Effects of L-Menthol and Carbon Dioxide on the Adenoma Detection Rate during Colonoscopy: L-Menthol and Carbon Dioxide on Colonoscopy.

BACKGROUND AND AIMS: We examined the efficacy of the combined use of L-menthol spraying (L-mentholS) as an antispasmodic agent and carbon dioxide insufflation (CO2I) on the adenoma detection rate (ADR) in a prospective, single-center trial with a 2 × 2 factorial design. METHODS: We randomly assigned 611 patients scheduled to undergo colonoscopy to 4 groups: (1) the L-mentholS + CO2I (n = 153), (2) L-mentholS + air insufflation (AI; n = 156), (3) CO2I (n = 153), and (4) AI (n = 149) groups. We used 20 mL of 0.8%-L-menthol solution for the L-mentholS. The primary outcome was the difference in the ADR, and the secondary outcomes were the differences in colonic peristalsis and abdominal pain. -Results: The ADRs were not different among the groups: 1/2/3/4; 39.9%/43.6%/41.2%/51.0%. CO2I was associated with a significant decrease in the ADR (OR 0.57; 95% CI 0.35- 0.93) with a multiple logistic regression. The interaction between L-mentholS and CO2I was associated with a suppression of the decrease in the ADR. Both L-mentholS and CO2I were associated with a significant decrease in abdominal pain, and L-mentholS was associated with a significant improvement of peristalsis. CONCLUSIONS: The fact that CO2I was associated with significant decreases in the ADR was a problem. The combined use of L-mentholS and CO2I could help to suppress the decrease in the ADR.

Characterization of enterohemorrhagic Escherichia coli O111 and O157 strains isolated from outbreak patients in Japan.

In April and May 2011, there was a serious food-poisoning outbreak in Japan caused by enterohemorrhagic Escherichia coli (EHEC) strains O111:H8 and O157:H7 from raw beef dishes at branches of a barbecue restaurant. This outbreak involved 181 infected patients, including 34 hemolytic-uremic syndrome (HUS) cases (19%). Among the 34 HUS patients, 21 developed acute encephalopathy (AE) and 5 died. Patient stool specimens yielded E. coli O111 and O157 strains. We also detected both EHEC O111 stx2 and stx-negative E. coli O111 strains in a stock of meat block from the restaurant. Pulsed-field gel electrophoresis (PFGE) and multilocus variable-number tandem-repeat analysis (MLVA) showed that the stx-negative E. coli O111 isolates were closely related to EHEC O111 stx2 isolates. Although the EHEC O157 strains had diverse stx gene profiles (stx1, stx2, and stx1 stx2), the PFGE and MLVA analyses indicated that these isolates originated from a single clone. Deletion of the Stx2-converting prophage from the EHEC O111 stx2 isolates was frequently observed during in vitro growth, suggesting that strain conversion from an EHEC O111 stx2 to an stx-negative strain may have occurred during infection.

Structure Elucidation of 16 Undescribed Steroidal Glycosides from the Underground Parts of Agapanthus africanus and Apoptosis-Inducing Activity in Small-Cell Lung Cancer Cell.

To explore new candidates for anticancer agents from natural products, the underground parts of Agapanthus africanus, commonly used as an ornamental plant, were investigated phytochemically. As a result, 16 undescribed steroidal glycosides (1-16) were obtained, and their structures were determined mainly by NMR spectroscopic analysis and chemical transformations. The cytotoxic activities of the isolated compounds (1-16) against SBC-3 human small-cell lung cancer cells, A549 human adenocarcinoma cells, and HL-60 human promyelocytic leukemia cells were evaluated using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2-tetrazolium bromide (MTT) assay. Compound 1, a bisdesmosidic furostanol glycoside, and 10, a bisdesmosidic spirostanol glycoside, were cytotoxic to all three cell lines with IC50 values ranging from 1.2 to 13 µM. As 1 exhibited the most potent cytotoxicity against SBC-3 cells among the isolated compounds, its apoptosis-inducing activity toward SBC-3 cells was examined. Compound 1 arrested SBC-3 cells at the G2/M phase of the cell cycle and effectively induced apoptosis via an intrinsic pathway accompanied by the dissipation of membrane potential and morphological changes in mitochondria.

In Silico Analysis and Synthesis of Nafamostat Derivatives and Evaluation of Their Anti-SARS-CoV-2 Activity.

Inhibition of transmembrane serine protease 2 (TMPRSS2) is expected to block the spike protein-mediated fusion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nafamostat, a potent TMPRSS2 inhibitor as well as a candidate for anti-SARS-CoV-2 drug, possesses the same acyl substructure as camostat, but is known to have a greater antiviral effect. A unique aspect of the molecular binding of nafamostat has been recently reported to be the formation of a covalent bond between its acyl substructure and Ser441 in TMPRSS2. In this study, we investigated crucial elements that cause the difference in anti-SARS-CoV-2 activity of nafamostat and camostat. In silico analysis showed that Asp435 significantly contributes to the binding of nafamostat and camostat to TMPRSS2, while Glu299 interacts strongly only with nafamostat. The estimated binding affinity for each compound with TMPRSS2 was actually consistent with the higher activity of nafamostat; however, the evaluation of the newly synthesized nafamostat derivatives revealed that the predicted binding affinity did not correlate with their anti-SARS-CoV-2 activity measured by the cytopathic effect (CPE) inhibition assay. It was further shown that the substitution of the ester bond with amide bond in nafamostat resulted in significantly weakened anti-SARS-CoV-2 activity. These results strongly indicate that the ease of covalent bond formation with Ser441 in TMPRSS2 possibly plays a major role in the anti-SARS-CoV-2 effect of nafamostat and its derivatives.

A Case of Nasopharyngeal Mycobacteriosis with Bony Erosion of the External Skull Base.

Primary nasopharyngeal mycobacteriosis is a rare disease. We present a case in which skull base bone erosion appeared and was alleviated during the course of the treatment. Bone complications occur in osteoarticular mycobacteriosis, but their occurrence in primary nasopharyngeal mycobacteriosis has not been reported. A 77-year-old immunocompromised Asian woman presented with a right occipitotemporal headache. An ulcerative mass covered with a thick yellowish discharge was found in the roof and posterior walls of the right nasopharynx. Because histopathological examination indicated the presence of mycobacterial infection, we began using antituberculosis medication for the treatment because of the possibility of primary nasopharyngeal tuberculosis. However, this was followed by glossopharyngeal and vagus nerve paralysis. Computed tomography (CT) showed a diffuse enhancing mucosal irregularity in the nasopharynx with bony erosion of the external skull base. Deep tissue biopsy was repeated to differentiate it from malignant lesions, and drainage of pus from the right nasopharynx was confirmed. Subsequently, the headache, neurological findings, and the yellowish discharge disappeared, and the bony erosion of the external skull base was alleviated. Surgical intervention should also be considered for drug-resistant mycobacteriosis. We concluded that mycobacteriosis should also be considered apart from carcinoma even if CT shows a diffuse enhancing mucosal irregularity with bone destruction in the nasopharynx.

Hepatitis B Virus Reactivation 55 Months Following Chemotherapy Including Rituximab and Autologous Peripheral Blood Stem Cell Transplantation for Malignant Lymphoma.

A 54-year-old woman underwent chemotherapy including rituximab and autologous peripheral blood stem cell transplantation (auto-PBSCT) for diffuse large B-cell lymphoma. Before the treatment, she exhibited a resolved hepatitis B virus (HBV) infection. She was diagnosed with HBV reactivation based on positive serum HBV-DNA test results, 55 months after her last treatment. Subsequently, he was treated with tenofovir alafenamide fumarate (TAF) therapy and her liver function improved. Patients undergoing chemotherapy including rituximab and auto-PBSCT are at a high risk of HBV reactivation. In such cases, careful and long-term observations may be required to detect HBV reactivation.

Severe Liver Injury Associated with Glecaprevir Plus Pibrentasvir Therapy in a Patient with Treatment-naïve Hepatitis C Virus Infection.

A 49-year-old man underwent treatment with glecaprevir plus pibrentasvir (G/P) for chronic hepatitis C infection. Six weeks later, he was admitted to our hospital because of jaundice and fatigue with no accompanying skin rash. A laboratory examination and evaluation of the patient's history resulted in a diagnosis of acute liver injury. Discontinuation of G/P and a rigorous medical protocol, including plasma exchange and hemodiafiltration, successfully mitigated the liver damage. The patient was also found to be allergic to two drugs other than the G/P therapy. In such cases with a history of drug allergy, careful observation may be required to detect serious adverse events.

An Autopsy Case of TAFRO Syndrome with Type II Respiratory Failure.

BACKGROUND TAFRO syndrome (thrombocytopenia, anasarca, fever, myelofibrosis, renal dysfunction, and organomegaly) is a systemic inflammatory disorder. The histological features of TAFRO syndrome are not fully understood and few autopsy cases have been reported. CASE REPORT A 66-year-old man with type II respiratory failure was diagnosed with TAFRO syndrome. He was initially treated with tocilizumab. Although some improvements were observed, his condition worsened, and the medication was switched to rituximab. His condition remained steady for 1 year with intermittent artificial ventilation. However, he died due to exacerbation of respiratory failure about 20 months after diagnosis. An autopsy revealed mucous fluid retention in the spaces between the axis cylinder and the myelin sheath of peripheral nerves and among the peripheral nerves, suggesting that this retention contributed to neurodegeneration with demyelination. Skeletal muscles, including respiratory muscles, were highly atrophic, which could have led to type II respiratory failure. CONCLUSIONS Fluid accumulation other than pleural effusion and ascites could occur in intra-organs at a cellular level.

Cervical squamous cell carcinoma coexisting with ectopic gastric mucosa treated by endoscopic submucosal dissection: A case report.

A 69-year-old Japanese man underwent an endoscopic submucosal dissection (ESD) for early gastric cancer 2 years prior to admission at Fukuchiyama City Hospital. A follow-up esophagogastroduodenoscopy (EGD) revealed a butterfly-shaped brownish area in the cervical esophagus. A successful endoscopic submucosal dissection of the esophageal lesion was performed for total biopsy. Histopathological analysis of the resected specimen revealed moderately differentiated squamous cell carcinoma of the esophagus, cervical esophagus tumor type 0-IIb, a tumor diameter of 14x8 mm, T1b pathological findings (invading into submucosa), infiltrative growth α, lymphatic invasion (-), venous invasion (-), a horizontal tumor free margin and a vertical tumor free margin. The results demonstrated that the squamous cell carcinoma had invaded into the submucosal layer under the ectopic gastric mucosa. After endoscopic treatment, chemoradiation therapy was administered to the patient.

Ribulose-1,5-bisphosphate carboxylase/oxygenase (RuBisCO)-mediated de novo synthesis of glycolate-based polyhydroxyalkanoate in Escherichia coli.

Ribulose-1,5-bisphosphate (RuBP) carboxylase/oxygenase (RuBisCO) generates 2-phosphoglycolate (2PG) as one of the metabolites from the Calvin-Benson-Bassham (CBB) cycle. In this study, we focused on the fact that glycolate (GL) derived from 2PG can be incorporated into the bacterial polyhydroxyalkanoate (PHA) as the monomeric constituent by using the evolved PHA synthase (PhaC1PsSTQK). In this study, the function of the RuBisCO-mediated pathway for GL-based PHA synthesis was evaluated using Escherichia coli JW2946 with the deletion of glycolate oxidase gene (ΔglcD) as the model system. The genes encoding RuBisCO, phosphoribulokinase and 2PG phosphatase (PGPase) from several photosynthetic bacteria were introduced into E. coli, and the cells were grown on xylose as a sole carbon source. The functional expression of RuBisCO and relevant enzymes was confirmed based on the increases in the intracellular concentrations of RuBP and GL. Next, PHA biosynthetic genes encoding PhaC1PsSTQK, propionyl-CoA transferase and 3-hydroxybutyryl(3HB)-CoA-supplying enzymes were introduced. The cells accumulated poly(GL-co-3HB)s with GL fractions of 7.8-15.1 mol%. Among the tested RuBisCOs, Rhodosprium rubrum and Synechococcus elongatus PCC7942 enzymes were effective for P(GL-co-3HB) production as well as higher GL fraction. The heterologous expression of PGPase from Synechocystis sp. PCC6803 and R. rubrum increased GL fraction in the polymer. These results demonstrated that the RuBisCO-mediated pathway is potentially used to produce GL-based PHA in not only E. coli but also in photosynthetic organisms.

Laparoscopy Endoscopy Cooperative Surgery for Inflammatory Fibroid Polyp in the Esophagus.

Inflammatory fibroid polyp (IFP) appears most often in the stomach. We herein report an extremely rare case of esophageal IFP resected using laparoscopy endoscopy cooperative surgery (LECS). A 73-year-old man with dysphagia underwent esophagogastroduodenoscopy. A 50-mm semi-pedunculated submucosal tumor was observed in the esophagogastric junction. Endoscopic ultrasonography showed a homogeneous, hypoechoic, and well-vascularized tumor in the second and third layers of the stomach, but endoscopic ultrasonography-guided fine-needle aspiration failed to establish a definite diagnosis. Since he was suffering from dysphagia, LECS was performed. The resected specimen proved that the tumor was an IFP originating from the esophagus.

[A case of primary mucinous carcinoma with endocrine differentiation of the skin].

Primary mucinous carcinoma of the skin (MCS) is a rare skin appendage tumor and only a few cases of MCS with endocrine differentiation have been reported. Here we report an additional case of primary pure MCS with endocrine differentiation arising in the face. Histopathologically, the tumor was located in the dermis and subcutis, and nests of slight atypical epithelial cells were floating in the mucinous pools. This tumor did not accompany carcinoma in situ or invasive non-mucinous carcinoma and was difficult to differentiate from metastatic mucinous carcinoma of the skin. There was no tumor in the other organs and synaptophysin and chromogranin A were sporadically shown immunohistochemically in the tumor cells; a diagnosis of primary pure MCS with endocrine differentiation was made. MCS resembles mammary mucinous carcinoma not only in morphological appearance but also in immunohistochemical phenotypes, such as positive immunoreactivity to gross cystic disease protein fluid-15, MUC2, MUC6, estrogen receptor and progesterone receptor. It is presumed that MCS is derived from the apocrine gland, which is closely related to the mammary gland. Although endocrine differentiation is not uncommon in pure mucinous carcinoma of the breast, there have been only a few reports published on endocrine differentiation in MCS. To clarify the difference and/or similarity between mucinous carcinoma of the breast and MCS, immunohistochemical and cytogenetic analyses of additional cases of MCS are required.

Anaplastic carcinoma of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration: a case report and review of the literature.

BACKGROUND: Anaplastic carcinoma of the pancreas is a rare pancreatic neoplasm with a poor prognosis. It is classified as a variant of ductal adenocarcinoma, but the clinical features and treatment of it remain unknown because of its rarity and aggressiveness. Endoscopic ultrasonography and endoscopic ultrasound-guided fine-needle aspiration are useful techniques for the diagnosis of pancreatic tumors with high sensitivity and specificity. CASE PRESENTATION: A 72-year-old Japanese woman presented with a diagnosis of acute pancreatitis, and a cystic lesion with slightly high density area was observed by computed tomography in her pancreatic head. In addition, endoscopic ultrasound revealed a heterogeneous lesion. Endoscopic ultrasound-guided fine-needle aspiration showed pleomorphic atypical cells. We diagnosed anaplastic carcinoma of the pancreas. We resected the lesion, and she has shown no sign of recurrence for > 6 months. There are few reports of anaplastic carcinoma of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration and treated by surgery. Our analysis indicates that anaplastic carcinoma of the pancreas is more likely than typical ductal carcinomas to have cystic lesions with the tumor. CONCLUSIONS: We report a case of anaplastic carcinoma of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration and subsequently resected with a clear margin. We speculate that anaplastic carcinoma of the pancreas is more likely to have cystic changes than pancreatic ductal adenocarcinoma. When we diagnose pancreas tumor as having cystic changes, anaplastic carcinoma of the pancreas should be considered one of the differential diagnoses.

Tocilizumab-resistant TAFRO Syndrome Complicated by Type II Respiratory Failure.

A 66-year-old man with a several year history of thrombocytopenia, pleural effusion and ascites, anasarca, and organomegaly presented with general fatigue, appetite loss, dyspnea with type II respiratory failure. The precise history of the patient and the re-evaluation of lymph node and bone marrow biopsies conducted by the previous physician indicated TAFRO syndrome. The patient's laboratory data improved for a year with tocilizumab, but then worsened to the point that the patient required artificial ventilation due to the deterioration of type II respiratory failure. The replacement of tocilizumab with rituximab yielded a steady improvement, but it was necessary to address the patient's persistent respiratory failure. Peripheral nerve disorder might have been involved with the patient's respiratory failure.

Cytoplasmic non-epithelial mucin accumulation associated with CD44 in an astrocytic tumor with signet ring features.

We report a case of an atypical astrocytic tumor rich in signet ring cells with cytoplasmic mucin and glycogen in the left lower temporal lobe of the brain found in a Japanese female tricenarian. The signet ring cell cytoplasm contained bovine testicular hyaluronidase sensitive non-epithelial mucin together with CD44 and laminin. Glycogen was also detected. After subtotal resection, the residual tumor rapidly enlarged; hence, it was finally extirpated 8 months later followed by post-surgical irradiation. The recurrent tumor did not have signet ring cells and was entirely comprised of solid nests of large pale polygonal cells filled with glycogen and hyperchromatic nuclei. Mucin was not demonstrated in their cytoplasm, but their surface was diffusely coated with non-epithelial mucin together with CD44. The results of our analysis revealed that non-epithelial mucin could accumulate in or on the surface of neoplastic astrocytes in close association with CD44, findings that give new insights into the spectrum of non-epithelial mucin metabolism in astrocytic tumors. The tumor has not recurred for more than 3 years after the irradiation therapy following the second surgery, but further clinical observation is needed to evaluate the exact clinical behavior of this unusual tumor.

Phenotypic and genetic analyses of Campylobacter jejuni Lior serotype 76 isolated from chicken meat and clinical specimens.

The aim of this study was to examine the link between Campylobacter jejuni isolates obtained from chicken meat (n = 7) and gastroenteritis patients (n = 744). In total, 751 isolates were subjected to Lior serotyping. All the isolates from chicken meats were serotyped as Lior serotype 76 (LIO76). Among 23 of the identified LIO76 strains, 13 strains (6 from chicken meat and 7 from clinical specimens) were indistinguishable by Penner serotyping, antimicrobial susceptibility testing, and pulsed-field gel electrophoresis. These strains were isolated in 2 different Japanese prefectures in 2004-2005, suggesting that chicken meat is an etiological agent of Campylobacter gastroenteritis and that a diffuse outbreak occurred during this time. Therefore, a continuous surveillance program should be established in Japan in order to prevent Campylobacter gastroenteritis, especially large-scale food-borne outbreaks.

Transcatheter arterial embolization for spontaneous rupture of the omental artery.

We encountered a rare case of spontaneous rupture of the omental artery. A 25-year-old man without any episode of abdominal trauma or bleeding disorders came to the emergency unit with left upper abdominal pain. Hematoma with extravasation of the greater omentum and a hemoperitoneum was confirmed on abdominal contrast-enhanced computed tomography. Bleeding from the omental artery was suspected based on these findings. Transcatheter arterial embolization was successfully performed after extravasation of the omental artery, which arises from the left gastroepiploic artery, was confirmed on arteriography. Partial ometectomy was performed 10 days after transcatheter arterial embolization, revealing that the hematoma measured 10 cm in diameter in the greater omentum. Pathological examination showed rupture of the branch of an omental artery without abnormal findings, such as an aneurysm or neoplasm. Thus, we diagnosed him with spontaneous rupture of the omental artery. The patient recovered and was discharged from the hospital 10 days after the surgery, with a favorable postoperative course.

Claudin expression profiles in Epstein-Barr virus-associated nasopharyngeal carcinoma.

Claudins are a family of proteins that are structural and functional components of tight junctions and have crucial roles in the maintenance of cellular arrangement, adhesion and paracellular transport. Recent studies have shown that changes and/or loss of claudin expression plays an important role in tumorigenesis and tumor progression, and altered expression of claudins has been reported in various human carcinomas. Non-keratinizing nasopharyngeal carcinoma (NPC) is a common Epstein-Barr virus (EBV)-associated carcinoma with characteristic clinicopathological features. The aim of this study was to investigate claudin expression profiles in EBV-associated non-keratinizing NPC. We analyzed expressions of claudin-1, -2, -3, and -4 in 18 cases of EBV-associated non-keratinizing NPC by immunohistochemical methods. Claudin-1 was expressed in all 18 cases, but claudin-2 was not expressed in any of the 18 cases. Claudin-3 expression was variable, with 8 of the 18 cases (45%) showing no immunoreactivity for claudin-3. Claudin-4 displayed positive immunoreactivity in all cases, even in claudin-3-negative cases. Claudin-3 and -4 are receptors for cytotoxic Clostridium perfringens enterotoxin (CPE) and CPE has emerged as a potential therapeutic target for malignant tumors expressing claudin-3 and/or -4, because CPE specifically and rapidly lyses cells expressing these proteins. Clinically, treatment of distant metastases is a serious problem in EBV-associated non-keratinizing NPC, because frequently there is lymph node involvement and distant metastasis before detection of the primary tumor. Therefore, CPE therapy may be a potential therapeutic target for EBV-associated non-keratinizing NPC, since our results clearly showed claudin-3 and/or -4 expression in all cases studied.