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Background and Objective: This study aimed to evaluate endoscopic findings using linked color imaging (LCI) and blue laser imaging (BLI) and to determine a diagnostic predictor for duodenal adenocarcinomas. Methods: All consecutive patients who underwent endoscopic resection for superficial non-ampullary duodenal epithelial tumors (SNADETs) between October 2012 and June 2019 were enrolled in this study. Two highly experienced endoscopists investigated six morphological findings using both white light imaging and LCI and three magnifying endoscopic findings using magnifying BLI (M-BLI). Results: A total of 90 patients with 110 SNADETs, including 87 adenocarcinomas and 23 adenomas, were analyzed in this study. Among the non-magnifying endoscopic findings, the presence of reddish color, orange color on LCI (orange color sign), lobulation, depression, and marginally white opaque substance were found significantly more frequently in adenocarcinomas than in adenomas (p = 0.015, p < 0.001, p = 0.048, p < 0.001, and p = 0.007, respectively). Among the magnifying endoscopic findings, a mixed microsurface pattern (MSP), irregular MSP, and irregular microvascular pattern were found significantly more frequently in adenocarcinomas than in adenomas (p < 0.001, p < 0.001, and p = 0.002, respectively). In the multivariate analysis of all endoscopic findings associated with adenocarcinoma, orange color sign (odds ratio [OR] 10.46; 95% confidence interval [CI]: 1.42–77.08; p = 0.021), mixed MSP (OR 4.66; 95% CI: 1.02–21.40; p = 0.048), and irregular MSP (OR 13.11; 95% CI: 1.41–121.99; p = 0.024) were independent predictors of adenocarcinoma. Conclusions: The presence of orange color sign on LCI and mixed/irregular MSP on M-BLI were independent diagnostic predictors that were frequently observed in duodenal adenocarcinoma.

Introduction: An innovative endoscopic system using 4-color light-emitting diodes (LED) was released between 2016 and 2017 in locations that had not approved laser endoscopes for use, including the United States and Europe. Objective: This study compared the diagnostic efficacy between magnifying blue light imaging with an LED light source (LED-BLI) and magnifying blue laser imaging with a laser light source (Laser-BLI) for early gastric cancer (EGC). Methods: In this prospective, single-center, noninferiority study, 80 gastric lesions were evaluated between January 2017 and July 2017. The magnifying findings of gastric lesions – including the demarcation line (DL), microvascular pattern (MVP), and microsurface pattern (MSP) – were evaluated using Laser-BLI and LED-BLI according to the vessel plus surface classification system (VSCS). The primary end point was to determine whether the diagnostic accuracy of LED-BLI for EGC was noninferior to that of conventional Laser-BLI. Results: Overall, we evaluated 79 gastric lesions histopathologically diagnosed as adenocarcinomas from the specimens obtained via endoscopic submucosal dissection. A DL was observed by Laser-BLI and LED-BLI in 98.7% (78/79) and 96.2% (76/79) of EGCs, respectively. The MVP observed using Laser-BLI and LED-BLI was irregular in 92.4% (73/79) and 89.9% (71/79), respectively. The MSP observed using Laser-BLI and LED-BLI was irregular in 83.5% (66/79) and 82.2% (65/79), respectively. According to the VSCS, diagnosable cancers were found in 94.9% (75/79) and 93.7% (74/79) of cases when using Laser-BLI and LED-BLI, respectively (p = 0.73; difference ratio, 1.2%; 95% CI –8.5 to 6.0%). Conclusions: LED-BLI could accurately visualize the DL, MVP, and MSP of EGCs and was not inferior to Laser-BLI. Therefore, LED-BLI can be used to diagnose EGC accurately according to the VSCS-based diagnosis criteria.

Background and aim Efficient intestinal wound healing is essential for good prognoses of ulcerative colitis (UC). Although bile acids and the transmembrane G-protein-coupled receptor (TGR) 5 have been reported to affect wound healing in intestinal epithelial cells, the detailed underlying mechanisms are unclear. Here, we investigated the role of TGR5 in wound healing in the context of colonic epithelial cells in the presence of bile acids. Methods The expression of TGR5 in the colonic epithelium of both a dextran sulfate sodium (DSS)-induced colitis mouse model (recovery phase), and UC patients in clinical remission, was evaluated. Young adult mouse colonic epithelial (YAMC) cells were then used to evaluate wound healing after treatment with deoxycholic acid (DCA); TGR5 was silenced in YAMC cells via shRNA-transfection, and a wound-healing assay in the presence of DCA was performed. Furthermore, we investigated the role of the activation of AKT in the context of wound healing. Results The expression of TGR5 was decreased in the colonic epithelium of both mice with DSS-induced colitis and UC patients. Additionally, DCA significantly delayed wound healing in YAMC cells but not in TGR5 silenced ones. Of note, the DCA-induced activation of AKT signaling in YAMC cells was inhibited by TGR5 silencing, and AKT inhibitors prevented the wound healing delay induced by DCA. Conclusions Overall, we show that DCA delays wound healing in the context of colonic epithelial cells through AKT activation. These results may support the development of new therapeutic approaches for epithelial regeneration in UC.

The visibility and diagnostic accuracy of early gastric cancer (EGC) after Helicobacter pylori (HP) eradication have been reported to improve using image-enhanced endoscopy (IEE) compared with white light imaging (WLI). The present study clarified the appropriate IEE for the detection and diagnosis of EGC in clinical settings. This prospective and cross-sectional study evaluated the visibility of EGC and endoscopic findings of gastric mucosa after successful HP eradication (n = 31) using videos with WLI and IEE. Three endoscopists evaluated high-definition videos in a randomized order. The mean visibility scores (MVSs) on linked color imaging (LCI) for atrophic border, intestinal metaplasia, map-like redness, and EGC were the highest among each modality (3.87 ± 0.34, 3.82 ± 0.49, 3.87 ± 0.50, and 3.35 ± 0.92, respectively). The MVSs with blue laser imaging (BLI) were highest for magnifying view of the demarcation line (DL), microsurface pattern (MSP), and microvascular pattern (MVP) for EGC (3.77 ± 0.49, 3.94 ± 0.25, and 3.92 ± 0.34, respectively). LCI had the highest visibility among findings of gastric mucosa and EGC after HP eradication, and BLI had the highest visibility of MVP, MSP, and DL in magnifying observation. These results suggest that LCI observation in the entire stomach and further magnifying BLI are the best methods for detecting and diagnosing EGCs after HP eradication, respectively.

This study aimed to evaluate endoscopic findings using non-magnifying blue laser imaging (BLI) to determine the risk factors for metachronous esophageal squamous cell carcinoma (ESCC). All consecutive patients who underwent endoscopic submucosal dissection (ESD) for primary superficial ESCC (SESCC) without a history of ESCC between January 2013 and January 2016 were enrolled. Three highly experienced endoscopists investigated seven endoscopic findings using non-magnifying BLI as follows: (1) a brownish area with unclear margin, (2) white flat deposits, (3) multiple foci of dilated vessels, (4) low capillary permeability, (5) multiple glycogenic acanthosis, (6) horizontal lines, and (7) a nonuniform color tone. Furthermore, Lugol-voiding lesions (LVLs) were graded according to the number of LVLs per endoscopic view (A, no lesions; B, 1–9 lesions; C, ≥ 10 lesions). A total of 102 SESCC patients who underwent ESD were included. Multivariate analyses showed that multiple foci of dilated vessels, low capillary permeability, and a nonuniform color tone were significantly associated with metachronous ESCC (hazard ratio [HR] 2.30; 95% confidence interval [CI] 1.01–5.46; P = 0.049, HR 5.25; 95% CI 1.86–15.01; P = 0.002 and HR 3.17; 95% CI 1.11–9.43; P = 0.032, respectively). The three-year cumulative incidence of metachronous ESCC was significantly higher in patients with low capillary permeability and a nonuniform color tone than in patients without these findings. (41.1% vs. 6.0%, 45.0% vs. 12.7%, respectively, P

In Japan, laser light source (Laser) endoscopy is widely available, and the characteristics of light-emitting diode light source (LED) endoscopy have not been clarified. We assessed the visibility of early gastric cancers (EGCs) and Helicobacter pylori (H. pylori)-associated gastritis for LED endoscopy compared with laser endoscopy using white-light imaging (WLI) and linked color imaging (LCI). We assessed 99 lesions between February 2019 and March 2020. The visibility was scored from four (excellent visibility) to one (poor visibility) by evaluating videos including EGCs and gastric mucosa captured using WLI and LCI with LED endoscopy (LED-WLI and LED-LCI, respectively) and laser endoscopy (Laser-WLI and Laser-LCI, respectively). The primary end point was the non-inferiority of the visibility of EGCs and H. pylori-associated gastritis between LED-/Laser-WLI and LED-/Laser-LCI. The visibility scores of EGCs for LED-/Laser-WLI and LED-/Laser-LCI were 3.14/2.97 and 3.39/3.35, respectively. The visibility scores of H. pylori-associated gastritis [intestinal metaplasia (IM), diffuse redness (DR), regular arrangement of collecting venules (RAC) and map-like redness (MR)] for LED-/Laser-WLI and LED-/Laser-LCI were 3.05/2.85 and 3.60/3.50 (IM), 2.76/2.50 and 2.96/2.86 (DR), 2.69/2.44 and 2.77/2.62 (RAC) and 2.97/2.75 and 3.39/3.27 (MR). Non-inferiority was demonstrated for visualizing EGCs and H. pylori-associated gastritis. LED-WLI and LED-LCI can be used to visualize EGCs and H. pylori-associated gastritis with non-inferiority to Laser-WLI and Laser-LCI. Furthermore, even with LED, LCI was more effective than WLI for evaluating EGCs and H. pylori-associated gastritis. Therefore, LED endoscopy can be used to detect EGCs and evaluate H. pylori-associated gastritis accurately.

Summary Identifying the depth of invasion (DOI) of superficial esophageal squamous cell carcinoma (SESCC) is crucial to determine the indication for endoscopic resection. This retrospective, single-center study aimed to evaluate the diagnostic efficacy of magnifying blue laser imaging (M-BLI) compared with white-light imaging (WLI) or magnifying narrow-band imaging (M-NBI) for identifying the DOI of SESCC. A total of 160 consecutive patients with SESCCs who underwent endoscopic submucosal dissection were enrolled in this study. Still images of the lesion were obtained using WLI, M-BLI and M-NBI prior to endoscopic submucosal dissection. Three endoscopists retrospectively evaluated the DOI using WLI according to non-magnifying findings and using M-BLI and M-NBI images according to the magnifying endoscopic classification of the Japan Esophageal Society. The diagnostic accuracy of each modality was compared using the chi-square test. The DOIs in 160 SESCCs evaluated pathologically were as follows: invasion to the epithelium or lamina propria mucosa in 130, invasion to the lamina muscularis mucosa or submucosa to a depth ≤ 200 μm in 18, and invasion to the submucosa to a depth > 200 μm in 12. The overall diagnostic accuracy rates of WLI, M-BLI, M-NBI, WLI with M-BLI (WLI + M-BLI), and WLI with M-NBI (WLI + M-NBI) were 86.9, 91.2, 90.6, 95.6 and 94.4%, respectively. Significant differences were found between WLI and WLI + M-BLI or WLI + M-NBI (P = 0.006 and P = 0.021, respectively). The concordance of intrapapillary capillary loops between M-BLI and M-NBI was 91.2%. The kappa coefficients for interobserver variability of the three endoscopists for M-BLI and M-NBI were 0.728/0.649/0.792 and 0.729/0.666/0.791, respectively, while those for intraobserver variability were 0.919/0.746/0.778 and 0.736/0.720/0.745, respectively. Similar to M-NBI, M-BLI was useful in predicting the DOI of SESCCs.

Background 5-ASA is a key drug to treat the patients with mild-to-moderate ulcerative colitis (UC). Probiotics is sometimes used to UC patients for the purpose to correct dysbiosis of intestine. In theory, the efficacy of 5-ASA, especially pH-dependent release formulation of mesalazine may be weakened by the co-treatment with probiotics because of its effect leading to acidic condition in large intestine. However, the detail analysis about UC patients treating with 5-ASA and probiotics has not been elucidated. In the present study, we demonstrated the clinical course of UC patients treated by 5-ASA with probiotics to investigate the effect of probiotics to 5-ASA treatment. Methods The subjects were 85 UC patients who were in clinical remission and taking 5-ASA at the hospital of Kyoto Prefectural University of Medicine from January to March 2014. The clinical characteristics (age, sex, clinical activity index, disease location, and type of 5-ASA) and the rate of relapse until October 2019 were compared between probiotics group and no probiotics group. Furthermore, the rates of relapse were analysed for each specific 5-ASA between probiotics user and no probiotics user. The clinical activity index (CAI) was determined using Lichtiger index. The relapse of UC is defined by the increase of CAI, additional medication for UC, and endoscopic deterioration of colonic mucosa. Results Patients were included 39 cases in probiotics group and 46 cases in no probiotics group. There was no significant difference between probiotics and no probiotics group on the average age (53.1 ± 16.8 vs. 51.3 ± 14.2 years old, p = 0.59), the rate of male gender (41.0% vs. 41.3%, p =0.97), the average CAI (2.1 ± 0.64 vs. 2.0 ± 0.73, p = 0.59), disease location (extensive/left/rectum: 20/7/12 vs. 21/10/15 cases, p = 0.31), and type of 5-ASA (salazosulfapyridine/time-dependent mesalazine/pH-dependent mesalazine: 5/18/16 vs. 6/18/22 cases, p = 0.46). Besides, there was no significant difference between probiotics group and no probiotics group (51.3% vs. 52.2%, p = 0.93) about the rate of relapse. Regarding each specific 5-ASA usage, there was no significant difference on salazosulfapyridine (40.0% vs. 33.3%, p = 1), time-dependent mesalazine (44.4% vs. 50.0%, p = 1), and pH-dependent mesalazine (62.5% vs. 59.1%, p = 0.90) between probiotics user and no probiotics user. Conclusion In the present study, the co-treatment with probiotics did not affect the relapse with UC patients regardless the type of 5-ASA, suggesting that the usage of probiotics might not disturb the efficacy of 5-ASA for UC patients.

Background and study aim This study aimed to assess the safety and feasibility of endoscopic submucosal dissection (ESD) using a scissors-type knife with prophylactic closure using over-the-scope clip (OTSC) for superficial non-ampullary duodenal epithelial tumors (SNADETs). Patients and methods Consecutive patients who underwent ESD for SNADETs >10 mm between January 2009 and July 2019 were retrospectively enrolled. We performed ESD using either a needle-type knife (Flush Knife-ESD) or a scissors-type knife (Clutch Cutter-ESD). Mucosal defects were prophylactically closed using three methods: conventional clip, laparoscopic closure, or OTSC. Results A total of 84 lesions were resected using the Flush Knife-ESD and the Clutch Cutter-ESD (37 and 47 patients, respectively), and conventional clip, laparoscopic closure, and OTSC for mucosal defect closure after ESD were applied in 13, 13, and 56 lesions, respectively. The R0 resection rate was significantly higher in the Clutch Cutter-ESD than that in the Flush Knife-ESD (97.9% vs 83.8%, respectively, P = 0.040). The intraoperative perforation rate was significantly lower in the Clutch Cutter-ESD than in the Flush Knife-ESD (0% vs 13.5%, respectively, P = 0.014). Complete closure rates of conventional clip, laparoscopic closure, and OTSC were 76.9%, 92.3%, and 98.2%, respectively (P = 0.021); and delayed perforation rates were 15.4%, 7.7%, and 1.8%, respectively (P = 0.092). Conclusions Endoscopic submucosal dissection using a scissors-type knife with prophylactic OTSC closure is safe and feasible for the low-invasive treatment of SNADETs.

Endoscopic diagnosis of Helicobacter pylori (H. pylori) infection, the most common cause of gastric cancer, is very important to clarify high-risk patients of gastric cancer for reducing morbidity and mortality of gastric cancer. Recently, the Kyoto classification of gastritis was developed based on the endoscopic characteristics of H. pylori infection-associated gastritis for clarifying H. pylori infection status and evaluating risk factors of gastric cancer. Recently, magnifying endoscopy with narrow-band imaging (NBI) has reported benefits of the accuracy and reproducibility of endoscopic diagnosis for H. pylori-related premalignant lesions. In addition to NBI, various types of image-enhanced endoscopies (IEEs) are available including autofluorescence imaging, blue laser imaging, and linked color imaging. This review focuses on understanding the clinical applications and the corresponding evidences shown to improve the diagnosis of gastritis based on Kyoto classification using currently available advanced technologies of IEEs.

Background: Management of antithrombotic agents during endoscopic treatment changed after the publishing of ­Japan Gastroenterological Endoscopy Society guidelines for gastroenterological endoscopy in antithrombotic drug users (GL-2012). Objectives: We aimed to evaluate the effect of implementing antithrombotic agent management guidelines (GL-2012) on postoperative bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and on the prevention of thromboembolic events. Methods: A total of 1,264 patients who underwent ESD for EGC at Kyoto Prefectural University Hospital between June 2002 and March 2017 were enrolled and divided into 2 groups: 621 patients before the publication of GL-2012 (Pre-GL group) and 643 patients after (Post-GL group). Relationships between postoperative bleeding and various clinicopathological factors in each group were investigated through propensity score-matching analysis. Results: In the Pre-GL group, antihypertensive agent use (p < 0.01) and upper third of the stomach (p < 0.01) were significantly related to postoperative bleeding in univariate analysis. Antihypertensive agent use (OR 4.6, 95% CI 1.6–12.8) and upper third of the stomach (OR 4.9, 95% CI 1.8–13.4) were significantly related to postoperative bleeding in multivariate analysis. In the Post-GL group, antihypertensive agent use (p < 0.01), dual antiplatelet agents use (p < 0.01), anticoagulant agents use (p < 0.01), and heparin replacement therapy (p < 0.01) were significantly related to postoperative bleeding in univariate analysis. Antihypertensive agent use (OR 3.4, 95% CI 1.1–9.6), dual antiplatelet agents (OR 12.3, 95% CI 2.4–63.0), and heparin replacement therapy (OR 10.2, 95% CI 2.5–41.5) were significantly related to postoperative bleeding in multivariate analysis. Conclusions: The adherence to GL-2012 might reduce risk of thromboembolic events. On the other hand, dual antiplatelet agents therapy and heparin replacement therapy were the new independent risk factors for ESD postoperative bleeding in EGC after GL-2012. Especially as for heparin replacement therapy, uninterrupted warfarin or a temporary short interruption of direct oral anticoagulants without heparin replacement therapy might be recommended rather than heparin replacement therapy.

Background Mucosal healing is important for the patients of ulcerative colitis (UC) to avoid clinical relapse and developing colitic cancer. Though Mayo endoscopic subscore (MES) has been widely used to evaluate mucosal healing of UC patients, it is not enough to predict relapse. We have reported the new endoscopic evaluation by linked colour imaging (LCI) that enhances mucosal redness and can predict relapse with more precision compared with MES1). However, the diagnosis in both MES and LCI depends on the local lesion and it has not been established the comprehensive evaluation because mucosal redness is not clearly recognised by white light image. In the present study, we examined the comprehensive evaluation of mucosal redness in the patients of UC by LCI and investigate the relation with long-term prognosis. Methods All examinations were carried out with an EG-L590WR endoscope and a LASEREO endoscopic system (FUJIFILM Co., Tokyo, Japan) including 47 UC patients (pan colitis type) with clinically remission (Under 4 of Lichtiger CAI score). Each part of the large intestine (ascending colon, transverse colon, descending colon, sigmoid colon and rectum) was observed with LCI and WLI (white light image), and the area of redness (regardless of strength) was evaluated. The score was marked 0, 1, 2 and 3, in case of the area of redness is 0%, Results The relapse ratio was 19.1% (9/47 cases). The average of total redness score by LCI was 4.02 ± 2.25 and total redness score by WLI was 3.11 ± 2.5. The average of total redness score by LCI in the patients with no relapse group was 3.94 ± 2.21, on the other hand, with relapse group was 4.33 ± 2.23 (p = 0.0354). However, total redness score measured by WLI showed no statistical difference between no relapse group and relapse (p = 0.278). Conclusion A comprehensive evaluation of mucosal redness using LCI is useful approach to predict relapse for UC patients with clinical remission.

Background Endoscopic mucosal healing is considered as an important therapeutic goal in ulcerative colitis (UC) patients, and several endoscopic evaluations for colonic mucosa such as Mayo endoscopic subscore (MES) and Colitis Endoscopic Index of Severity (UCEIS) are used in clinical practice. Though the strict mucosal healing is defined as MES 0, the relapse of UC has been shown in the patients diagnosed as MES 0. In the present study, we aimed to investigate the efficacy of Linked Color Imaging (LCI), a novel endoscopic enhancement system, to predict long-term prognosis in UC patients diagnosed with MES 0. Methods Twenty-six patients with UC in clinical remission and diagnosed with MES 0 were enrolled. Endoscopic colonic images were assessed by LCI and UCEIS, using a LASEREO endoscopic system (FUJIFILM Co., Tokyo, Japan). Endoscopic LCI images were classified into three subgroups by LCI classification as previously reported. Briefly, LCI patterns were classified as A, no redness; B, redness with visible vessels; and C, redness without visible vessels. Forty months was defined as the time interval between endoscopic diagnosis and relapse of UC. Histological activity was scored according to the Geboes’ score (GS) and the active mucosa was defined by GS>2B.1. Results LCI classification can further subdivide the colonic mucosa diagnosed as MES 0. The patients with LCI-A showed no relapse and the non-relapse rates compared with the patients with LCI-B showed significantly higher (p = 0.033), while the relapse rates of the patients with UCEIS 0 showed no difference compared with UCEIS 1 (p = 0.148). There was no statistical difference in the composition of LCI-A and relapse rate between active and inactive mucosa diagnosed by GS score. Conclusion Endoscopic LCI classification can further subdivide samples diagnosed MES 0. LCI can be a novel and surpassing approach to evaluate mucosal healing and predict the outcome in UC patients.

Background In many clinical trials of ulcerative colitis (UC), Mayo endoscopic subscore (MES) has been used to diagnose mucosal healing to evaluate the effectiveness of various treatment. Although both MES 0 and MES 1 were defined as the endoscopic mucosal healing, several studies reported that the risk of clinical relapse was significantly higher in the patients diagnosed as MES 1 compared with MES 0. However, it has not been established the beneficial effect to escalate the treatment for the patients diagnosed as MES 1 to avoid clinical relapse. In the present study, we retrospectively investigated the effectiveness about the escalation of treatment for UC patients with clinical remission diagnosed as MES 1. Methods A total of 68 patients with UC diagnosed as clinical remission (4 and under of Lichtiger CAI score) between April 2014 to October 2019 were enrolled in this study. All patients were endoscopically diagnosed as MES 1 and observation period was 12 months from the time of endoscopy. Relapse of UC was defined as the need for more aggressive treatment for UC due to aggravation of clinical symptoms or endoscopic findings. The relapse ratio was compared between the patients who continued the same treatment and the patients who had enhanced treatment. Enhanced treatment was defined as additional oral medicine or local preparations including enemas, suppositories, and foams within 3 months from endoscopic examination. Results In 68 patients, 12 patients were received enhanced treatment and 56 patients were continued the same treatments. There were no significant differences in clinical background between the two groups such as mean age (enhanced treatment group vs. same treatment group: 47.9 years vs. 42.9 years), disease type, disease duration (110.3 months vs. 94.8 months), and disease activity (Lichtiger CAI score: 2.5 vs. 2.8). The group of the enhanced treatment included 8 patients with oral 5-aminosalicylates escalation and 4 patients with additional local preparations. The relapse ratio was higher in patients with same treatment group (0%) compared with enhanced treatment group (14.3%). Conclusion Our results indicate that the enhancement of the treatment for UC patients with clinical remission diagnosed as MES 1 is effective to avoid relapse.

Background/Aims: The purpose of this study was to evaluate the safety and efficacy of gastric endoscopic submucosal dissection (ESD) using the Clutch Cutter (CC), a scissor-type knife, compared with those of procedures using conventional devices. Methods: This single-center retrospective study evaluated 237 patients with early gastric cancer: 83 who underwent ESD using the CC group and 154 who underwent ESD using the insulated-tip knife 2 (IT2 group). Clinicopathological features and technical outcomes were compared between the 2 groups using a propensity score-matched analysis. Results: In 61 pairs of matched patients, there was no significant difference in R0 resection, perforation, or postoperative bleeding between the CC and IT2 groups. Comparisons between the 2 groups showed similar treatment outcomes for an expert endoscopist. Nevertheless, there were significant differences between the 2 groups for nonexperts in terms of self-completion (61.7 and 24.5%, respectively, p < 0.001), mean procedure times (45 and 61 min, respectively, p = 0.002), and mean numbers of intraoperative bleeding points and bleeding points requiring hemostatic forceps (3 and 0 vs. 8 and 3, respectively, p < 0.001). Conclusion: Better self-completion rates and shorter procedure times were noted for gastric ESD using the CC by nonexperts than for that using IT2, probably due to hemostatic efficacy.

We have improved the agarose gel electrophoresis method reported previously for size-dependent separation of proteins. Good resolution in protein separation was achieved using a novel agarose gel, containing both sodium dodecyl sulfate (SDS) and lithium dodecyl sulfate (LDS). The gel was divided into stacking and separating gels. We determined the optimal conditions for horizontal gel electrophoresis to be a voltage of 100V for the separating gel and 50V for the stacking gel, in an electrophoretic buffer solution of 25mM Tris-190mM glycine containing 0.03% LDS and 0.02% SDS (pH 8.3), which was also used to make the agarose gel. Separation of proteins in the molecular weight range 14.2-205K and of the proteins in human serum showed good resolution under these conditions. This method should be useful for clinical laboratories because it is simple and requires little bench space.

We compared the results of two bacterial identification methods: 1) a traditional method based on phenotypic identification of the causative organism using gram-staining, culture and biochemical markers and 2) matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). A total of 111 isolates, including 107 strains of common bacteria species and 4 strains of 3 yeast species, were tested by the traditional method and MALDI-TOF MS method(VITEK MS and Micro flex LT). Data obtained using MALDI-TOF MS were classified as Level 1 and Level 2 according to the confidence level of identification results from the VITEK MS ver. 1.0 database (VITEK MS) and MALDI Biotyper ver. 2.0 database (Microflex LT). The proportions of measured samples identified as Level 1 were 98.2% with the VITEK MS database and 87.4% with the MALDI Biotyper database. The concordance rates of the traditional method were 93.7% with the VITEK MS database and 82.0% with the MALDI Biotyper database. Identification results of five strains were mismatched between the traditional method and MALDI-TOF MS. Their ribosomal RNA sequences were identical to the results obtained from MALDI-TOF MS. We concluded that the performance of VITEK MS is superior to that of the traditional method and Microflex LT.

A 38-year-old woman on medical therapy for Basedow disease and hypertension with a history of recent heart failure became pregnant. At the 13th week of gestation, her echocardiography showed pulmonary hypertension with 63 mmHg of estimated systolic pulmonary arterial pressure. At the 26th week of gestation, she was admitted to our hospital with dyspnea and uncontrolled hypertension. After medical treatments, elective caesarean section was scheduled at the 30th week of gestation. While monitoring continuously arterial blood pressure and central venous pressure, continuous infusion of prostaglandin E1 was initiated. After epidural anesthesia had been established, surgical procedure was safely performed. The patient was discharged 9 days after surgery, and her estimated systolic pulmonary arterial pressure dropped to 35 mmHg on echocardiography 2 months after the operation. We speculate that pregnancy induced her severe pulmonary hypertension.

We analyzed the clinical characteristics of extensively-drug resistant tuberculosis (XDR-TB).Thirteen cases diagnosed with XDR-TB encountered in our hospital over the last ten years were enrolled in our study.The patients included 9 males and 4 females. The mean age was 49.1 years old in males and 42.0 years old in females. Eight patients were Japanese and 5 were foreigners (Chinese, 3; Korean, 1; Nepali, 1). Nine cases had a smoking history and 6 had underlying diseases, including 1 with bacterial pneumonia, 3 with diabetes mellitus, 1 with chronic renal failure, and 1 with collagen vascular disease receiving immunosuppressive treatment. All 13 cases had been diagnosed at other hospitals. The mean period from TB diagnosis to XDR-TB diagnosis was 56.8 months, and the mean period from TB diagnosis to referral to our hospital was 81.6 months. Among the 13 cases, 3 had no drug sensitivity, 1 was sensitive to only 1 drug, 2 were sensitive to 2 drugs, 6 were sensitive to 3 drugs, and 1 was sensitive to 4 drugs. Nine of the 13 cases had surgical treatment. Six cases, all of whom had surgical treatment, showed negative conversion in sputum examinations. Three patients died, including two who had surgical treatment. Among the 3 cases with no drug sensitivity, 1 was cured after surgical treatment. Another case had been working in the same hospital with two other MDR-TB cases. Two of the three had the same RFLP pattern.XDR-TB and MDR-TB are man-made diseases. We need to take measures not to create more XDR strains and induce more MDR-TB cases.

Saito et al. isolated novel mycobacterium strains from the sputum of 12 patients with pulmonary disease. They reported, that the strains were clearly different from Mycobacterium tuberculosis (TB) in cultural, biochemical and immunological properties, despite the high homology (99.1%) of the 16S rRNA gene sequence between the two. Recently, we isolated four strains having similar properties as the above strains among mycobacterial strains that were sent to the Research Institute of Tuberculosis for identification. We examined these isolates using commercial systems for identification of mycobacteria.Four strains of the unidentified mycobacteria were used in this study.Tests used in the study included cultural on solid media, biochemical characteristics, DNA sequence analyses of 16S rRNA and rpoB genes, TRC, COBAS AMPLICOR, COBAS TaqMan, MTD, DDH, Accu-Probe, Capilia TB, and a drug susceptibility tests.After three weeks of culture, smooth and non-photochromogenic colonies were formed. The niacin accumulation test was negative. The homologies of DNA sequence between the new strains and M. tuberculosis for 16S rRNA and rpoB genes were 97.8% and 90.2%, respectively. The tests with TRC and MTD kits were positive, whereas the tests with AMPLICOR, TaqMan, Accu-Probe and Capilia TB kits were negative. The organism was not identified with the DDH system.

Fluorescent smear microscopy is one of the recommended methods to detect highly infectious tuberculosis (TB) patients. Recently, fluorescent microscopy using a light emitting diode (LED) as a light source has been developed and introduced. The objective of this study is to evaluate the efficiency of LED fluorescent microscopy.The clinical specimens were collected from TB suspects and follow-up patients of mycobacteriosis in Double Barred Cross Hospital through Sept. to Oct. in 2008. The specimens were subjected to the ordinary decontamination/concentration process, and the sediments were smeared and stained with auramine O. The slides were examined using an ordinary mercury vapour lamp and a LED fluorescent microscope by at least two laboratory technologists independently. If there was a discrepancy between the first and second reader, the third reader (umpire) judged the result. The treated specimens were also cultured using BACTEC MGIT or 2% Kudoh medium. The smear and culture results were compared with the results of LED fluorescent microscopy.A total of 1324 specimens, including 1192 sputa and 23 pleural fluid, were collected from TB suspects and patients. The overall agreement, smear positive versus smear negative, occurred in 1,300 of 1,324 specimens (98.2%). Among the mutually positive readings, the agreement on grading was 256 out of 334 (76.6%), and disagreement beyond two grades was observed only in 3 specimens. The smear positive/culture positive rates were not statistically different between two smear methods.The overall efficiency of LED fluorescent microscopy was similar to that of ordinary fluorescent microscopy with a mercury vapour lamp. The LED costs less than mercury vapour lamp, and has a usable life of more than 40,000 h. It does not require either a dark room for observation, or a long waiting time for stabilization. It was expected that the LED fluorescent microscopy would be utilized widely for the efficient detection of acid-fast bacilli in clinical practices.

A combination of a rapid culture system, BACTEC MGIT 960 (MGIT), and a commercial polymerase chain reaction (PCR) system for the detection of Mycobacterium tuberculosis was evaluated to predict final culture results within 2 weeks. A total of 79 sputum specimens were collected from 59 tuberculosis (TB) patients before anti-TB chemotherapy. Among the 22 specimens that were smear negative and culture positive, the COBAS Amplicor nucleic amplification method for sputum resulted in 13 positives (59.1%) before culturing. In contrast, 21 liquid culture specimens (95.5%) showed positive results by COBAS Amplicor after 7 days. Similarly, 8 specimens (80%) were positive for Mycobacterium avium complex (MAC) based on COBAS Amplicor, and 10 liquid culture specimens (100%) showed positive results after 7 days. Among the 26 specimens that took more than 7 days to become positive by MGIT, 25 specimens (96.1%) were positive using COBAS Amplicor with 7-day-old cultures. Of the 26 positives, 21 were M. tuberculosis, which took 11 to 38 days to appear positive (mean, 16.6 days), and 4 were MAC, which took 8 to 10 days (mean, 8.8 days). As a result, 96.8% (31/32) of the positives could be detected by MGIT with COBAS Amplicor by day 7, and the negative predictive value was 97.9%. A combination of MGIT and COBAS Amplicor on day 7 was demonstrated as a useful method for rapid diagnosis of positives and negatives, without waiting 42 days for confirmation.

Comparison of usefulness of IS1245 RFLP and VNTR in M. avium genotyping.Thirty-six cases (55 strains) from sputum and BALF and twelve cases (29 strains) isolated from blood of HIV-infected patients were used. VNTR and RFLP using IS1245 were performed.Multiple samples were taken from 16 patients and 52 clinical isolates were used for VNTR and RFLP for comparison. (1) VNTR and RFLP results were identical in 12 out of 16 cases whose samples were collected several times. (2) Eight isolates were obtained from one patient. In this eight isolates, there were the cases of M. avium polyclonal infection and of mixed infection with M. intracellulare. VNTR patterns were two types and RFLP were 5 kinds of different in this case. (3) VNTR patterns of six isolates from one HIV-infected patient were identical, but there were three variations in RFLP patterns. There were three cases of mixed infections with M. tuberculosis or M. intracellulare, and six strains polyclonal infection of M. avium (7.1 %) in 84 isolates. These 6 clinical isolates were derived from sputum or BALF (5 strains) and HIV-infected blood (one strain). VNTR patterns were similar in four pairs (9 strains) who did not contact closely, but they were distinguished clearly by RFLP. Seventeen strains had three or less IS1245-related bands in RFLP analyses of 89 strains.As there is a possibility of polyclonal infection with M. avium and mixed infection with other species, the single clonal infection should be confirmed first by VNTR. When single colony was obtained, VNTR and RFLP were performed for genotyping of M. avium. Furthermore, strains with less bands by RFLP should be carefully judged in terms of both VNTR and RFLP. It is recommended that the specimens should be collected from each patient several times.