A simpler diagnostic algorithm of the Japan Esophageal Society classification for Barrett's esophagus-related superficial neoplasia

BACKGROUND

We previously developed a Japan Esophageal Society Barrett's Esophagus (JES-BE) magnifying endoscopic classification for superficial BE-related neoplasms (BERN) and validated it in a nationwide multicenter study that followed a diagnostic flow chart based on mucosal and vascular patterns (MP, VP) with nine diagnostic criteria. Our present post hoc analysis aims to further simplify the diagnostic criteria for superficial BERN.

METHODS

We used data from our previous study, including 10 reviewers' assessments for 156 images of high-magnifying narrow-band imaging (HM-NBI) (67 dysplastic and 89 non-dysplastic histology). We statistically analyzed the diagnostic performance of each diagnostic criterion of MP (form, size, arrangement, density, and white zone), VP (form, caliber change, location, and greenish thick vessels [GTV]), and all their combinations to achieve a simpler diagnostic algorithm to detect superficial BERN.

RESULTS

Diagnostic accuracy values based on the MP of each single criterion or combined criteria showed a marked trend of being higher than those based on VP. In reviewers' assessments of visible MPs, the combination of irregularity for form, size, or white zone had the highest diagnostic performance, with a sensitivity of 87% and a specificity of 91% for dysplastic histology; in the assessments of invisible MPs, GTV had the highest diagnostic performance among the VP of each single criterion and all combinations of two or more criteria (sensitivity, 93%; specificity, 92%).

CONCLUSION

The present post hoc analysis suggests the feasibility of further simplifying the diagnostic algorithm of the JES-BE classification. Further studies in a practical setting are required to validate these results.

Endoscopic Ultrasonography-guided Fine-needle Aspiration Cytology Combined with a Cell-block Method for Gastrointestinal Subepithelial Lesions

Objective The diagnostic accuracy of an endoscopic ultrasound-guided fine-needle aspiration cytology/biopsy combined with a cell-block method (FNA-CB) for gastrointestinal subepithelial lesions (GI-SELs) has not been fully studied. Methods A total of 109 patients (with 110 GI-SELs) were evaluated to clarify the rate of obtaining evaluable histology specimens using FNA-CB. In addition, we investigated the following: 1) the accuracy for determining the histology, 2) effects of the number of cell clusters obtained via FNA-CB, 3) correlation of the Ki67 labelling index (Ki67LI) of the gastrointestinal stromal tumor (GIST) lesions between FNA-CB and resected specimens, and 4) clinical courses for patients followed up after FNA-CB. Results Of the 110 GI-SELs for which FNA-CB was performed, 95 (86%) were able to be histologically evaluated using the first FNA-CB. For the 70 resected GI-SELs, the accuracy of FNA-CB to determine histology was 96%, remaining at 90% even when only a few cell clusters were obtained. The concordance rate of the risk-grouping of GIST (high-risk, Ki67LI ≥8; low-risk, <8) between FNA-CB and resected specimens was 84%. Of the 29 patients followed up after the first FNA-CB, 12 with benign GI-SELs determined using the first FNA-CB showed no obvious increases in their GI-SEL sizes. Conclusion Since FNA-CB can be used to determine the histology and reproductive activity of GI-SELs accurately, not only preoperative histological confirmation but also reliable information to determine clinical plans, such as follow-up without surgery or neoadjuvant chemotherapy, can be obtained.

[Endoscopic mucosal resection of localized plasmablastic lymphoma with early rectal cancer:a rare case report and literature review]

A 79-year-old male with a positive fecal occult blood test result underwent total colonoscopy, which revealed a 15-mm-semipedunculated polyp in the rectum. The polyp appeared to be an adenoma using narrow-band imaging observation in magnifying endoscopy, although a 3mm reddish segment with a different surface structure was identified adjacent to the base of the polyp. En-bloc endoscopic mucosal resection (EMR) was performed. From the pathological evaluation using the specimen, the polyp was mainly a tubular adenoma with an adenocarcinoma component within the lesion. Additionally, a tiny plasmablastic lymphoma (PBL) component, which was positive for CD45, CD79a, CD30, CD38, MUM1, and lambda light chain;negative for CD3, CD5, CD20, CD56, CD138, cyclin D1, PAX5, IgG, IgA, IgM, IgE, HHV8, and kappa light chain, coexisted near the stalk. The proliferation index using Ki-67 immunohistochemistry was approximately 80%. Furthermore, Epstein-Barr virus-encoded RNAs were identified in in-situ hybridization, although the human immunodeficiency virus was not detected. The patient received contrast-enhanced computed tomography (CT) and positron emission tomography-CT (PET-CT) follow-ups after treatment without recurrence for two years. This is the first report of gastrointestinal PBL that could be treated using EMR.

Predictive Factors for Short-Term Survival after Non-Curative Endoscopic Submucosal Dissection for Early Gastric Cancer

BACKGROUND/AIMS

For early gastric cancer (EGC) treated using endoscopic submucosal dissection (ESD) with poor curability defined by the Japanese Guidelines (non-curative EGC, N-EGC), additional gastrectomy has been recommended. However, N-EGC patients without additional gastrectomy often die of other diseases within a relatively short interval after ESD. It has been unclear whether additional gastrectomy is beneficial or not for such patients. The aim of this study was to clarify predictors for short-term survival of N-EGC patients without additional gastrectomy after ESD.

METHODS

One hundred six N-EGC patients without additional gastrectomy were included in this study. Factors related to short-term survival, defined as death within 3 years after ESD, were evaluated using uni- and multivariate analyses by comparing patients with and without short-term survival (Groups S and C, respectively).

RESULTS

During the mean follow-up period of 89 months, 39 patients died (14 patients died within 3 years, being Group S). The cause of death was gastric cancer for only 1 patient in the Group C. The 3- and 5-year overall survival rates were 86.8 and 81.8%, respectively, and the 3- and 5-years disease-specific survival rates were 100 and 98.9%, respectively. Univariate analyses showed that short-term survival was statistically associated with elevated morphology, high-risk status for lymph node metastases as defined by the eCura system, severe comorbidity (Charlson Comorbidity Index [CCI] ≥3), low level of activity in daily living (being unable to go out by oneself), habitation (a nursing home), and several poor nutritional prognostic indices (neutrophil to lymphocyte ratio ≥2.5, geriatric nutritional risk index <92, C-reactive protein ≥1.0). In the multivariate analysis, a high CCI (≥3) was the independent predictor for short-term survival after ESD (odds ratio, 8.1; 95% confidence interval, 1.53-43.0; p = 0.014).

CONCLUSIONS

Severe comorbidity indicated by a high CCI score (≥3) was the independent predictor for short-term survival for EGC patients without additional gastrectomy after non-curative ESD. Since the cause of death for most patients was not gastric cancer, observational follow-ups without additional gastrectomy might be a reasonable option for patients with a poor general status indicated by a CCI ≥3.

60Fe and 244Pu deposited on Earth constrain the r-process yields of recent nearby supernovae

Half of the chemical elements heavier than iron are produced by the rapid neutron capture process (r-process). The sites and yields of this process are disputed, with candidates including some types of supernovae (SNe) and mergers of neutron stars. We search for two isotopic signatures in a sample of Pacific Ocean crust-iron-60 (⁶⁰Fe) (half-life, 2.6 million years), which is predominantly produced in massive stars and ejected in supernova explosions, and plutonium-244 (²⁴⁴Pu) (half-life, 80.6 million years), which is produced solely in r-process events. We detect two distinct influxes of ⁶⁰Fe to Earth in the last 10 million years and accompanying lower quantities of ²⁴⁴Pu. The ²⁴⁴Pu/⁶⁰Fe influx ratios are similar for both events. The ²⁴⁴Pu influx is lower than expected if SNe dominate r-process nucleosynthesis, which implies some contribution from other sources.

Safety and Recipient Satisfaction of Propofol Sedation in Outpatient Endoscopy: A 24-Hour Prospective Investigation Using a Questionnaire Survey

Background/Aims

The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy.

Methods

In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated.

Results

Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations.

Conclusions

Propofol sedation was found to be safe-without severe adverse events or accidents-for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.

Effect of 4-phenylbutyrate and valproate on dominant mutations of WFS1 gene in Wolfram syndrome

PURPOSE

Wolfram syndrome (WS) is a rare disorder caused by mutations in WFS1 that is characterized by diabetes mellitus, optic atrophy, sensorineural deafness, diabetes insipidus, and neurodegeneration. This disease is usually inherited as an autosomal recessive trait, but an autosomal dominant form has been reported. WFS1 encodes a transmembrane protein, which is a maintenance component of endoplasmic homeostasis. These dominant mutations were thought to increase endoplasmic reticulum (ER) stress. Recent studies suggest that 4-phenylbutyrate (PBA) and valproate (VPA) reduce ER stress. The objective of this study was to analyze the effect of PBA and VPA on dominant WFS1 mutants in vitro.

METHODS

We determined whether dominant WFS1 mutants (p.His313Tyr, p.Trp314Arg, p.Asp325_Ile328del, p.Glu809Lys, and p.Glu864Lys) have the dominant negative effect using a luciferase assay of ER stress response element marker as ER stress. Moreover, the rescue of cell apoptosis induced by dominant WFS1 mutants following treatment with PBA or VPA was determined by quantitative real-time PCR of C/EBP homologous protein (CHOP) mRNA expression.

RESULTS

These mutants showed the dominant negative effect on the wild-type WFS1. In addition, the levels of ER stress and CHOP mRNA were significantly elevated by all dominant WFS1 mutants. After treatment with PBA or VPA, ER stress and cell apoptosis were reduced in each mutant.

CONCLUSIONS

PBA and VPA could reduce the ER stress and cell apoptosis caused by dominant WFS1 mutants.

[Helicobacter pylori-negative gastric mucosa-associated lymphoid tissue (MALT) lymphoma with MALT translocation gene 1 diagnosed using an endoscopic submucosal dissection specimen]

A 15-mm whitish, depressed lesion was observed in the stomach of a 39-year-old using screening esophagogastroduodenoscopy. The lesion had grown to a size of 40mm and had a cobblestone-like appearance at an 11-year endoscopic follow-up. Using endoscopic submucosal dissection (ESD) as a diagnostic therapy, gastric mucosa-associated lymphoid tissue (MALT) lymphoma with MALT translocation gene 1 without Helicobacter pylori infection was detected. Although the patient did not undergo additional treatments, he remained alive without for recurrence 5 years after ESD.

Immune microenvironment in Barrett's esophagus adjacent to esophageal adenocarcinoma: possible influence of adjacent mucosa on cancer development and progression

The immune microenvironment plays a pivotal role in cancer development and progression. Therefore, we studied the status of immune cells in esophageal adenocarcinoma (EAC) and adjacent Barrett's esophagus (BE) and their association with the clinical course of patients. We included 87 patients with EAC who underwent surgical resection or endoscopic submucosal dissection. CD3, CD8, Foxp3, p53, and Ki-67 were immunolocalized in EAC and adjacent BE (N = 87) and BE without EAC (N = 13). BE adjacent to EAC exhibited higher CD3+ lamina propria lymphocyte (LPL) numbers than BE without EAC. Abundant Foxp3+ LPLs in BE were associated with dysplasia and increased Ki-67 labeling index (LI) in BE glandular cells and tended to link to aberrant p53 expression. Abundant CD8+ LPLs in adjacent BE were associated with worse prognosis of EAC patients (P = 0.019). Results of our present study firstly revealed the potential influence of the tissue immune microenvironment of BE adjacent to EAC on cancer development and eventual clinical outcome of EAC patients. T cell infiltration could play pivotal roles in facilitating the dysplasia-adenocarcinoma sequence in BE. The number of Foxp3+ T cells is increased at the early stage of carcinogenesis and could help identify patients harboring dysplastic and highly proliferating cells. CD8+ T cells could reflect unfavorable inflammatory response in adjacent tissue microenvironment and help predict worse prognosis of EAC patients.

Glucocorticoid receptor and serum- and glucocorticoid-induced kinase-1 in esophageal adenocarcinoma and adjacent Barrett's esophagus

Barrett's esophagus (BE) is a consequence of gastroesophageal reflux disease and is predisposed to esophageal adenocarcinoma (EAC). EAC is an exemplar model of inflammation-associated cancer. Glucocorticoids suppress inflammation through glucocorticoid receptor (GR) and serum- and glucocorticoid-induced kinase-1 (Sgk1) expressions. Therefore, we immunolocalized GR and Sgk1 in EAC and the adjacent BE tissues and studied their association with clinical disease course in 87 patients with EAC who underwent surgical resection (N = 58) or endoscopic submucosal dissection (N = 29). Low GR and Sgk1 expressions in adjacent BE tissues were associated with adverse clinical outcomes (P = 0.0008 and 0.034, respectively). Patients with low Sgk1 expression in EAC cells exhibited worse overall survival (P = 0.0018). In multivariate Cox regression analysis, low GR expression in the adjacent nonmalignant BE tissues was significantly associated with worse overall survival (P = 0.023). The present study indicated that evaluation of GR and Sgk1 expressions in both the EAC cells and adjacent nonmalignant BE tissues could help to predict clinical outcomes following endoscopic and surgical treatments. In particular, the GR status in BE tissues adjacent to EAC was an independent prognostic factor.

Estimate of Fukushima-derived radiocaesium in the North Pacific Ocean in summer 2012

Distributions of radiocaesium (134Cs and 137Cs) derived from the Tokyo Electric Power Company (TEPCO) Fukushima Dai-ichi Nuclear Power Plant (FNPP1) accident in the North Pacific Ocean in the summer of 2012 were investigated. We have estimated the radiocaesium inventory in the surface layer using the optimal interpolation analysis and the subducted amount into the central mode water (CMW) by using vertical profiles of FNPP1-134Cs and mass balance analysis as the first approach. The inventory of the 134Cs in the surface layer in the North Pacific Ocean in August-December 2012 was estimated at 5.1 ± 0.9 PBq on 1 October 2012, which corresponds to 8.6 ± 1.5 PBq when it was decay corrected to the date of the FNPP1 accident, 11 March 2011. It was revealed that 56 ± 10% of the released 134Cs into the North Pacific Ocean, which was estimated at 15.3 ± 2.6 PBq, transported eastward in the surface layer in 2012. The amount of 134Cs subducted in the CMW was estimated to be 2.5 ± 0.9 PBq based on the mass balance among the three domains of the surface layer, subtropical mode water, and CMW.

Newly developed magnifying endoscopic classification of the Japan Esophageal Society to identify superficial Barrett's esophagus-related neoplasms

AIM AND METHODS

The Japan Esophageal Society created a working committee group consisting of 11 expert endoscopists and 2 pathologists with expertise in Barrett's esophagus (BE) and esophageal adenocarcinoma. The group developed a consensus-based classification for the diagnosis of superficial BE-related neoplasms using magnifying endoscopy.

RESULTS

The classification has three characteristics: simplified, an easily understood classification by incorporating the diagnostic criteria for the early gastric cancer, including the white zone and demarcation line, and the presence of a modified flat pattern corresponding to non-dysplastic histology by adding novel diagnostic criteria. Magnifying endoscopic findings are composed of mucosal and vascular patterns, and are initially classified as "visible" or "invisible." Morphologic features were evaluated for "visible" patterns, and were subsequently rated as "regular" or "irregular," and the histology, non-dysplastic or dysplastic, was predicted.

CONCLUSION

We introduce the process and outline of the magnifying endoscopic classification.

Metal Stent Placement in the Afferent Loop Obstructed by Peritoneal Metastases-Experience of Five Cases

Afferent loop syndrome is often difficult to resolve. Among patients with afferent loop syndrome whose data were extracted from databases, 5 patients in whom metal stent placement was attempted were included and evaluated in this study. The procedure was technically successful without any adverse events in all patients. Metal stent(s) was placed with an endoscope in the through-the-scope manner in 4 patients and via a percutaneous route in 1 patient. Obvious clinical efficacy was observed in all patients. Adverse events related to the procedure and stent occlusion during the follow-up period were not observed. Metal stent placement for malignant obstruction of the afferent loop was found to be safe and feasible.

Novel biallelic SZT2 mutations in 3 cases of early-onset epileptic encephalopathy

The seizure threshold 2 (SZT2) gene encodes a large, highly conserved protein that is associated with epileptogenesis. In mice, Szt2 is abundantly expressed in the central nervous system. Recently, biallelic SZT2 mutations were found in 7 patients (from 5 families) presenting with epileptic encephalopathy with dysmorphic features and/or non-syndromic intellectual disabilities. In this study, we identified by whole-exome sequencing compound heterozygous SZT2 mutations in 3 patients with early-onset epileptic encephalopathies. Six novel SZT2 mutations were found, including 3 truncating, 1 splice site and 2 missense mutations. The splice-site mutation resulted in skipping of exon 20 and was associated with a premature stop codon. All individuals presented with seizures, severe developmental delay and intellectual disabilities with high variability. Brain MRIs revealed a characteristic thick and short corpus callosum or a persistent cavum septum pellucidum in each of the 2 cases. Interestingly, in the third case, born to consanguineous parents, had unexpected compound heterozygous missense mutations. She showed microcephaly despite the other case and previous ones presenting with macrocephaly, suggesting that SZT2 mutations might affect head size.

Carbon dioxide insufflation in esophageal endoscopic submucosal dissection reduces mediastinal emphysema: A randomized, double-blind, controlled trial

AIM

To assess the efficacy of CO₂ insufflation for reduction of mediastinal emphysema (ME) immediately after endoscopic submucosal dissection (ESD).

METHODS

A total of 46 patients who were to undergo esophageal ESD were randomly assigned to receive either CO₂ insufflation (CO₂ group, n = 24) or air insufflation (Air group, n = 22). Computed tomography (CT) was carried out immediately after ESD and the next morning. Pain and abdominal distention were chronologically recorded using a 100-mm visual analogue scale (VAS). The volume of residual gas in the digestive tract was measured using CT imaging.

RESULTS

The incidence of ME immediately after ESD in the CO₂ group was significantly lower than that in the Air group (17% vs 55%, P = 0.012). The incidence of ME the next morning was 8.3% vs 32% respectively (P = 0.066). There were no differences in pain scores or distention scores at any post-procedure time points. The volume of residual gas in the digestive tract immediately after ESD was significantly smaller in the CO₂ group than that in the Air group (808 mL vs 1173 mL, P = 0.013).

CONCLUSION

CO₂ insufflation during esophageal ESD significantly reduced postprocedural ME. CO₂ insufflation also reduced the volume of residual gas in the digestive tract immediately after ESD, but not the VAS scores of pain and distention.

Usefulness of the thread-traction method in esophageal endoscopic submucosal dissection: randomized controlled trial

BACKGROUND AND AIM

To assess the usefulness of the thread-traction method (TT method) in esophageal endoscopic submucosal dissection (ESD).

METHODS

A total of 40 lesions that were scheduled to be treated by esophageal ESD were included in the study. The TT method was used for 20 lesions (group TT) and conventional ESD was used for 20 lesions (group C) after randomization. The hook-knife method was used in all cases. In group TT, after circumferential mucosal incision, a clip with thread was attached to the oral edge of the lesion.

RESULTS

ESD was carried out in all cases. Effective countertraction was created by the TT method, and it was possible to carry out an efficient dissection operation. Significant shortening of dissection time was achieved in group TT compared with group C (19.8 min vs 31.8 min, P = 0.044). Mean number of local injections during dissection was significantly less in group TT compared with that in group C (0.6 times vs 2.2 times, P < 0.001). As for the amount of local injection, group TT required significantly less compared with group C (2.6 mL vs 7.5 mL, P < 0.01). No complications were encountered.

CONCLUSION

The TT method in esophageal ESD was safe and contributed to shortening of dissection time. The TT method is expected to become widespread as a safe and useful procedure.

A prospective, randomized, double-blind, controlled trial on the efficacy of carbon dioxide insufflation in gastric endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS

Carbon dioxide (CO2) insufflation is expected to be safe and effective in endoscopic submucosal dissection (ESD) as well as in other endoscopic procedures. The present study aimed to clarify the usefulness and safety of CO2 insufflation in gastric ESD.

PATIENTS AND METHODS

A total of 102 consecutive patients were randomly assigned to CO2 insufflation (CO2 group, n = 54) or air insufflation (Air group, n = 48). Abdominal pain and distension were chronologically recorded on a 100-mm visual analog scale (VAS). The volume of residual gas in the digestive tract was measured by computed tomography performed immediately after ESD.

RESULTS

Abdominal pain on a 100-mm VAS in the CO2 vs. Air group was 4 vs. 3 immediately after ESD, 4 vs. 4 one hour after the procedure, 3 vs. 3 three hours after the procedure, and 1 vs. 4 the next morning, showing no difference between the groups. In addition, there was no difference in abdominal distension on the 100-mm VAS over the time course of the study. The volume of residual gas in the digestive tract in the CO2 group was significantly smaller than that in the Air group (643 mL vs. 1037 mL, P < 0.001). The dose of sedative drugs did not differ between the groups. Neither the incidences of complications nor clinical courses differed between the groups.

CONCLUSIONS

Compared with air insufflation, CO2 insufflation during gastric ESD significantly reduced the volume of residual gas in the digestive tract but not the VAS score of abdominal pain and distension.

Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding

BACKGROUND AND AIMS

To prospectively evaluate the role of contrast-enhanced computed tomography (CE-CT) in the detection of colonic diverticular bleeding (CDB).

PATIENTS AND METHODS

Consecutive patients who presented with hematochezia and were clinically suspected of CDB were prospectively enrolled. Those who could undergo both CE-CT and total colonoscopy, and who were finally diagnosed as CDB, were included in the analysis.

RESULTS

Fifty-two cases were finally included in the analysis. The detection rate of CDB by CT was 15.4 % (8/52). Univariate analysis showed that the interval from the latest episode of hematochezia to the performance of CT and the presence of a past history of CDB were contributing factors for detection. The interval was 1.6 ± 4.6 h (mean ± SD) in patients detected by CT, and 3.4 ± 3.2 h in those without detection. The detection rate of CDB by total colonoscopy was 38.5 % (20/52). The overall detection rate was 46.2 % (24/52), which was superior to what CT or colonoscopy alone achieved.

CONCLUSIONS

CE-CT may play a complementary role to colonoscopy in patients with suspected CDB, but is not recommended for all cases due to its low detection rate. Patients who can be examined within 2 h of last hematochezia would be candidates for urgent CT.

Intermittent breath holding during moderate bicycle exercise provokes consistent changes in muscle oxygenation and greater blood lactate response

AIM

This study examined the effect of intermittent breath holding (IBH) on physiological response, including oxygenation in working muscle, to moderate-intensity exercise.

METHODS

Thirteen men performed bicycle exercise for 5 min at 65% of peak oxygen uptake with normal breathing (NB) and with IBH. Muscle oxygenation, concentration changes of oxyhemoglobin (ΔOxy-Hb), deoxyhemoglobin (ΔDeoxy-Hb) and total hemoglobin (ΔTotal-Hb), in the right vastus lateralis were continuously monitored using near-infrared spectroscopy (NIRS). Finger capillary blood samples were taken after exercise for analyzing blood lactate concentration (BLa).

RESULTS

NIRS parameters showed acute changes to each BH episode in the IBH condition (Total-Hb and ΔOxy-Hb decreased, ΔDeoxy-Hb increased). Accordingly, in the IBH condition, ΔOxy-Hb was lower (P<0.05) and ΔDeoxy-Hb was higher (P<0.05) compared to that in the NB condition, whereas there was no difference in ΔTotal-Hb in the both conditions. BLa levels were greater (P<0.05) in the IBH condition compare to the NB condition.

CONCLUSION

These results suggest that IBH during moderate-intensity exercise provokes consistent changes in muscle oxygenation, leading to lower tissue oxygenation. Our data also indicate that exercise with IBH induces higher BLa.

Clinicopathological study on endocrine cell micronests associated with early gastric cancer

OBJECTIVE

The purpose of this study was to review cases of early gastric cancer associated with Endocrine cell micronests (ECM) and investigate the incidence and characteristics of these lesions.

METHODS

A total of 482 patients who had undergone endoscopic or surgical resection for gastric epithelial neoplasms from April 2008 to March 2010 were enrolled in this study. After detection of ECM in the lamina propria mucosa by histological examination of the resected specimens with hematoxilin-eosin staining, immunostaining was also performed. Clinical manifestation and endoscopic findings, as well as histological findings, were examined.

RESULTS

Among the 482 patients, 5 (1.0%) had ECM. The histological type of gastric epithelial cancers associated with ECM was tubular adenocarcinoma and carcinoma in situ (Tis) in the WHO classification in all 5 cases. ECM were round to oval or trabecular and located within the area of the early gastric cancer in all the 5 cases. The background gastric mucosa was Type A gastritis in 2 patients and ordinary atrophic gastritis in 2 patients. In the other case, it was difficult to determine the type of gastritis.

CONCLUSION

ECM developed not only from the background of Type A gastritis but also from ordinary atrophic gastritis. ECM coexistent with gastric cancer were present in 1.0% of resectable gastric epithelial neoplasms.

Significant relationship between local angle at fused segments and C2-7 angle: Average duration of longer than 20 years after anterior cervical discectomy and fusion

Background:

The authors have focused their attention to the radiological durability of cervical sagittal alignment after anterior cervical discectomy and fusion (ACDF) using autologous bone grafting.

Materials and Methods:

Among the patients who underwent ACDF with trans-unco-discal (TUD) approach between 1976 and 1997, 22 patients (16 males and 6 females) made return visits for a clinical evaluation. Patients with trauma or previously treated by anterior cervical fusion or by posterior decompression were excluded from the present study. Clinical evaluation included adjacent segment degeneration (ASD), osseous fusion, local angle at the fused segments and C2-7 angle of cervical spine.

Results:

The duration after ACDF ranged from 13 to 34 years with an average of 21.3 ± 7.0 years. A single level fusion was done on 8 patients, 2 levels on 11 patients, 3 levels on 2 patients, and 4 levels on 1 patient. Imaging studies indicated that 12 of the 22 patients (54.5%) were graded as having symptomatic ASD. Osseous bony fusion at ACDF was recognized in all cases. None of the patients demonstrated kyphotic malalignment of the cervical spine. Average degrees of local angle at the fused segments and the C2-7 angle were 7.06 and 17.6, respectively. Statistical analysis indicated a significant relationship between the local at the fused segments and C2-7 angles.

Conclusions:

Sagittal alignment of the cervical spine was durable long after ACDF when the local angle at the fused segments was well stabilized.

Normal variation of diffusion tensor parameters of the spinal cord in healthy subjects at 3.0-Tesla

AIMS

The purposes of the present study were to clarify the normal variation and to determine the normal reference values of diffusion tensor (DT) parameters (mean diffusivity [MD] and fractional anisotropy [FA]) of the spinal cord in single-shot fast spin-echo-based sequence at 3.0-Tesla (3T).

MATERIALS AND METHODS

Thirty healthy subjects (mean age = 44.2 years, range = 20-72 years) were enrolled for this study. Mean values of MD and FA in six spinal levels (C2/3, C3/4, C4/5, C5/6, C6/7, and C7/Th1) were measured. Mean values, variances, and distributions of the MD and FA in each spinal level were analyzed. Age-dependent change of MD and FA as well as correlation between MD and FA was also analyzed.

RESULTS

At all spinal levels, the values can be considered to be Gaussian distribution in MD but not in FA. A significant statistical negative correlation was observed between aging and the values of MD (r = 0.429, P = 0.018), but insignificant between the values of FA (P = 0.234). A slight significant statistical negative correlation was observed between the values of MD and FA (r = 0.156, P = 0.037). One way repeated measures analysis of variance indicated the significant difference between the spinal levels in both MD (P = 0.003) and FA (P < 0.0001).

CONCLUSIONS

The analyzed data in the present study would be helpful for comparison when investigating the spinal condition of spinal disorders.

A dipole mode in the tropical Indian Ocean

For the tropical Pacific and Atlantic oceans, internal modes of variability that lead to climatic oscillations have been recognized, but in the Indian Ocean region a similar ocean-atmosphere interaction causing interannual climate variability has not yet been found. Here we report an analysis of observational data over the past 40 years, showing a dipole mode in the Indian Ocean: a pattern of internal variability with anomalously low sea surface temperatures off Sumatra and high sea surface temperatures in the western Indian Ocean, with accompanying wind and precipitation anomalies. The spatio-temporal links between sea surface temperatures and winds reveal a strong coupling through the precipitation field and ocean dynamics. This air-sea interaction process is unique and inherent in the Indian Ocean, and is shown to be independent of the El Niño/Southern Oscillation. The discovery of this dipole mode that accounts for about 12% of the sea surface temperature variability in the Indian Ocean--and, in its active years, also causes severe rainfall in eastern Africa and droughts in Indonesia--brightens the prospects for a long-term forecast of rainfall anomalies in the affected countries.

Efficacy of acetic acid-spraying method in diagnosing extension of Barrett's cancer under the squamous epithelium

AIM

Endoscopic diagnosis of the lateral extension of Barrett's cancer under the squamous epithelium (BCUS) is sometimes difficult because the cancer is unobservable in the esophageal lumen. The aim of the present study was to clarify the endoscopic features of the extension of BCUS and verify the usefulness of the acetic acid-spraying method (AAS) for diagnosis.

METHODS

A total of 25 patients with Barrett's cancer who had undergone endoscopic resection were included in this study. Histological examination of patients' resected specimens was performed to identify the presence of BCUS. Then, the endoscopic images of the BCUS cases were reviewed to summarize the findings and to evaluate the feasibility of diagnosing the extent of BCUS with each imaging technique.

RESULTS

Of the 25 patients, 10 (40%) had BCUS. With white-light imaging, subtle reddish change was observed in the area of BCUS in 80% of the patients, and a flat elevated lesion was recognized in 30%. With narrow band imaging, slight brownish change was observed in the area of BCUS in 86% of the patients. Slight white changes were visualized in all cases with AAS. The extension of BCUS was correctly diagnosed by white-light imaging, narrow band imaging and AAS in 50%, 43% and 100% of the cases, respectively. Histology verified the opening of cancerous glands, which extended under the squamous epithelium, into the esophagus in the area showing slight white changes by AAS.

CONCLUSION

AAS can be useful for diagnosing the extension of BCUS.

Separation of pygmy dipole and M1 resonances in 90Zr by a high-resolution inelastic proton scattering near 0°

A high-resolution measurement of inelastic proton scattering off (90)Zr near 0° was performed at 295 MeV with a focus on a pronounced strength previously reported in the low-energy tail of giant dipole resonance. A forest of fine structure was observed in the excitation energy region 7-12 MeV. A multipole decomposition analysis of the angular distribution for the forest was carried out using the ECIS95 distorted-wave Born approximation code with the Hartree-Fock plus random-phase approximation model of E1 and M1 transition densities and inclusion of E1 Coulomb excitation. The analysis separated pygmy dipole and M1 resonances in the forest at E(PDR)=9.15±0.18 MeV with Γ(PDR)=2.91±0.64 MeV and at E(M1)=9.53±0.06 MeV with Γ(M1)=2.70±0.17 MeV in the Lorentzian function, respectively. The B(E1)↑ value for pygmy dipole resonance over 7-11 MeV is 0.75±0.08 e(2)fm(2), which corresponds to 2.1±0.2% of the Thomas-Reiche-Kuhn sum rule.

A pilot study to assess mediastinal emphysema after esophageal endoscopic submucosal dissection with carbon dioxide insufflation

BACKGROUND AND AIMS

Mediastinal emphysema sometimes develops following esophageal endoscopic submucosal dissection (ESD) without perforation because the esophagus has no serosa. Carbon dioxide (CO2) insufflation during esophageal ESD may reduce the incidence of mediastinal emphysema. The aim of the present study was to compare the incidence and severity of post-ESD mediastinal emphysema in patients receiving CO2 insufflation vs. standard air insufflation during esophageal ESD.

PATIENTS AND METHODS

A total of 27 patients who had undergone esophageal ESD with insufflation of CO2 between July 2009 and March 2010 were enrolled in this study (CO2 group). Another 105 patients who had undergone esophageal ESD with air insufflation between March 2004 and May 2009 were included as historical controls (air group). Multi-detector row computed tomography (MDCT) was carried out immediately after ESD. A conventional chest radiograph was taken the next day. Mediastinal emphysema findings on MDCT and radiography were compared between the groups.

RESULTS

Mediastinal emphysema detected by chest radiography was 0 % in the CO2 group vs. 6.6 % in the air group (n.s.). Mediastinal emphysema on MDCT was significantly less frequent in the CO2 group compared with the air group (30 % vs. 63 %; P = 0.002). The severity of mediastinal emphysema also tended to be lower in the CO2 group.

CONCLUSIONS

Whereas mediastinal emphysema detected by radiography is not so common, MDCT immediately after ESD revealed a certain prevalence of post-ESD mediastinal emphysema. Insufflation of CO2 rather than air during esophageal ESD significantly reduced postprocedural mediastinal emphysema. CO2 can be considered as insufflating gas for esophageal ESD.

A case of early gastric cancer in which the degree of histological atypia was correctly predicted by magnifying endoscopy combined with narrow band imaging

We herein report a case of early gastric cancer with mixed components having different grades of atypia, which was correctly predicted by magnifying endoscopy combined with narrow band imaging. A 67-year-old man had a flat elevated lesion (0-IIa) in the anterior wall of the gastric antrum. With narrow band imaging, a flat lateral extension (0-IIb), not recognized with white light imaging was seen in the anal side of the main tumor. Magnifying endoscopy combined with narrow band imaging saw a relatively regular fine network pattern of micro-vessels in the surface of the 0-IIa area. However, in the surface of the 0-IIb area, a villous structure with villi of various size and heterogeneity, micro-vessels showing tortuousity were observed. We judged the grade of atypia to be higher in the 0-IIb area than in the 0-IIa area. Histological examination of the resected specimen verified the 0-IIa area and 0-IIb area as adenoma and adenocarcinoma, respectively.

Efficacy of propofol sedation for endoscopic submucosal dissection (ESD): assessment with prospective data collection

OBJECTIVE

The indications for endoscopic treatment in early stage cancer of the digestive tract are expanding with the emergence and technical development of endoscopic submucosal dissection (ESD). ESD requires longer term stable sedation than conventional endoscopic procedures due to the necessity of meticulous control of the devices during the procedure. Propofol has a very short half-life and can be administered continuously, which is advantageous for long-term sedation. Propofol, thus, is likely to be useful for sedation during ESD.

METHODS

Fifty consecutive patients who underwent ESD for early gastric cancer with propofol sedation (Group P) and those with midazolam sedation (Group M) were included in this study. Cardiorespiratory suppression rate and the condition of arousal were compared between the groups. A questionnaire survey on the satisfaction of endoscopists, anesthesiologists, endoscopy nurses, and ward nurses with the use of propofol was also carried out.

RESULTS

Respiratory suppression was observed in 50% in Group M and in 20% in Group P (p<0.05). Hypotension was seen in 14% and 36% in Groups M and P, respectively (p<0.05). No sedation-related complications were encountered in either of the groups. Arousal rates 1 hour and 3 hours after the procedure were 23% and 60% in group M and 86% and 100% in Group P (p<0.05). As for the questionnaire survey, most respondents, in particular the ward nurses, supported the use of propofol.

CONCLUSION

Our data suggest that propofol is safe and useful during ESD as compared with midazolam.

[A case of giant esophageal leiomyoma successfully resected by endoscopic submucosal dissection followed by retrieval via laparotomy]

A 30-year-old woman with chest discomfort at swallowing and occasional vomiting was referred to our department with a diagnosis of esophageal submucosal tumor. CT visualized a mass 70 mm in diameter in the middle esophagus. Esophagogastroduodenoscopy revealed a pedunculated submucosal tumor, and endoscopic resection was considered. As the size of the tumor was so large, retrieval of the resected specimen via the stomach following incision, laparotomy was planned. En bloc resection by endoscopic submucosal dissection with a Hook-knife was performed. Retrieval of the resected specimen was carried out as planned. The specimen, which was 53×48×43mm in size with a distinct margin, was diagnosed as leiomyoma derived from the muscularis mucosae histologically. Her postprocedural course was uneventful. Endoscopic resection can be chosen when an esophageal submucosal tumor is pedunculated with abundant mobility, making it possible to avoid invasive surgery.

Autism spectrum disorder is related to endoplasmic reticulum stress induced by mutations in the synaptic cell adhesion molecule, CADM1

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with an unknown molecular pathogenesis. A recent molecular focus has been the mutated neuroligin 3, neuroligin 3(R451C), in gain-of-function studies and for its role in induced impairment of synaptic function, but endoplasmic reticulum (ER) stress induced by mutated molecules also deserves investigation. We previously found two missense mutations, H246N and Y251S, in the gene-encoding synaptic cell adhesion molecule-1 (CADM1) in ASD patients, including cleavage of the mutated CADM1 and its intracellular accumulation. In this study, we found that the mutated CADM1 showed slightly reduced homophilic interactions in vitro but that most of its interactions persist. The mutated CADM1 also showed morphological abnormalities, including shorter dendrites, and impaired synaptogenesis in neurons. Wild-type CADM1 was partly localized to the ER of C2C5 cells, whereas mutated CADM1 mainly accumulated in the ER despite different sensitivities toward 4-phenyl butyric acid with chemical chaperone activity and rapamycin with promotion activity for degradation of the aggregated protein. Modeling analysis suggested a direct relationship between the mutations and the conformation alteration. Both mutated CADM1 and neuroligin 3(R451C) induced upregulation of C/EBP-homologous protein (CHOP), an ER stress marker, suggesting that in addition to the trafficking impairment, this CHOP upregulation may also be involved in ASD pathogenesis.

Predominant inhibition of Th1 cytokines in New Zealand black/white F1 mice treated with FK506

The T-helper 1/T-helper 2 (Th1/Th2) cell balance was examined in 6-month-old New Zealand black/white F1 (B/WF1) mice treated with an immunosuppressive agent, FK506. The survival rate of mice treated with 10 mg/kg/day of FK506 was 7/8, while that of those treated with 2.5 mg/kg/day was 5/8, and 4/8 after treatment for 8 weeks with placebo. Proteinuria, which was already positive in all mice before the treatment, in the seven of eight mice treated with 10 mg/kg/day remained mildly positive (< or = 1+), while seven of eight mice treated with 2.5 mg/kg/day and six of eight mice treated with the placebo showed severe proteinuria (> or = 2+). Pathological changes in the kidneys of mice treated with 10 mg/kg/day of FK506 were less severe than in mice treated with the placebo or 2.5 mg/kg/day of FK506. Expression of mRNA was unchanged for all cytokines determined in the groups treated with 2.5 mg/kg/day of FK506 or placebo. In contrast, expression of mRNA for interleukin (IL)-2, and interferon (IFN)-gamma was suppressed, while that for IL-4 and IL-10 was not suppressed in the group treated with 10 mg/kg of FK506. The serum levels of IgG-class anti-DNA antibodies, which had been elevated before the treatment, were suppressed--especially in the IgG2a subclass--and the deposition of IgG2a and IgG2b in the glomeruli was reduced in the group treated with 10 mg/kg/day of FK506 compared with the other groups. These findings suggest that an improvement in the lupus nephritis of 6-month-old B/WF1 mice induced by FK506 might be associated with a predominant inhibition of Th1 cytokine.

112. DIFFERENTIAL DEVELOPMENT OF SEX-RELATED CHARACTERS OF THE GSP AND PNP/DO CHICKENS AFTER LEFT-OVARIECTOMY

To elucidate the strain difference in the sex reversal of genetic female to phenotypic male, GSP and PNP/DO females were left ovariectomized (ovx) between one day to three days after hatching and the degree of masculinization based on sex-related characters, histological analysis of the right gonad and hormone assay were assessed at one year of age. The GSP and PNP/DO inbred lines were both derived from the Fayoumi breed and are only differentiated based on red blood cell antigens type carried by each of the inbred line. Comb and wattles were found to be significantly bigger (P < 0.05) in the GSP ovx compared to the PNP/DO ovx, although male plumage pattern were more pronounced in the PNP/DO ovx. Spurs were observed both in the GSP and PNP/DO ovx with no significant difference (P > 0.05) in length to the respective male controls and body weight were not significantly different (P > 0.05) to the female controls. The size of the right gonad were significantly bigger (P < 0.05) in the GSP ovx than the PNP/DO ovx. Positive correlations were found in the sex related characters as well as plasma testosterone level and the right gonad weight both in the GSP and PNP/DO ovx except for the spur length which resulted into a negative correlation in the PNP/DO ovx. Histological analysis revealed that the right gonad of PNP/DO ovx are morphologically developed compared to GSP ovx showing more advance stages of spermatogenesis. It could be inferred that PNP/DO females which exhibit hereditary persistent right oviduct, are more responsive to the masculinizing effect of ovariectomy compared to GSP females, suggesting that genetic background may have a possible contribution on the degree of masculinization and subsequent development of sex related characters.

M1 gamma strength for zirconium nuclei in the photoneutron channel

Photoneutron cross sections were measured for 91Zr, 92Zr, and 94Zr near the neutron separation energy with quasimonochromatic gamma rays. The data exhibit some extra components around the neutron threshold. A coherent analysis of the photoneutron data for 92Zr together with the neutron capture on 91Zr based on the microscopic Hartree-Fock-Bogoliubov plus quasiparticle random-phase approximation model for the E1 strength has revealed the presence of an M1 resonance at 9 MeV. The microscopic approach systematically shows the same M1 strength in the photoneutron cross section for 91Zr and 94Zr. The total M1 strength is about 75% larger than the strength predicted by the systematics, being qualitatively consistent with the giant M1 resonance observed in the inelastic proton scattering.

Improvement of pulmonary function and dyspnea by tiotropium in COPD patients using a transdermal β2-agonist

BACKGROUND

A combination of bronchodilators may be effective in the treatment of chronic obstructive pulmonary disease (COPD). We examined the effect of adding a long-acting anti-cholinergic agent (tiotropium) to a transdermal-type beta(2)-agonist (tulobuterol) on dyspnea as well as pulmonary function.

METHODS

In a multicentre, randomized, parallel design study, 60 COPD patients treated with the transdermal beta(2)-agonist tulobuterol were divided into a tiotropium added group (Tulo+Tio group, n=40) or transdermal beta(2)-agonist tulobuterol alone group (Tulo group, n=20), and then treated for 4 weeks after a 2 week run-in period. Pulmonary function and a dyspnea (Medical Research Council (MRC)) scale were assessed before and after the treatment. Daily peak expiratory flow (PEF) monitoring was also performed.

RESULTS

After 4 weeks, the Tulo+Tio group showed a significant increase in pulmonary function compared with the Tulo group; DeltaFVC (0.31+/-0.06 L vs. 0.06+/-0.05 L, p< 0.01), DeltaFEV(1) (0.15+/-0.03 L vs. -0.02+/-0.02 L, p<0.0001), and DeltaPEF (41.0+/-5.1 L/min vs. 0.5+/-3.5 L/min, p<0.0001). The MRC dyspnea scale was also significantly improved in Tulo+Tio, but not in Tulo group.

CONCLUSION

These results suggest that tiotropium caused a significant improvement in both pulmonary function and dyspnea in COPD patients already treated with the transdermal beta(2)-agonist tulobuterol.

Extraction of weak transition strengths via the (3He, t) reaction at 420 MeV

Differential cross sections for transitions of known weak strength were measured with the (3He, t) reaction at 420 MeV on targets of 12C, 13C, 18O, 26Mg, 58Ni, 60Ni, 90Zr, 118Sn, 120Sn, and 208Pb. Using these data, it is shown that the proportionalities between strengths and cross sections for this probe follow simple trends as a function of mass number. These trends can be used to confidently determine Gamow-Teller strength distributions in nuclei for which the proportionality cannot be calibrated via beta-decay strengths. Although theoretical calculations in the distorted-wave Born approximation overestimate the data, they allow one to understand the main experimental features and to predict deviations from the simple trends observed in some of the transitions.

Possible Impact of Salivary Influence on Cytokine Analysis in Exhaled Breath Condensate

Background

Exhaled breath condensate (EBC) is thought to contain substances of the lower airway epithelial lining fluid (ELF) aerosolized by turbulent flow. However, contamination by saliva may affect the EBC when collected orally.

Objective

The purpose of this study was to compare the cytokine expression levels in EBC with those in saliva, and to clarify the influence of saliva on cytokine measurements of EBC.

Methods

EBC and saliva samples were obtained from 10 adult subjects with stable asthma. To estimate differences in the contents of substances between EBC and saliva, the total protein concentration of each sample was measured. Further, we also measured the total protein concentration of ELF obtained from another patient group with suspected lung cancer using a micro sampling probe during bronchoscopic examination and roughly estimated the dilution of EBC by comparing the total protein concentration of EBC and ELF from those two patient groups. The cytokine expression levels of EBC and saliva from asthmatic group were assessed by a cytokine protein array.

Results

The mean total protein concentrations in EBC, saliva and ELF were 4.6 μg/ml, 2,398 μg/ml and 14,111 μg/ml, respectively. The dilution of EBC could be estimated as 1:3000. Forty cytokines were analyzed by a cytokine protein array and each cytokine expression level of EBC was found to be different from that of saliva. Corrected by the total protein concentration, all cytokine expression levels of EBC were significantly higher than those of saliva.

Conclusion

These results suggest that the salivary influence on the cytokine assessment in EBC may be negligible.