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type:Other, Tokyo -one of the largest cities in the world- exhibits intensive urban land use, urban sprawl, and high anthropogenic heat exhaustion, which produce characteristic urban temperature distributions. Typical features of the nocturnal temperature distribution from November to February under conditions of clear skies and weak winds were analyzed for the Tokyo metropolitanwardarea using data from spatially high-density observations from the Automated Meteorological Data Acquisition System(AMeDAS) of the Japan Meteorological Agency(JMA), municipal air pollution monitoring systems, and Extended-METROS from 2006/2007 to 2009/2010. To analyze the structure of temperature distributions in the Tokyo-ward area, hourly temperature data at 124 stations were interpolated into grid points with 1-km intervals. When high temperatures in central Tokyo were expressed as a difference in AMeDAS temperature between central Tokyo(Otemachi) and an average of four points outside the Tokyoward area, the weather conditions most strongly affecting this temperature differ ence at 06:00 Japan Standard Time(JST), prior to sunrise, were cloud amount followed by wind speed. The temperature difference at night under clear-sky and weak-wind conditions (average cloud amount of 2/10 or less and aver age wind speed of 3 m/s or less) generally showed an abrupt increase during the several hours before and after sunset followed by a gradual increase, reaching maximum levels before sunrise(06:00 JST). When the temperature difference before sunrise was large, the difference would evidently increase even after midnight; however, if this difference was small, it would tend to decrease after midnight.The high temperatures in the metropolitan area were concentrated throughout the nightnear the southern area of Chuo ward. In particular, it is noted th at several zones of steep horizontal temperature gradients were detected in the metropolitan-ward area. These zones (e.g.starting from the southern part of Saitama P

Background and Objective: Antispasmodic drugs (ADs) have been used to reduce examination time or improve the quality of gastrointestinal endoscopy, although the practice is controversial. No evidence about the efficacy of AD for endoscopic ultrasonography/EUS-guided fine-needle aspiration (EUS/EUS-FNA) is available. This study was aimed to evaluate the efficacy of AD in EUS/EUS-FNA. Patients and Methods: A total of 400 patients with pancreaticobiliary, peripancreatic, or peribiliary disease or disorder undergoing EUS/EUS-FNA were prospectively and evenly randomized to undergo EUS/EUS-FNA with AD (w-AD) or without AD (w/o-AD). The primary endpoint was total EUS/EUS-FNA examination time. The secondary endpoints were visual analogue scale (VAS) scores of endoscopists (patient body motion, gastrointestinal peristalsis, and accomplishment of the purpose) and patients (pain, discomfort, and willingness to undergo re-examination), vital sign changes, adverse events, and sedative dose. Results: Two hundred patients in the w-AD group and 197 patients in the w/o-AD group were ultimately analyzed. The total examination time was similar between the groups (2299 ± 937 vs. 2259 ± 1019 s). The difference in total examination time from w/o-AD group to w-AD group was −40 s (95% confidence interval, −234-153 s), which was within the noninferiority margin. No statistical differences were observed in endoscopist and patient VAS scores, changes in vital signs, adverse events, or total sedative dose other than fentanyl between the groups. Conclusion: EUS/EUS-FNA can be effectively and safely performed w/o-AD. Further, randomized controlled trials on EUS/EUS-FNA in various disease entities may be required to confirm the results of this study (UMIN000008047).

Background and Objective: Antispasmodic drugs (ADs) have been used to reduce examination time or improve the quality of gastrointestinal endoscopy, although the practice is controversial. No evidence about the efficacy of AD for endoscopic ultrasonography/EUS-guided fine-needle aspiration (EUS/EUS-FNA) is available. This study was aimed to evaluate the efficacy of AD in EUS/EUS-FNA. Patients and Methods: A total of 400 patients with pancreaticobiliary, peripancreatic, or peribiliary disease or disorder undergoing EUS/EUS-FNA were prospectively and evenly randomized to undergo EUS/EUS-FNA with AD (w-AD) or without AD (w/o-AD). The primary endpoint was total EUS/EUS-FNA examination time. The secondary endpoints were visual analogue scale (VAS) scores of endoscopists (patient body motion, gastrointestinal peristalsis, and accomplishment of the purpose) and patients (pain, discomfort, and willingness to undergo re-examination), vital sign changes, adverse events, and sedative dose. Results: Two hundred patients in the w-AD group and 197 patients in the w/o-AD group were ultimately analyzed. The total examination time was similar between the groups (2299 ± 937 vs. 2259 ± 1019 s). The difference in total examination time from w/o-AD group to w-AD group was −40 s (95% confidence interval, −234-153 s), which was within the noninferiority margin. No statistical differences were observed in endoscopist and patient VAS scores, changes in vital signs, adverse events, or total sedative dose other than fentanyl between the groups. Conclusion: EUS/EUS-FNA can be effectively and safely performed w/o-AD. Further, randomized controlled trials on EUS/EUS-FNA in various disease entities may be required to confirm the results of this study (UMIN000008047).

The controversy over whether and how to perform preoperative biliary drainage (PBD) in patients with hilar cholangiocarcinoma (HCA) remains unsettled. Arguments against PBD before pancreatoduodenectomy have recently been gaining momentum. However, the complication-related mortality rate is as high as 10% for patients with HCA who have undergone major liver resection, and liver failure is a major cause of postoperative death. This suggest the need for PBD to treat jaundice in HCA patients scheduled for major surgical resection of the liver and to perform major surgery only after recovery of hepatic function. No definite criteria or guidelines outlining indications for PBD are currently available. In patients with HCA, PBD may be performed by either percutaneous transhepatic biliary drainage (PTBD) or endoscopic biliary drainage (EBD). No consensus, however, has been reached regarding which drainage method is more appropriate. No reported study has compared the effectiveness of PTBD, endoscopic biliary stenting (EBS), and endoscopic nasobiliary drainage (ENBD) in patients with HCA. This review summarizes the results of our study comparing the three methods and outlines the preoperative endoscopic management of segmental cholangitis (SC) in HCA patients undergoing PBD.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and related procedures can cause abdominal pain and discomfort. Two clinical trials have indicated, using the visual analogue scale (VAS) score, that CO2 insufflation during ERCP ameliorates the suffering of patients without complications, as compared with air insufflation. However, differences in patient suffering between CO2 and air insufflation after ERCP under deep conscious sedation have not been reported. We focused on the gas volume score (GVS) as an objective indicator of gas volume, and designed a multicenter, prospective, double-blind randomized controlled study with CO2 and air insufflation during ERCP. Methods: Between March 2010 and August 2010, 80 patients who required ERCP were enrolled and evenly randomized to receive CO2 insufflation (CO2 group) or air insufflation (air group). ERCP and related procedures were performed under deep conscious sedation with fentanyl citrate or pethidine and midazolam or diazepam. The GVS was evaluated as the primary endpoint in addition to the VAS score as the secondary endpoint. Results: The GVS after ERCP and related procedures in the CO2 group was significantly lower than that in the air group (0.14 ± 0.06 vs. 0.31 ± 0.11, P < 0.01), as well as the increase in the rate of GVS ([GVS after - GVS before] / [GVS before ERCP and related procedures] x 100) (3.8 ± 5.9 vs. 21.0 ± 11.1%, P < 0.01). VAS scores 3 and 24 hours after ERCP and related procedures were comparable between the CO2 and air groups for abdominal pain, abdominal distension, and nausea. Additionally, VAS scores were not correlated with the GVS. Conclusions: CO2 insufflation during ERCP reduces GVS (bowel gas volume), but not the VAS score of suffering, as compared with air insufflation. Deep and sufficient sedation during ERCP and related procedures is important for the palliation of patients' pain and discomfort.

Background and study aims: Localized-type bile duct carcinoma (LBDC) is often accompanied by extensive intraepithelial tumor spread (ITS) ≥2 cm which makes radical resection more difficult. This retrospective case review compared the diagnostic accuracy of endoscopic retrograde cholangiography (ERC) and peroral cholangioscopy (POCS) to detect ITS beyond the visible LBDCs. Patients and methods: Forty-four consecutive LBDC patients diagnosed between April 2004 to October 2008 who underwent radical resection with histopathological analysis were included in this study. Extensive ITS was found histopathologically in one-third of the cases (32%). The outcome parameters were the presence or absence of extensive ITS and the extent of extensive ITS proximal and distal to the main tumor. Results: It was not possible to pass the cholangioscopic through the tumor sites in 6 cases. ERC correctly identified the presence of extensive ITS in 11/14 cases and did not yield any false-positive results. The three ERC-negative cases were all correctly identified by POCS plus biopsy since the cholangioscope could be passed in all three cases. The extent of extensive ITS was correctly diagnosed by ERC alone, ERC with POCS, and ERC with POCS plus mapping biopsy in 22%, 77%, and 100% of cases, respectively. Conclusions: The presence of extensive ITS could be correctly detected in 80% of cases by ERC alone. POCS with mapping biopsy provided perfect diagnostic accuracy of not only the presence/absence but also the extent of extensive ITS. However, POCS has the limitation that the cholangioscope cannot be passed through the tumor sites in approximately 15% of cases.