Prognostic Impact of Diabetes Mellitus on Overall Survival in a Nationwide Population-Based Cohort of Patients With Pancreatic Cancer.

OBJECTIVE: Diabetes mellitus (DM) is a risk factor for pancreatic cancer but its prognostic impact remains controversial. We aimed to investigate the association between long-standing DM and the risk of mortality. METHODS: This population-based cohort study analyzed data from the national healthcare database in Taiwan. We identified all patients diagnosed with pancreatic cancer and excluded those who were diagnosed with DM with-in 2 years of the cancer diagnosis. Eligible patients were grouped into long-standing DM (>2 years) and nondiabetic controls, and were compared for overall survival using a Cox proportional hazard model. Sensitivity tests stratified by cancer stages (as indicated by specific treatment) were performed. RESULTS: Patients with long-standing DM were significantly older (mean age, 71.38 years versus 66.0 years; P<.0001) and had a higher Charlson comorbidity index (9.53 versus 6.78; P<.0001) and diabetes comorbidity severity index (2.38 versus 0.82; P<.0001) compared with the non-DM controls. Although the unadjusted analysis showed a higher risk of mortality in the patients with long-term DM (crude hazard ratio [HR], 1.26; 95% confidence interval [CI], 1.20 to 1.33; P<.0001), the association became insignificant after adjustment for age, sex, and comorbidity index (adjusted HR, 1.01; 95% CI, 0.95 to 1.06, P = .84). Subgroup analyses also showed no association between long-term DM and mortality in various subgroups stratified by cancer treatment. CONCLUSION: After adjusting for associated comorbidities and complications, long-standing DM per se was not an independent prognostic factor for overall survival in this nationwide population-based cohort with pancreatic cancer. ABBREVIATIONS: CCI = Charlson Comorbidity Index; CI = confidence interval; DCSI = Diabetes Complication Severity Index; DM = diabetes mellitus; HR = hazard ratio; ICD = International Classification of Diseases; NHIRD = National Health Insurance Research Database; RCIPD = Registry for Catastrophic Illness Patient Database.

Linear echoendoscope-guided ERCP for the diagnosis of occult common bile duct stones.

BACKGROUND: Less than 67% of patients with intermediate risk for common bile duct (CBD) stones require therapeutic intervention. It is important to have an accurate, safe, and reliable method for the definitive diagnosis of CBD stones before initiating therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Few publications detail the diagnostic efficacy of linear echoendoscopy (EUS) for CBD stones. METHODS: 30 patients with biliary colic, pancreatitis, unexplained derangement of liver function tests, and/or dilated CBD without an identifiable cause were enrolled in the study. When a CBD stone was disclosed by linear EUS, ERCP with stone extraction was performed. Patients who failed ERCP were referred for surgical intervention. If no stone was found by EUS, ERCP would not be performed and patients were followed-up for possible biliary symptoms for up to three months. RESULTS: The major reason for enrollment was acute pancreatitis. The mean predicted risk for CBD stones was 47% (28-61). Of the 12 patients who were positive for CBD stones by EUS, nine had successful ERCP, one failed ERCP (later treated successfully by surgical intervention) and two were false-positive cases. No procedure-related adverse events were noted. For those 18 patients without evidence of CBD stones by EUS, no false-negative case was noted during the three-month follow-up period. Linear EUS had sensitivity, specificity, positive and negative predicted values for the detection of CBD stones of 1, 0.9, 0.8 and 1, respectively. CONCLUSION: Linear EUS is safe and efficacious for the diagnosis of occult CBD stones in patients with intermediate risk for the disease.

Suggested cutoff tumor size for management of small EUS-suspected gastric gastrointestinal stromal tumors.

BACKGROUND/PURPOSE: Although the incidence of asymptomatic small gastric submucosal tumors increased gradually with routine medical health examination, there was little clinical evidence for management consensus in these small gastric submucosal tumors including endoscopic ultrasound (EUS)-suspected gastric gastrointestinal stromal tumors (GISTs). We investigated the clinical course of small EUS-suspected gastric GISTs and propose a cutoff value of tumor size for treatment policy. METHODS: In this retrospective study, 50 patients with EUS-suspected gastric GISTs of sizes less than 3 cm were enrolled and were followed up by EUS at least twice over a period of more than 24 months (range 24-101 months). An at least 20% increase of the maximal diameter of the tumors was set as a significant change. RESULTS: Significant changes in tumor size were found during the follow-up in 14 patients (28.0%). The one-dimensional 20% change corresponded well to 50% change in two-dimensional area measurement (correlation coefficient = 0.929). The receiver operating characteristic curve analysis showed that the best cutoff size, associated with tumor progression, was 1.4 cm having an 85.7% sensitivity, 86.1% specificity, and 86.0% accuracy. A larger tumor size (35.7% vs. 2.8%, p = 0.005) and irregular tumor margin on the EUS (71.4% vs. 0, p = 0.004) were two significant factors associated with the progression of tumor growth of small suspected gastric GISTs. CONCLUSION: Small EUS-suspected GISTs, larger than 1.4 cm, with irregular margin were associated with significant progression. This subgroup is suggested to be monitored by more intensive follow-up.

RGL2 Drives the Metastatic Progression of Colorectal Cancer via Preventing the Protein Degradation of ß-Catenin and KRAS.

Colorectal cancer (CRC) is one of the most common cancers and results in high mortality worldwide, owing to cancer progression, i.e., metastasis. However, the molecular mechanism underlying the metastatic evolution of CRC remains largely unknown. Here, we find that the upregulation of Ral Guanine Nucleotide Dissociation Stimulator Like 2 (RGL2) is commonly detected in primary tumors compared normal tissues and is significantly associated with a poorer prognosis in CRC patients. Moreover, RGL2 expression appeared to positively correlate with the metastatic potentials of CRC cells. Whereas RGL2 knockdown dramatically suppresses the metastatic potentials of CRC cells in vitro and in vivo, RGL2 overexpression in the poorly metastatic CRC cells and reconstitution in the RGL2-silenced CRC cells enhanced and rescued the cellular metastatic ability, respectively. Computational simulation using Gene Set Enrichment Analysis program and cell-based assays demonstrated that RGL2 expression causally associated with the activity of Wnt/ß-catenin signaling axis and Kirsten ras (KRAS)S, as well as the progression of epithelial-mesenchymal transition (EMT) in the detected CRC cells. Importantly, RGL2 upregulation was capable of preventing the protein degradation of ß-catenin and KRAS in CRC cells. These findings suggest that RGL2 acts as a driver to promote the metastatic progression of CRC and also serves as a poor prognostic biomarker in CRC patients.

Saxagliptin-induced recurrent acute pancreatitis.

Although dipeptidyl peptidase-4 (DPP-4) inhibitors have been implicated in the development of acute pancreatitis, the causality of this phenomenon is not well established. We herein report the case of an 85-year-old woman who presented with epigastric pain after taking saxagliptin for five months. A high serum lipase level with characteristic computed tomography findings confirmed the diagnosis of acute pancreatitis. The patient's symptoms rapidly resolved after admission, although they recurred when she resumed treatment with saxagliptin for 18 days after discharge. In the absence of any identifiable causes of pancreatitis and considering the temporal sequence of events, the saxagliptin therapy was highly suspected to be the triggering factor. Although drug-induced pancreatitis is rare, treatment with DPP-4 inhibitors should be included as a potential etiology of acute pancreatitis.

Clinical practice of endoscopic submucosal dissection for early colorectal neoplasms by a colonoscopist with limited gastric experience.

Objectives. Endoscopic submucosal dissection (ESD) for early colorectal neoplasms is regarded as a difficult technique and should commence after receiving the experiences of ESD in the stomach. The implementation of colorectal ESD in countries where early gastric cancer is uncommon might therefore be difficult. The aim is to delineate the feasibility and the learning curve of colorectal ESD performed by a colonoscopist with limited experience of gastric ESD. Methods. The first fifty cases of colorectal ESD, which were performed by a single colonoscopist between July 2010 and April 2013, were enrolled. Results. The mean of age was 64 (±9.204) years with mean size of neoplasm at 33 (±12.63) mm. The mean of procedure time was 70.5 (±48.9) min. The rates of en bloc resection, R0 resection, and curative resection were 86%, 86%, and 82%, respectively. Three patients had immediate perforation, but no patient developed delayed perforation or delayed bleeding. Conclusion. Our result disclosed that it is feasible for colorectal ESD to be performed by a colonoscopist with little experience of gastric ESD through satisfactory training and adequate case selection.

Carbon dioxide insufflation during withdrawal of the colonoscope improved postprocedure discomfort: a prospective, randomized, controlled trial.

In colonoscopy, the question of when and how to use carbon dioxide (CO(2)) insufflation remains uncertain. Inspection for the pathological changes during colonoscopy takes place during the withdrawal of the scope. This study aimed to determine whether CO(2) insufflation only at the withdrawal of the colonoscope has an effect comparable to that of CO(2) usage throughout the course of the procedure. Symptomatic patients were randomized in three groups: (1) patients given air insufflation (A; n = 33); (2) patients given CO(2) insufflation only at the time of scope withdrawal (CW; n = 33); and (3) patients given the CO(2) insufflation (C; n = 34) for the whole course of the colonoscopy. Patients were requested to answer questionnaires about their pain score during, at the end, and 1 h after the colonoscopy by using a pain numerical scale ranging from 0 to 10. The disparities of the pain score were noted at the end of the procedure and 1 h after the procedure (p = 0.026 and p < 0.001, respectively). We further analyzed the scores between two of the three groups. Both CW (vs. A; procedure end: p = 0.012, 1 h after: p = 0.001) and C (vs. A; procedure end: p = 0.072, 1 h after: p < 0.001) showed less postprocedure pain when compared with the group A. The pain score between CW and C were similar at each time segment (procedure end: p = 0.555, 1 h after: p = 0.491). CO(2) insufflation merely at the withdrawal of the colonoscope improved postprocedural abdominal discomfort and the effect was not inferior to that of full course CO(2) insufflation.