Search

Objectives: High‐resolution manometry (HRM) and esophagography are used for achalasia diagnosis; however, achalasia phenotypes combining esophageal motility and morphology are unknown. Moreover, predicting treatment outcomes of peroral endoscopic myotomy (POEM) in treatment‐naïve patients remains an unmet need. Methods: In this multicenter cohort study, we included 1824 treatment‐naïve patients diagnosed with achalasia. In total, 1778 patients underwent POEM. Clustering by machine learning was conducted to identify achalasia phenotypes using patients' demographic data, including age, sex, disease duration, body mass index, and HRM/esophagography findings. Machine learning models were developed to predict persistent symptoms (Eckardt score ≥3) and reflux esophagitis (RE) (Los Angeles grades A–D) after POEM. Results: Machine learning identified three achalasia phenotypes: phenotype 1, type I achalasia with a dilated esophagus (n = 676; 37.0%); phenotype 2, type II achalasia with a dilated esophagus (n = 203; 11.1%); and phenotype 3, late‐onset type I–III achalasia with a nondilated esophagus (n = 619, 33.9%). Types I and II achalasia in phenotypes 1 and 2 exhibited different clinical characteristics from those in phenotype 3, implying different pathophysiologies within the same HRM diagnosis. A predictive model for persistent symptoms exhibited an area under the curve of 0.70. Pre‐POEM Eckardt score ≥6 was the greatest contributing factor for persistent symptoms. The area under the curve for post‐POEM RE was 0.61. Conclusion: Achalasia phenotypes combining esophageal motility and morphology indicated multiple disease pathophysiologies. Machine learning helped develop an optimal risk stratification model for persistent symptoms with novel insights into treatment resistance factors. [ABSTRACT FROM AUTHOR]

Objectives: Clinical outcomes of endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) with esophageal varices (EVs) are obscure. We aimed to elucidate the clinical outcomes of ESD for ESCC with EVs in a multicenter, retrospective study. Methods: We established a retrospective cohort of 30 patients with ESCC complicating EVs, who underwent ESD at 11 Japanese institutions. Rates of en bloc resection and R0 resection, procedure time, and adverse events were evaluated as indicators of the feasibility and safety of ESD. Additional treatment, recurrence, and metastasis of the lesions were evaluated as indicators of the long‐term efficacy of ESD. Results: Portal hypertension was caused by cirrhosis, of which alcohol was the most common cause. En bloc resection was achieved in 93.3% and R0 resection in 80.0% of the patients. The median procedure time was 92 min. Adverse events included a case of uncontrolled intraoperative bleeding leading to discontinuation of ESD and a case of esophageal stricture due to extensive resection. During the follow‐up period of a median for 42 months, a patient with local recurrence and another patient with liver metastasis were observed. One patient died of liver failure after receiving chemoradiotherapy as an additional treatment after ESD. No patient died of ESCC. Conclusion: This multicenter, retrospective cohort study demonstrated the safety and efficacy of ESD for ESCC with EVs. Further studies are needed to establish appropriate treatment methods for EVs before ESD and additional treatments for patients with insufficient ESD. [ABSTRACT FROM AUTHOR]

Objectives: Long‐term outcomes of gastric subepithelial lesions have not been elucidated. To reveal the natural history, we initiated a prospective, 10‐year follow‐up of patients with small (≤20 mm) gastric subepithelial lesions in September 2014. Here, we report the results of an interim analysis of a prospective observational study. Methods: In total, 567 patients with 610 lesions were prospectively registered between September 2014 and August 2016. The location, size, morphology, and number of subepithelial lesions were recorded on a web‐based case report form. This study has been conducted as an Academic Committee Working Group of the Japan Gastroenterological Endoscopy Society. Results: The endoscopic follow‐up period was 4.60 ± 1.73 years (mean ± standard deviation), and survival data were investigated for 5.28 ± 1.68 years. This interim analysis revealed that the estimated cumulative incidence of a size increase ≥5 mm, after accounting for patients' death and resection of the tumor as competing risk events, was 4.5% at 5 years. In addition, the estimated cumulative incidence of lesion size increase ≥5 mm or resection of lesions was 7.9% at 5 years, and that of size increase ≥10 mm or resection of lesions was 4.5% at 5 years. Conclusion: These results indicate that approximately one in 13 patients with small (≤20 mm) gastric subepithelial lesions may require resection or further investigation for increased tumor size (≥5 mm) within 5 years. [ABSTRACT FROM AUTHOR]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to evaluate the age‐specific characteristics, prognosis, and complications of patients with lean nonalcoholic fatty liver disease (NAFLD). Methods: Background factors (age, sex, diabetes, dyslipidemia, hypertension, and PNPLA3 gene polymorphism), blood test results, liver histology findings, muscle mass, and grip strength were investigated in 782 patients with NAFLD who underwent liver biopsy. Prognosis and complications were compared among 549 patients with nonlean or lean NAFLD who were followed up for 6.5 years. Additionally, background factors, blood test results, liver histology findings, prognosis, and complications were compared according to age (≥60 years vs. <60 years) in patients with lean NAFLD. Results: Lean NAFLD patients showed lower aspartate aminotransferase, alanine aminotransferase, homeostasis model assessment–insulin resistance, high‐sensitivity C‐reactive protein, ferritin, and leptin but higher adiponectin and hemoglobin A1c (HbA1c) levels than patients with nonlean NAFLD. Furthermore, lean NAFLD patients showed less liver fibrosis, inflammation, steatosis, and ballooning. Among lean NAFLD patients, those aged 60 years and older were more frequently female, showed higher rates of hypertension, diabetes, and dyslipidemia, had higher HbA1c and type IV collagen 7S levels, lower platelet count, higher liver fibrosis and inflammation grades, and lower muscle mass and grip strength. Lean NAFLD was associated with a worse prognosis in patients aged 60 years and over than in those younger than 60 years of age and with a higher incidence of liver‐related disease, cerebrocardiovascular events, and nonliver cancer. Conclusions: Age is an important consideration in patients with lean NAFLD. Compared with nonlean NAFLD, lean NAFLD was associated with a worse prognosis and higher risk of complications in patients aged 60 years and older. [ABSTRACT FROM AUTHOR]

Background and Aim: The clinical severity and course of acute lower gastrointestinal bleeding (ALGIB) are believed to differ between inpatient‐onset and outpatient‐onset cases, but no reports have investigated these issues in detail. We aimed to evaluate the clinical differences between inpatient‐onset and outpatient‐onset ALGIB. Methods: Medical records of patients who had undergone emergency colonoscopy for ALGIB were retrospectively reviewed. The severity was evaluated using the NOBLADS score. Patients with obvious ALGIB relapse and/or persistent iron‐deficiency anemia after emergency colonoscopy were considered to exhibit a poor clinical course. Results: We reviewed 723 patients with ALGIB and divided them into the inpatient‐onset cohort (172 patients) and outpatient‐onset cohort (551 patients). Compared with the outpatient‐onset cohort, the inpatient‐onset cohort had a significantly higher proportion of patients with a poor clinical course (51.2% vs 21.6%; P < 0.001) and a significantly higher mean NOBLADS score (3.6 ± 1.1 vs 2.5 ± 1.0; P < 0.001). The most common bleeding source was acute hemorrhagic rectal ulcer (52.3%) in the inpatient‐onset cohort and colonic diverticular bleeding (29.4%) in the outpatient‐onset cohort. Multivariate analysis showed that a platelet count < 15 × 104/μL and albumin concentration < 3 g/dL were significantly associated with a poor clinical course in the inpatient‐onset cohort. Conclusions: The clinical course was significantly worse in the inpatient‐onset cohort than in the outpatient‐onset cohort. The bleeding source, clinical characteristics, and clinical course differed between the inpatient‐onset and outpatient‐onset cohorts. The clinical course in the inpatient‐onset cohort may depend on the patient's condition at ALGIB onset. [ABSTRACT FROM AUTHOR]

Objectives: Patients with esophageal motility disorders (EMDs) including achalasia after gastric surgery have not been thoroughly characterized. Furthermore, the efficacy of peroral endoscopic myotomy (POEM) in this population should be clarified. Methods: In this retrospective multicenter study of 3707 patients with EMDs, 31 patients (0.8%) had a history of gastric surgery. Patient characteristics and POEM efficacy were compared between patients with and without previous gastric surgery. Results: In patients with EMD after gastric surgery, age at EMD diagnosis was higher (72.0 years), male sex was predominant (90.3%), and the American Society of Anesthesiologists physical status score was higher (≥II, 48.4%). High‐resolution manometry (HRM) findings did not reveal significant differences. In patients who underwent gastric surgery, atrophic gastritis was common (80.6%), and gastric cancer was the primary surgical indication (32.3%). Distal gastrectomy was performed in 28 patients (90.3%). POEM was effective (3.3% adverse events; 100% treatment success). The incidence rates of reflux esophagitis (RE) and symptomatic gastroesophageal reflux disease (GERD) were 60.0% and 16.7%, respectively, without significant intergroup differences, and severe RE was not observed in the long‐term follow‐up. Extended gastric myotomy was a risk factor for RE. Conclusion: Patients with gastric surgery often present severe disease manifestations; the surgical indication is mainly gastric cancer. HRM findings can be similarly used for diagnosis in patients with and without gastric surgery. POEM maintains safety and efficacy with acceptable RE and symptomatic GERD rates. To prevent RE, extended myotomy should be avoided. [ABSTRACT FROM AUTHOR]

Summary: Although materials for lithium‐ion batteries have been extensively studied, alternatives such as sodium‐ion batteries have acquired a renewed interest due to the abundance of Na compared to Li. However, the investigation of new materials for Na battery anodes is still in progress. In this work, a density functional study of the electronic properties of hydrogen passivated silicon nanowires (H‐SiNWs) with interstitial Na atoms is presented. The studied H‐SiNWs are grown along the [001] crystallographic direction and have a diameter close to 2.5 nm. Moreover, from 1 to 12 interstitial Na atoms per H‐SiNW unit cell were considered. The results reveal that the former semiconducting nanowires become metallic for all the Na concentrations, even for the case of a single Na atom. The formation energy diminishes as a function of the concentration of Na atoms, revealing a loss of energetic stability since the size of the Na atoms strongly modify the Si‐Si bonds. Moreover, when the Na atoms are removed from the metallic sodiated H‐SiNW and relaxed again, for concentrations between 1 and 8 Na atoms, the resulting structure corresponds to the original H‐SiNW one, indicating that the Na insertion/extraction process is a reversible one. In contrast, for concentrations between 10 and 12 Na atoms, the structure that results from removing of these Na atoms has a different atomic arrangement, in comparison with the initial H‐SiNW, and also smaller band gap. These results open the possibility to consider the H‐SiNWs as potential anodic materials in sodium rechargeable batteries. [ABSTRACT FROM AUTHOR]

Aim: Although malnutrition is an important prognostic factor in patients with chronic heart failure (CHF), no effective treatment for malnutrition has been established. Rikkunshito (RKT) is a Japanese herbal drug that has been used in daily practice for patients with loss of appetite. However, no data have demonstrated whether or not RKT can improve the body composition in patients with CHF. The aim of this study was to elucidate the effect of RKT on the nutritional status of patients with CHF. Methods: This single‐center retrospective observational study included 14 patients with CHF and loss of appetite who were treated with RKT. Body mass index (BMI) and body composition including fat‐free mass index (FFMI), skeletal muscle mass index (SMI) and fat mass index (FMI) were measured by the bioimpedance method. Body composition was measured at baseline and 12 weeks later. The primary endpoint was the change of BMI and body composition. Results: BMI was significantly improved from 23.7 (20.0–26.1) kg/m2 to 24.2 (20.3–27.3) kg/m2 (p = 0.0494). FFMI was significantly improved from 13.7 (11.3–14.9) kg/m2 to 14.2 (12.0–15.7) kg/m2 (p = 0.0002). SMI was also improved from 5.0 (3.0–6.2) kg/m2 to 5.3 (3.3–6.8) kg/m2 (p = 0.0085). On the other hand, FMI was not significantly changed (9.4 (7.2–12.0) kg/m2 to 10.3 (7.9–12.0) kg/m2, p = 0.8552). Conclusion: The Japanese herbal drug RKT was effective in improving the nutritional status of patients with CHF. [ABSTRACT FROM AUTHOR]

Background: Although post‐bulbar duodenal ulcers (PBDUs) could become a source of upper gastrointestinal bleeding, the whole picture of the disease is unknown. We compared the characteristic features and treatment outcomes after endoscopic hemostasis between PBDUs and bulbar duodenal ulcers (BDUs). Methods: Data on duodenal ulcers with evidence of endoscopically‐active bleeding were extracted from the data that were retrospectively collected from 12 institutes in Japan between 2011 and 2018. Rebleeding and in‐hospital mortality were compared between patients with PBDUs and those with BDUs by logistic regression analyses. Results: Among 468 consecutive patients with bleeding duodenal ulcers, 96 (20.5%) had endoscopically‐confirmed PBDUs. PBDUs were more frequently observed in patients with a poor general condition in comparison to BDUs. The rates of rebleeding and in‐hospital mortality in patients with PBDUs were approximately three times higher than those in patients with BDUs (PBDU vs. BDU: 29.2% vs. 10.2% [P < 0.0001] and 14.6% vs. 5.1% [P = 0.0029], respectively). Although the high in‐hospital mortality in PBDUs could be explained, to a lesser extent, by the likelihood of rebleeding, and, to a greater extent, by the patients' poor general condition, the presence of a PBDU itself was largely responsible for the high rebleeding rates in PBDUs. Conclusion: This is the first study focusing on the nature and treatment outcomes of bleeding PBDUs. PBDUs were associated with much higher rebleeding and mortality rates in comparison to BDUs, and the likelihood of rebleeding may be derived from their unique anatomic location. [ABSTRACT FROM AUTHOR]

Objectives: Indications for peroral endoscopic myotomy (POEM) and endoscopic submucosal dissection (ESD) in patients with achalasia concomitant with esophageal carcinoma (EC) are unclear. This study aimed to clarify the role of POEM in cases of achalasia concomitant with EC and to elucidate the indications for ESD and efficient surveillance for EC. Methods: We conducted a multicenter cohort study at 14 hospitals in Japan, including 3707 cases of achalasia‐related esophageal motility disorders (EMDs). Factors contributing to EC risk, the characteristics of EC, and clinical outcomes of POEM/ESD were analyzed. Results: In patients undergoing POEM, screening and surveillance endoscopy throughout a 1‐year period resulted in diagnosis of 72.1% new EC cases. Of 62 patients with 123 ECs, 40.3% had multiple or metachronous lesions within 37.5 months. EC was predominantly observed in the middle thoracic esophagus (58.5%) and posteriorly (73.2%). POEM had comparable safety and efficacy in cases of concomitant EC even after ESD. Endoscopic en bloc resection was performed in 95.8% and 89.3% of ECs diagnosed before and after POEM, respectively (P = 0.351); however, ESD on the POEM‐line was impaired by fibrosis. Multivariate analysis revealed risk factors for EC, including regular alcohol consumption, a history of smoking, advanced age, and extended disease duration. Alcohol intake and smoking had a synergistic effect on EC development. Conclusions: Screening and surveillance of POEM help in detecting EC. ESD is feasible in achalasia, although on the POEM‐line is challenging. Surveillance endoscopy for EC is recommended for cases with specific risks and a history of ECs. [ABSTRACT FROM AUTHOR]

Aim: To elucidate the impact of the coronavirus disease 2019 (COVID‐19) on the practice of high‐resolution manometry (HRM) and peroral endoscopic myotomy (POEM) in Japan. Methods: We utilized a large‐scale database involving 14 high‐volume centers in Japan to investigate changes in the numbers of HRM and POEM procedures performed and outcomes of POEM between 2019 and 2020. A questionnaire survey was also conducted to analyze pandemic‐associated changes in the HRM and POEM protocols. Results: Compared to that in 2019, the number of HRM and POEM procedures decreased by 17.2% (1587–1314) and 20.9% (630–498), respectively. These declines were prominent during the state of emergency from April to May 2020, particularly in pandemic areas. HRM and POEM in nonpandemic areas were relatively unaffected. From 2019 to 2020, there was a 0.4% (254–248) decrease in POEM cases within the prefecture, but the number outside the prefecture decreased by 33.6% (372–247). During the pandemic, the safety and efficacy of POEM were maintained. The implementation of personal protective equipment (PPE) measures varied among facilities, and PPE for POEM was relatively insufficient compared to that for HRM. Conclusion: The COVID‐19 pandemic influenced HRM and POEM practices in Japan. It is necessary to establish a sufficient system for HRM and POEM in each hospital as well as countrywide to overcome the effects of the pandemic. [ABSTRACT FROM AUTHOR]

Objects: Although anti‐thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti‐thrombotic agents on in‐hospital mortality following UGIB. Methods: Information on clinical parameters, including usage of anti‐thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high‐volume centers in Japan between 2011 and 2018. The all‐cause in‐hospital mortality rate was evaluated according to the usage of anti‐thrombotic agents. Results: Clinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty‐five (29.3%) patients used anti‐thrombotic agents. The all‐cause in‐hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end‐stage malignancy, 96 deaths (bleeding‐related, n = 22 ; non‐bleeding‐related, n = 74) were considered "preventable." Overall, the "preventable" mortality rate in anti‐thrombotic users was significantly higher than that in non‐users (6.0% vs. 3.7%, P < 0.05). However, the "preventable" mortality of anti‐thrombotic users showed a marked improvement over time; although the rate in users remained significantly higher than that in non‐users until 2015 (7.3% vs. 4.2%, P < 0.05), after 2016, the difference was no longer statistically significant (4.8% vs. 3.5%). Conclusions: Although the usage of anti‐thrombotic agents worsened the outcomes after UGIB, the situation has recently been improving. We speculate that the recent revision of the Japanese guidelines on the management of anti‐thrombotic treatment after UGIB may have partly contributed to improving the survival of users of anti‐thrombotic agents. [ABSTRACT FROM AUTHOR]

Objectives: The first aim of this study was to elucidate the detection rate of esophagogastroduodenoscopy (EGD) in patients complaining of dysphagia with esophageal motility disorders; the second was to clarify the useful parameters of EGD associated with esophageal motility disorders. Methods: Participants included 380 patients who underwent EGD before high‐resolution manometry (HRM) for dysphagia. EGD findings were investigated according to the following five parameters: resistance when passing through the esophagogastric junction (EGJ), residue in the esophageal lumen, esophageal dilation, and spastic and nonocclusive contractions. HRM diagnoses were based on the Chicago classification (v3.0). Results: The percentage of abnormal EGD findings was 64.4% among patients with esophageal motility disorders, and the results differed for each esophageal motility disorder. The rate of abnormal EGD for both EGJ outflow obstruction and major disorders of peristalsis was significantly higher than that for manometrically normal subjects. On multivariate analysis, resistance when passing through EGJ, residue in the esophageal lumen, spastic and nonocclusive contraction were significantly associated with esophageal motility disorders. The sensitivity, specificity, positive predictive value, and negative predictive value of these parameters for detection of esophageal motility disorders were 75.1%, 86.6%, 84.8% and 77.8%, respectively. Conclusion: Esophagogastric junction outflow obstruction and major disorders of peristalsis can be screened with EGD. Among several endoscopic parameters, resistance when passing through EGJ, residue in the esophageal lumen, spastic and nonocclusive contraction are considered significantly useful indicators. [ABSTRACT FROM AUTHOR]

The new dumbbell‐shaped, covered self‐expanding metallic stent can efficiently remove the choledocholiths in cases with common bile duct (CBD) strictures; moreover, it may potentially prevent a positional displacement and contribute to the better improvement of the CBD stricture. [ABSTRACT FROM AUTHOR]

Aims: Cardiohepatic interactions have been a focus of attention in heart failure (HF). The model for end‐stage liver disease excluding international normalized ratio (MELD‐XI) score has been shown to be useful for predicting poor outcomes in patients with acute decompensated HF (ADHF). Furthermore, the fibrosis‐4 (FIB‐4) index, a simple marker to assess liver fibrosis, predicts adverse prognoses in patients with HF as well. However, there is little information available on the prognostic significance of the combination of the MELD‐XI score and FIB‐4 index in patients with ADHF and its association with left ventricular ejection fraction (LVEF) subgroup. Methods and results: We prospectively studied 466 consecutive patients who were admitted for ADHF [HF with reduced LVEF (LVEF < 40%): n = 164, HF with mid‐range LVEF (40% ≤ LVEF < 50%): n = 104, and HF with preserved LVEF (LVEF ≥ 50%): n = 198]. We calculated the MELD‐XI score and FIB‐4 indices at discharge. The primary endpoint was all‐cause death (ACD). During the mean follow‐up period of 2.8 years, 143 patients had ACD. In the multivariate Cox analysis, the MELD‐XI score and FIB‐4 index were independently associated with ACD. Patients were stratified into the following three groups according to the median value of MELD‐XI score (=11) and FIB‐4 index (=2.13): Group 1 had both a low MELD‐XI score and a low FIB‐4 index; Group 2 had either a high MELD‐XI score (MELD‐XI score ≥11) or a high FIB‐4 index (FIB‐4 index ≥2.13); and Group 3 had both a high MELD‐XI score and a high FIB‐4 index. Kaplan–Meier analysis revealed that Group 2 and Group 3 had a significantly greater risk of ACD than Group 1 [Group 2 vs. Group 1: adjusted hazard ratio, 2.48 (95% confidence interval: 1.75–3.53), P < 0.0001; Group 3 vs. Group 1: adjusted hazard ratio, 7.03 (95% confidence interval: 3.95–13.7), P < 0.0001]. In addition, the patients with both a higher MELD‐XI score and FIB‐4 index showed a significantly higher risk of ACD also in the patients with HF with reduced LVEF, HF with mid‐range LVEF, and HF with preserved LVEF (all P < 0.0001). Conclusions: The combination of MELD‐XI score and FIB‐4 index may be useful for stratifying patients at risk for ACD in patients with ADHF, irrespective of LVEF. [ABSTRACT FROM AUTHOR]

Aims: Co‐morbidities are associated with poor clinical outcomes in patients with chronic heart failure, while cardiac iodine‐123 (I‐123) metaiodobenzylguanidine (MIBG) imaging provides prognostic information in such patients. We sought to prospectively investigate the incremental prognostic value of cardiac MIBG imaging over the co‐morbid burden, in patients admitted for acute decompensated heart failure (ADHF). Methods and results: In 433 consecutive ADHF patients with survival to discharge, we measured the co‐morbidity using age‐adjusted Charlson co‐morbidity index (ACCI), commonly employed to evaluate a weighted and scored co‐morbid condition, adding additional points for age. In cardiac MIBG imaging, the cardiac MIBG heart‐to‐mediastinum ratio (late HMR) was measured on the delayed image. Over a follow‐up period of 2.9 ± 1.5 years, 160 patients had a cardiac event (a composite of cardiac death and unplanned hospitalization for worsening heart failure). Patients with high ACCI (≥6: median value) had a significantly greater risk of a cardiac event. In multivariate Cox analysis, the ACCI and late HMR were significantly and independently associated with a cardiac event. In both high and low ACCI subgroups (ACCI ≥ 6 and <6, respectively), patients with low late HMR had a significantly greater risk of a cardiac event (high ACCI: 51% vs. 34% P = 0.0026, adjusted HR 1.74 [1.21–2.51]; low ACCI: 34% vs. 17%, P = 0.0228, adjusted HR 2.19 [1.10–4.37]). Conclusions: Cardiac MIBG imaging could provide additional prognostic information over ACCI, which was also promoted to be a useful risk model, in patients admitted for ADHF. [ABSTRACT FROM AUTHOR]

Background and Aim. A wet suction technique ("wet" technique) has been developed to improve the quality of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for sampling various solid lesions. However, no studies have reported on the wet technique for EUS-FNA for gastrointestinal (GI) subepithelial lesions (SELs). We conducted a pilot randomized crossover trial to explore whether the wet technique could be useful with regard to tissue adequacy of upper GI-SELs (UGI-SELs) compared to the conventional EUS-FNA technique ("dry" technique). Methods. Twenty-six patients with UGI-SELs indicated for EUS-FNA were randomly assigned to the dry-first arm using the dry technique for the first two passes or the wet-first arm using the wet technique for the first two passes using a cross-over design with a ratio of 1 : 1. The primary endpoint was the cellularity score of the EUS-FNA specimens rated on a 4-point scale (0-3). The secondary endpoints were the factors influencing cellularity in each suction technique. Results. The mean cellularity score was 1.65 ± 1.20 for the wet technique and 2.00 ± 0.98 for the dry technique (p = 0.068). Logistic regression analysis showed that higher cellularity may be related to the final diagnosis of gastrointestinal stromal tumors in the dry technique and the SEL location in the upper stomach in the wet technique. Conclusion. The wet EUS-FNA technique failed to show a potential for improved cellularity of specimens compared to the dry technique for UGI-SELs. [ABSTRACT FROM AUTHOR]

This is a significant study since it establishes objectively that RDI improves the EV visibility in intravariceal sclerotherapy for EVs by employing color difference evaluation. Endoscopic injection sclerotherapy (EIS) or endoscopic variceal ligation (EVL) has been used to treat potentially risky esophageal varices (EVs).1 Although the recurrence rate following endoscopic therapy of EVs has been reported to be lower with EIS, particularly with intravariceal sclerotherapy, than with EVL, EVL is widely applied worldwide due to its simplicity. In the current issue of I Digestive Endoscopy i , Furuichi I et al i .3 explored the utility of red dichromatic imaging (RDI), a novel image-enhanced endoscopic function, in the intravariceal sclerotherapy of EVs. [Extracted from the article]

Aims: Acute decompensated heart failure (ADHF) is generally treated by decongestion using diuretic therapy. However, the use of loop diuretics is associated with increased cardiac sympathetic nerve activity (CSNA). We aimed to evaluate the effect of adjunctive tolvaptan therapy on CSNA in ADHF patients with preserved left ventricular ejection fraction (LVEF). Methods and results: We enrolled 51 consecutive ADHF patients with LVEF ≥45%. Patients were randomly assigned to receive either tolvaptan add‐on (n = 25) or conventional diuretic therapy (n = 26). Cardiac iodine‐123 metaiodobenzylguanidine (MIBG) imaging was performed after stabilisation of heart failure symptoms, and the cardiac MIBG heart‐to‐mediastinum ratio (HMR) and washout rate (WR) were calculated. There were no significant differences in the body weight change and total urine volume during 2 days after randomisation or in the HMR on delayed image (HMR(d)) and WR between the tolvaptan and conventional groups. After stratification based on the median change in body weight, the patients with higher weight reduction had a significantly lower HMR(d) (P = 0.0128) and tended to have a higher WR (P = 0.0786) in the conventional group, whereas the cardiac MIBG imaging results were not influenced by body weight reduction in the tolvaptan group. Conclusions: Adjunctive tolvaptan therapy may provide rapid decongestion without a harmful effect on CSNA in ADHF patients with preserved LVEF. [ABSTRACT FROM AUTHOR]

Pyogenic facet joint infection is a rare but severe infection. The most common complaint on presentation is pain followed by fever, then neurologic impairment. While the lumbar spine is involved in the vast majority of cases presented in the literature, the case presented here occurred in the thoracic spine. The patient was a 48-year-old immune-competent female who presented with left back pain. Magnetic resonance imaging (MRI) indicated a facet effusion, paraspinal abscess, and epidural abscess in the level of 9th-11th thoracic vertebra. On the 6th day of treatment, she presented a neurological disorder and underwent decompressive laminectomy and surgical debridement. We observed immediate improvement as a result of the surgery. [ABSTRACT FROM AUTHOR]

Planar chiral building blocks based on 4,7,12,15‐tetrasubstituted [2.2]paracyclophanes were obtained via a synthetic route involving an optical resolution step. Planar chiral enantiomers, comprising two fluorophores that were stacked to form a V‐shaped higher‐ordered structure, were synthesized from these building blocks. The V‐shaped molecules emitted intense circularly polarized luminescence (CPL). Their chiroptical properties were compared with those of X‐shaped molecules bearing the same two fluorophores stacked together. The CPL sign of the X‐shaped molecule was opposite to that of the V‐shaped molecule, which is supported by the theoretical results, indicating that the CPL sign can be controlled by the orientation of the stacked fluorophores. [ABSTRACT FROM AUTHOR]

Aim: The present study was designed to evaluate the safety and feasibility of transabdominal preperitoneal (TAPP) repair for very old patients with groin hernia and to identify the risk factors predicting perioperative complications. Methods: A total of 140 patients treated by TAPP were reviewed retrospectively. They were divided into two groups: patients ≥80 years of age (≥80 years group; n = 26) and those <80 years of age (<80 years group; n = 114). Patient characteristics and surgical outcomes were then statistically compared between the two groups. Results: Number of patients with any comorbidities was significantly higher in the ≥80 years group than in the <80 years group (96.2% vs 61.4%, P = 0.003). There were no significant differences in surgical outcomes between the two groups. In the univariate analysis of perioperative complications, poor performance status (PS) (P = 0.014), lower hemoglobin level (P = 0.038) and lower albumin level (P = 0.016) were significantly associated with the occurrence of postoperative complications, and multivariate analysis showed that only poor PS was an independent factor (PS 0‐2 vs 3‐4: P = 0.034, OR 5.192 [95% CI; 1.137 to 23.71]). Conclusions: This is the first report to show that the incidence of postoperative complications in TAPP repair for groin hernia is influenced by poor PS rather than old age. TAPP can be a safe surgical procedure for very old patients with a good PS, with benefits that are equal to those in young patients. [ABSTRACT FROM AUTHOR]

We aimed to characterize the mucosal immune microenvironment and immune checkpoint of Ulcerative colitis (UC) by immunohistochemistry with correlation to prognosis: requirement of second‐line steroid‐therapy within the 2‐years after diagnosis (SR). A series of 72 cases included 56 UC, 43 non‐SR (with first‐line treatment 5‐ASA) and 13 SR, 11 infectious colitis and 5 normal colonic biopsies. Normal mucosa was characterized by low infiltrates but high BTLA and TNFRSF14. Compared to normal, UC had increased pan‐immune‐markers of CD3, CD8, FOXP3, PD‐1, CD68, CD16, CD163, PTX3 and CD11C but had decreased BTLA (P < 0.05); by GSEA analysis comparable results were found in an independent UC gene‐expression‐data set (GSE38713). Compared to infectious, UC had higher CD4, CD8, PTX3 and CD11C but lower BTLA (P < 0.05). Compared to non‐SR, SR had lower FOXP3 + Tregs (Odds‐Ratio = 0.114, P = 0.002), PD‐1 (OR = 0.176, P = 0.002) and CD163/CD68 M2‐ratio (OR, 0.019, P = 0.019) but higher CD68 + pan‐macrophages (OR = 6.034, P = 0.002). Higher Baron endoscopic and Geboes histologic disease activity scores also correlated with SR. In summary, UC was characterized by increased pan‐immune‐markers, normal TNFRSF14 and low BTLA. SR had increased CD68 + pan‐macrophages but lower immune inhibitors of FOXP3 + Tregs, PD‐1 and CD163/CD68 M2‐macrophage ratio. In conclusion, alterations of the immune homeostasis mechanisms are relevant in the UC pathogenesis and steroid‐requiring situation. [ABSTRACT FROM AUTHOR]

Background and Aim. The clinical outcomes of endoscopic submucosal dissection (ESD) for gastric tube cancer (GTC) after esophagectomy remain unclear. The aim of this study was to evaluate the clinical outcomes and safety of ESD for GTC. Patients and Methods. Twenty GTC lesions in 18 consecutive patients who underwent ESD between February 2008 and June 2018 were included in this retrospective study. The endpoints were the treatment outcomes of ESD (i.e., en bloc resection rate, complete en bloc resection rate, and curative resection rate), the adverse events following ESD, and the long-term outcomes. Results. The en bloc resection rate was 100%, while the complete en bloc resection rate and curative resection rate were 80% each. Adverse events were observed in 16.7% (3/18) of patients: one postoperative bleeding, 1 intraoperative perforation that required emergency surgery, and 1 pyothorax that required chest drainage. The 1-, 3-, and 5-year overall survival rates were 100%, 70.9%, and 70.9%, respectively. Although local recurrence was detected in 1 case of noncurative resection, no GTC- or ESD-related deaths were observed. Conclusion. ESD for GTC was feasible and acceptable to enable en bloc resection and to prevent cancer death. However, ESD for GTC should be performed more carefully than common gastric ESD because serious adverse events specific to the gastric tube may occur. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) for achalasia is technically challenging to carry out in patients with type III, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the POEM difficulty score (PDS). Aim: To demonstrate the application and discuss the utility of PDS and present the feasibility, safety, and efficacy of POEM in complex achalasia patients. Methods: Forty consecutive POEM were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score ≤3) at a minimum of 3 months follow‐up. Secondary outcomes included adverse events, procedural velocity and PDS. Results: Twenty‐eight complex and 12 non‐complex POEM procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15 months (complex) and 8 months (non‐complex). Mean velocities for non‐complex, type III, prior myotomy, ≥4 procedures and sigmoid type were as follows: 4.4 ± 1.6, 4.8 ± 1.5, 5.9 ± 2.2, 6.9 ± 2.2 and 8.2 ± 3.2 min/cm, respectively. Median PDS for non‐complex, type III, prior myotomy, ≥4 treatments and sigmoid type were 1 (0–3), 2 (0–4), 2.5 (1–6), 3 (2–6) and 3.5 (1–6), respectively. PDS was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's P < 0.001). Conclusions: PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, ≥4 treatments and sigmoid type. [ABSTRACT FROM AUTHOR]

A word can carry different meanings for different people. Conjoint analysis was applied to assess preferences for various words describing integrated resorts (IR) including casinos, to be introduced in Japan in the future. We discuss how the participants understood particular words (e.g., a specific casino's place name or wording regarding restrictions on betting) that define the characteristics of a casino, as well as how casino-related words influenced participants' preferences. Implications for enhancing public understanding of casinos are explored in the conclusion. [ABSTRACT FROM AUTHOR]

The Japanese workforce has decreased rapidly over the past few decades, and this is expected to continue. Retail and service industries are already experiencing human-resource shortages. In these industries, nonregular employees feature prominently. For most companies, recruitment is difficult, and employees change jobs often, making securing staff an important business issue. Nonregular and regular employees are treated differently; the problem is thus partly social in nature. However, some nonregular employees are content, although their work conditions are not good. Here, text mining was used to explore differences between the values of regular and nonregular employees in the retail and service industries. [ABSTRACT FROM AUTHOR]

Abstract: A new type of planar chiral (Rp)‐ and (Sp)‐4,7,12,15‐tetrasubstituted [2.2]paracyclophanes was prepared from racemic 4,7,12,15‐tetrabromo[2.2]paracyclophane as the starting substrate. Regioselective lithiation and transformations afforded racemic bis‐(para)‐pseudo‐meta‐type [2.2]paracyclophane (4,15‐dibromo‐7,12‐dihydroxy[2.2]paracyclophane). Its optical resolution was performed by the diastereomer method using a chiral camphanoyl group as the chiral auxiliary. The diastereoisomers were readily isolated by simple silica gel column chromatography, and the successive hydrolysis afforded (Rp)‐ and (Sp)‐bis‐(para)‐pseudo‐meta‐type [2.2]paracyclophanes ((Rp)‐ and (Sp)‐4,15‐dibromo‐7,12‐dihydroxy[2.2]paracyclophanes). They can be used as pseudo‐meta‐substituted chiral building blocks. [ABSTRACT FROM AUTHOR]

Aim: We aimed to examine the association between attention‐deficit/hyperactivity disorder (ADHD) symptoms and suicidal behavior in psychiatric outpatients and whether this association differs among patients with different psychiatric disorders. Methods: Cross‐sectional data came from the Japan Prevalence Study of Adult ADHD at Psychiatric Outpatient Care, which included psychiatric outpatients aged 18–65 years recruited from one university hospital and three general psychiatric outpatient clinics in Kitakyushu City, Fukuoka, Japan from April 2014 to January 2015 (N = 864). The Adult ADHD Self‐Report Scale (ASRS) Screener was used to collect information on ADHD symptoms. Reports of current and lifetime suicidal behavior were also obtained. A multivariable Poisson regression analysis was used to examine the association between ADHD symptoms and suicidal behavior. Results: After adjusting for covariates there was a strong association between possible ADHD (ASRS ≥14) and suicidal behavior with prevalence ratios ranging from 1.17 (lifetime suicidal ideation) to 1.59 (lifetime suicide attempt) and 2.36 (current suicidal ideation). When ASRS strata were used, there was a dose–response association between increasing ADHD symptoms and suicidal ideation and suicide attempts. Analyses of individual ICD‐10 psychiatric disorders showed that associations varied across disorders and that for anxiety disorder, ADHD symptoms were significantly linked to all forms of suicidal behavior. Conclusion: ADHD symptom severity is associated with an increased risk for suicidal behavior in general psychiatric outpatients. As ADHD symptoms are common among adult psychiatric outpatients, detecting and treating ADHD in this population may be important for preventing suicidal behavior. [ABSTRACT FROM AUTHOR]

The micronucleus (MN) test has become an attractive tool both for evaluating the genotoxicity of test chemicals because of its ability to detect clastogenic and aneugenic events and for its convenience. As the MN assay has been mostly performed using only DNA repair‐proficient mammalian cells, we believed that the comparison of the MN frequency between DNA repair‐proficient and ‐deficient human cells may be an excellent indicator for detecting the genotoxic potential of test chemicals and for understanding their mode of action. To address this issue, the following five genes encoding DNA‐damage‐response (DDR) factors were disrupted in the TK6 B cell line, a human cell line widely used for the MN test: FANCD2, DNA polymerase ζ (REV3), XRCC1, RAD54, and/or LIG4. Using these isogenic TK6 cell lines, the MN test was conducted for four widely‐used DNA‐damaging agents: methyl methanesulfonate (MMS), hydrogen peroxide (H2O2), γ‐rays, and mitomycin C (MMC). The frequency of micronuclei in the double strand break repair‐deficient RAD54−/−/LIG4−/− cells after exposure to γ‐rays, H2O2, MMS and MMC was 6.2‐7.5 times higher than that of parental wild‐type TK6 cells. The percentages of cells exhibiting micronuclei in the base excision repair‐ and single strand break repair‐deficient XRCC1−/− cells after exposure to H2O2, MMC and MMS were all ∼5 times higher than those of wild‐type cells. In summary, a supplementary MN assay using the combination of RAD54−/−/LIG4−/−, XRCC1−/− and wild‐type TK6 cells is a promising method for detecting the genotoxic potential of test chemicals and their mode of action. Environ. Mol. Mutagen., 2018. © 2018 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to review the suitability of endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) for ruling out malignancy in autoimmune pancreatitis patients. Methods We retrospectively reviewed 40 autoimmune pancreatitis patients (type 1:37 patients; type 2: two patients; possible autoimmune pancreatitis: one patient) who received EUS-FNA. Among the 40 autoimmune pancreatitis patients, 34 were not histopathologically diagnosed with autoimmune pancreatitis by EUS-FNA, and they were followed up for more than 6 months in our hospital. Moreover, 14 pancreatic cancer patients who were not diagnosed by EUS-FNA were selected as a control group. These 14 patients constituted 3.9% of the 360 pancreatic cancer patients who received EUS-FNA. We evaluated the prognoses of the 34 autoimmune pancreatitis patients and the clinical differences between these 34 autoimmune pancreatitis patients and the 14 pancreatic cancer patients. Results All 34 autoimmune pancreatitis patients showed reduced pancreatic swelling. The main pancreatic duct dilation ( > 3 mm), the diameter of the main pancreatic duct, the capsule-like rim sign, and serum CA19-9 levels were significantly different between the autoimmune pancreatitis and pancreatic cancer patients (2.9% versus 69.2%, P < .01; 1.7 ± 1.6 mm versus 6.8 ± 5.0 mm, P < .01; 79.4% versus 0%, P < .01; 41.4 ± 79.0 U/mL versus 2079.1 ± 275.3 U/mL, P = .02). Conclusions Almost all pancreatic cancers can be diagnosed by EUS-FNA. Furthermore, other clinical characteristics of pancreatic cancer undiagnosed by EUS-FNA were different from autoimmune pancreatitis undiagnosed by EUS-FNA. Endoscopic ultrasonography-guided FNA can be used to rule out malignancy in autoimmune pancreatitis patients. [ABSTRACT FROM AUTHOR]

Objective. A wide mucosal defect after endoscopic submucosal dissection (ESD) for esophageal cancer is associated with increased risk of stricture. This study was conducted to evaluate the feasibility of short-period, high-dose intravenous methylprednisolone administration (steroid pulse therapy) in preventing post-ESD esophageal stricture. Methods. This prospective study examined 13 lesions in 11 consecutive patients with esophageal squamous cell carcinoma who underwent ESD that involved three-quarters or more of the circumference of the esophagus or who had a longitudinal resected specimen diameter of ≥5 cm. Steroid pulse therapy was initiated the day after ESD and continued for 3 consecutive days. The primary endpoint was the stricture rate after ESD. Secondary endpoints were adverse events (AEs) associated with steroid pulse therapy, time until the development of stricture, and the frequency and duration of endoscopic balloon dilation (EBD). Results. The stricture rate was 54.5% (6/11). The median time until stricture development was 15 days. The median number of EBD sessions required was 2.5. The median duration of EBD was 14.5 days. AEs related to steroid pulse therapy and postprocedure complications were not observed. Conclusion. No preventive effect of the stricture after esophageal ESD by steroid pulse therapy was found, although the therapy was administered safely. [ABSTRACT FROM AUTHOR]

We report the case of a 46-year-old man who achieved remarkable improvement of characteristic non-alcoholic steatohepatitis by dieting. Initially, his body mass index was 40.7 kg/m2. He proactively commenced a low calorie diet and his body mass index decreased to 28 kg/m2 after 4 years. During the same period, we carried out liver biopsy four times. Liver fibrosis as well as inflammation, steatosis and ballooning improved, and the non-alcoholic fatty liver disease activity score decreased from 4 to 0. The fat deposits of liver tissue changed from macrovesicular droplets to microvesicular, and finally disappeared. Along with improved histology, alanine aminotransferase, homeostasis model assessment-insulin resistance, ferritin, leptin, high-sensitivity C-reactive protein and cytokeratin 18 decreased, and adiponectin increased linearly. However, no clear changes were observed in markers for Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA+M2BP), type IV collagen 7S, procollage III peptide and fibrosis-4 index along with dieting. This is the first study to report gradual improvement of liver histology during four liver biopsies and fibrosis markers in a patient with non-alcoholic steatohepatitis who achieved complete recovery solely by dieting. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 40‐year‐old woman with palpable hard mass in the upper outer quadrant of the left breast. Topics discussed include findings of ultrasound (US), an oval‐shaped heterogeneous mass with a circumscribed margin; mentions a linear or cystic high‐signal intensity area on a T2‐weighted sequence reflect pseudo‐vascular proliferation on pathologic findings; and information on the benign disease such as fibroadenoma.

A series of porphyrins fused with acenaphthylene, phenanthroline, and benzofluoranthene polycyclic aromatic rings were prepared by means of a 3+1 porphyrin synthesis approach and subsequent retro-Diels-Alder reaction of bicyclo[2.2.2]octadiene-fused precursors. Analysis of the magnetic circular dichroism spectra and the results of time-dependent DFT calculations are used to identify the reasons for the trends observed in the wavelengths and relative intensities of the Q bands of the products. Michl's perimeter model is used as a conceptual framework to explain the changes in the relative energies of the frontier π-molecular orbitals. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopy, barium esophagram and manometry are used in the diagnosis of achalasia. In the case of early achalasia, characteristic endoscopic findings are difficult to recognize. As a result, the diagnosis of achalasia is often made several years after symptom onset. Therefore, we examined the endoscopic findings of the cardiac orifice in achalasia and propose a new classification. Methods A total of 400 patients with spastic esophageal motility disorders who underwent peroral endoscopic myotomy (POEM) at our hospital between March 2014 and August 2015 were screened for this study. Champagne glass sign (CG) was defined as when the distal end of the lower esophageal sphincter relaxation failure (LESRF) was proximal to the squamocolumnar junction (SCJ) and the SCJ was dilated in the retroflex view. Specifically, CG-1 was defined as a distance from the SCJ to the lower end of LESRF of <1 cm, and CG-2 was defined as a distance ≥1 cm. Results CG-0 was seen in 73 patients (28.0%), whereas the CG sign was seen in 186 patients (71.3%), of whom 170 (65.1%) were CG-1 and 16 (6.1%) were CG-2. Conclusions The CG sign is often observed in esophageal achalasia patients. CG-0 (equal to Maki-tsuki) was observed in 28.0% of achalasia patients only. Its absence with dilated SCJ cannot be used to rule out achalasia. Barium esophagram and manometry should be done if esophageal achalasia is strongly suspected. [ABSTRACT FROM AUTHOR]

Objective: To examine the incidence of hepatitis B virus (HBV) reactivation in patients with rheumatoid arthritis (RA) receiving biological disease-modifying antirheumatic drugs (DMARDs). Methods: We retrospectively reviewed RA patients treated with biological DMARDs at our institution from July 2010 to December 2012. Patients with antibodies for hepatitis B core antigen and/or hepatitis B surface antigen were regarded as having prior HBV infection. Clinical data on these patients, including HBV-DNA levels, were retrieved from the medical records. Results: During the study period, 251 patients were administered various biological DMARDs. Six patients with a history of HBV vaccination and one patient with positive HBV surface antigen were excluded from the study. Fifty-seven of the remaining 244 patients (23.4%) had prior HBV infection. These patients were followed for a median of 18 months (range: 2-27 months) and HBV-DNA was examined a median of seven times (range: 2- 27). HBV-DNA was detected in three patients (5.3%), comprising two receiving tocilizumab and one receiving etanercept. However, HBV-DNA levels were below the quantitation limit (<2.1 log copies mL 1) in all three patients. HBV-DNA became negative again within several months in all three patients, while biological DMARDs were continued and liver function tests remained normal throughout. Conclusion: HBV-DNA reactivation occurred in 5.3% of RA patients with prior HBV infection during treatment with biological DMARDs, but there were no associated clinical manifestations. Accordingly, it seems that biological DMARDs can be used safely in patients with RA. [ABSTRACT FROM AUTHOR]

Objective In major depressive disorder (MDD) patients, higher morning cortisol levels due to a hyperactive hypothalamic-pituitary-adrenal (HPA) axis have been reported. The aim of the present study was to evaluate the relationship between cortical thinning and the serum cortisol levels during the first depressive episode in drug-naïve MDD patients using an automated surface-based morphometry (SBM) method. Methods The institutional review board approved this prospective study. MR imaging data were obtained using a 3T scanner by a three-dimensional fast-spoiled gradient recalled acquisition with steady state (3D-FSPGR). Thirty drug-naïve patients with MDD and 41 age- and gender-matched healthy subjects (controls) were enrolled. We then used the SBM method (Freesurfer) to generate cortical thickness maps, and measured the cortical thickness in each subject. Morning blood samples were drawn from all participants for cortisol measurements. Results We found the serum cortisol levels were significantly higher in the MDD patients than in the controls. The MDD patients manifested significant thinning of the left lateral orbitofrontal cortex compared with the controls. There was a significant negative linear correlation between the thickness of the left lateral orbitofrontal cortex and the serum cortisol levels in the MDD patients. Conclusions In the early stage of MDD, the thickness of the lateral orbitofrontal cortex was significantly reduced, and also showed a significant inverse correlation with the serum cortisol levels. Since the lateral orbitofrontal cortex contains a high concentration of glucocorticoid receptor, glucocorticoid receptor-mediated signaling transductions could contribute to neurotoxicity, which might occur when there are high cortisol levels in patients with MDD. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic submucosal dissection ( ESD) becomes more difficult with an increased risk of complications if patient sedation is insufficient. We assessed the safety and effectiveness of propofol-based monitored anesthesia care ( MAC) without intubation during ESD for early esophageal cancer ( EEC) or early gastric cancer ( EGC) in the endoscopy room. Methods We investigated 1013 consecutive patients with 1126 lesions who underwent ESD for EGC/ EEC with either MAC or regular sedation by endoscopists (control group) between July 2010 and March 2013. Patient characteristics, endoscopic findings, technical results, body movement, oxygen saturation ( SpO2), and drug dosages were then examined. Results MAC was carried out in 137 EGC (16%) and 82 EEC patients (57%), whereas regular sedation was used in 731 EGC (84%) and 63 EEC patients (43%). MAC was conducted in 21% of all ESD procedures. In the MAC and control groups, body movement requiring a third person for control occurred in 30 (22%) and 533 (72%) cases during gastric ESD ( P < 0.0001) and in 36 (44%) and 53 (84%) cases during esophageal ESD ( P < 0.0001), respectively. The median minimum SpO2 was significantly lower in the MAC group than in the control group during both gastric and esophageal ESD (96% vs 98%, P < 0.0001; 96% vs 98%, P < 0.0004, respectively). MAC did not cause any adverse effects requiring prolongation of hospitalization. Conclusions Propofol-based MAC without intubation provided a safer treatment environment by significantly reduced body movement and was very effective for difficult cases requiring longer procedure times or more powerful sedation. [ABSTRACT FROM AUTHOR]

Chondroitin sulfate (CS) is a carbohydrate component of proteoglycans. Several types of sulfotransferases determine the pattern of CS sulfation, and thus regulate the biological functions of proteoglycans. The protochordate ascidians are the closest relatives of vertebrates, but the functions of their sulfotransferases have not been investigated. Here, we show that two chondroitin 4- O-sulfotransferases (C4STs) play important roles in the embryonic morphogenesis of the ascidian Ciona intestinalis. Ci-C4ST-like1 is predominantly expressed in the epidermis and muscle. Epidermal and muscle cells became spherical upon the injection of a Ci-C4ST-like1-specific morpholino oligo (MO), thus suggesting weakened cell adhesion. Co-injection of a Ci-C4ST-like1-expressing transgene rescued the phenotype, suggesting that the effects of the MO were specific. Ci-C4ST-like3 was expressed in the central nervous system, muscle, and mesenchyme. A specific MO appeared to affect cell adhesion in the epidermis and muscle. Convergent extension movement of notochordal cells was also impaired. Forced expression of Ci-C4ST-like3 restored normal morphogenesis, suggesting that the effects of the MO were specific. The present study suggests that Ci-C4ST-like1 and Ci-C4ST-like3 are required for cell adhesion mainly in the epidermis and muscle. [ABSTRACT FROM AUTHOR]

Background: Chondroitin sulfate (CS) is a sulfated polysaccharide chain that binds to various core proteins to form proteoglycans. The amount and position of sulfate groups in CS are variable among different tissues, and are determined by specific sulfotransferases. Although the ascidians are the closest relatives of vertebrates, the functions of their sulfotransferases have not been studied. Results: The genome of the ascidian Ciona intestinalis contains eight genes encoding proteins similar to chondroitin 6-O-sulfotransferases (C6STs), which appear to have independently diverged in the ascidian lineage during evolution. Among them, Ci-C6ST-like1 and Ci-C6ST-like7 were predominantly expressed in the developing notochord. In addition, they were weakly expressed in the neural tube. The disruption of either one of them affected the convergent extension movement of notochordal cells. Presumptive notochord cells coming from both sides of the embryo did not intercalate. The results suggest that both of them are necessary. In some cases, the anterior neural tube failed to close. Forced expression of Ci-C6ST-like1 or Ci-C6ST-like7 in the notochord restored the normal intercalation of notochordal cells, indicating that the effects of morpholino oligos are specific. Conclusions: Ci-C6ST-like1 and Ci-C6ST-like7 are required for the morphogenesis of the notochord in the ascidian embryo. Developmental Dynamics 243:1637-1645, 2014. © 2014 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Vancomycin-resistant Staphylococcus aureus ( S. aureus) (VRSA) uses depsipeptide-containing modified cell-wall precursors for the biosynthesis of peptidoglycan. Transglycosylase is responsible for the polymerization of the peptidoglycan, and the penicillin-binding protein 2 (PBP2) plays a major role in the polymerization among several transglycosylases of wild-type S. aureus. However, it is unclear whether VRSA processes the depsipeptide-containing peptidoglycan precursor by using PBP2. Here, we describe the total synthesis of depsi-lipid I, a cell-wall precursor of VRSA. By using this chemistry, we prepared a depsi-lipid II analogue as substrate for a cell-free transglycosylation system. The reconstituted system revealed that the PBP2 of S. aureus is able to process a depsi-lipid II intermediate as efficiently as its normal substrate. Moreover, the system was successfully used to demonstrate the difference in the mode of action of the two antibiotics moenomycin and vancomycin. [ABSTRACT FROM AUTHOR]

Objective We investigated the plasma levels of interleukin (IL)-6 and 5-HTT polymorphisms in patients with major depressive disorder (MDD). This is the first report, to our knowledge, of an investigation into the association between 5-HTT gene polymorphism, plasma IL-6 levels, and responses to selective serotonin reuptake inhibitors (SSRIs) in Japanese patients with MDD. Method One-hundred and eighteen patients (51 male, 67 female) who met the DSM-IV criteria for MDD were enrolled. Their ages ranged from 24 to 78 (mean ± SD = 44 ± 12) years. The patients were treated with SSRIs (paroxetine in 66 cases, sertraline in 42 cases) for 8 weeks. Results The plasma levels of IL-6 were significantly higher in the SSRI responders than in the nonresponders ( p = 0.0328), and the changes in plasma IL-6 levels correlated significantly with the changes in severity of depressive state ( p = .0.007). No difference was found in baseline and the changes in plasma IL-6 levels between the patients with a 5-HTT gene (5-HTTLPR) L-carrier and those with S/S. Conclusion These results suggest that the plasma levels of IL-6 reflect the severity of MDD and that plasma IL-6 levels might be another biological-state marker for the depressive state. In addition, the 5-HTTLPR polymorphism might be independent of plasma IL-6 levels. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

We classify the groups that are the inverse limits of sequences of free groups of finite rank. Except free groups of finite rank, there exist four groups that are the inverse limits of sequences of free groups of finite rank. [ABSTRACT FROM AUTHOR]

Objectives Neuropsychiatric systemic lupus erythematosus (NPSLE) is accompanied by neurological or psychiatric symptoms that can be severe. We hypothesized plasma 3-methoxy-4-hydroxyphenylglycol (MHPG) and homovanillic acid (HVA) levels were the biological marker that reflected the severity of the NPSLE psychiatric symptoms, and we examined MHPG and HVA levels in systemic lupus erythematosus (SLE) patients. Methods The participants were 42 healthy volunteers and 41 SLE patients. SLE patients were divided into the three groups: NPSLE with psychiatric symptoms (NP group), NPSLE without psychiatric symptoms (NN group), and SLE without neuropsychiatric symptoms (S group). All blood samples were drawn before (T0) and after 4 weeks of treatment (T4) in all SLE patients, and once in the healthy volunteers. Plasma levels of MHPG and HVA were analyzed using high-performance liquid chromatography. Results Plasma MHPG levels at T0 were significantly increased in the SLE compared to those in healthy volunteers. The NN group had the greatest increase compared with other SLE patient groups. There were no significant differences in plasma HVA levels at T0 between the four groups, and there was also no difference in MHPG and HVA plasma levels between T0 and T4. Conclusion Hyperactivity of noradrenergic neurons and/or sympathetic nerves might be involved in SLE pathophysiology. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Introduction: A prior study with 22-gauge needles recommended more than seven needle passes for endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) of solid pancreatic lesions (SPL) without onsite cytopathology for optimal acquisition of cytopathological diagnosis. The feasibility of this recommendation should be re-evaluated considering the later development and popularity of 25-gauge EUS-FNA needles. We aimed to determine the optimal number of needle passes for cytopathological specimen acquisition with 25-gauge needles for EUS-FNA of SPL. Methods: A preliminary prospective study of 22 patients with an onsite cytopathology technician showed a sensitivity of 93.3% and a specificity of 100% with four needle passes that was not statistically different from five needle passes. Based on our preliminary study, we fixed the number of needle passes to four (Group A). As a control group, we carried out sampling in consecutive patients using 25-gauge needles with an onsite cytopathologist (Group B). Sampling rate, diagnostic value and complications were evaluated. Results: We enrolled 20 patients in each group. Sampling rate was higher in Group B (20/20, 100%) than in Group A (19/20, 95%), but there was no statistical difference between them ( P-value = 0.31). In Group A, sensitivity, specificity and accuracy were 100% among 19. In Group B, sensitivity was 94.1%, specificity 100%, accuracy 95%. There were also no statistical differences between the groups. No complications were seen. Conclusion: Our study suggests that four needle passes using a 25-gauge needle may be sufficient for EUS-FNA of SPL where onsite cytology is not available. [ABSTRACT FROM AUTHOR]