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Background: Gastric emptying plays an important role in gastroesophageal reflux disease. Acid suppressants such as H2 receptor antagonists and/or proton pump inhibitors are often used in patients with gastroesophageal reflux disease. However, it remains controversial whether H2 receptor antagonists and proton pump inhibitors delay or accelerate gastric emptying. Here, the influence of acid suppressants on gastric emptying was evaluated via a cross-over study using the [13C]-labeled acetate breath test. Methods: Twenty normal male subjects without gastroesophageal reflux disease symptoms were enrolled. Gastric emptying was investigated five times in every subject by the [13C]-labeled acetate breath test with oral administration of the vehicle, domperidone, and three acid suppressants: ranitidine, famotidine and rabeprazole. Gastric emptying was estimated by the values of Tmax-calc, T1/2 and %dose/2 h calculated from the 13CO2 breath excretion curve. Results: Using the Tmax-calc values, rabeprazole, ranitidine and famotidine did not influence gastric emptying time in comparison with vehicle administration. Using the T1/2 and %dose/2 h values, rabeprazole tended to delay gastric emptying. Domperidone produced a statistically significant acceleration of gastric emptying for all three variables ( P < 0.05). Conclusion: Oral dosage of the H2 receptor antagonists, ranitidine and famotidine, has no significant effect on gastric emptying. However, rabeprazole may delay gastric emptying more strongly than H2 receptor antagonists. [ABSTRACT FROM AUTHOR]

Eosinophilic esophagitis (EE) is a rarely diagnosed condition involving eosinophilic infiltration of the esophageal mucosa. Here we present a case of EE in a 69-year-old Japanese man, who presented with abdominal pain, appetite loss, and a history of bronchial asthma. Laboratory findings included peripheral eosinophilia and an increased serum immunoglobulin E level. Computed tomography showed diffuse severe thickening of the esophageal wall, and a barium esophagogram revealed a small caliber of the middle and lower portion of the esophagus, without normal peristaltic contractions. Endoscopy of the esophagus showed a pale mucosa, with adherent whitish exudates resembling fungal infection, and prominent ring-like contractions. Histologic examination of a biopsy specimen revealed marked eosinophil infiltration into the esophageal mucosa. Endoscopic ultrasonography (EUS) demonstrated marked circumferential thickening of the esophageal submucosal layer, and an esophageal manometry study showed a high percentage of ineffective esophageal peristalsis and high-amplitude esophageal body contractions. EUS findings showed no change even after oral corticosteroid therapy, although the histological findings were improved. This is thought to be the first documented Japanese case of EE. EE should be considered in the differential diagnosis in cases of esophageal motility disturbance, even if the patients do not complain of dysphagia. [ABSTRACT FROM AUTHOR]

Hereditary spherocytosis is a disease with chronic hemolytic anemia found mostly in childhood. We encountered a rare case of sporadic hereditary spherocytosis in a 68-year-old woman who developed periodic jaundice caused by hemolytic crises. Since the hemolytic crises were caused by cholelithiasis-related biliary inflammation, administration of ursodeoxycholic acid was useful for the prevention of the hemolytic crises. In the differential diagnosis of periodic increases in indirect bilirubin, the possibility of hemolytic diseases, including hereditary ones, should be considered, even if the patients are elderly. [ABSTRACT FROM AUTHOR]

The therapeutic effect of combined administration of prokinetics and histamine H2 receptor antagonists (H2RA) in gastroesophageal reflux disease is reported to be superior to that of monotherapy with H2RA alone. In addition to its acid-suppressing effect, the H2RA nizatidine also has a prokinetic action by suppressing acetylcholine esterase. The present multicenter, randomized controlled study was performed to investigate whether nizatidine is superior to famotidine, which does not suppress acetylcholine esterase activity, in maintenance therapy for erosive esophagitis. In addition, the question as to whether the grade of erosive esophagitis affects the non-recurrence rate during the maintenance therapy with H2RA was also investigated.Seventy-two patients with endoscopically healed erosive esophagitis after 8 weeks of initial treatment with proton pump inhibitors were randomly divided into two groups. Patients in the nizatidine group were treated with 150 mg nizatidine twice a day (b.i.d.), while patients in the famotidine group were treated with 20 mg famotidine b.i.d. for 6 months. At the end of therapy, and at the time when patients complained of symptoms, endoscopic investigations were repeated to find out whether the esophagitis had recurred.Nizatidine produced a significantly higher non-recurrence rate than famotidine (P = 0.049 in intention-to-treat[ITT] analysis). This difference of remission rate between nizatidine and famotidine was observed mainly in grade B esophagitis (P = 0.016 in ITT analysis).Nizatidine is a more effective H2RA than famotidine in the maintenance therapy of patients with reflux esophagitis. [ABSTRACT FROM AUTHOR]

A case study of a 73-year-old Japanese man who was bought into the hospital due to loss of memory mainly linguistic memory is presented. It notes that on magnetic resonance imaging diagnosis it was shown that bilateral atrophy of the hippocampus and occipital lobe. The study also suggests the diagnosis of optic agnosia and alexia and therefore was given cognitive rehabilitation. The importance of family education programmes that gives insight into patient's disorder is offered.

Research Question: Does tailor-made embryo transfer (TmET), timed with respect to embryonic developmental speed, affect pregnancy outcomes in patients with recurrent implantation failure?, Design: Among 741 patients identified as receptive through endometrial receptivity testing, the clinical pregnancy rates and live birth rates were retrospectively compared between those who underwent standard personalized embryo transfer and those who underwent TmET in hormone replacement therapy cycles. Personalized embryo transfer was performed according to endometrial receptivity test results (standard personalized embryo transfer group) or considering embryonic developmental speed (TmET group). For TmET, the expansion grade of warmed blastocysts was estimated based on each patient's previous embryonic developmental pattern. The embryo transfer days were set so that estimated blastocyst grades 3, 4, 5 and 6 were transferred on days P+5, P+5.5, P+6.0 and P+6.5, respectively., Results: In a propensity score matching analysis, the clinical pregnancy rate was significantly higher in the TmET group than the standard personalized embryo transfer group (P = 0.014), whereas the live birth rates were similar between the two groups (P = 0.65). In a subgroup analysis with euploid embryo transfers, the clinical pregnancy rate was significantly higher in the TmET group than the standard personalized embryo transfer group, although there was no difference in live birth rate between the two groups (P = 0.045 and P = 0.057, respectively)., Conclusions: For patients experiencing recurrent implantation failure and identified as receptive through endometrial receptivity testing, subsequent TmET strategies may further enhance pregnancy outcomes., (Copyright © 2024 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: Although fetal growth restriction (FGR) is associated with an increased risk of cesarean delivery during induced labor, there is limited evidence to guide labor management. This study aimed to investigate the prognosis of induced labor in pregnancies with suspected FGR and whether oxytocin discontinuation during the active phase of labor affects maternal and neonatal outcomes., Study Design: This retrospective cohort study investigated singleton pregnancies with vertex presentation and indications for labor induction owing to FGR after 34.0 weeks of gestation at Osaka University Hospital. From January 2010 to December 2013, women were conventionally managed, and oxytocin was continued until delivery unless there was an indication for discontinuation (conventional management group). From January 2013 to December 2020, oxytocin was routinely discontinued, or the dose was reduced at the beginning of the active phase of labor (oxytocin discontinuation group)., Results: A total of 161 women (conventional management group, n  = 74; oxytocin discontinuation group, n  = 87) were included. After the active phase of induced labor, the total incidence of cesarean delivery was very low (3.1%), and the duration was short (173 ± 145 minutes). Oxytocin discontinuation was associated with lower cesarean delivery (1.1 vs. 5.4%; p  = 0.12) and uterine tachysystole (9.8 vs. 23.0%; p  = 0.08) rates and longer duration of the second stage of labor (mean: 56.5 ± 90 vs. 34.2 ± 45 minutes; p  = 0.08) than conventional management; however, the difference was not significant. The other maternal and neonatal outcomes, including postpartum hemorrhage, did not also significantly differ between them., Conclusion: After the active phase of induced labor for suspected FGR, the risk of cesarean delivery is low, and the high incidence of uterine tachysystole and rapid labor progression should be considered cautiously. Oxytocin can be safely discontinued during the active phase of labor in women undergoing labor induction for FGR without an increased risk of cesarean delivery or other unfavorable outcomes., Key Points: · The cesarean delivery rate was low after the active phase.. · The labor progress after the active phase was rapid.. · Oxytocin can be safely discontinued during the active phase.., Competing Interests: None declared., (Thieme. All rights reserved.)

Vanishing twin syndrome (VTS) refers to the spontaneous reduction of a fetus during multiple pregnancies, resulting in its invisibility during gestation. Vanishing twin syndrome is commonly identified through ultrasonographic examination in early pregnancy; nonetheless, the genetic causes of VTS are rarely detected. This report aimed to investigate the feasibility of genetic testing for VTS using low-coverage whole-genome sequencing and short tandem repeat (STR) analysis. We report a 39-year-old woman who underwent in vitro fertilization and conceived dichorionic diamniotic twins. The heartbeat of 1 fetus ceased at 11 weeks, leading to a diagnosis of VTS, whereas the surviving fetus developed normally and was delivered at full term. Placental examination revealed a rudimentary gestational sac adjacent to the placenta that correlated with the vanished fetus. Chorionic tissues were collected from the placenta of the live-born infant and the rudimentary gestational sac that was considered to have originated from the vanished fetus. Genetic testing of chorionic tissues from the gestational sac and placenta showed that both fetuses were monozygotic twins with a normal 46, XY male karyotype. However, a triallelic pattern at the Penta E locus was identified in the vanished fetus on STR analysis, which was a unique genetic characteristic. This report highlights the feasibility of genetic testing for VTS, despite the unclear relationship between the identified genetic pattern and the vanished fetus., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Reverse water-gas shift (RWGS) operation at lower temperatures has multiple advantages such as use of low-cost materials and improvement of thermal efficiency. This report demonstrates the enhancement of CO selectivity by Au addition and clarifies the relationship between the enhanced CO selectivity and the density of state (DOS) in the vicinity of the Fermi level (Ef)., Competing Interests: There are no conflicts to declare., (This journal is © The Royal Society of Chemistry.)

Purpose: This study aimed to elucidate the effects of neuraxial analgesia on labor in women classified based on the Robson classification system., Methods: We retrospectively reviewed the clinical data of singleton cephalic nulliparous deliveries in labor at term between January 2018 and December 2021 and compared obstetrical outcomes between deliveries with and without neuraxial analgesia in women of Robson group 1 (spontaneous labor) and group 2a (induced labor). Statistical analyses were performed using the Wilcoxon ranked-sum test, Fisher's exact test, and logistic regression model. Statistical significance was set at p < 0.05., Results: We identified 2726 deliveries during the period, of which 387 deliveries (215 with analgesia and 172 without analgesia) were in Robson group 1 and 502 deliveries (258 with analgesia and 244 without analgesia) in Robson 2a. In Robson group 1 pregnancies, the cesarean section (CS) rate was higher in those who received analgesia (15%) than in those who did not (3%) (p = 0.0001). Multivariate analysis revealed that labor with analgesia was a significant risk factor for CS (p < 0.0001). Similarly, in Robson group 2a pregnancies, we observed a higher CS rate in those with analgesia than in those without analgesia (18 vs. 11%, p = 0.042)., Conclusion: A higher CS rate was observed in deliveries with analgesia than in those without analgesia both in the Robson group 1 and group 2a pregnancies., (© 2022. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Purpose: To identify risk factors for clinical failure of uterine artery embolization (UAE) for postpartum hemorrhage (PPH), with particular attention to the uterine artery diameter., Materials and Methods: This retrospective study included 47 patients who underwent UAE for PPH between January 1, 2010, and January 31, 2021. Technical success was defined as the completion of embolization of the arteries thought to be the cause of the bleeding. Clinical success was defined as no recurrent bleeding or need for additional therapeutic interventions. Univariate and multivariate analyses were performed to examine the risk factors associated with clinical failure of UAE., Results: Of the 47 patients, 6 had recurrent bleeding. Of the 6 patients, 4 underwent hysterectomy, and 2 underwent repeat embolization. The clinical success rate was 87.2% (41/47), with no major adverse events such as uterine infarction or death. In univariate analysis, there were slight differences in multiparity (P = .115) and placental abruption (P = .128) and a significant difference in the findings of a narrow uterine artery on digital subtraction angiography (DSA) (P = .005). In multivariate analysis, only a narrow uterine artery on DSA was a significant factor (odds ratio, 18.5; 95% confidence interval, 2.5-134.8; P = .004)., Conclusions: A narrow uterine artery on DSA was a risk factor for clinically unsuccessful UAE for PPH. It may be prudent to conclude the procedure only after it is ensured that vasospasm has been relieved., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: We investigated the utility of combinational elastography with point shear wave elastography (pSWE) and real-time tissue elastography (RTE) for evaluating liver fibrosis in patients with liver injury., Methods: In this prospective single-institution study, patients scheduled for a liver biopsy to determine the presence of liver disease were enrolled. Liver fibrosis in each patient was evaluated using both shear wave velocity (Vs) shown by pSWE and the liver fibrosis index (LFI) shown by RTE, while a liver biopsy sample was obtained from the same area that was subjected to an elastography examination. Results of the latter were compared with those obtained in a histological examination., Results: Multivariate analysis showed that Vs and LFI were significantly correlated with the liver fibrosis stage in all of the enrolled patients. Sub-analysis findings compared patients with and without non-alcoholic fatty liver disease (NAFLD) and demonstrated that Vs was significantly correlated with the liver fibrosis stage in both groups, whereas LFI was correlated with that only in the non-NAFLD patients. However, a multivariate analysis demonstrated a significant correlation between steatosis grade and LFI in the NAFLD patients., Conclusions: RTE is less useful than pSWE for assessing liver fibrosis in patients with NAFLD.

Purpose: To assess the clinical efficacy of personalized embryo transfer (pET) guided by a new endometrial receptivity test, ERPeak SM , in patients with recurrent implantation failure (RIF)., Methods: Recurrent implantation failure patients of all ages at two private Japanese clinics from April 2019 to June 2020 were retrospectively analyzed. The intervention group ( n  = 244) received pET in accordance with endometrial receptivity testing results and was compared to control group ( n  = 306) receiving standardized timing, non-personalized embryo transfer (npET). In propensity score matching analysis, the clinical pregnancy rate (CPR) and live birth rate (LBR) were compared between groups, and a subanalysis of advanced maternal age (AMA) (≥38 years old) versus non-AMA (<38 years old) patients was also conducted., Results: The CPR and LBR of the pET group were significantly higher than those of the npET group (37.7% vs. 20.0%, adjusted OR: 2.64; 95%CI, 1.70-4.11, p  < 0.001 and 29.9% vs. 9.7%, adjusted OR: 4.13; 95%CI, 2.40-7.13, p  < 0.001, respectively). Furthermore, in the subanalyses, the CPR and LBR of the pET group were significantly higher than those of the npET group in both the AMA non-AMA patients., Conclusions: The new ERPeak SM endometrial receptivity test is a useful alternative diagnostic tool for poor-prognosis patients, regardless of age., Competing Interests: The authors declare that they have no conflict of interest., (© 2022 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

A 65-year-old woman with a history of chronic hepatitis B was referred to our hospital for the examination of abdominal lymphadenopathy and diffuse lesions in the liver. Endoscopic ultrasound-guided fine-needle aspiration biopsy and liver biopsy were performed, and mucosa-associated lymphoid tissue (MALT) lymphoma was found in both. Based on the results of various images, a diagnosis of primary hepatic MALT lymphoma, Ann Arbor classification stage IV was reached at. Entecavir administration, H. pylori eradication therapy, and chemotherapy were performed, and remission was induced. The tumor condition remained unchanged after H. pylori eradication therapy and Entecavir administration. Subsequently, she became symptomatic, so chemotherapy was performed, leading to remission. We herein report a case of hepatic MALT lymphoma associated with chronic hepatitis B.

Preeclampsia is one of the most common as well as most severe complications of pregnancy, characterized by new-onset hypertension and proteinuria or other organ dysfunction. It predominantly occurs after 20 weeks of gestation. Very rarely, it can be triggered earlier in some specific situations. Here we report a case of fetal triploidy presenting as an extraordinarily early-onset preeclampsia. A healthy 36-year-old multiparous woman who had conceived naturally was hospitalized due to acute-onset severe hypertension accompanied by proteinuria at 18 weeks of gestation. Laboratory testing ruled out the presence of underlying maternal disease. Ultrasound findings, including multicystic large placenta and multiple fetal anomalies, strongly suggested fetal triploidy. Maternal ovaries showed hyperreactio luteinalis. The soluble fms-like tyrosine kinase-1/ placental growth factor (sFlt-1/PlGF) ratio was elevated, at 270. Medical abortion was carried out at 19 weeks of gestation; thereafter, her symptoms quickly resolved. Fetal triploidy was confirmed by genetic testing. We should be aware that fetal disorders including triploidy as well as pre-existing maternal diseases can provoke such very early-onset preeclampsia. Fetal ultrasound evaluation is critical and the sFlt-1/PlGF ratio is important for prompt diagnosis and management to prevent adverse maternal outcomes associated with atypical preeclampsia before 20 weeks of gestation., (© 2022 The Authors. Published by Elsevier B.V.)

Background: Postcolonoscopy surveillance colonoscopy based on positive fecal occult blood testing (FOBT) is often performed, although its long-term efficacy has not been established. The aim of this study was to clarify the low potency of FOBT surveillance at short intervals after colonoscopy., Methods: Colonoscopy was performed in 1308 average-risk patients, based on positive results of immunological FOBT [fecal immunological test (FIT)]. Patients were stratified according to the length of time since their last colonoscopy and their colonoscopy results [no adenoma or 1-2 small (<10 mm) adenomas]. Tumor detection rates were determined., Results: The baseline patients characteristics did not differ between the groups. The advanced lesion detection rate (ALDR) among the patients who had never undergone a colonoscopy was 21.9% [95% confidence interval (CI), 19.1-25.0%]. Among the patients who had no adenoma detected in the previous colonoscopy within the past 5 years, the past 5-10 years and over 10 years, the ALDRs were 2.5% (95% CI, 1.0-5.5%), 4.1% (95% CI, 1.5-9.4%) and 9.3% (95% CI, 3.1-22.2%), respectively. Among the patients who had 1-2 small adenomas, the ALDRs were 7.4% (95% CI, 3.4-14.8%), 12.1% (95% CI, 4.2-27.9%) and 27.8% (95% CI, 12.2-51.2%), respectively. Invasive cancer was not observed in any patients within 5 years since the prior colonoscopy., Conclusion: In average-risk patients whose prior colonoscopy detected no adenomas or low-risk adenomas, postcolonoscopy surveillance by FIT has a low positive predictive value within a 5-year interval., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The retained products of conception (RPOC) and related conditions (RPOC-ARC) are the main cause of secondary postpartum hemorrhage (sPPH), but there is no clear consensus for their management. The purpose of this study was to characterize those RPOC-ARC that require invasive treatment and those that could be managed more conservatively., Methods: We retrospectively analyzed 96 cases of RPOC-ARC that occurred after miscarriage, abortion, or delivery at a gestational age between 12 and 42 completed weeks, that were managed within our institution from May 2015 to August 2020. We reviewed the associations between the occurrence of sPPH requiring invasive treatment with clinical factors such as the maternal background and the characteristics of the lesions., Results: The range of gestational age at delivery in our study was 12-21 weeks in 61 cases, 22-36 in 5, and 37 or later in 30. Among them, nine cases required invasive procedures for treatment. The onset of sPPH was within one month of delivery in all but two cases, with a median of 24 days (range 9-47). We found significant differences between requirements for invasive versus non-invasive strategies according to gestational age at delivery, assisted reproductive technology (ART) pregnancy, amount of blood loss at delivery, and the long axis of the RPOC-ARC lesion (p = 0.028, p = 0.009, p = 0.004, and p = 0.002, respectively). Multivariate analysis showed that only the long axis of the lesion showed a significant difference (p = 0.029). The Receiver Operating Characteristic (ROC) curve for predicting the need for invasive strategies using the long axis of the lesion showed that with a cutoff of 4.4 cm, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) was 87.5, 90.0, 43.8, and 98.7%, respectively., Conclusion: The long axis of the RPOC-ARC is a simple indicator for predicting which sPPH will require invasive procedures, which use is rare in cases with lesions less than 4.4 cm or those occurring after the first postpartum month. Conservative management should be considered in such cases., (© 2021. The Author(s).)

Background: Sigmoid volvulus is a common condition in elderly patients with elongated colons. Although endoscopic de-torsion is effective as the primary treatment of sigmoid volvulus, elective surgery is recommended because of the high risk of recurrence and high mortality rate., Aim: The aim of this study was to determine the risk factors for the recurrence of sigmoid volvulus., Methods: Clinical records of patients treated at Shimane Prefectural Central Hospital were reviewed retrospectively. Among 41 sigmoid volvulus patients who were successfully treated by endoscopic de-torsion and followed up, 30 were observed over 1 year. Among the 30 patients, eight (26.7%) did not experience recurrence, while 22 (73.3%) did. Initial computed tomography (CT) findings indicating the sigmoid colon extending to the diaphragm or ventral to the liver were defined as "extension findings." Extension findings and sigmoid diameter were evaluated in relation to sigmoid volvulus recurrence., Results: Extension findings were significantly more frequent in the recurrent group (77.3%) than in the nonrecurrent group (25.0%) (P = 0.009). Distended sigmoid colon diameter was significantly larger in the recurrent group (11.7 ± 3.8 cm) than in the nonrecurrent group (7.1 ± 1.1 cm) (P = 0.044). Receiver operating characteristic curve analysis demonstrated that the performance threshold was greater than 8.9 cm. Kaplan-Meier analysis showed the significantly high sigmoid volvulus recurrence rate in the patients with extension findings and a distended sigmoid colon greater than 8.9 cm., Conclusions: CT findings of a long and distended sigmoid colon in initial sigmoid volvulus are risk factors for the recurrence of sigmoid volvulus.

Background: A diagnostic sign on magnetic resonance imaging, suggestive of posterior extrauterine adhesion (PEUA), was identified in patients with placenta previa. However, the clinical features or surgical outcomes of patients with placenta previa and PEUA are unclear. Our study aimed to investigate the clinical characteristics of placenta previa with PEUA and determine whether an altered management strategy improved surgical outcomes., Methods: This single institution retrospective study examined patients with placenta previa who underwent cesarean delivery between 2014 and 2019. In June 2017, we recognized that PEUA was associated with increased intraoperative bleeding; thus, we altered the management of patients with placenta previa and PEUA. To assess the relationship between changes in practice and surgical outcomes, a quasi-experimental method was used to examine the difference-in-difference before (pre group) and after (post group) the changes. Surgical management was modified as follows: (i) minimization of uterine exteriorization and adhesion detachment during cesarean delivery and (ii) use of Nelaton catheters for guiding cervical passage during Bakri balloon insertion. To account for patient characteristics, propensity score matching and multivariate regression analyses were performed., Results: The study cohort (n = 141) comprised of 24 patients with placenta previa and PEUA (PEUA group) and 117 non-PEUA patients (control group). The PEUA patients were further categorized into the pre (n = 12) and post groups (n = 12) based on the changes in surgical management. Total placenta previa and posterior placentas were more likely in the PEUA group than in the control group (66.7% versus 42.7% [P = 0.04] and 95.8% versus 63.2% [P < 0.01], respectively). After propensity score matching (n = 72), intraoperative blood loss was significantly higher in the PEUA group (n = 24) than in the control group (n = 48) (1515 mL versus 870 mL, P < 0.01). Multivariate regression analysis revealed that PEUA was a significant risk factor for intraoperative bleeding before changes were implemented in practice (t = 2.46, P = 0.02). Intraoperative blood loss in the post group was successfully reduced, as opposed to in the pre group (1180 mL versus 1827 mL, P = 0.04)., Conclusions: PEUA was associated with total placenta previa, posterior placenta, and increased intraoperative bleeding in patients with placenta previa. Our altered management could reduce the intraoperative blood loss.

A 57-year-old female with a history of Cowden's disease was referred to our hospital because of black stool, loss of consciousness, and severe anemia. Upper and lower gastrointestinal endoscopy findings could not confirm the source of hemorrhage. Capsule endoscopy (CE) of the small intestine showed an active exudative hemorrhagic site near the ileum, although a definitive diagnosis was difficult. In a double balloon enteroscopy examination, it was difficult to observe the entire small intestine due to adhesions and the responsible lesion could not be confirmed, even when ink spots were applied to the deepest observation points through the mouth and anus. Hemostasis spontaneously occurred, and then anemia occurred again approximately 1 month later and a second CE examination was performed including passage of an ink stick through the oral side, which revealed an exudative elevated polyp with erosion and a white moss appearance in the ileum. Partial ileal resection was performed and pyogenic granuloma of the small intestine was the diagnosis. We report here a case of pyogenic granuloma of the small intestine associated with Cowden's disease.

Objective: Angular and interstitial pregnancies have been reported with live births and are often complicated by adherent placentas. Most cases had been treated with hysterectomy or corneal resection., Case Report: We successfully treated four patients with conservative management (including one reported previously). Case 1 had a vaginal delivery, but the placenta remained attached. We maintained the patient under observation and delivered the placenta on postpartum day 9. Case 2 underwent a C-section. Uterine artery embolization controlled the hemorrhage without placenta removal. The placenta had disappeared by postpartum day 136. Case 3 underwent a C-section. The right uterine angle, where the placenta was attached, was bulging. We manually removed the placenta., Conclusion: We propose a new entity in angular or interstitial pregnancies called "angular placenta attachment" that could be diagnosed during C-sections or after vaginal delivery without placental separation. Expectant management may be considered for adherent placentas in these cases., Competing Interests: Declaration of Competing Interest The authors indicated no potential conflicts of interest., (Copyright © 2020. Published by Elsevier B.V.)

Background: This study aimed to identify and review associations between the types of sutures used for uterine compression suture (UCS) and its outcomes in postpartum hemorrhage., Methods: An electronic search using PubMed and Scopus databases was performed. We included the English articles reported from January 1, 1997, to May 31, 2017, using search words or terms regarding the types of suture and needle used for UCSs. We only included studies describing the sutures in the systematic review., Results: We found 196 studies and included 76 (38.8%) in our analysis. We collected data on maternal outcomes for 924 patients and categorized them. Of the 76 studies, suture sizes 0, 1, and 2 were used in 6, 44, and 32 articles, respectively (some studies used multiple sutures). Of the 45 studies mentioning the needles, curved and straight needles were used in 35 and 10, respectively. The results of our review revealed that about 80% of previous articles used Catgut and Polyglactin 910 sutures. Because no studies that compared the efficacy of different size of sutures were identified, we investigated the differences using the cases reported in previous studies mentioned above. In the first analysis, we compared the uterine preservation rate between size 1 and size 2 sutures. We found no significant difference in uterine preservation rate (92.8%: size 1 vs. 94.2%: size 2, p > 0.05) but found significant difference in transfusion rate (62.4% vs. 79.1%, p < 0.01). With the hypothesis that non-transfusion cases were less severe, we excluded these cases from second analysis. Although our second analysis of only Catgut or Polyglactin showed strong selection bias, we observed that uterine preservation rate was significantly higher in cases with size 2 suture than in those with size 1 suture (86.9% vs. 93.5%, p = 0.033)., Conclusions: Our systematic review showed that approximately 80% of cases were treated by Catgut and Polyglactin 910. Due to the heterogeneity of cases included in this review, it is difficult to estimate which suture is better for UCSs. More robust studies are necessary to enable the identification of the superior suture for performing UCSs.

Mid-esophageal diverticulum is a rare disease, formed by the traction caused by inflamed bronchial lymph nodes or by pulsion induced by motility disorder. We herein report a case of mid-esophageal diverticular bleeding in a patient with kyphosis who was taking an anti-platelet drug. She was successfully treated with endoscopic hemostasis. An 80-year-old woman presented to our emergency department with hematemesis. She had kyphosis and was taking dipyridamole for her chest pain. Emergent upper endoscopy revealed bleeding from a mid-esophageal diverticulum; hemostasis was achieved via clipping. Mid-esophageal diverticula can cause upper gastrointestinal bleeding. An endoscopic examination and hemostasis are effective treatments.

As a rarely recognized foreign body in the upper gastrointestinal tract, rice cake frequently requires endoscopic removal. We herein report six patients with characteristic sonography, computed tomography (CT), spectroscopy, endoscopy, and histological findings. A review of all published cases, including ours, revealed that retained rice cake in the stomach typically shows the following: abdominal pain (93.3%), mucosal injury (93.3%) with bleeding (42.9%); high-density (120-206 Hounsfield units) CT findings; and indication for endoscopy (80%). In the esophagus, hot, toasted rice cake causes thermal injury. Primary physicians should be aware of this popular-food-induced, but rare, disorder.

Background: We developed a dedicated blunt straight needle with No. 2 polydioxanone sutures (2-Monodiox®) for uterine compression sutures (UCSs) and aimed to assess the outcomes and complication rates of UCSs for postpartum hemorrhage by comparing with commercially available needle and suture types., Methods: A retrospective analysis was performed between January 2010 and February 2018. During the study period, two types of commercially available sutures and 2-Monodiox® were used. PubMed, MEDLINE, and Scopus databases were searched for English articles published between January 1997 and May 2017 using search terms related to the suture and needle types for UCSs to discuss the dedicated needles and sutures for UCS., Results: The analysis included 47 cases of UCSs for the uterine body with three suture types (No. 0 polydioxanone, 7 cases; No. 1 poliglecaprone 25, 21 cases; and No. 2 polydioxanone, 19 cases). B-Lynch suture using No. 0 sutures was associated with a significantly lower uterine preservation rate than those with Nos. 1 and 2 sutures (42.9% vs. 95.2 and 89.5%, respectively; p < 0.01). A modified Hayman suture technique was performed using 2-Monodiox® sutures, which achieved a similar uterine preservation rate compared with B-Lynch suture using No. 1 poliglecaprone 25 sutures. No patients developed severe complications. The literature review showed that no dedicated sutures have developed for UCSs. Three dedicated needles for UCSs have been developed, and 2-Monodiox® is the first dedicated blunt straight needle for UCSs., Conclusion: Our data showed that No. 0 sutures should not be used for B-Lynch suture. The uterine preservation rate is similar for 2-Monodiox® with modified Hayman suture and No. 1 poliglecaprone 25 sutures with B-Lynch suture, without the occurrence of severe complications.

Intravascular large B-cell lymphoma (IVLBCL) frequently involves the hepatobiliary system, but its clinical course and pathophysiology are still not fully known. We herein describe a case of IVLBCL mimicking acute hepatobiliary infection. An 85-year-old woman was admitted because of fever and epigastric pain, and she was diagnosed to have acute acalculous cholecystitis based on gallbladder wall thickening with fluid collection. The gallbladder swelling regressed within several days, and areas of intrahepatic hypoperfusion appeared. Inflammation continued despite treatment with antibiotics, and she died within 21 days. An autopsy examination revealed IVLBCL. IVLBCL can present as acute cholecystitis with an improvement in the imaging findings and the presence of a subsequent liver mass.

We sought to investigate obstetric outcomes and acceptance rates for blood products or types of autotransfusion by Jehovah's Witnesses (JWs) at a single institution in Japan. We retrospectively reviewed cases of 84 pregnant JW patients and 95 deliveries from April 2001 to August 2017. We examined the acceptance rates of blood transfusions, blood products, and autotransfusion types in patients who experienced postpartum hemorrhage (PPH), and investigated estimated hemorrhage volume at delivery and PPH treatments. Of the 84 JW patients, none accepted blood transfusion; however, 75 patients (89.3%) accepted blood products, 57 (67.9%) accepted autotransfusion using intraoperative cell salvage, and four (4.8%) refused all alternatives to blood transfusion. Furthermore, PPH > 1000 mL occurred in 18 of the 95 (18.9%) deliveries. Of these 18 patients, four (22.2%) required blood products and three (16.7%) required supracervical hysterectomy to control PPH. No maternal deaths occurred. Approximately 95% of the patients observed accepted all or some alternatives to blood transfusion. To treat JW patients in a safer manner, understanding their individual acceptance of alternatives to blood transfusion is important for the strategic use of such alternatives.

Fitz-Hugh-Curtis syndrome (FHCS) is defined as inflammation on the surface of the liver following sexually transmitted chlamydia infection. We successfully observed the microvascular structure of the inflamed portion between the abdominal wall and surface of the liver in an elderly patient with FHCS using a superb microvascular imaging (SMI) system, a new technology developed for observing minute vascular flow. An 80-year-old Japanese female with right dorsal to lateral abdominal pain and fever came to our hospital. Anti-chlamydia antibodies were positive. SMI revealed signals suggesting small vessels passing from the liver surface to the hypoechoic space.

Background: Vascular endothelial growth factor (VEGF) plays a pivotal role in angiogenesis and is overexpressed in many kinds of malignant tumors. Soluble VEGF receptor 1 (sVEGFR-1/ soluble fms-like tyrosine kinase 1 [sFlt-1]) plays a role as an inhibitor of VEGF, and an antitumor effect has been shown in several studies using sFlt-1. Recently, in addition to its antiangiogenic effect, it was reported that sFlt-1 has direct cytotoxicity., Materials and Methods: Transfection of sFlt-1 plasmid DNA was performed in the BeWo choriocarcinoma cell line. Overexpression of sFlt-1 in BeWo cells was confirmed by ELISA. In order to evaluate cell proliferation, cell counting and BrdU uptake assay were performed. Cytotoxicity was tested by LDH assay. TdT-Mediated dUTP Nick end Labeling (TUNEL) staining and quantitative analysis of caspase-cleaved keratin 18 (ccK18) level were done to evaluate cell apoptosis., Results: The cell number was significantly less, and the ratio of cytotoxicity was significantly higher in sFlt-1 group compared to the control group. TUNEL staining and ccK18 level suggested nonapoptotic cell death., Conclusion: Soluble Flt-1 showed a cytotoxic effect on BeWo cells. Our results suggest that sFLT-1 could be therapeutic for malignant tumors.

Gastritis cystica polyposa is a polypoid lesion that arises from the gastric mucosa at the gastrojejunal anastomotic site and is characterized by cystic dilation of the gastric glands. A 78-year-old man who underwent distal gastrectomy for a gastric ulcer with Billroth II reconstruction approximately 40 years previously, exhibited a gastritis cystica polyposa at the anastomotic site. Ulceration was observed on an annual endoscopic examination. Endoscopic ultrasonography revealed a submucosal hypoechoic mass with multiple cystic lesions. Gastrectomy was performed and histological examination revealed a large-cell neuroendocrine carcinoma with cystic dilation of the gastric glands. Here, we report the first case of a large-cell neuroendocrine carcinoma arising from a gastritis cystica polyposa. Endoscopic ultrasonography was effective at diagnosing a submucosal hypoechoic mass with cystic dilation of the gastric glands.

Background: Nonalcoholic steatohepatitis (NASH) is an active form of nonalcoholic fatty liver disease. Risk factors for NASH include type 2 diabetes mellitus (T2DM) and obesity. Sodium-glucose cotransporter 2 (SGLT2) inhibitors used to treat T2DM prevent glucose reabsorption in the kidney and increase glucose urinary excretion. Dapagliflozin is a potent, selective SGLT2 inhibitor that reduces hyperglycemia in patients with T2DM and has been demonstrated to reduce some complications associated with NASH in rodent models., Objective: To assess the efficacy and safety profile of dapagliflozin for the treatment of NASH-associated with T2DM., Methods: In this single-arm, nonrandomized, open-label study, 16 patients with percutaneous liver biopsy-confirmed NASH and T2DM were enrolled to be prescribed dapagliflozin 5 mg/d for 24 weeks. Of these, 11 patients were evaluable. Patients with chronic liver disease other than NASH were excluded. Body composition, laboratory variables related to liver tests and metabolism, and glucose homeostasis were assessed at baseline and periodically during the study. Changes from baseline were evaluated with the Wilcoxon signed-rank test., Results: Administration of dapagliflozin for 24 weeks was associated with significant decreases in body mass index ( P < 0.01), waist circumference ( P < 0.01), and waist-to-hip ratio ( P < 0.01). Changes in body composition were driven by reductions in body fat mass ( P < 0.01) and percent body fat ( P < 0.01), without changes in lean mass or total body water. Liver tests (ie, serum concentrations of aspartate aminotransferase, alanine aminotransferase, ferritin, and type IV collagen 7S) also significantly improved during the study. Insulin concentrations decreased ( P < 0.01 by Week 24) in combination with significant reductions in fasting plasma glucose ( P < 0.01) and glycated hemoglobin ( P < 0.01) levels and increases in adiponectin ( P < 0.01) levels from Week 4 onward., Conclusions: Dapagliflozin was associated with improvements in body composition, most likely a reduction in visceral fat, which occurred together with improvements in liver tests and metabolic variables in patients with NASH-associated with T2DM. UMIN Clinical Trial Registry identifier: UMIN000023574.

Objectives: Gastroesophageal reflux is considered to cause sleep disturbance, whereas proton pump inhibitor (PPI) administration is reported to improve insomnia associated with gastroesophageal reflux disease (GERD). The majority of patients with gastroesophageal reflux are asymptomatic and a significant number with erosive esophagitis are also reported to be asymptomatic. We examined whether PPI administration has a therapeutic effect for improving insomnia in patients without reflux symptoms in the same manner as patients with reflux symptoms., Methods: We performed a randomized multicenter double-blind placebo-controlled trial using 176 patients with insomnia regardless of the presence of reflux symptoms. The patients were divided into those administered omeprazole (20 mg) or a placebo for 14 days. Four self-reporting questionnaires, QOLRAD-J (Japanese translation of Quality of Life in Reflux and Dyspepsia), Pittsburg Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and a sleep diary, were used for evaluating GERD-related quality of life (QOL) and sleep disturbance., Results: We evaluated 171 patients with insomnia, of whom 69 had typical reflux symptoms. Omeprazole statistically significantly improved GERD-related QOL from 30.8±0.7 to 33.0±0.5 (P<0.01) (QOLRAD-J, total) and from 6.0±0.2 to 6.6±0.1 (P<0.01) (QOLRAD-J, sleep-related) when administrated to patients with reflux symptoms. Omeprazole also improved insomnia significantly better than the placebo in patients with reflux symptoms; PSQI, from 9.3±0.5 to 7.9±0.5 (P<0.01) and sleep diary, from 2.1±0.1 to 1.8±0.1 (P<0.01). On the other hand, the therapeutic effects of omeprazole and the placebo were not different in patients without reflux symptoms., Conclusions: Our results showed that PPI administration is effective only for insomnia in patients with reflux symptoms.

Eosinophilic esophagitis is a rare chronic disease that mainly occurs in middle-aged males. Treatment with a glucocorticoid and/or proton pump inhibitor is usually necessary to relieve unpleasant symptoms. An 83-year-old female patient with dysphagia and heartburn was diagnosed with eosinophilic esophagitis based on endoscopic findings, while histological examination identified dense infiltration of intraepithelial eosinophils. The symptoms and eosinophil infiltration spontaneously disappeared without any treatment approximately 2 months later. No obvious lifestyle or dietary changes to explain elimination of possible antigens were identified in this case. We report an atypical case of eosinophilic esophagitis with spontaneous regression.

Detection of a hepatocellular carcinoma (HCC) in the early stage is critical, as clinical stage influences treatment selection and patient prognosis. Carcinogenetic development of an HCC is a multi-step process, and a differential diagnosis between a dysplastic nodule and a well-differentiated HCC is often difficult. A bright loop appearance is a significant finding that indicates disappearance of fatty deposition in the central area of the nodule during the progression toward HCC, however such a finding is rare in cases of sub-centimeter-sized HCCs. We encountered a case of HCC that developed a bright loop appearance on ultrasound (US) without enlargement approximately 2 years after diagnosis as a dysplastic nodule. Moreover, the hypoechoic area in the center of the nodule showed an HCC pattern in contrast enhanced US with Sonazoid™. Vascularity in the nodule could not be observed on dynamic contrast-enhanced CT or Gd-EOB-DTPA-enhanced MRI. When a change in the intranodular echo pattern is observed in sub-centimeter-sized nodules, examination of intranodular vascularity by contrast-enhanced US is important to evaluate borderline lesions.

Objective: Virtual CT sonography is a system for synchronizing multiplanar reconstructed CT scans with corresponding conventional ultrasound images in real time. The aim of this study was to prospectively evaluate the feasibility of virtual CT sonography for detection of nodules difficult to detect with conventional sonography alone., Subjects and Methods: Fifty-nine patients with 140 nodules were included in the study. All patients underwent CT angiography then conventional sonography and finally virtual CT sonography. The number, location, and echogenicity of nodules and parenchyma were assessed., Results: Among 140 nodules detected with CT angiography, 71 were detected with conventional sonography and another 46 were detected with virtual CT sonography, increasing the overall sensitivity from 50.7% to 83.57%. The average diameter of nodules detected only with virtual CT sonography (9.7 +/- 3.3 mm) was significantly smaller than that of nodules detected with conventional sonography (16.6 +/- 6.2 mm). The results of multivariate analysis suggested that nodule size (p < 0.001), echo pattern (p = 0.004), and location (p = 0.028) are associated with the difference in detection. Interestingly, 87% of the nodules 10 mm in diameter or smaller were already dysplastic or malignant., Conclusion: Nodules 10 mm in diameter or smaller have significant malignant potential and therefore are clinically important. Even though we do not consider virtual CT sonography a screening tool, we conclude it superior to conventional sonography for detection of small hepatic nodules, allowing bedside percutaneous ultrasound-guided biopsy and treatment that would not be possible with conventional sonography alone.

Sustained virologic response with peg-interferon and ribavirin combination therapy for 48 weeks is still inadequate. Our study examined whether short-term administration of retinol clinically influences the anti-viral activity of interferon early during interferon and ribavirin combination therapy. The control group received 6 MIU of interferon alpha-2b every day for two weeks and then 3 times a week for 22 weeks intramuscularly plus 600 mg or 800 mg per day of ribavirin orally for 24 weeks. The retinol group, in addition to above treatment, received retinol 30,000 units per day orally for 3 weeks from one week before the start of interferon alpha-2b plus ribavirin combination therapy. The hepatitis C virus (HCV) RNA negativity rate at 1 week after the end of interferon alpha-2b and ribavirin combination therapy was 46.7% (28/60) for the retinol group and 31.7% (19/60) for the control group, which was significantly higher for the retinol group. The level of serum HCV RNA in the retinol group was significantly lower at 1 week after beginning treatment as compared to the control group (p<0.01). Furthermore, serum 2,5'AS protein at 1 week after beginning treatment was significantly higher in the retinol group (p = 0.0002). The results suggest that retinol supplement increases the antiviral effect of interferon alpha-2b plus ribavirin only during the administration of IFN alpha-2b, ribavirin and retinol in patients with chronic hepatitis C.

The Izumo Scale is a new questionnaire for the assessment of quality of life of the patients with gastrointestinal symptoms comprehensively. The validity and reliability of the scale were verified in 170 patients with gastrointestinal symptoms. Spearman's rank correlation coefficient between the Izumo Scale and visual analog scale (VAS) showed a positive correlation of 0.581-0.753. Internal consistency was also good with Cronbach's coefficient alpha of 0.616-0.805. The reproducibility was good with an intra-class correlation coefficient of 0.755-0.887. The results suggest that the Izumo Scale may be useful as a disease-specific quality of life assessment scale for patients with gastrointestinal symptoms.

Aim: To determine the prophylactic effect of antibiotics administration in the prevention of infection following an ultrasound-guided percutaneous liver biopsy or treatment of liver tumors, we performed an open-labeled randomized prospective study of patients who received prophylactic antibiotics after undergoing those procedures., Methods: We studied 101 patients, with ultrasound-guided percutaneous aspiration biopsies of the liver performed in 48 to diagnose diffuse liver diseases or liver tumors, while percutaneous ethanol-injection therapy was performed in two patients with malignant liver tumors and percutaneous radiofrequency ablation was performed in 51 patients. An oral administration of levofloxacin at 400 mg/day was given to 50 of the enrolled patients from the morning of the treatment day for three days. Preventive antibiotics were not administered to the remaining 51 patients. Body temperature, peripheral blood leukocyte number, c-reactive protein, alanine aminotransferase, and lactic dehydrogenase were measured daily for three days after treatment., Results: Most parameters changed following percutaneous treatments of liver tumors, though no significant differences were seen between the patients treated with antibiotics and those untreated. Most significantly, there was no difference in the frequency of post-procedure infection between the groups., Conclusion: Our results suggest that prophylactic administration of antibiotics following a percutaneous liver biopsy and treatment of liver tumors does not have a significant impact on the post-procedure results or incidence of infection.

Background and Aim: Several studies have examined the factors involved with expansion of the coagulation volume following radiofrequency ablation (RFA). Ferucarbotran contains superparamagnetic iron oxide that generates heat in a radiofrequency electric field and may have an effect on the area affected by RFA. We attempted to determine whether ferucarbotran administration expands radiofrequency-ablated volume using a rabbit model., Methods: A total of 15 male Japanese white rabbits (16 weeks old) were used and divided into three groups of five each. A 1-mL saline solution was given intravenously into a dorsal ear vein in the control group, whereas 1 mL ferucarbotran solution (0.016 mL/kg bodyweight) was given to the common-dose group and 1 mL of a twofold concentrated ferucarbotran solution (0.032 mL/kg bodyweight) was given to the high-dose group. RFA was performed with a cool-tip electrode 4 h after the administration and immediately thereafter the rabbits were killed, and the volume of the ablated area measured using magnetic resonance imaging (MRI). Following the MRI analysis, the rabbit's livers were resected, and the maximum short axis diameter of the ablated area in each was measured., Results: None of the rabbits died during the RFA procedure. The volume of the ablated area estimated on MR images in the ferucarbotran-administered groups was larger than that in the control group. Further, our macroscopic assessment showed that the maximum short axis diameter had a tendency to increase with ferucarbotran administration., Conclusion: Ferucarbotran may expand the area treated by RFA.

Background and Aim: The size of radiofrequency ablation (RFA) in the liver can be negatively influenced by the surrounding blood flow. The indocyanine green (ICG) test can be used to evaluate the effective blood flow in the liver, and distance from the hilus can affect local blood flow. The aim of this study was to assess whether the ICG test or distance from the hilus could be used to predict the size of the ablated area in liver by RFA treatment of hepatocellular carcinoma (HCC) nodules., Methods: The RFA measurements of 44 HCC nodules in 39 patients were retrospectively studied. Cases were included if they met the following criteria: (i) no catheter treatment before RFA; (ii) no movement of the RFA device; (iii) strict ablation time; and (iv) only one ablation. In all patients, ICG-R15 testing was done immediately before RFA and the initial therapeutic efficacy was evaluated by dynamic computed tomography scanning 2-5 days after RFA. The correlation between the maximum size of the RFA area and the ICG test results or the distance of the target area from the hilus (site of first portal vein divergence) were analyzed statistically., Results: The ICG-R15 result was significantly correlated with the maximum diameter of the ablated area both in 2 cm-electrode tip length (R2 = 0.35, P = 0.0012), and in 3 cm-tip length (R2 = 0.26, P = 0.0377). Multiple-regression analysis showed that the electrode tip length (P = 0.0010) and ICG-R15 (P = 0.0046) were independent factors that could predict the maximum diameter of the RFA area., Conclusion: The results of ICG testing can be used to predict the size of the area that will be ablated at a target liver site before RFA treatment.

Background: Differentiation between functional dyspepsia and early chronic pancreatitis is difficult because these diseases do not produce specific abnormalities in laboratory testing. The aim of this study was to examine the potential efficacy of camostat mesilate, a protease inhibitor, against functional dyspepsia and to characterize patients with favorable responses., Methods: Dyspeptic patients who exhibited no abnormalities on laboratory blood and urine testing, abdominal ultrasonography and upper gastrointestinal endoscopy were randomized to receive camostat mesilate 200 mg three times daily or famotidine 20 mg twice daily for 4 weeks. Symptoms severity was recorded before and at 2 and 4 weeks after starting treatment using a visual analog scale., Results: Epigastralgia was significantly improved after 2 and 4 weeks of treatment in both groups (P < 0.01); this improvement tended to be more marked in the camostat mesilate group (P < 0.05 at 2 weeks). The beneficial effect of camostat mesilate on epigastralgia was more prominent in chronic alcohol drinkers at 2 weeks (P < 0.05) and 4 weeks (P < 0.01)., Conclusions: Camostat mesilate is superior to famotidine for relieving epigastralgia in patients with functional dyspepsia. Its pain-relieving effect is greater in patients who habitually drink alcohol.