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Aims The relationship between left ventricular (LV) function and AF detection in embolic stroke of undetermined source (ESUS) patients with insertable cardiac monitors (ICMs) remains unclear. We investigated the association between LV function and AF detection in patients with ESUS after ICMs implantation. Methods We enrolled patients with ESUS who underwent ICMs implantation from September 2016 to September 2020 using a single-center, prospective registry. LV systolic and diastolic functions were assessed on precordial echocardiography by LV fractional shortening (LVFS) and average E/e', respectively. Associations between characteristics of LV function and detection of AF by ICMs were analyzed. Results Participants comprised 101 patients (median age, 74 years; male, 62%). During a median follow-up period of 442 days (interquartile range (IQR), 202-770 days), AF was detected in 24 patients (24%). Median duration from ICMs implantation to AF detection was 71 days (IQR, 13-150 days). When LVFS and E/e' were dichotomized by cutoff value, each of low LVFS (＜35.5%; adjusted hazard ratio (HR), 4.77; 95% confidence interval (CI), 1.77-12.9) and high E/e' (≥ 8.65; adjusted HR, 4.56; 95%CI, 1.17-17.7) were independently associated with AF detection after adjusting for age and sex. When patients were divided into four groups according to dichotomized LVFS and E/e', the combination of low LVFS and high E/e' was independently associated with AF. Conclusions In patients with ESUS after ICMs implantation, the LV characteristics of low LVFS and high E/e' were associated with AF detection.

Introduction: Side-to-side relative reduction in end-diastolic velocity (EDV) of the common carotid artery (CCA) may discriminate ipsilateral anterior circulation large vessel occlusion (LVO), which will contribute faster patient triage for reperfusion therapy. We evaluated the discriminative accuracy of this simple sonographic index for anterior circulation LVO in acute stroke population, including intracerebral hemorrhage (ICH). Methods: Among patients with acute stroke admitted to our institute between 2016-2018, those who underwent both carotid ultrasonography and head MRA or CTA within 24 hours after last known normal time were reviewed. Relative EDV reduction was calculated as a ratio by dividing the CCA EDV lower side by the EDV higher side. Anterior circulation LVO was defined as occlusion of the internal carotid artery (ICA) or M1 segment of the middle cerebral artery on the lower EDV side. Discriminative performance of relative EDV reduction for anterior circulation LVO was assessed by receiver operating characteristics analysis. Results: A total of 688 patients (411 males; median age 77 years; 87 with anterior circulation LVO) were analyzed. When compared to no occlusion, value of relative EDV reduction was remarkably lower in ICA occlusion, followed by that in M1 occlusion (Figure). Area under the curve (AUC) of relative EDV reduction for ICA occlusion was 0.96 (95% confidence interval [CI] 0.94-0.99) with an appropriate cut-off value of 0.50 (sensitivity 94%, specificity 94%). When the discrimination target was set to anterior circulation LVO, the AUC was 0.78 (95% CI 0.72-0.85) with an appropriate cut-off value of 0.67 (sensitivity 69%, specificity 83%). At this cut-point, 51% of patients with M1 occlusion was classified as false negative. Conclusions: The discriminative performance of the relative CCA EDV reduction in acute stroke population was excellent for ICA occlusion and acceptable for anterior circulation LVO.

Various embolic sources and pathogenetic mechanisms underlie cryptogenic stroke (CS). We investigated the association of etiological diversity with short-term outcomes in patients with CS using a modified atherosclerosis (A), small-vessel disease (S), cardiac pathology (C), other causes (O), and dissection (D) (ASCOD) system.Patients with CS who underwent transesophageal echocardiography were registered in this multicenter, observational study. In the modified classification system, O and D were inapplicable and thus excluded. Instead, atherosclerosis, small-vessel disease, cardiac pathology-CS classification was specifically constructed for the etiological diagnosis of CS. We utilized this system to explore the mechanism of CS by grading each pathology and evaluated its association with poorer modified Rankin Scale scores of 3-6 at hospital discharge.A total of 672 patients (68.7±12.8 years, 220 females) were analyzed. In the multiple logistic regression model, female sex (odds ratio [OR], 1.87 [1.15-3.04]; P=0.012), body mass index (OR, 0.93 [0.88-0.99]; P=0.025), National Institute of Health Stroke Scale score (OR, 1.16 [1.12-1.21]; P＜0.001), CHADS2 score (OR, 1.56 [1.30-1.86]; P＜0.001), D-dimer (OR, 1.04 [1.01-1.08]; P=0.015), diffusion-weighted image (DWI) lesion size (OR, 1.44 [1.10-1.89]; P=0.009), and S＋C score (OR, 1.26 [1.03-1.56]; P=0.029) were associated with poor functional outcome at discharge whereas the S＋C score was marginally associated with poor functional outcome after excluding 137 patients with a premorbid modified Rankin Scale score of ≥ 3.The coexistence of small-vessel disease and cardiac pathology might be associated with poor in-hospital functional outcome in CS.

The detection of underlying atrial fibrillation (AF) has become increasingly possible by insertable cardiac monitoring (ICM). During hospitalization for cryptogenic stroke, factors related to the early and late development of AF have not been studied. CHALLENGE ESUS/CS is a multicenter registry of cryptogenic stroke patients undergoing transesophageal echocardiography. Twelve-lead electrocardiogram, continuous cardiac monitoring, and 24-h Holter electrocardiogram were all used for the detection of AF. Early and late detection of AF was determined with an allocation ratio of 1:1 among patients with AF. A total of 677 patients (68.7 ± 12.8 years; 455 men) were enrolled, and 64 patients developed AF during hospitalization. Four days after admission was identified as the approximate median day to classify early and late phases to detect AF: ≤ 4 days, 37 patients; > 4 days, 27 patients. Multiple logistic regression analysis showed that spontaneous echo contrast (SEC) (OR 5.91; 95% CI 2.19–15.97; p 3 cm in diameter (OR 3.28; 95% CI 1.35–7.97; p = 0.009) was associated with AF > 4 days. SEC and large infarctions were important predictors of in-hospital AF detection, particularly in the early and late stages, respectively; thus, they could serve as indications for recommending ICM.

The purposes of this study were as follows: to compare premorbid IQ with present IQ in patients with more severe anorexia nervosa restricting type (AN-R) and to investigate the relationship between decreasing IQ and symptoms in patients with severe AN-R. Twenty-two participants were recruited (12 were AN-R patients; 10 were healthy controls). The average BMI in AN-R patients and healthy controls was 12.65 and 19.82, respectively. We assessed the outcomes using the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III), the Japanese Adult Reading Test, The Eating Disorders Inventory-2 (EDI-2), Beck Depression Scale-2 (BDI-2) and State-Trait Anxiety Index. In two-way ANOVA, there were significant interactions for the FIQ and PIQ. Only in the AN-R group, a significant single main effect of time was evidenced for the FIQ and PIQ. In the AN-R group, a significantly high positive correlation was found between changes in the PIQ and the body dissatisfaction subscale of the EDI-2. These findings raise the possibility that in patients with severe AN-R, an excessive decrease in body weight induces decreased PIQ; as a result, they have worse dissatisfaction with their body shape.

A 54-year-old woman presented at the hospital with headache and posterior neck pain, which worsened when standing or in the sitting position and improved when in the supine position. A diagnosis of rheumatoid arthritis was made at the age ofin 33 years, and the patient has been taking methotrexate and methylprednisolone. Cervical MRI and magnetic resonance myelography showed the appearance of CSF leakage, resulting in a diagnosis of spontaneous intracranial hypotension. A diagnosis of atlantoaxial subluxation was also made based on the abnormal anterior position of the atlas (C1) in the cervical X-ray image. The CSF leakage corresponded with the atlantoaxial subluxation region, which indicated that spontaneous intracranial hypotension was caused by the compression of the dura mater. These symptoms were improved following treatment with the intravenous drip of the extracellular fluids, and she was discharged from the hospital on day 25. The disruption of the dura matter induced by atlantoaxial subluxation is a rare complication but is worth considering when determining the etiology of spontaneous intracranial hypotension.

Lipid droplets (LDs) are essential organelles in most eukaryotes, and tracking intracellular LD dynamics using synthetic small molecules is crucial for biological studies. However, only a limited n...

Gangliosides are a family of sialic-acid-containing glycosphingolipids that form dynamic domains (lipid rafts) with proteins in cell plasma membranes (PMs), and are involved in various biological processes. The dynamic behavior of gangliosides can be elucidated by analyzing fluorescently-labeled molecules with a powerful technique known as single-molecule imaging. We previously developed fluorescent probes for ganglioside subfamilies such as the ganglio- and globo-series, and investigated their behavior in cell PMs. This study targeted a lacto-series ganglioside, sialyl-lactotetraosylceramide, whose behavior in PMs has not yet been investigated. We applied a recently reported method for the direct sialylation of oligosaccharyl lipid acceptors to synthesize the fluorescent ganglioside probes. The glycolipid acceptor exhibited high solubility in organic solvents owing to the installation of a large quantity of

Background: Thyroid diseases and elevated thyroid autoantibodies are associated with moyamoya disease (MMD). MMD susceptibility variant RNF213 p.R4810K is known to increase the risk of ischemic stroke (IS), but whether thyroid diseases and thyroid autoantibody levels are altered in IS patients carrying the RNF213 p.R4810K variant remains elusive. Methods: Of the consecutive adult IS patients from 2011 to 2020 admitted in our institute, patients who signed a consent form for RNF213 genotyping were included, while definitive MMD patients were excluded. We compared the patient background, history of thyroid disease (hyperthyroidism or hypothyroidism), and levels of serum triiodothyronine (T3), thyroxine (T4), thyroid stimulating hormone (TSH), antithyroperoxidase antibody (TPOAb), and antithyroglobulin antibody (TgAb) between the variant carrier and non-carrier. Each thyroid autoantibody was measured by the electro-chemiluminescent immunoassay method. Results: Of the 1570 patients (525 women; 72 years of median age) analyzed, 74 (4.7%) patients had the RNF213 p.R4810K variant. The variant carriers were more likely to be female (52.7% vs. 35.3%, P P P =0.01), middle cerebral artery M1 stenosis (29.7% vs. 6.0%, P =0.01), and large-artery atherosclerosis (47.3% vs. 25.0%, P P P Conclusions: Hypothyroidism and elevated TPOAb levels were frequently observed in IS patients with the RNF213 p.R4810K variant, which may be associated with immune aberrancies relevant to or underlying thyroid autoimmunity, contributing to the different features of IS.

Background and aims Current trends have suggested covert atrial fibrillation as a mechanism of cryptogenic stroke. However, etiological heterogeneity regarding the underlying embolic sources remains a critical issue in cryptogenic stroke. Methods CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke) is a multicenter observational registry of cryptogenic stroke patients admitted to participating hospitals, who underwent transesophageal echocardiography between April 2014 and December 2016. We obtained baseline characteristics, radiological and laboratory data, and echocardiographic findings, especially for embolic sources demonstrated on transesophageal echocardiography, and conducted comparisons according to CHADS2 and CHA2DS2-VASc scores (0–1 vs. ≥2, respectively). This study was registered at http://www.umin.ac.jp/ctr/ (UMIN000032957). Results The study comprised 677 patients (age, 68.7 ± 12.8 years; 455 males; median National Institutes of Health Stroke Scale score, 2) with cryptogenic stroke. On multiple logistic regression analysis, large aortic arch plaque ≥4 mm (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.51–3.36; p Conclusions The CHALLENGE ESUS/CS registry is a large TEE registry, and clarifies potential embolic etiologies of cryptogenic stroke using TEE. Large aortic arch plaques were associated with high CHADS2 and CHA2DS2-VASc scores, and represented important embolic sources in cryptogenic stroke.

Although amebiasis is usually asymptomatic, fulminant amebic colitis is associated with a high mortality rate. Here, we report the case of a patient with amebic colitis in which bowel perforation occurred despite treatment with metronidazole. A man in his 70s underwent steroid pulse therapy to treat serious acute hepatitis A. After corticosteroid therapy, he developed acute abdomen because of amebic colitis. We immediately administered metronidazole and his symptoms improved. After completing treatment, he developed colon perforation. Amebic colitis can progress to bowel perforation even after administering the appropriate medication, so this abdominal symptom requires careful attention.

Background International immigration to Japan, where homogeneous ethnicity is a population characteristic, has been growing. Although immigration is recognised as a risk factor for multiple mental-health related issues, there are few regional reports on foreign nationals accessing the psychiatric services in Japan. We aimed to reveal their current status and provide information to develop an optimal service system. Methods A multicentre retrospective document review research was conducted. The subjects were foreign nationals who resided in Japan and presented at the psychiatry departments in three core regional hospitals in the Keihin region, which faces Tokyo Bay and is well known to include the largest traditional industrial zone in Japan, over a period of 3 years. We investigated the patients’ demographic and clinical information including country/region of origin, spoken language, use of a medical interpreter, pathway to hospitals and outcome. Results The percentage of foreign patients among all patients (1.4%) was quite low. Their age distribution (45.8 years on average) was dissociated from the age distribution of foreign nationals who resided in Japan. Regarding the country/region of origin, China (35.1%) was the most common country, followed by the Philippines, Korea and Brazil. Several subjects (22.9%) could not speak Japanese; therefore, interpretation was required by family members/friends (17.1%) or a professional interpreter (5.4%). Neurotic and stress-related disorders were the most common diagnosis (24.4%). The proportion of psychoactive substance use was higher than that for Japanese national data as immigrants are known to be at risk for it. Conclusions The results suggest that foreign nationals who reside in Japan are less likely to contact appropriate services for mental illness, especially young people at relatively high risk of mental illness do not access services. Furthermore, lack of medical interpreters may impede the mental health conditions of foreign nationals. The development of a community-based integrated care system accessible to foreign nationals seems to be indispensable.

Lipid droplets (LDs) are essential organelle in most eukaryotes, and tracking intracellular LDs dynamics using synthetic small molecules is crucial for biological studies. However, only a limited number of fluorescent markers that satisfy all requirements, such as the selective staining of LDs, high photostability, and sufficient biocompatibility, have been developed. Herein, we report a series of donor-p-acceptor dyes based on the thiophene-containing fused polycyclic scaffold [1]benzothieno[3,2-b][1]benzothiophene (BTBT), in which either or both thiophene rings are oxidized into thiophene-S,S-dioxide to form an electron-accepting building block. Among these dyes, LAQ1 satisfied all the aforementioned requirements, and allowed us capturing ultra-small LDs on the endoplasmic reticulum (ER) membrane by stimulation emission depletion (STED) microscopy with a super-resolution below the diffraction limit of light. Moreover, the extremely high photostability of LAQ1 enabled recording the lipolysis of LDs and the concomitant lipogenesis as well as long-term trajectory analysis of micro LDs at the single particle level in living cells.

Background: International immigration to Japan, where homogeneous ethnicity is a population characteristic, has been growing. Although immigration is recognized as a risk factor for multiple mental-health related issues, there are few regional reports on foreign residents who visit a hospital for mental health problems in Japan. We aimed to examine such patients’ characteristics.Methods: A multicenter retrospective study using medical records was conducted. The subjects were foreign patients who presented at the psychiatry departments in three core regional hospitals in the Keihin region, which faces Tokyo Bay and is well known to include the largest traditional industrial zone in Japan, over a period of three years. We investigated the patients’ demographic and clinical information including country/region of origin, spoken language, use of a medical interpreter, pathway to hospitals, and outcome.Results: The percentage of foreign individuals among all patients was 1.4% (205/14511). The mean age of the foreign patients was 45.8 years, and the sex ratio was 1:1.9 (men: women). Regarding the country/region of origin, China (35.1%) was the most common country, followed by the Philippines (18.5%), Korea (16.1%), and Brazil (4.9%). Several subjects (22.9%) could not speak Japanese; therefore, interpretation was required by family members/friends (17.1%) or a professional interpreter (5.4%). Neurotic disorder (ICD-10 code: F4) was the most common diagnosis (24.4%).Conclusions: The percentage of foreign patients seeking psychiatric treatment (1.4%) was relatively low, compared with the percentage of foreign residents living in the Keihin region (4.4%). The age distribution of foreign residents who visited psychiatric department was dissociated from the age distribution of foreign residents in Japan. This suggests that young foreign residents with a relatively high risk for mental illness are not accessing appropriate services. The development of a community-based integrated care system accessible to foreign residents seems to be indispensable.

Background Patients with vascular Ehlers-Danlos syndrome (EDS) occasionally suffer from arterial dissection. Eagle syndrome, which is caused by an elongated styloid process and also causes arterial dissection, is difficult to diagnose and could sometimes be overlooked. Little is known of the coexistence of these two diseases, and treatment strategy is not established. Here, we present a case of bilateral internal carotid artery (ICA) dissection due to Eagle syndrome in a patient with vascular EDS. Case presentation A 30-year-old man was admitted to our hospital because of sudden onset of mild sensory disturbance in his left limbs. He had a history of Ehlers-Danlos syndrome (EDS) and also had left cervical internal carotid artery (ICA) dissection 3 years before. Diffusion-weighted imaging showed acute cerebral infarcts in the right hemisphere. Cervical computed tomography angiography (CTA) revealed the right ICA narrowing at the cervical portion in addition to the previous left cervical ICA dissection. Cervical magnetic resonance imaging (MRI) revealed double-lumen and intramural hematoma at the narrowing portion of the right cervical ICA, which indicates arterial dissection. CT also revealed bilateral elongated styloid processes which are close to each side of cervical ICA. We diagnosed him as bilateral ICA dissection due to bilateral Eagle syndrome. Considering vascular complications due to vascular EDS, we performed closer follow-up with transoral carotid ultrasonography (TOCU). In 4 months, his right ICA dissection gradually improved without stroke recurrence or deterioration of dissection. Conclusions Since patients with vascular EDS easily develop arterial dissection, Eagle syndrome may be overlooked. Clinicians should consider Eagle syndrome in the case of vascular EDS with extracranial ICA dissection and close follow-up should be prioritized in cases of Eagle syndrome with vascular EDS.

Aims: Awareness of potentially embologenic diseases is critical to determining the prognosis of cryptogenic stroke. The clinical significance of atrial septal aneurysm (ASA) in cryptogenic stroke has not been fully studied. Therefore, we explored clinical characteristics and in-hospital recurrence in patients with ASA in cryptogenic stroke. Methods: A multicenter observational registry of cryptogenic stroke patients was conducted. We obtained baseline characteristics, radiological and laboratory findings, and echocardiographic findings, especially of embolic sources on transesophageal echocardiography. The CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for embolic stroke of undetermined source/cryptogenic stroke) registry was recorded at http://www.umin.ac.jp/ctr/ (UMIN000032957). Patients’ clinical characteristics were compared according to the presence of ASA, and factors associated with in-hospital stroke recurrence were assessed. Results: The study included 671 patients (age, 68.7±12.7 years; 450 males; median National Institutes of Health Stroke Scale score, 2). ASA was detected in 92 patients (14%), displaying higher age (72.4±11.0 vs. 68.1 ±12.9 years, p =0.004), reduced frequency of diabetes mellitus (16% vs. 27%, p =0.030), higher frequency of right-to-left shunt (66% vs. 45%, p ＜0.001), and in-hospital stroke recurrence (8% vs. 3%, p =0.034). ASA was relatively associated with in-hospital recurrence (odds ratio 2.497, 95% confidence interval 0.959–6.500, p = 0.061). Conclusions: The CHALLENGE ESUS/CS registry indicated that ASA was not rare in cryptogenic stroke, and ASA’s clinical characteristics included higher age, reduced frequency of diabetes mellitus, and increased frequency of concomitant right-to-left shunt. ASA may be related to in-hospital stroke recurrence in cryptogenic stroke.

In patients with schizophrenia, motivation has been assumed to act as an intervening factor between cognitive function and social functioning. Motivation is thought to comprise three domains defined by their orientations: intrinsic motivation, extrinsic motivation, and amotivation. Although these orientations can confound each other, the effects of motivation domains on social functioning remain obscure. We investigated these relationships after confirming the factor structure of social functioning using the Social Functioning Scale (SFS). A total of 97 stable outpatients with schizophrenia were recruited. In addition to the SFS, the General Causality Orientations Scale (GCOS) was used to measure the motivation domains. First, we examined the factor structure of the SFS using exploratory and confirmatory factor analyses. Next, we conducted structural equation modeling to examine the effects of motivation domains on social functioning. The SFS showed a two-factor structure: interpersonal and intrapersonal functioning. The structural equation model revealed that (1) amotivation was negatively related to both intrapersonal and interpersonal functioning, (2) intrinsic motivation was positively related only to intrapersonal functioning, and (3) extrinsic motivation was positively related only to interpersonal functioning. Each motivation domain was associated with different factors of social functioning. Future interventions aimed at improving social functioning should consider these motivation domains based on their orientations. Cognitive remediation accompanied by considerations for and approaches to each of the domains may maximize recovery in patients with schizophrenia.

BACKGROUND Glucose excursions and hypoglycemia are associated with cardiovascular complications. However, no studies have evaluated glucose excursions and the frequency of hypoglycemia in patients treated with mitiglinide/voglibose versus glimepiride as add-on to dipeptidyl peptidase-4 inhibitor therapy. METHODS This cross-over trial included 20 patients with type 2 diabetes. After initiating vildagliptin 100 mg, patients were randomly assigned to receive mitiglinide 10 mg/voglibose 0.2 mg three times daily for 3 days followed by glimepiride 1 mg once daily for the subsequent 3 days as add-on therapy, or vice versa. Glucose excursions and hypoglycemia frequency were measured using 24-h continuous glucose monitoring. Metabolic profile changes were evaluated using a meal tolerance test. RESULTS The mean glucose levels in the mitiglinide/voglibose and glimepiride phases were identical (8.01 vs 8.24 mmol/L, respectively). However, during the mitiglinide/voglibose phase compared with the glimepiride phase, the standard deviation of glucose (1.30 vs 2.10 mmol/L; P 10 mmol/L (0.18 vs 0.52 mmol/L per h; P < 0.001) were significantly lower. Hypoglycemia (glucose

Some cardiac abnormalities could be a substrate for potential embolic source in cryptogenic stroke (CS). We evaluated whether cardiac and echocardiographic markers were associated with CS in patients with incidental patent foramen ovale (PFO) as defined using the Risk of Paradoxical Embolism (RoPE) score.Among 677 patients enrolled in a multicenter observational CS registry, 300 patients (44%) had PFOs detected by transesophageal echocardiography. They were classified into probable PFO-related stroke (RoPE score6, n = 32) and stroke with incidental PFO (RoPE score≤6, n = 268) groups, and clinical characteristics, laboratory findings, cardiac and echocardiographic markers (i.e. brain natriuretic peptide, left atrial [LA] diameter, ejection fraction, early transmitral flow velocity/early diastolic tissue Doppler imaging velocity [E/e'], LA appendage flow velocity, spontaneous echo contrast, atrial septal aneurysm, substantial PFO, and aortic arch plaques), stroke recurrence, and excellent outcome (modified Rankin scale score2) at discharge were compared. Risk factors for low RoPE scores were determined using multiple logistic regression analysis.Higher brain natriuretic peptide levels (p = 0.032), LA enlargement (p 0.001), higher E/e' (p = 0.001), lower LA appendage flow velocity (p 0.001), non-substantial PFO (p = 0.021), and aortic arch plaques (p = 0.002) were associated with the low RoPE score group. Patients with high RoPE scores had excellent outcomes (58% versus 78%, p = 0.035). LA enlargement (age- and sex-adjusted odds ratio, 1.15; 95 % confidence interval, 1.00-1.32; p = 0.039) was an independent predictor of low RoPE scores.Abnormal cardiac substrate could be associated with CS occurrence in a subset of patients with PFO. Patients with CS who had incidental PFO may be at risk of cardioembolism.

Aim To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) using the clutch cutter (CC) (ESD-CC) for gastric adenoma (GA). Methods From June 2007 to August 2015, 122 consecutive patients with histological diagnoses of GA from specimens resected by ESD-CC were enrolled in this prospective study. The CC was used for all ESD steps (marking, mucosal incision, submucosal dissection, and hemostatic treatment), and its therapeutic efficacy and safety were assessed. Results Both the en-bloc resection rate and the R0 resection rate were 100% (122/122). The mean surgical time was 77.4 min, but the time varied significantly according to tumor size and location. No patients suffered perforation. Post-ESD-CC bleeding occurred in six cases (4.9%) that were successfully resolved by endoscopic hemostatic treatment. Conclusion ESD-CC is a technically efficient, safe, and easy method for resecting GA.

Cryptogenic stroke encompasses diverse emboligenic mechanisms and pathogeneses. Cerebral microbleeds (CMBs) occur differently among stroke subtypes. The association of CMBs with cryptogenic stroke is essentially unknown. CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for ESUS/CS) is a multicenter registry with comprehensive data including gradient-echo T2*-weighted magnetic resonance imaging of cryptogenic stroke patients who underwent transesophageal echocardiography. Patients’ clinical characteristics were compared according to the presence and location of CMBs. A total of 661 patients (68.7 ± 12.7 years; 445 males) were enrolled, and 209 (32%) had CMBs. Age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00–1.04, p = 0.020), male sex (OR 1.85, 95% CI 1.18–2.91, p = 0.007), hypertension (OR 1.71, 95% CI 1.03–2.86, p = 0.039), chronic kidney disease (OR 1.64, 95% CI 1.11–2.43, p = 0.013), deep and subcortical white matter hyperintensity (OR 1.82, 95% CI 1.16–2.85, p = 0.009), and periventricular hyperintensity (OR 2.18, 95% CI 1.37–3.46, p = 0.001) were independently associated with the presence of CMBs. Aortic complicated lesions (OR 1.78, 95% CI 1.12–2.84, p = 0.015) were associated with deep and diffuse CMBs, whereas prior anticoagulant therapy (OR 7.88, 95% CI, 1.83–33.9, p = 0.006) was related to lobar CMBs. CMBs were common, and age, male sex, hypertension, chronic kidney disease, and cerebral white matter diseases were related to CMBs in cryptogenic stroke. Aortic complicated lesions were associated with deep and diffuse CMBs, while prior anticoagulant therapy was related to lobar CMBs.

Introduction: Recently, The New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial versus Aspirin to Prevent Embolism in Embolic Stroke of Undetermined Source (NAVIGATE-ESUS) failed to show the efficacy of rivaroxaban for secondary prevention of ESUS. In particular, paroxysmal atrial fibrillation was detected only 3% of patients during follow up, and was not a major cause of recurrent stroke in ESUS. Thus, current trends indicate that diverse embolic etiologies are critical in the management of ESUS/cryptogenic stroke. Methods: The CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for ESUS/Cryptogenic Stroke) is an observational and multicenter registry of ESUS/CS patients who were admitted to the participating hospitals and underwent transesophageal echocardiography (TEE) from April 2014 to December 2016. We obtained baseline characteristics, radiological and laboratory data, and echocardiographic findings especially in embolic sources demonstrated on TEE, which were compared according to CHADS 2 and CHA 2 DS 2 -VASc scores. Results: A total of 694 patients (age, 68.7 ± 12.9 years; 468 males; median National Institutes of Health Stroke Scale score, 2) were enrolled. Frequency of aortic arch plaques ≥ 4mm were significantly increased in correlation with the increases in CHADS 2 score (19%, 0 points; 33%, 1; 40%, 2; 49%, 3; 59%, 4 to 6, P 2 DS 2 -VASc score (12%, 0 points; 19%, 1; 35%, 2; 39%, 3; 46%, 4; 55%, 5 to 8, P 2 score ≥ 2 points (odds ratio, 1.79; 95% confidence interval, 1.25-2.57; P =0.002) and CHA 2 DS 2 -VASc score ≥ 2 points (odds ratio, 3.04; 95% confidence interval, 1.77-5.24; P Conclusions: Aortic arch plaques ≥ 4 mm are closely related to high CHADS 2 and CHA 2 DS 2 -VASc scores in ESUS/CS. CHADS 2 and CHA 2 DS 2 -VASc scores are linked with stroke recurrence, and thus large aortic plaques are important embolic source in ESUS/CS.

Current trends have suggested covert atrial fibrillation as a mechanism of cryptogenic stroke. However, etiological heterogeneity regarding the underlying embolic sources remains a critical issue in cryptogenic stroke.CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke) is a multicenter observational registry of cryptogenic stroke patients admitted to participating hospitals, who underwent transesophageal echocardiography between April 2014 and December 2016. We obtained baseline characteristics, radiological and laboratory data, and echocardiographic findings, especially for embolic sources demonstrated on transesophageal echocardiography, and conducted comparisons according to CHADSThe study comprised 677 patients (age, 68.7 ± 12.8 years; 455 males; median National Institutes of Health Stroke Scale score, 2) with cryptogenic stroke. On multiple logistic regression analysis, large aortic arch plaque ≥4 mm (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.51-3.36; p 0.001), with ulcerative or mobile components (OR, 2.37; 95%CI, 1.38-4.06; p = 0.002), was associated with CHADSThe CHALLENGE ESUS/CS registry is a large TEE registry, and clarifies potential embolic etiologies of cryptogenic stroke using TEE. Large aortic arch plaques were associated with high CHADS

Background Liddle’s syndrome is a rare monogenic form of hypertension caused by truncating or missense mutations in the C termini of the epithelial sodium channel (ENaC) β or γ subunits. Patients with this syndrome present with early onset of hypertension, hypokalemia, metabolic alkalosis, hyporeninemia and hypoaldosteronism, and a potassium-sparing diuretics (triamterene or amiloride) can drastically improves the disease condition. Although elderly patients having these characteristics were considered to have Liddle’s syndrome or Liddle’s-like syndrome, no previous report has indicated that Liddle’s-like syndrome could be caused by nephrotic syndrome of primary glomerular disease, which is characterized by urinary excretion of > 3 g of protein/day plus edema and hypoalbuminemia, or has explained how the activity function of ENaC could be affected in the setting of high proteinuria. Case presentation A 65-year-old Japanese man presented with nephrotic syndrome. He had no remarkable family history, but had a medical history of hypertension and hyperlipidemia. On admission, hypertension, spironolactone-resistant hypokalemia (2.43 mEq/l), hyporeninemic hypoaldosteronism, and metabolic alkalosis, which suggested Liddle’s syndrome, were observed. Treatment with triamterene together with a steroid for nephrotic syndrome resulted in rapid and remarkable effective on improvements of hypertension, hypokalemia, and edema of the lower extremities. Renal biopsy revealed membranous nephropathy (MN) as the cause of nephrotic syndrome, and advanced gastric cancer was identified on screening examination for cancers that could be associated with the development of MN. After total gastrectomy, triamterene was not required and proteinuria decreased. A mutation in the β or γ subunits of the ENaC gene was not identified. Conclusion We reported for the first time a case of Liddle’s-like syndrome associated with nephrotic syndrome secondary to MN. Aberrant activation of ENaC was suggested transient during the period of high proteinuria, and the activation was reversible with a decrease in proteinuria.

Introduction: Histopathological analysis of the thrombi, which was retrieved from stroke patients with large-vessel occlusion during mechanical thrombectomy, may provide information about underlying pathologies. It is likely that the size of the thrombi differ between stent retriever and aspiration catheter. Objective: This study aimed to evaluate the thrombus composition and its association with radiological findings, stroke subtypes, and reperfusion times. Methods: From June 2014 to August 2016, 51 patients were treated at our hospital by mechanical thrombectomy using stent retriever and/or aspiration catheter. The received thrombi were subjected to semi-quantitative analysis to quantify red blood cells, platelet, and/or fibrin in the overall area. We divided the patients into two groups according to the predominant composition of the thrombus: red thrombus group or white thrombus group. These two groups were compared with respect to imaging, clinical, and neurointerventional data. Results: Histopathological analysis of retrieved thrombus from 44 patients with acute stroke due to internal carotid artery, middle cerebral artery, or basilar artery occlusion was performed. There were no significant changes with respect to the time from onset to reperfusion, time from puncture to reperfusion, and type of atrial fibrillation (paroxysmal or persistent). Postoperative stenotic lesion was significantly higher in patients with white thrombi than in those with red thrombi (83% vs 19%, p = 0.001). Preoperative susceptibility vessel sign on magnetic resonance imaging correlated with the proportion of red thrombi than with that of white thrombi (59% vs 33%, p = 0.04). The maximum diameter of thrombi was significantly larger in the combination Penumbra aspiration catheter group compared with that in the non-combination group (9.2 ± 3.7 vs 5.3 ± 4.7mm, p < 0.001). Conclusion: Histological thrombus features vary significantly according to the underlying cause and may help to differentiate between large-artery atherosclerosis and cerebral embolism. Aspiration first pass technique could retrieve a large thrombus.

Fluorophores with intramolecular charge-transfer (ICT) character in the excited state exhibit significant solvatochromism of their fluorescence. Here, we report an example for such compounds, a ben...

Glucose excursions and hypoglycemia are associated with cardiovascular complications. However, no studies have evaluated glucose excursions and the frequency of hypoglycemia in patients treated with mitiglinide/voglibose versus glimepiride as add-on to dipeptidyl peptidase-4 inhibitor therapy.This cross-over trial included 20 patients with type 2 diabetes. After initiating vildagliptin 100 mg, patients were randomly assigned to receive mitiglinide 10 mg/voglibose 0.2 mg three times daily for 3 days followed by glimepiride 1 mg once daily for the subsequent 3 days as add-on therapy, or vice versa. Glucose excursions and hypoglycemia frequency were measured using 24-h continuous glucose monitoring. Metabolic profile changes were evaluated using a meal tolerance test.The mean glucose levels in the mitiglinide/voglibose and glimepiride phases were identical (8.01 vs 8.24 mmol/L, respectively). However, during the mitiglinide/voglibose phase compared with the glimepiride phase, the standard deviation of glucose (1.30 vs 2.10 mmol/L; P 0.001), mean amplitude of glycemic excursions (3.47 vs 5.28 mmol/L; P 0.001), M-value (24.6 vs 70.0; P 0.001), continuous overlapping net glycemic action for a 1-h time interval (22.6 vs 31.0; P 0.001), and area under the curve10 mmol/L (0.18 vs 0.52 mmol/L per h; P 0.001) were significantly lower. Hypoglycemia (glucose3.8 mmol/L) was not observed during the mitiglinide/voglibose phase, but occurred 0.35 times/day in those taking glimepiride. Moreover, the mitiglinide/voglibose phase had higher premeal and lower post-meal glucose levels than the glimepiride phase.Adding mitiglinide/voglibose to vildagliptin therapy results in more efficient postprandial glucose control and less hypoglycemia than adding glimepiride.

A man in his 60s was referred to our institution for the evaluation of a gastric neuroendocrine tumor (G-NET) located in the fornix and that measured 13mm in size. Blood test results revealed hypergastrinemia (up to 3376pg/ml). Additional tests, including esophagogastroduodenoscopy, computed tomography, and intragastric pH monitoring, indicated that hypergastrinemia was not associated with type A autoimmune gastritis or gastrinoma. The patient was positive for the immunoglobulin G antibody against Helicobacter pylori, suggesting type B chronic atrophic gastritis as the cause for the condition. This report describes a rare case of G-NET with hypergastrinemia following type B chronic atrophic gastritis. Evaluation of similar cases is necessary to determine if H. pylori-associated chronic atrophic gastritis is frequently associated with G-NET.