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Nitric oxide (NO) may aggravate neuronal damage after spinal cord injury (SCI). We hypothesized that NO produced by inducible nitric oxide synthase (iNOS) accelerates secondary damage to spinal tissue, which may be reversed by the neuroprotectant, melatonin. This study investigated the effects of combination therapy with melatonin (10 mg/kg) and exercise (10 m/min) on recovery from SCI caused by contusion. We examined locomotor recovery, iNOS gene expression, autophagic and apoptotic signaling, including Beclin-1, LC3, p53 and IKKalpha protein expression and histological alterations in the ventral horn of the spinal cord. Melatonin in combination with exercise resulted in significantly increased hindlimb movement (P < 0.05), a reduced level of iNOS mRNA (P < 0.05) and more motor neurons in the ventral horn, versus control SCI and SCI plus exercise alone, with no effect on the other signaling molecules examined. This study shows that combined therapy with melatonin and exercise reduces the degree of secondary damage associated with SCI in rats and supports the possible use of melatonin in combination with exercise to reduce the side effects related to exercise-induced fatigue and impairment.

The title compounds were synthesized and characterized. The vibrational frequencies of (Me 3 Si) 3 SiX (X  H, Cl, OH, OD, Me, OMe, SiMe 3 ) were determined by means of IR and Raman spectroscopy. Based on our AM1 semiempirical calculation and the literature group frequencies of CH 3 , Me 3 Si, SiSi 3 , SiX (X  H, Cl, OH, OD, CH 3 , OCH 3 ) have been assigned. The intensities of the Raman lines of the stretching vibrations of (Me 3 Si) 3 SiX (X  Cl, OH, OMe) and (Me 3 Si) 3 SiOH are very low compared with those of the IR lines. This indicates that the bonds have a strong ionic nature.

Intestinal Behcet’s disease (BD) is a chronic inflammatory bowel disease, as are Crohn’s disease (CD) and ulcerative colitis (UC). But unlike CD and UC, serologic markers for intestinal BD are not well known. Recently, anti-α-enolase antibody (AAEA) has been detected in sera from BD patients. The aim of this study was to evaluate the prevalence of AAEA in intestinal BD and its clinical correlations. The study sample included 80 patients with intestinal BD and 23 healthy controls. IgM AAEA was detected by ELISA. The positivity of IgM AAEA was defined as an optical density greater than three standard deviations above the mean of the control sera. Other parameters, such as demographic information, subtype of BD, colonoscopic findings, disease severity and treatment modality, were analyzed retrospectively. The prevalence of IgM AAEA was 67.5% in intestinal BD and 0% in the control group. The positivity rate of IgM AAEA was higher in complete or incomplete BD than in suspected BD (77.5% vs. 51.6%, P = 0.016). The mean HBI score was higher in antibody positive patients than in antibody negative patients (5.60 vs. 4.61, P = 0.003). The cumulative probability of steroid use for aggravation of intestinal and extra-intestinal symptoms was higher in antibody positive patients than in antibody negative patients (P = 0.012). The number of patients with systemic involvement was higher in the AAEA positive group than in the negative group. Monitoring IgM AAEA may be helpful for diagnosis of intestinal BD and could be used to predict clinical course and disease severity.

In colonoscopy examination, luminal visibility is frequently limited due to intraluminal bubbles. In present study was evaluated factors affecting bubble formation and the effects of simethicone in preventing bubble formation during colonoscopy.Consecutive patients (n=164) who received polyethylene glycol or sodium phosphate for bowel preparation were prospectively enrolled. Before colonoscopy, 57 patients took 80 mg simethicone after ingestion of bowel preparation solution and 107 did not to determine whether simethicone decreased bubble formation. Intraluminal gas bubbles were assessed and graded as follows: 0, minimal or none; 1, covering less than half the lumen; 2, covering at least half the lumen or the entire circumference. Grade 2 bubbles were regarded as significant, limiting visibility.Sodium phosphate preparation tended to have more bubbles than the polyethylene glycol. Significant bubbles were more likely to occur in males than females (p = 0.020). Significant bubbles were noted in 34.6% of patients without simethicone and 7% of patients with simethicone. Simethicone significantly lowered the incidence of bubbles during colonoscopy when given after a preparation solution (p0.05),The present study findings indicate that taking simethicone after an oral polyethylene glycol or sodium phosphate preparation can improve colonic visibility by diminishing colonic bubbles.

Several reports have suggested a trend of right-side shift of colorectal cancer; however, there were only a few studies on the chronologic changes in the distribution of adenomatous polyps. We aimed to study the changes in the distribution of colorectal adenomatous polyps over the past ten years.We reviewed medical records of patients who underwent a colonoscopy at Yonsei University Severance Hospital, Seoul, Korea between January 1996 and December 2005. Patients who had an adenomatous polyp with a diameter of at least 5mm were included. Of these, patients with a history of colon resection, colorectal cancer, colorectal polyp, inflammatory bowel disease, HNPCC, or familial adenomatous polyposis were excluded.A total of 2,498 patients and 4,591 adenomatous polyps were included in this study. Analysis with respect to number of patients showed significant increases in the proportion of patients with adenomatous polyp on the proximal colon, from 48.5% to 66.3% (p0.001). Analysis with respect to number of polyps revealed that the proportion of adenomatous polyps on the proximal colon significantly increased from 48.9% to 62.3% (p0.001).The proportion of adenomatous polyp on the proximal colon significantly increased over the past 10 years.

Olmesartan medoxomil (OLM) is an antihypertensive angiotensin II receptor blocker. OLM has a low bioavailability (BA), approximately 26% in humans, due to its low water solubility and efflux by drug resistance pumps in the gastrointestinal tract. Self-microemulsifying drug delivery system (SMEDDS), which is easily emulsified in aqueous media under gentle agitation and digestive motility, was formulated to increase the oral BA of OLM. Among the surfactants and oils studied, Capryol 90, Tween 20, and Tetraglycol were chosen and combined at a volume ratio of 1:6:3 on the basis of equilibrium solubility and phase diagram experiments. The mean droplet size of SMEDDS was 15 nm. In an oral absorption study in rats, SMEDDS formulation brought faster absorption compared to suspension, showing a T(max) value of 0.2 hr. The C(max) and AUC values of SMEDDS formulation were significantly higher than those of suspension, revealing a relative BA of about 170%. Our study demonstrated the potential usefulness of SMEDDS for the oral delivery of poorly absorbable compounds, including OLM.

Background: Endoscopic resection (endoscopic mucosal resection, EMR, and endoscopic submucosal dissection, ESD) has been accepted worldwide as a less invasive standard treatment for early gastric cancer (EGC). However, the risk of synchronous and metachronous gastric cancer developing in the post-endoscopic resection patient has become a major problem. We investigated the incidence and characteristics of synchronous and metachronous multiple gastric cancers in a retrospective study of patients with EGC after endoscopic resection. Patients and Methods: We studied the clinicopathological features of 235 patients with EGC who had undergone endoscopic resection and were periodically followed up using endoscopic examinations (181 with a single lesion, 34 synchronous multiple lesions, and 20 metachronous multiple lesions). Results: The overall incidence of synchronous and metachronous multiple gastric cancer was 14.5 and 8.5%, respectively, during a follow-up of 12–77 (median 26.5) months. Undifferentiated histology of the primary lesion was related to the occurrence of synchronous gastric cancer (p < 0.001). Undifferentiated histology and upper location of the primary lesion were correlated with the occurrence of metachronous gastric cancer (p = 0.002, 0.001). Most synchronous and metachronous lesions were well to moderately differentiated (82.4 and 80.0%); however, the proportion with undifferentiated histology (including poorly differentiated carcinoma and signet ring cell carcinoma) in synchronous and metachronous gastric cancer was significantly higher than in single gastric cancer (p = 0.008). Conclusions: Undifferentiated histology of EGC may predict the occurrence of synchronous and metachronous lesions after endoscopic resection.

Many biological systems are regulated by an intricate set of feedback loops that oscillate with a circadian rhythmicity of roughly 24 hr. For example, increases in body temperature, heart rate, blood pressure, and cortisol secretion occur early in the day. Histone proteins exist in a delicate balance between acetylated and deacetylated states. Acetylation leads to nucleosomal relaxation and increased expression of numerous genes. Recent work implicates this chromatin remodeling response in hypertrophic growth of the myocardium. trichostatin A(TSA), a potent inhibitor of histone deactylase(HDAC) activity, imposes a dose-dependent blockade to hypertrophy and fetal gene activation in neonatal cardiac cells. To explore the role of HDAC activation in an in vitro, we studied the effects of TSA, NaB and melatonin in neonatal and H9c2 cells. Chemicals such as TSA and NaB treated neonatal cardiac cells had an increase of global histone H3 and H4(P

We report on fabrication and photon detection experiments of Nb/Al and Ta/Al superconducting tunnel junctions (STJs). 5-layer STJ thin-films were fabricated using UV photolithography, DC magnetron sputtering, reactive ion etching, and chemical vapor deposition techniques. STJs with 4 different sizes (20, 40, 60 and 80 μm) were deposited on sapphire substrates and tested in a two stage adiabatic demagnetization refrigerator with an operating temperature ~ 50 mK. Photons from different light sources are injected into the junctions via an optical fiber in combination with a monochromator which can produce photons from 30 nm to 550 nm with 0.1 nm resolution. The junction is read out through a charge-sensitive preamplifier followed by a shaping stage. We have measured some performance indicators and quality factors of the junctions from resultant I-V curves.

Well differentiated rectal carcinoid tumors which are less than 1cm in diameter can be treated by endoscopic resection. We aimed to evaluate the efficacy of endoscopic resection in treating small sized rectal carcinoids.Medical records of 30 rectal carcinoid cases treated by endoscopic resection in Yonsei University College of Medicine, Severance Hospital between January 1995 and March 2007 were reviewed retrospectively.Mean age was 49.7 years and male to female ratio was 1:0.88. Mean size of tumor was 6.29+/-3.06 mm and 25 out of 30 patients (83.3%) had tumors of diameter less than 10 mm. Twenty-two out of 30 patients treated by conventional polypectomy, 6 by endoscopic mucosal resection using a transparent cap (EMR-C) and 2 by endoscopic submucosal dissection (ESD). Histological examination revealed that 9 patients had resection margin positive for tumor; 7 (31.8%) were in polypectomy group, 1 (16.7%) in EMR-C group, and 1 (50%) in ESD group (p=0.868). Five patients underwent transanal excision to remove residual tumor. No residual tumor was found in additionally resected tissue. Mean follow-up duration was 19. 3 months (range 0-122), and there were no recurrence.Endoscopic resection is an effective method in the treatment of small rectal carcinoids. However, long-term outcome remains to be elucidated by a large scaled prospective study.

Endoscopic mucosal resection (EMR) is widely accepted as a standard treatment for early gastric cancer or gastric adenoma. However, EMR inevitably results in the formation of large iatrogenic ulcer at the resected area. Although the characteristics of EMR-induced ulceration are not fully understood, this type of ulcer is thought to heal faster and to recur less often than non-iatrogenic gastric ulcer. Current available evidences have suggested that EMR-induced ulcers heal within 2-3 months. Herein, we report two cases of non-healing persistent gastric ulcers after EMR. One is a case of gastric carcinoma which developed at the same site of previous EMR site for the low grade dysplasia. The other is a case in which persistent EMR-induced ulcer was healed in the long run after Helicobacter pylori eradication therapy.

Background and Objective Endoscopic resection (ER) has become an important curative option for early gastric cancer (EGC). However, the application of ER for undifferentiated EGC remains controversial. The aim of this study was to evaluate the clinicopathologic outcomes of ER performed in undifferentiated EGC with special reference to histopathologic subtypes to examine the feasibility of ER in undifferentiated EGC. Design and Setting Retrospective, single-center study. Patients From January 2001 to April 2007, 58 lesions in 58 patients with undifferentiated EGC (17 poorly differentiated adenocarcinoma; 41 signet-ring cell carcinoma) were treated by ER at Severance Hospital, Seoul, Korea. Main Outcome Measurements The therapeutic efficacy of ER was assessed according to en bloc resection, histologic complete resection (CR), lateral or vertical cut end-positive (including submucosal invasion), and recurrence rates in 3- to 65-month follow-up periods. Results The en bloc resection and CR rates were 84.5% and 67.2%, respectively. The en bloc and CR rates in poorly differentiated were 82.4% and 58.8%, whereas those in signet-ring cell were 85.4% and 70.7%, respectively. There were no significant differences between poorly differentiated and signet-ring cell. However, all (100%) of the histologic incomplete resections in poorly differentiated were vertical cut end-positive, whereas 83.3% of these resections in signet-ring cell were lateral cut end-positive. The recurrence rate was 5.1% in CR during the follow-up period. Limitations Retrospective, short-term follow-up period. Conclusions ER may be a feasible local treatment for undifferentiated EGC if CR can be achieved. However, a different approach is necessary between poorly differentiated and signet-ring cell before ER to prevent incomplete resection.

Background/Aims: Serrated polyps have emerged as important evidence supporting the serrated polyp-neoplasia pathway in colorectal carcinogenesis, an alternate to the classical adenoma-carcinoma sequence. However, there is confusion over the diagnostic criteria for serrated polyps including traditional serrated adenoma (TSA) and sessile serrated adenoma (SSA). In addition, clinical and pathologic characteristics of each are largely unknown and need further exploration. Methods: The 753 polyps that were previously diagnosed as serrated adenoma (SA) from 14 tertiary care university hospitals in Korea between 2003 and 2005 were evaluated for the clinicopathologic findings of TSA and SSA. Results: Among 753 cases, 420 (55.8%) were reclassified as TSA and 56 (7.4%) as SSA. Among the pathologic parameters, crypt branching, crypt dilatation, and horizontal crypts were more frequent in SSA than in TSA (p < 0.001). SSA was larger than TSA (12.6 ± 7.3 vs. 9.8 ± 6.9 mm, p = 0.005), was more likely to be flat type (p = 0.006), and was more frequently located in the proximal colorectum (p = 0.012). There were no significant differences in age, sex, and body mass index between TSA and SSA. Conclusions: Locationand endoscopic features of the polyps with abnormal crypt morphology in histologic findings could be helpful for the diagnosis and classification of SAs.

Saccharomyces boulardii (S. boulardii) has beneficial effects in the treatment of intestinal inflammation; however, little is known about the mechanisms by which these effects occur. We investigated the effects of S. boulardii on the expression of peroxisome proliferator-activated receptor-gamma (PPAR-gamma) and interleukin-8 (IL-8), using human HT-29 colonocytes and a rat model of trinitrobenzene sulfonic acid (TNBS)-induced colitis. The effect of S. boulardii on gene expression was assessed by semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR), and Northern blot and Western blot assays. Pharmacological inhibitors for various signaling pathways were used to determine the signaling pathways implicated in the S. boulardii regulation of PPAR-gamma and IL-8. We found that S. boulardii up-regulated and down-regulated PPAR-gamma and IL-8 expression at the transcription level, both in vitro and in vivo (P < 0.05, respectively). Saccharomyces boulardii blocked tumor necrosis factor-alpha (TNF-alpha) regulation of PPAR-gamma and IL-8 through disruption of TNF-alpha-mediated nuclear factor kappa B (NF-kappaB) activation. Furthermore, S. boulardii suppressed colitis and expression of pro-inflammatory cytokine genes in vivo (P < 0.05, respectively). Our study demonstrated that S. boulardii reduces colonic inflammation and regulates inflammatory gene expression.

Behcet's disease has been recognized as a systemic vasculitis characterized by the involvement of multiple organs such as orogenital ulcers, eye lesions including uveitis and optic neuritis, and skin lesions including folliculitis and erythema nodosum. Vascular involvement occurs occasionally and is classified into thrombosis and aneurysm. However, massive gastrointestinal bleeding from arterial aneurysm is a rare manifestation of intestinal Behcet's disease. Recently, we experienced a case of intestinal Behcet's disease presenting with massive gastrointestinal bleeding due to aneurysmal rupture of ileo-colic artery. A 30-year-old male with Behcet's disease was admitted because of massive gastrointestinal bleeding. A large ileo-cecal ulcer was revealed as a bleeding focus on colonoscopic examination. Celiac angiography showed aneurysm and stenosis of ileo-colic artery. After the failure of hemostasis with arterial embolization, ileocecectomy was performed. After the resection hematochezia was completely stopped.

The da Vinci system is a newly developed device for colorectal surgery, therefore experience of its use for rectal cancer surgery is limited and there are no reports describing the use of four robotic arms with this system. The aim of this study is to evaluate the safety and feasibility of the four-arm da Vinci system for total mesorectal excision in rectal cancer patients.Clinicopathologic data were prospectively collected on nine patients who underwent robotic total mesorectal excision using four robotic arms for the treatment of mid or low rectal cancer between November 2006 and Febuary 2007. Patient demographics, perioperative clinical outcomes, and pathology results with macroscopic grading (complete, nearly complete, incomplete) were evaluated.nine patients with mid or low rectal cancer underwent robotic total mesorectal excison using four robotic arms without serious complications. The mean length of hospital stay was 7.4 +/- 1.3 days (range 5.0-10.0 days) and the mean operating time was 220.8 +/- 49.4 min (range 153-315 min). Macroscopic grading of the specimen was complete in eight patients and nearly complete in one patient. There were no cases of conversion.In the present study, we accomplished nine robot-assisted rectal resections safely and effectively.

endoscopic and fluoroscopic guidance. Symptom response and procedure and stent related outcomes were measured prospectively. Results: 11 patients (9 F, 2 M) were treated with a LAMS from Apr-Nov 2014. 6 pts had GOO (Bn-S Z 1, Mal-S Z 1, IndS Z 4) and 5 had ASs (gastro-jejunal post Roux-en-Y gastric bypass (RYGB) Z 4, gastric post vertical banded gastroplasty (VBG) Z 1). Obstructive symptoms resolved in 10 pts; there was no response in 1 pt with extrinsic duodenal compression from metastatic sarcoma. Stent removal was possible in all 9 pts in whom it was attempted. 4 pts had LAMS placed more than once; LAMSs were removed for stricture re-evaluation and a new LAMS placed simultaneously in 2 pts, and LAMSs were removed and replaced28 days later for symptom recurrence in 2 pts (benign GOO and AS in RYGB). Mean duration of LAMS in-situ (cumulative time used for the 2 pts with simultaneous Ax-Ss) was 62 days (range 11-152). There were no stent related complications including occlusion, migration or perforation. 1 pt with a radiation induced Bn-S with GOO was treated with a LAMS followed by an esophageal FCSEMS through the lumen of the LAMS with the LAMS acting as an anchor for the FCSEMS, without migration at 6 months. In the 4 pts with Ind-Ss with GOO, a Mal-S was confirmed by EUS-FNA in 1 pt and surgery in 1 pt, a peptic stricture in 1 pt and follow-up is pending in 1 pt. Amongst AS pts, the LAMS was removed for persistent pain (onset pre-dated LAMS) in 1 pt, for AS resolution in 2 pts and was left in place long term in 2 pts (one after initial stent removal). Conclusions: LAMS offers a new option for focal strictures causing GOO or occurring after surgery and have the advantages of easy placement and removal, if necessary, with no associated complications on short-term follow-up. Furthermore, the stent offers an easy new option for anchoring FCSEMS in strictures requiring a longer stent.

predicting the depth of invasion from Mar 1, 2010 to Dec 31th, 2012 in PUMCH. All patients underwent endoscopic or surgical resention after EUS. Assessed the diagnostic sensitivity, specificity and accuracy of EUS by comparing the pre-treatment EUS results with the postoperative histopathological findings. The clinico-pathological factors may influencing the accuracy of EUS were also analyzed. Results: 59 lesions were evaluated by EUS for 59 patients (39 males and 20 females, mean age: 62.2+8.4 years old). Among these lesions, 10 cases located in the upper 1/3 stomach, 13 in the middle 1/3 and 27 in the lower 1/3. The maximal diameters of lesions distributed from 0.7cm to 5.5cm, and 21 lesions were bigger than 2.0cm in diameter. For the macroscopic type, 30 cases showed as 0-IIc, 13 cases were 0-IIa. 49 lesions were confirmed by histopathologic exam to be limited within mucosal layer (M) and the rest 10 invaded to the submucosal layer (SM). The overall diagnostic sensitivity, specificity and accuracy of EUS for the depth of early gastric cancer invasion were 79.7%, 81.4% and 79.7%, respectively. (M: sensitivity 66.1%, specificity 80.0%, accuracy 79.7%, SM: sensitivity 80.0%, specificity 81.6%, accuracy 81.4%, there were no obvious diference between the two groups). The overgrading rate was 16.9%, which mainly happened in leisons located in upper third (20.0%) and middle third (27.3%),with macroscopic elevated type (0-I:25%,0-IIa:38.5%) or with histologically confirmed ulcer (33.3%). The above mentioned lesions had a relatively lower diagnostic accurancy. The overall undergradeing rate was 3.4%. Conclusions: EUS has a quite high diagnostic accuracy in evaluating the depth of early gastric cancer invasion which helps the planning of treatment strategy. The location, macroscopic type and coexisting ulcer of lesion will affect the dignostic accurancy. The comparation of the depths of tumor invasion assessed by endoscopic ultrasonography (EUS) with the pathologic results for early gastric cancer AB438 GASTR EUS results OINTESTINAL END Pathologic results OSCOPY V Number of cases olume 8 Percentage(%) EUS agree with pathologic

BackgroundThere is controversy about the effect of Helicobacter pylori (H. pylori) eradication on the prevention of metachronous gastric cancer after endoscopic resection (ER).AimsThe aim of this study was to systematically evaluate the effect of H. pylori eradication on the prevention of metachronous gastric lesions after ER of gastric neoplasms.MethodsWe performed a systematic search of PubMed, EMBASE, the Cochrane Library, and MEDLINE that encompassed studies through April 2014. Our meta-analysis consisted of 10 studies, which included 5881 patients who underwent ER of gastric neoplasms.ResultsWhen we compared the incidence of metachronous lesions between H. pylori-eradicated and non-eradicated groups, H. pylori eradication significantly lowered the risk of metachronous lesions after ER of gastric neoplasms (five studies, OR = 0.392, 95% CI 0.259 - 0.593, P < 0.001). When we compared H. pylori-eradicated and persistent groups, again, H. pylori eradication significantly lowered the incidence of metachronous lesions after ER of gastric neoplasms (six studies, OR = 0.468, 95% CI 0.326 - 0.673, P < 0.001). There was no obvious heterogeneity across the analyzed studies.ConclusionsThis meta-analysis suggests a preventive role for H. pylori eradication for metachronous gastric lesions after ER of gastric neoplasms. Thus, H. pylori eradication should be considered if H. pylori infection is confirmed during ER.

Objective Endoscopic Submucosal Dissection (ESD) has been accepted and established as a standard treatment for early gastric cancer (EGC) without distant metastasis. With increase of elderly population, many aged patients have chance to receive ESD for their EGC. However, some patient resulted in unsuccessful non-curative ESD, and followed-up without additional surgery by limitation of various risks of comorbid disease and low performance status or patients' refusal for additional treatment. The aim of the present study is to assess the longterm clinical outcomes of non-curative ESD with or without additional surgery and effect of additional surgery for non-curative ESD. Methods We reviewed chart data on all patients who had undergone ESD for EGC at two foundation hospitals of Saga Medical school hospital and Saga prefectural Hospital between 2001 and 2012. A total of 957 cases (1047 lesions) of EGC underwent ESD, and a total of 99 cases resulted in non-curative ESD. We excluded 20 cases because un-enough follow-up period less than 36 months. As to the target 79 cases, we divided into observation group and additional surgery group. We compared overall and disease-specific survival rate between two groups Results After unsuccessful non-curative ESD, 28 patients (35.4%) underwent additional surgery and 51 patients (64.6%) were followed without surgery. Average age of patients without additional surgery was higher than that of additional surgery group (75.8 y.o. vs. 71.6 y.o.; P=0.03). There was no significant difference in gender ratio. The incidence of complicated hypertension was significantly higher in the observation group compared to additional surgery group (49.0% vs. 25.9%; P=0.04). Incidence of other comorbid diseases, such as cardiac disease, cerebrovascular disease, chronic liver disease, chronic kidney disease, and diabetes did not differ between the two groups. There was no significant difference in pathological feature except for ulcer findings. Mean follow-up period of patients with additional surgery was 60.2 months and that of patient observation alone was 57.0 months. Overall survival rate of additional surgery group was longer than observation group. However, only one patient died from gastric cancer in the observation group. Main causes of death were their comorbid diseases. Diseasespecific survival rate was not significantly different between the two groups. Conclusions It is acceptable to follow up without additional surgery for EGD patients with comorbid disease and low performance resulted in non-curative ESD.

Background EUS is an operator-dependent procedure and requires more technical and cognitive skills than a routine endoscopic procedure. The learning curve for the staging of gastric cancer, however, has not been evaluated. Objective To evaluate the threshold number of EUS examinations for gastric cancer T staging. Design Retrospective study. Setting University-affiliated tertiary care hospital in the Republic of Korea. Patients Four trainees with no previous EUS experience. Intervention Analyzing performance of EUS trainees in gastric cancer T staging by using cumulative sum (CUSUM) analysis. Main Outcome Measurements CUSUM plot and a minimal number of procedures for reaching a plateau. Results A total of 553 initial EUS examinations for treatment-naive gastric cancers, performed by trainees, were enrolled in the study. The final T stage was determined by experts by using EUS in 332 gastric cancer cases, whereas the T stage of the other 221 lesions was determined by trainees by using EUS. The accuracy of EUS examinations performed by trainees and experts was 72.6% and 84.3%, respectively. The number of EUS examinations required to reach the first plateau in each trainee was 20, 41, 60, and 65. Limitations Retrospective study with a relatively small number of trainees. Conclusion The CUSUM scores of all of 4 trainees in the study reached a plateau by the 65th examination.

Background Although endoscopic submucosal dissection (ESD) is routinely performed under sedation, the difference in ESD performance according to sedation method is not well known. This study attempted to prospectively assess and compare the satisfaction of the endoscopists and patient stability during ESD between two sedation methods. Methods One hundred and fifty-four adult patients scheduled for ESD were sedated by either the IMIE (intermittent midazolam/propofol injection by endoscopist) or CPIA (continuous propofol infusion by anesthesiologist) method. The primary endpoint of this study was to compare the level of satisfaction of the endoscopists between the two groups. The secondary endpoints included level of satisfaction of the patients, patient’s pain scores, events interfering with the procedure, incidence of unintended deep sedation, hemodynamic and respiratory events, and ESD outcomes and complications. Results Level of satisfaction of the endoscopists was significantly higher in the CPIA Group compared to the IMIE group (IMIE vs. CPIA; high satisfaction score; 63.2% vs. 87.2%, P=0.001). The incidence of unintended deep sedation was significantly higher in the IMIE Group compared to the CPIA Group (IMIE vs. CPIA; 17.1% vs. 5.1%, P=0.018) as well as the number of patients showing spontaneous movement or those requiring physical restraint (IMIE vs. CPIA; spontaneous movement; 60.5% vs. 42.3%, P=0.024, physical restraint; 27.6% vs. 10.3%, P=0.006, respectively). In contrast, level of satisfaction of the patients were found to be significantly higher in the IMIE Group (IMIE vs. CPIA; high satisfaction score; 85.5% vs. 67.9%, P=0.027). Pain scores of the patients, hemodynamic and respiratory events, and ESD outcomes and complications were not different between the two groups. Conclusion Continuous propofol and remifentanil infusion by an anesthesiologist during ESD can increase the satisfaction levels of the endoscopists by providing a more stable state of sedation. Trial Registration ClinicalTrials.gov NCT01806753

박 현 아·남 수 연·이 상 길·김 상 균·심 기 남·박 상 민·이 선 영·한 혜 승·신 용 문·김 경 미·이 경 재·이 태 용· 최 일 주·홍 성 숙·김 재 우·이 윤 재·김 수 영·김 열·이 원 철·정 일 권 | 인제대학교 의과대학 서울백병원 가정의학과, 경북대학교 의과대학 경북대학교병원 소화기내과, 연세대학교 의과대학 세브란스병원 내과, 서울대학교 의과대학 내과학교실 간연구소, 이화여자대학교 의학전문대학원 내과학교실, 서울대학교 의과대학 가정의학교실, 건국대학교 의학전문대학원 내과학교실, 건국대학교 의학전문대학원 병리학교실, 울산대학교 의과대학 서울아산병원 영상의학과, 성균관대학교 의과대학 병리학교실, 순천향대학교 의과 대학 순천향대학 서울병원 직업환경의학과, 충남대학교 의학전문대학원 예방의학교실, 국립암센터 위암센터, 순천향대학교 서울병원 영상의학과, 국립암센터 암검진사업과, 분당차병원 한방부인과, 한림대학교 의과대학 강동성심병원 가정의학과, 가톨릭대학교 의과 대학 예방의학교실, 순천향대학교 의과대학 순천향대학 천안병원 내과학교실

Purpose During sedated esophagogastroduodenoscopy (EGD), patients may not be able to perform inspiration, which is necessary to examine the esophagogastric junction. Therefore sedation may affect diagnosis of gastroesophageal reflux-related findings. The aim of our study was to investigate the effect of sedation on diagnosis of gastroesophageal reflux-related findings during EGD. Materials and Methods This retrospective study evaluated 28914 patients older than 20 years who underwent EGD at our institution between January 2011 and December 2011. Ultimately, 1546 patients indicated for EGD for health check-up and symptom evaluation were included. Results There were 18546 patients who had diagnostic EGD: 10471 patients (56%) by non-sedated EGD and 8075 patients (43%) by sedated EGD. After statistical adjustment for age, sex, and body mass index, minimal change esophagitis, and hiatal hernia were significantly less frequently observed in the sedated EGD group [odds ratio (OR), 0.651; 95% confidence interval (CI), 0.586 to 0.722 and OR, 0.699; 95% CI, 0.564 to 0.866]. Nevertheless, there was no significant difference in other findings at the gastroesophageal junction, such as reflux esophagitis with Los Angeles classification A, B, C, and D or Barrett's esophagus, between the two groups. Similarly, there were no differences in early gastric cancer, advanced gastric cancer, and gastric ulcer occurrence. Conclusion Sedation can impede the detection of minimal change esophagitis and hiatal hernia, but does not influence detection of reflux esophagitis of definite severity and Barrett's esophagus.

The clinical course of patients with inflammatory bowel disease (IBD) frequently leads to the use of immunosuppressants and immunomodulators. We investigated the risk of postoperative infection in patients with IBD undergoing elective bowel surgery and whether the use of corticosteroid (CS) and/or 6-mercaptopurine/ azathioprine (6-MP/AZA) before surgery was associated with the increased risk of postoperative infection.Patients who were diagnosed as Crohn's disease (n=25) or ulcerative colitis (n=19) and underwent elective bowel surgery between 1986 and 2005 were identified. Medical records were retrospectively analyzed including age, sex, duration of disease, indication for surgery, duration of surgery, type of surgery, type of postoperative infection, admission period, usage of CS and 6-MP/AZA, and preoperative laboratory values. There were 27 patients receiving CS alone, 6 patients receiving 6-MP/AZA alone or with CS, and 16 patients receiving neither CS nor 6-MP/AZA.There were 17 postoperative infections (38.6%) among IBD patients who had undergone surgery and wound infection was the most common type of infection (76.5%). In IBD patients, patients receiving CS had higher postoperative infection rate than those patients receiving neither CS nor 6-MP/AZA (p=0.039). Patients receiving CS in conjunction with 6-MP/AZA did not have significantly higher postoperative infection rate than those with CS only (p=0.415).Preoperative use of CS in patients with IBD is associated with the increased risk of postoperative infections. Addition of 6-MP/AZA in patients receiving CS does not increase the risk of postoperative infections.

This large prospective study attempted to analyze the effect of various prior surgery on colonoscopy performance.It is generally presumed that colonoscopy in patients with a history of abdominal or pelvic surgery is difficult. This difficulty is apparently due to adhesions and anatomic alterations after surgery but the incidence, site, and severity of adhesions are different according to the types of surgery.We analyzed completion rate and insertion time in 4089 consecutive colonoscopies in patients with intact colon.The adjusted completion rate for colonoscopy was 96.7%. The mean insertion time was 6.2+/-4.0 minutes. Not only old age [odds ratio (OR) 1.46; 95% confidence interval (CI) [1.04, 2.04]] and inadequate bowel cleansing (OR 5.82; 95% CI [4.19, 8.09]) but also a surgical history (OR 1.71; 95% CI [1.18, 2.48]) were independent factors associated with procedural incompleteness. Of surgical history, gastrectomy and hysterectomy were significantly associated with procedural incompleteness (P0.001 and P=0.001, respectively). Old age (OR 1.48; 95% CI [1.22, 1.79]), female sex (OR 1.22; 95% CI [1.01, 1.48]), constipation as an indication (OR 1.58; 95% CI [1.24, 2.02]), and inadequate bowel cleansing (OR 1.46; 95% CI [1.13, 1.88]) were independent factors associated with prolonged insertion time (10 min), but a surgical history lost statistical power as a predictor for prolonged insertion time in multivariate analysis.Although the difference in insertion time was not substantial, a history of abdominal or pelvic surgery is associated with difficulty in colonoscopy.

Two new macrolides from the pikromycin biosynthetic pathway of Streptomyces venezuelae, neopikromycin (9) and novapikromycin (10), were identified and structurally characterized through mass spectrometry and NMR spectroscopy. The established structures showed that 9 and 10 have hydroxyl groups at C-14 (9) and at both C-12 and C-14 (10), on the basis of a comparison with narbomycin (7). The purified PikC cytochrome P450 monooxygenase catalyzes the in vitro hydroxylation of 7 and pikromycin (8) to yield 9 and 10, respectively, thus expanding the substrate- and regio-flexibility of this enzyme.

Gastrectomy is known to be a risk factor for adenocarcinoma in remnant stomach. It is suggested that reflux of bile juice or duodenal secretion to remnant stomach induces atrophic gastritis, intestinal metaplasia, and gastric adenocarcinoma. Malignant lymphoma in remnant stomach after gastrectomy is very rare. Only about thirty cases are reported in the world, and there is no case report in Korea. Gastric MALT (mucosa-associated lymphoid tissue) lymphoma is associated with Helicobacter pylori infection but the mechanism of lymphoma development in remnant stomach is still unknown. We report a case of low grade gastric MALT lymphoma of gastric stump after 10 years from partial gastrectomy.

Cigarette smoking is the most significant environmental factor identified in inflammatory bowel disease (IBD). Smoking has a beneficial effect on ulcerative colitis (UC) patients. In contrast, Crohn's disease (CD) is associated with smoking, and a detrimental effect of smoking on the course of CD has been demonstrated. The aim of this study was to explore the prevalence in smoking in CD and UC at the time of diagnosis compared with the general population in a single center study.Prevalence of smoking at the time of IBD diagnosis were compared between CD and UC patients in Kyung-Hee Medical Center with healthy general population at age-, gender-, and time period-adjusted rates. We investigated the smoking status of IBD patients at the time of diagnosis by telephone interview. There were 178 IBD patients (98 UC patients and 80 CD patients) between January 1995 and December 2004.The male to female ratio in CD and UC were 2:1 and 1:1.4, respectively. The onset of age was 28.2 years and 38.8 years, respectively. The prevalence of smoking was significantly lower in CD and UC patients than in the general population (CD; odds ratio 0.21, 95% confidence interval 0.12-0.41, p0.001, UC; odds ratio 0.06, 95% confidence interval 0.03-0.14, p0.001). After statistical adjustment for gender and age at the diagnosis of IBD, the odds ratio of a current smoker diagnosed as UC was 73% lower than that of CD (adjusted odds ratio 0.27, 95% confidence interval 0.12-0.59, p0.001). In contrast, being a former smoker showed a risk of approximate 1.27-fold higher likelihood of having UC diagnosis (adjusted odds ratio 1.27, confidence interval 0.41-3.95, p=0.68).Cigarette smoking is protective against developing UC at any age, but is not associated with the development of CD in Korean population. Former smoking is not the high risk factor in developing UC.

Recently, germ-line mutation in the base excision repair gene MYH has been identified to cause a novel autosomal recessive form of familial adenomatous polyposis (FAP). Interestingly, a striking evidence for MYH mutations within different ethnic groups has been demonstrated. In this study, we screened 30 patients with multiple adenomatous polyps for MYH mutations to assess its prevalence and ethnic specificity in Korea.Thirty patients (21 men and 9 women; mean age 62.3 years) with multiple adenomatous polyps were examined for MYH mutations. The mean number of adenomas per patient was 10.0. Sixteen exonic regions and their intronic sequences were amplified by PCR and subjected to SSCP and DNA sequencing analyses.None of the patients was identified to carry any truncating or sequence alterations in MYH. Our screening for the mutational regions, which were recognized from Caucasian patients or affected Indian families, also failed to detect sequence substitutions.Mutation in MYH may be rarely involved in the pathogenesis of multiple sporadic colorectal adenomas in Korean population, although a large-scale analysis will be required to clarify the presence of specific MYH variants in a subset of patients and their role in the predisposition of multiple colorectal adenomas in Korean population.

Intestinal epithelial cells not only present a physical barrier to bacteria but also participate actively in immune and inflammatory responses. The migration of epithelial cells from the crypt base to the surface is accompanied by a cellular differentiation that leads to important morphological and functional changes. It has been reported that the differentiation of colonic epithelial cells is associated with reduced interleukin (IL)-8 responses to IL-1beta. Although toll-like receptor 4 (TLR4) has been previously identified to be an important component of mucosal immunity to lipopolysaccharide (LPS) in the colon, little is known about the regulation of TLR4 in colonic epithelial cells during cellular differentiation. We investigated the effects of differentiation on LPS-induced IL-8 secretion and on the expression of TLR4. Differentiation was induced in colon cancer cell line HT-29 cells by butyrate treatment or by post-confluence culture and assessed by measuring alkaline phosphatase (AP) activity. IL-8 secretion was measured by ELISA, and TLR4 protein and mRNA expressions were followed by Western blot and RT-PCR, respectively. HT-29 cells were found to be dose-dependently responsive to LPS. AP activity increased in HT-29 cells by differentiation induced by treatment with butyrate or post-confluence culture. We found that IL-8 secretion induced by LPS was strongly attenuated in differentiated cells versus undifferentiated cells, and that cellular differentiation also attenuated TLR4 mRNA and protein expressions. Pretreating HT-29 cells with tumor necrosis factor (TNF)-alpha or interferon (INF)-gamma augmented LPS-induced IL-8 secretion and TLR4 expression. These TNF-alpha- or INF-gamma-induced augmentations of LPS response and TLR4 expression were all down-regulated by differentiation. Collectively, we conclude that cellular differentiation attenuates IL-8 secretion induced by LPS in HT-29 cells, and this attenuation is related with the down-regulation of TLR4 expression.