnosis of histological gastritis based on the Kyoto classification of gastritis in Japanese subjects - including evaluation of aging and sex difference of histological gastritis

OBJECTIVES

The Kyoto classification of gastritis was established for diagnosing Helicobacter pylori (H. pylori) infection via endoscopic findings. We investigated the role of the Kyoto classification of gastritis in the diagnosis of H. pylori infection and histological gastritis in Japanese individuals. Moreover, the histological findings of gastritis in H. pylori infection were examined based on age and sex differences.

METHODS

We selected 561 patients aged 20-79 years who underwent gastroduodenal endoscopy at our hospital between 2010 and 2018. Endoscopic biopsy specimens from the antrum and corpus were used to investigate H. pylori infection and histology. Endoscopic findings were based on the Kyoto classification of gastritis, and histological findings were based on the updated Sydney System.

RESULTS

Endoscopic findings based on the Kyoto classification of gastritis (H. pylori positive, 303 patients; H. pylori negative, 258 patients, based on endoscopic findings) had 98.7% sensitivity and 98.4% specificity for histological gastritis. In addition, endoscopic findings in the three age groups (20-39, 40-59, and 60-79 years) had high sensitivity and specificity. Atrophy and intestinal metaplasia were found only in the H. pylori-positive group and progressed with age. Histological inflammation of pyloric mucosa in the younger age group of H. pylori-positive patients was significantly higher than that in the elderly group. Significant inflammation was observed in young women.

CONCLUSIONS

The Kyoto classification of gastritis can not only diagnose H. pylori infection but also detect histological gastritis. Histological gastritis has varying characteristics of inflammation, atrophy, and intestinal metaplasia, depending on age and sex.

Inflammatory Cell Numbers in the Stomach of Japanese Subjects with Endoscopically Normal Mucosa without Helicobacter pylori Infection

INTRODUCTION

Since inflammatory cells, such as lymphocytes and plasma cells, normally inhabit the stomach, the border between normal and mild inflammation is difficult to visually determine using the updated Sydney system scale of gastritis. Additionally, eosinophils in the gastric mucosa must be counted to diagnose eosinophilic gastritis. We aimed to determine the normal number of inflammatory cells in patients with endoscopically normal mucosa and without Helicobacter pylori infections.

METHODS

We assessed patients aged 20-79 years, who had undergone upper gastrointestinal endoscopy at Kawasaki Medical School Hospital between January 2010 and December 2014. Inflammatory cells were counted in 1,000 μm2 fields of pyloric and fundic gland mucosal biopsy specimens. We finally included 325 (male, n = 141; female, n = 184; average age = 49.3 years) patients without inflammation who had H. pylori-negative endoscopic results and negative histological findings interpreted based on the updated Sydney System and the Kyoto classification of gastritis.

RESULTS

The average numbers of nucleated cells were 83.3 ± 14.2 and 65.4 ± 12.6/mm2 in the pyloric and fundic gland mucosae, respectively. Inflammatory cells were significantly more abundant in the pyloric mucosa than in the fundic gland mucosa (p < 0.05). Age and sex distribution did not significantly differ. Eosinophils were absent or scanty in the gastric mucosae of both glands in all patients.

CONCLUSION

We determined the absolute values of inflammatory cells, including eosinophils, in normal mucosae of pyloric and fundic glands. These findings could be important in defining gastric mucosal inflammation, including eosinophilic gastritis diagnosis.

The SARC-F Score on Admission Predicts Falls during Hospitalization in Older Adults

OBJECTIVES

Community-dwelling older adults with sarcopenia are likely to fall. However, few studies have investigated whether sarcopenia is associated with falls during hospitalization in older adults. The purpose of this study was to determine whether the SARC-F when used as a simple screening tool for sarcopenia at the time of admission, predicts in-hospital falls.

DESIGN

A retrospective, observational study.

SETTING

A 900-bed university hospital.

PARTICIPANTS

A total of 9,927 patients aged 65 years and older were hospitalized at the hospital between April 2019 and March 2020.

MEASUREMENTS

The SARC-F contains five items: strength, assistance in walking, rise from a chair, climb stairs, and falls were evaluated at hospital admission. To investigate the relationship between the SARC-F score and falls, a ROC curve analysis was performed. Multivariate analysis adjusted for fall-related confounding factors such as age, gender, ADL, and disease were performed.

RESULTS

Mean age: 75.9±6.7 years; male: 56.2% were analyzed, and 159 patients (1.6%) fell during hospitalization. SARC-F scores at admission were significantly higher in the fall group than in the control group (3 [1-6] points vs. 0 [¬0-2] point, p<0.001). Statistical association was observed between the SARC-F and in-hospital fall (area under the curve = 0.721 [0.678-0.764], p < 0.001). The cut-off value for the highest sensitivity and specificity of the SARC-F score for in-hospital falls was two (sensitivity = 0.679, specificity = 0.715). Among the subitem of the SARC-F, the hazard ratios for climbing stairs were significantly higher (HR = 1.52 [1.10-2.09], p = 0.011) and for a history of fall was significantly higher (HR = 1.41 [1.02-1.95], p = 0.036). A SARC-F score ≥ 2 had a significantly higher incidence of in-hospital falls compared to a SARC-F score <2 (3.7% vs. 0.7%, p < 0.001). Also, a SARC-F score ≥ 2 had a significantly higher hazard ratio for falls (2.11 [1.37-3.26], p < 0.001).

CONCLUSION

SARC-F can help predict falls among hospitalized older adults.

SARC-F Predicts Mortality Risk of Older Adults during Hospitalization

OBJECTIVES

To determine the association between SARC-F scores and the in-hospital mortality risk among older patients admitted to acute care hospitals.

DESIGN

Single-center retrospective study.

SETTING

A university hospital.

PARTICIPANTS

All consecutive patients aged older than 65 were admitted and discharged from the study hospital between July 2019 and September 2019.

MEASUREMENTS

Relevant patient data included age, sex, body mass index, nutritional status, fat-free mass, disease, activities of daily living (ADL), duration of hospital stay, SARC-F, and occurrence of death within 30 days of hospitalization. The diseases that caused hospitalization and comorbidities (Charlson Comorbidity Index; CCI) were obtained from medical records. The Eastern Cooperative Oncology Group-performance status (PS) was used to determine ADL, and the in-hospital mortality rate within 30 days of hospitalization as the outcome.

RESULTS

We analyzed 2,424 patients. The mean age was 75.9±6.9 and 55.5% were male. Fifty-three in-hospital mortalities occurred among the participants within the first 30 days of hospitalization. Patients who died in-hospital were older, had poorer nutritional status and severer PS scores, and more comorbidities than those who did not. A SARC-F score of ≥4 predicted a higher mortality risk within those 30 days with the following precision: sensitivity 0.792 and specificity 0.805. There were significantly more deaths in Kaplan-Meier curves regarding a score of SARC-F≥4 than a score of SARC-F<4 (p<0.001). Cox proportional hazard analysis was used to identify the clinical indicators most associated with in-hospital mortality. SARC-F≥4 (Hazard Ratio: HR 5.65, p<0.001), CCI scores (HR1.11, p=0.004), and infectious and parasitic diseases (HR3.13, p=0.031) were associated with in-hospital mortality. The SARC-F items with significant in-hospital mortality effects were assistance with walking (HR 2.55, p<0.001) and climbing stairs (HR 2.46, p=0.002).

CONCLUSION

The SARC-F questionnaire is a useful prognostic indicator for older adults because a SARC-F ≥4 score during admission to an acute care hospital predicts in-hospital mortality within 30 days of hospitalization.

A bolus of saline injection leads to increase in coronary flow based on the viscosity reduction effect: the mechanism of saline induced Pd/Pa ratio

Background

In conjunction with fractional flow reserve (FFR), our previous study has shown the accuracy and utility of saline induced Pd/Pa ratio (SPR) for the assessment of myocardial ischemia. However, the potential mechanism how saline injection leads to increase in coronary flow remains speculative.

Purpose

This study aimed to clarify the underlying mechanism of SPR by using swine models.

Methods

The study was conducted in four swine models, and bolus of 25°C saline, 40°C saline, and 25°C dextran was injected at rates of 40mL/5sec through a catheter inserted into the superior mesenteric artery. Its peripheral arterioles were observed and recorded by a digital microscope, and transit time of each fluid and a luminal diameter of arterioles before and after injection were measured.

Results

The result from arterioles diameters of pre- and post-injection (0.049±0.016mm vs. 0.050±0.016mm; P=0.636) indicated that luminal diameters remained unchanged regardless of fluid administration. The transit time of 25°C saline was significantly shorter than 25°C dextran (3.19±0.68sec vs. 6.15±1.19sec; P&lt;0.0001). Although the result showed no significance, the transit time of 40°C saline with lower viscosity was shorten compared to 25°C saline (3.1±0.43sec vs. 3.65±0.46sec; P=0.088).

Conclusions

Compared to 25°C dextran (viscosity of 4.991mPa·s) having the same viscosity as 37°C whole blood, 25°C saline (viscosity of 1.012mPa·s) caused increasing to double the intravascular flow volume without dilating arterioles. The results strongly suggested that the potential mechanism of SPR was viscosity reduction effect. Combined with FFR which is based on vasodilation-mediated hyperemia, these findings may contribute to clarifying the pathophysiology and especially the microcirculation in coronary artery diseases.

Funding Acknowledgement

Type of funding source: None

The developing mechanism of atherosclerotic lesion in coronary side branch on the ventricular free wall differs by the location of lesion

Background

The effective treating method of coronary side branch lesions such as ostial stenosis or thin arteries has not been established. On the other hand, tortuous side branch rarely has stenotic lesions.

Purpose

We focused on coronary side branches on the ventricular free wall, and examined coronary risk factors and bending and stretching motion of branch which can contribute to the development of atherosclerotic lesion.

Methods

In elective and first-time coronary angiograms, we included side branches on the ventricular free wall (&gt;2mm in diameter) and excluded previously treated ones. Study A; we divided arteries into proximal, middle, and distal segment, and examined the presence of tortuosity and stenotic lesions exceeding 50% diameter stenosis (DS) for each segment. A score of 1 was assigned to tortuous segment, and 0 to non-tortuous one. Study B; we included stenotic lesion (&gt;50% DS) in side branch ostium and excluded those extended across main coronary arteries. Relation between lesions and patients' characteristics was examined.

Results

Study A; in 1,828 side branches from 472 patients, middle and distal segments had significantly higher tortuosity score than proximal (0.68, 0.78 vs. 0.34; p&lt;0.0001). On the contrary, proximal segments had more stenotic lesions except ostial stenosis (230 vs. 69, 5; p&lt;0.0001). Study B; in 1,740 side branches from 465 patients, 122 ostial stenotic lesions were found (7.0%). Multivariate logistic regression analysis revealed diabetes mellitus and age as independent contributors to development of ostial stenosis (Table).

Conclusions

Side branch stenosis developed less frequently in middle and distal segments, where stronger ventricular wall motion reinforces bending and stretching motion and tortuosity of arteries. This fact indicates that those characteristics may prevent developing atherosclerosis through increasing shear stress. On the other hand, diabetes mellitus strongly contributes to the development of ostial stenosis. Thus, the developing mechanism of atherosclerotic lesion in side branch on the ventricular free wall differs by the location of lesion.

Funding Acknowledgement

Type of funding source: None

SARC-F as a Screening Tool for Sarcopenia and Possible Sarcopenia Proposed by AWGS 2019 in Hospitalized Older Adults

OBJECT

The SARC-F questionnaire is a sarcopenia screening tool. However, the validity of the SARC-F score ≥4 (SARC-F≥4) for the evaluation of sarcopenia in the hospital setting has not been investigated. This study investigated the validity of SARC-F≥4 as a screening tool for sarcopenia among hospitalized older adults.

DESIGN

Cross-sectional retrospective study.

SETTING

A university hospital.

PARTICIPANTS

This study included older adult patients (age ≥65 years) who were hospitalized at, and subsequently discharged from, the hospital between April and September 2019 and underwent a nutritional assessment by the nutrition support team during their hospitalization.

MEASUREMENTS

SARC-F was recorded at the time of admission, and the criteria specified by the Asia Working Group for Sarcopenia in 2019 (AWGS 2019) were applied to diagnose sarcopenia and possible sarcopenia. Appendicular muscle mass was estimated through validated equations, and three different models were developed for sarcopenia diagnosis. The sensitivity, specificity, and positive/negative likelihood ratios were calculated to analyze the accuracy of the SARC-F≥4 for sarcopenia and possible sarcopenia. Receiver-operating characteristic analyses were conducted to calculate the area under the curve (AUC).

RESULTS

In total, 1,689 patients (mean age: 77.2±7.3 years; male: 54.4%) were analyzed, and 636 patients (37.7%) had SARC-F≥4. Patients with SARC-F≥4 had a statistically significant higher prevalence of AWGS 2019-defined sarcopenia than patients with SARC-F <4 in the models (65.4-78.9% vs 40.9-45.2%, p<0.001). The sensitivity, specificity, and positive/negative likelihood ratios of SARC-F≥4 for sarcopenia and possible sarcopenia were 49.1-51.3%, 73.9-81.2%, and 1.88-2.72/0.60-0.69 and 48.0%, 84.5%, and 3.11/0.62, respectively. The AUC for sarcopenia and possible sarcopenia were 0.644-0.695 and 0.708, respectively. The AUC of SARC-F for possible sarcopenia was equivalent to or larger than that for sarcopenia (DeLong test p=0.438, 0.088, and <0.001 vs the three models).

CONCLUSIONS

SARC-F≥4 is suitable as a screening tool for sarcopenia in hospitalized older adults. SARC-F assessment could facilitate the detection and exclusion of sarcopenia at hospitalization and may lead to early adoption of a therapeutic and preventive approach.

Burden of Premorbid Consumption of Texture Modified Diets in Daily Life on Nutritional Status and Outcomes of Hospitalization

OBJECTIVES

Due to the water-rich cooking process required to soften texture modified diets (TMDs), TMDs may have poorer nutrition. The aim of this study was to investigate the associations between daily premorbid TMD consumption and nutritional status at the time of hospitalization, and its burden on hospitalization outcomes.

DESIGN

Retrospective observational study.

SETTING

An academic hospital.

PARTICIPANTS

The cohort comprised 3,594 older adult patients aged ≥65 years admitted to the hospital.

MEASUREMENTS

Patients were interviewed on admission using a premorbid daily consumption meal form to determine whether the patient ate a TMD. Nutritional status was examined using nutritional screening tools (Mini-Nutritional Assessment Short Form [MNA-SF], Malnutrition Universal Screening Tool [MUST], Geriatric Nutritional Risk Index [GNRI]) and the European Society of Clinical Nutrition and Metabolism (ESPEN)-defined criteria of malnutrition at admission. Length of hospital stay (LOS) and in-hospital mortality were considered outcomes of hospitalization. Multivariate analyses were performed to detect associations between premorbid TMD consumption and nutritional status and outcomes.

RESULTS

The mean age of the subjects was 75.9±7.0 years, including 58% males. Overall, 110 (3.1%) patients consuming a premorbid TMD were identified. They were older (p<0.001), had poor nutritional status (lower MNA-SF score [p<0.001] and GNRI value [p<0.001], higher MUST score [p<0.001], and more prevalent ESPEN-defined malnutrition [61.8% vs. 14.0%, p<0.001] than did patients without a TMD. The mortality rate and LOS of patients with TMD was higher (7.3% vs. 2.9%, p=0.017) and longer (19 days vs. 8 days, p<0.001) than those without TMD. Multivariate analyses showed that TMD consumption was independently associated with poor nutritional status and prolonged LOS after adjusting confounders.

CONCLUSION

Daily consumption of a TMD during the premorbid period affects nutritional status at the time of hospitalization and outcomes. Further studies are necessary to investigate whether nutritional intervention can improve outcomes for people on a TMD.

Overexpression of CD55 from Barrett's esophagus is associated with esophageal adenocarcinoma risk

BACKGROUND AND AIM

Although several molecular biomarkers for esophageal adenocarcinoma (EAC) have been shown to be useful disease indicators, none has been established as a reliable indicator for risk of EAC or have progressed to routine use. The aim was to identify biomarkers of high risk for EAC in patients with Barrett's esophagus (BE).

METHODS

Following endoscopic observation by magnified endoscopy with narrow band imaging (ME-NBI), brushing was followed by obtaining biopsy samples from columnar-lined esophagus (CLE) and from EAC lesions of EAC patients, and from age- and sex-matched non-EAC controls with BE. Total RNA was extracted for microarray analysis using Affymetrix GeneChip Human Genome U133 plus 2.0 Array. Real-time-PCR analysis of identified candidate genes was used to confirm the results.

RESULTS

Overall, 9 EAC patients and 50 patients with BE were studied. Seventy-nine candidate genes were identified by microarray analysis based on a proportional hazards model (P < 0.005). Six genes exhibited significantly differential expressions in both BE and cancer lesions of the EAC group compared to BE of the controls. In the brushing samples, median CD55 relative expression levels in cancer lesions were highest and decreased in BE of EAC group and BE of the controls, in that order (P < 0.001).

CONCLUSION

Over expression of CD55 in brushing samples taken from BE may be associated with the risk of EAC.

A novel APC mosaicism in a patient with familial adenomatous polyposis

Using next-generation sequencing (NGS) to analyze a patient with sporadic familial adenomatous polyposis in whom no APC mutations were found by Sanger sequencing, we identified a novel APC mosaicism at a spliced donor site (c.834+2 T>C) in his leukocytes, normal colonic mucosa and adenoma. The detection of APC mosaicism using NGS can be useful in providing appropriate genetic counseling and surveillance of at risk family members as well as the proband.

Safety of gastrointestinal endoscopic biopsy in patients taking antithrombotics

BACKGROUND AND AIM

Current Japanese gastrointestinal (GI) endoscopic guidelines permit endoscopic biopsy without cessation of antiplatelet agents and warfarin in patients with a therapeutic range of prothrombin time-international normalized ratio (PT-INR) levels, although the evidence levels are low. We evaluated the safety of endoscopic biopsy in patients currently taking antithrombotics.

METHODS

Consecutive patients receiving antithrombotics who underwent GI endoscopy from August 2012 to August 2013 were enrolled. Adverse events and endoscopic hemostasis after biopsy were evaluated. PT-INR level was measured in patients taking warfarin the day before endoscopy.

RESULTS

Among 7939 patients undergoing endoscopy, 1034 patients (13.0%, 706 men and 328 women, average age 72.8 years) were receiving antithrombotics. Antithrombotics included aspirin (44.8%), warfarin (34.7%), thienopyridine (16.1%), cilostazol (10.3%), dabigatran (4.8%) etc. PT-INR levels in patients taking warfarin were >3.0 in 13 patients (4.3%), between 2.5 and 3.0 in 18 patients (6.0%), <2.5 in 269 patients (89.7%). Two hundred and six patients received endoscopic biopsy while taking aspirin (51.2%), warfarin (22.8%), and thienopyridine (13.6%). Endoscopic hemostasis was required in three patients after endoscopic biopsy (spraying thrombin in two patients, spraying thrombin and clipping in one patient). There were no major complications. The incidence of endoscopic hemostasis after biopsy in patients without antithrombotic cessation was not significantly different than in the controls not taking antithrombotics (1.5% vs 0.98%, P = 0.51).

CONCLUSION

Endoscopic biopsy did not increase the bleeding risk despite not stopping antithrombotics prior to biopsy even among patients taking warfarin whose PT-INR was within the therapeutic range.

Temporospatial localization of dentine matrix protein 1 following direct pulp capping with calcium hydroxide in rat molars

AIM

To examine the temporospatial expression of dentine matrix protein 1 (DMP1; a noncollagenous protein involved in mineralized tissue formation), osteopontin (another noncollagenous protein detected during reparative dentinogenesis) and nestin (a marker of differentiating/differentiated odontoblasts), following direct pulp capping with calcium hydroxide in rat molars.

METHODOLOGY

The maxillary first molars of 8-week-old Wistar rats had their pulps exposed and capped with calcium hydroxide. The pulp-capped teeth were collected from 6 h to 14 days postoperatively and processed for immunohistochemistry for DMP1, osteopontin and nestin. Cell proliferation was monitored using 5-bromo-2'-deoxyuridine (BrdU) labelling.

RESULTS

The capped pulps initially exhibited superficial necrotic changes followed by the formation of new matrix and its mineralization. DMP1 immunoreactivity was observed in the matrix beneath the necrotic layer from 6 h onwards and present in the outer portion of the newly formed mineralized matrix from 7 days onwards. Osteopontin displayed a similar expression pattern, although it occupied a narrower area than DMP1 at 6 and 12 h. Nestin-immunoreactive cells appeared beneath the DMP1-immunoreactive area at 1 day, were distributed beneath the newly formed matrix at 5 days and exhibited odontoblast-like morphology by 14 days. BrdU-positive cells significantly increased at 2 and 3 days (P < 0.05) and then decreased.

CONCLUSIONS

The deposition of DMP1 at exposed pulp sites preceded the appearance of nestin-immunoreactive cells, active cell proliferation and new matrix formation after pulp capping with calcium hydroxide in rat molars, suggesting that DMP1 acts as a trigger of pulp repair. The colocalization of DMP1 and osteopontin suggests that these two proteins play complementary roles.

[European guideline for the management of precancerous conditions in the stomach and it's application to Japan]

Atrophic gastritis, intestinal metaplasia, and Helicobacter pylori (H. pylori) infection are commonly recognized as the risk factor of gastric cancer. In Japan mass screening by the X-ray examination or endoscopy has been performed for a long time in general population or in work place because of the high death rate and high incidence of gastric cancer. Periodic endoscopy has been recommended for the subjects with atrophic gastritis and/or intestinal metaplasia to detect gastric cancer in early stage. On the other hand, there was no guideline to manage premalignant conditions such as atrophic gastritis, intestinal metaplasia, and dysplasia in foreign countries. Recently the guideline for the management of precancerous conditions and lesions in the stomach (MAPS) has been published by the combined efforts of the European Society of Gastrointestinal Endoscopy, European Helicobacter Study Group, European Society of Pathology, and the Sociedade Portuguesa de Endoscopia Digestiva. In this article the main statements have been discussed on comparing the understandings as the premalignant conditions in Japan.

Comparison of three dimensional and radiographic measurements in the analysis of distal radius malunion

To estimate the accuracy of radiographic deformity evaluation for distal radius malunion, we compared the results obtained from radiographic measurements (palmar tilt, radial angle, and ulnar variance) with those from the three-dimensional (3D) method using computer bone models in 20 dorsally tilted malunions. Dorsal tilt deformity, radial tilt deformity, and shortening deformity were calculated using the unaffected side as a reference. The 3D method showed a slightly lower value for dorsal tilt deformity than the radiographic evaluation, but the difference was < 10° in all cases. In patients with dorsal tilt ≥ 40°, notable differences in radial tilt evaluation were observed between the two methods compared with patients with less dorsal tilt. The 3D shortening showed positive correlations with radiographic evaluation, but a discrepancy of ≥ 2 mm was observed in eight cases. Palmar tilt is reliable for surgical planning, but radial angle and ulnar variance may be less accurate than previously thought.

Relationship between gastroesophageal junction adenocarcinoma and Helicobacter pylori infection in Japan

BACKGROUND/AIMS

The relationship between gastroesophageal junction adenocarcinoma (GEJA) and Helicobacter pylori infection is not well defined; thus, we retrospectively investigated this relationship.

METHODS

We examined 852 cases (646 men) of gastric cancer. GEJA was defined as type II according to the classification system of Siewert and Stein. We compared the prevalence of H. pylori infection and corporal gastritis in GEJA patients with distal gastric cancer.

RESULTS

GEJA was observed in 80 (including 6 cases of Barrett's esophageal cancer) of the 852 cases of gastric cancer examined (9.4%). The rate of H. pylori infection was significantly lower in patients with GEJA than in patients with distal gastric cancer (73.8 vs. 94.1%, p < 0.05). The prevalence of corporal gastritis was also significantly lower in patients with GEJA than in patients with distal gastric cancer (80.7 vs. 94.6%, p < 0.05). Concurrent H. pylori infection and corporal gastritis were not observed in patients with Barrett's esophageal cancer.

CONCLUSION

Our study demonstrated that GEJA has 2 etiologic types; one of these types is associated with H. pylori infection and resembles distal gastric cancer, and the other one is not associated with H. pylori infection or Barrett's esophageal cancer.

Usefulness of endoscopic brushing and magnified endoscopy with narrow band imaging (ME-NBI) to detect intestinal phenotype in columnar-lined esophagus

BACKGROUND

Barrett's esophagus with specialized intestinal metaplasia (SIM), which is at high risk of progressing to esophageal adenocarcinoma, has been identified by obtaining biopsy specimens randomly. Magnified endoscopy with narrow band imaging (ME-NBI) is reported to be useful for detecting SIM or the intestinal phenotype. We aimed to evaluate the usefulness of endoscopic brushing followed by ME-NBI for the detection of the intestinal phenotype.

METHODS

Biopsy and brushing samples were taken following endoscopic observation by ME-NBI. Total RNA was extracted from the whole sample and microdissected samples, and quantitative reverse transcription-polymerase chain reaction (PCR) analysis of SHH, CDX2, and mucin mRNA expression was performed.

RESULTS

Fifty patients (32 men, 18 women, average age 67.3 years) with metaplastic columnar epithelium of the lower esophagus were studied. MUC2 (85 vs. 65 %) and CDX2 (95 vs. 75 %) were detected more frequently in the brushing samples than in the biopsy samples. MUC2 expression levels were significantly higher in the brushing samples than those in the biopsy samples. CDX2 and MUC2 expression levels in the brushing samples were significantly higher in the mucosa with tubular/villous pattern observed by ME-NBI than the levels in mucosae with other patterns.

CONCLUSIONS

Endoscopic brushing in mucosa of columnar epithelium with a tubular/villous pattern visualized by ME-NBI is useful to detect the intestinal phenotype.

Three-dimensional deformity analysis of malunited distal radius fractures and their influence on wrist and forearm motion

Little information exists about three-dimensional (3-D) deformity patterns of malunited distal radius fractures including axial deformity. The current study aimed to clarify the 3-D deformity pattern of malunited distal radius fractures and reveal the influence of osseous deformities, including axial rotation deformity, on wrist and forearm motion. The deformity of 20 dorsally tilted malunions were evaluated using 3-D computer models created from CT data, and correlations between deformity components and range of motion were assessed. The 3-D deformity analysis showed that axial malalignment in pronation, which showed a correlation with the degree of radial tilt deformity, was very common. A radial tilt deformity of > 5° was observed in only 45% of cases. Although the range of wrist flexion and extension showed a correlation with dorsal tilt deformity, the range of forearm pronation and supination did not correlate with distal radius deformities.

Preserved autonomic function in patients with POEMS syndrome

AIM

We systematically performed autonomic testing on patients with polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes syndrome (POEMS) to determine whether autonomic function is preserved in such patients.

METHODS

We studied 17 POEMS patients, 17 diabetic neuropathy (DN) patients and 17 age-matched normal subjects. Blood pressure responses to the head-up tilt test and heart rate variability were used to evaluate cardiovascular autonomic function. Sweat responses and cutaneous vasoconstriction to several stimuli were recorded via the finger tips to estimate cutaneous sympathetic function. In addition, motor nerve conduction studies were performed.

RESULTS

Although the results of the autonomic testing were normal in POEMS patients, motor disability was severe, and motor nerve conduction studies provided evidence of extensive axonal loss. The DN patients showed significantly impaired autonomic responses despite mild motor dysfunction.

CONCLUSIONS

Autonomic function was normal in POEMS patients, indicating the preservation of autonomic fibers and selective involvement of large fibers.

Lysine392, a K63-linked ubiquitination site in NEMO, mediates inflammatory osteoclastogenesis and osteolysis

PMMA particles released from bone implants are considered major contributor to osteolysis and subsequent implant failure. Although the ensuing inflammatory response has been described, the mechanisms underlying PMMA particulate-induced osteolysis remain enigmatic. In previous studies, we have established that activation of Nuclear factor kappa-B (NF-κB) and MAP kinase pathways plays a central role in the pathogenesis of inflammatory osteolysis. Specifically, we have shown that impeding IKK complex assembly, and thus subsequent NF-κB activation, dampens particle-induced osteolysis. The IKK complex consists of IKKα, IKKβ, and IKKγ, also known as NEMO. NEMO has no catalytic activity and serves as a scaffold protein facilitating assembly and distal activation of NF-κB signaling. In fact, blocking binding of NEMO with IKKα/β abolishes NF-κB activity. In the current study, we identify Lysine 392 residue in NEMO as crucial mediator of PMMA particle-induced inflammatory osteoclastogenesis and osteolysis. Using mice in which NEMO-K392R mutation has been introduced, we provide evidence that PMMA-induced osteoclasts and osteolytic responses are impaired. Furthermore, we show that this impairment is likely due to poor activation of NF-κB and Erk, but not other MAP kinases. Our findings suggest that NEMO Lysine392, a well-established K63-linked polyubiquitination site, is an important mediator of PMMA-induced osteolysis. Therefore, this NEMO motif should be considered as a target to combat PMMA particle-induced osteolysis.

Long-term results of conventional varus half-wedge proximal femoral osteotomy for the treatment of osteonecrosis of the femoral head

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years.

Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally.

Preoperative concurrent chemoradiotherapy for stages II-IV oral squamous cell carcinoma: a retrospective analysis and the future possibility of this treatment strategy

This study evaluated survival in 154 patients with stages II-IV oral squamous cell carcinoma (OSCC) treated with preoperative concurrent chemoradiotherapy and assessed the future use of this treatment strategy. 14 patients exhibited advanced stage II, 73 exhibited stage III and 67 exhibited stage IV. All patients received 40Gy irradiation and concurrent cisplatin-based chemotherapy in two courses. Radical surgery was undertaken after 2-6 weeks. The clinical tumour response, histopathologic regression grade, residual tumour grade (RGrade) in the primary tumour and the level of residual pN+ were associated with prognosis. 90% of patients with complete response and 73% of patients with good partial response in the primary tumour were RGrade 0 (no residual tumour cells) or RGrade 1 (viable tumour cells remained within central superficial portion). In patients with complete response in the neck, residual pN+ was only seen in levels IB (8%) and IIA (8%); the higher the level of residual pN+, the lower the survival rate (p<0.0001). This treatment strategy was excellent for stages II-IV OSCC. It may be possible to perform minimally invasive surgery in which the extent of resection in primary tumour and neck is reduced in patients who achieve good response following preoperative chemoradiotherapy.

The Chiari pelvic osteotomy for patients with dysplastic hips and poor joint congruency

We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001).

We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.