Expression of Leucine-rich Repeat-containing Protein 32 Following Lymphocyte Stimulation in Patients with Non-IgE-mediated Gastrointestinal Food Allergies.

The lymphocyte stimulation test (LST) facilitates the diagnosis of non-IgE-mediated gastrointestinal food allergies (non-IgE-GI-FAs). However, LSTs require large volumes of blood and prolonged culture durations. Recently, we found that IL2RA mRNA expression in peripheral blood mononuclear cells (PBMCs) of patients with non-IgE-GI-FAs increased after a 24 h stimulation with milk proteins. We designated this gene expression test as the instant peripheral blood allergen stimulation test (iPAST). In this study, we investigated whether other activated T cell-associated genes are superior to IL2RA in the iPAST for the supplementary diagnosis of non-IgE-GI-FAs. After incubating PBMCs with milk proteins for 24 h, the mRNA levels of three genes, LRRC32, TNFRSF4, and CD69, were assessed using quantitative RT-PCR. The diagnostic significance of the mRNA expression was evaluated by analyzing the receiver operating characteristic (ROC) curve. Upon stimulation with α-casein, κ-casein, α-lactalbumin, or a mixture of four milk protein components (Pmix), LRRC32 expression in the PBMCs of 16 patients with non-IgE-GI-FAs was found to be higher than that in their 17 control counterparts, whereas TNFRSF4 and CD69 levels remained unaltered. Except for ß-lactoglobulin and cow's milk (CM), the area under the ROC curve (AUC) for LRRC32 mRNA expression upon stimulation was >0.7, which validated the diagnostic ability of this test. Notably, α-casein and Pmix had higher AUC scores of 0.820 and 0.842, respectively, than other antigens. iPAST assessed by LRRC32 as well as IL2RA may be useful for the supplementary diagnosis of non-IgE-GI-FAs as an alternative to LSTs and provide insight into the pathogenesis of non-IgE-GI-FAs.

Retroflexion-assisted endoscopic mucosal resection: a useful and safe method for removal of low rectal laterally spreading tumors.

BACKGROUND AND AIM: Lesions below or involving the dentate line cannot be removed by standard forward-viewing endoscopic mucosal resection (EMR). Data about retroflexion technique applied during EMR for low rectal laterally spreading tumors (LSTs) are quite limited. Therefore, we aimed to determine the efficacy and safety of retroflexion-assisted EMR (REMR) for the removal of large LSTs from the lower rectum. PATIENTS AND METHODS: EMR employing a complete retroflexion technique was performed in 49 consecutive patients (28 men, 21 women; mean age 51.8 years) with low rectal LSTs that were considered unresectable by conventional forward-viewing EMR due to the narrow and poor endoscopic view. Colonoscopy follow-up data were collected after resection. RESULTS: The low rectal LSTs had a median size of 51 mm (range 30-85 mm). All the tumors were successfully resected in two sessions (median procedure time 57.4 min, range 29-126 min). Procedure-related early bleeding occurred in 14 patients, and delayed hemorrhage occurred in four patients. Serious complications such as perforation or anal dysfunction were not observed, and any procedure-related bleeding was well controlled. The median follow-up period was 8.4 months (range 3-36 months). Nine patients (nine out of 49, 18.4%) experienced recurrence based on follow-up colonoscopy examinations, and the recurrent lesion was completely eradicated by additional endoscopic treatments. CONCLUSIONS: This is the first pilot study to evaluate the efficacy and safety of REMR for removal of low rectal LSTs. The short-term outcomes observed in this study indicate that REMR is a valuable method for the removal of low rectal LSTs. However, further studies evaluating the long-term efficacy and comparing REMR with other interventional therapies are needed.

Using solid phase adsorption toxin tracking and extended local similarity analysis to monitor lipophilic shellfish toxins in a mussel culture ranch in the Yangtze River Estuary.

Harmful algal blooms (HABs) and their associated phycotoxins are increasing globally, posing great threats to local coastal ecosystems and human health. Nutrients have been carried by the freshwater Yangtze River and have entered the estuary, which was reported to be a biodiversity-rich but HAB-frequent region. Here, in situ solid phase adsorption toxin tracking (SPATT) was used to monitor lipophilic shellfish toxins (LSTs) in seawaters, and extended local similarity analysis (eLSA) was conducted to trace the temporal and special regions of those LSTs in a one-year trail in a mussel culture ranch in the Yangtze River Estuary. Nine analogs of LSTs, including okadaic acid (OA), dinophysistoxin-1 (DTX1), yessotoxin (YTX), homoyessotoxin (homoYTX), 45-OH-homoYTX, pectenotoxin-2 (PTX2), 7-epi-PTX2 seco acid (7-epi-PTX2sa), gymnodimine (GYM) and azaspiracids-3 (AZA3), were detected in seawater (SPATT) or rope farmed mussels. The concentrations of OA + DTX1 and homoYTX in mussels were positively correlated with those in SPATT samplers (Pearson test, p < 0.05), indicating that SPATT (with resin HP20) would be a good monitoring tool and potential indicator for OA + DTX1 and homoYTX in mussel Mytilus coruscus. The eLSA results indicated that late summer and early autumn were the most phycotoxin-contaminated seasons in the Yangtze River Estuary. OA + DTX1, homoYTX, PTX2 and GYM were most likely driven by the local growing HAB species in spring and summer, while Yangtze River diluted water may impact the accumulation of HAB species, causing potential phycotoxin contamination in the Yangtze River Estuary in autumn and winter. Together, the results showed that the mussel harvesting season, late summer and early autumn, would be the season with the greatest phycotoxin risk and would be the most contaminated by local growing toxic algae. Routine monitoring sites should be set up close to the local seawaters.

Diagnosis and treatment of colorectal tumors: Differences between Japan and the West and future prospects.

Dye-based chromoendoscopy has long been used routinely for endoscopic diagnosis of gastrointestinal tumors including colorectal tumors in Japan. In the West, on the other hand, dye-based chromoendoscopy was not so commonly used. However, with the development of narrow band imaging (NBI), image-enhanced endoscopy diagnosis has rapidly increased in the West. The most critical difference between Japan and the West is the histopathological evaluation of the lesions, which determines a major cause of differences in diagnostic and treatment strategies. In the West, intramucosal adenocarcinoma is not diagnosed until the cancer has invaded submucosal layer. In Japan, on the other hand, cancer is mainly diagnosed based on nuclear and structural atypia, and thus intramucosal adenocarcinoma is diagnosed in lesions that correspond to high-grade adenoma in the West. In the West, since intramucosal carcinoma is not diagnosed by pathology, all benign adenomas are treated by piecemeal endoscopic resection, and only cancer invading the superficial submucosal layer is indicated for endoscopic submucosal dissection (ESD). Because of the risk of lymph node metastasis in the deep submucosal invasion, the European Society of Gastrointestinal Endoscopy and American Society for Gastrointestinal Endoscopy guidelines state that only superficial submucosal cancer is an indication for ESD. Unfortunately, it is impossible to selectively extract only superficial submucosal invasive cancer even with the use of magnified NBI and pit pattern observation. Therefore, we think that pathologists need to diagnose intramucosal adenocarcinoma with the potential to invade the submucosal layer based on the nuclear and structural atypia. Consequently, intramucosal adenocarcinoma and superficial submucosal cancers should be considered for en-bloc ESD.

Endoscopic resection for colorectal laterally spreading tumors in East Asian countries: a systematic review.

Background: To assess the efficacy and safety of different endoscopic resection methods for colorectal laterally spreading tumors (LSTs) in East Asian countries. Methods: A literature search was performed in PubMed, Embase, Cochrane Library and Web of Science databases. Colorectal LSTs of the included studies were resected with endoscopic mucosal resection (EMR) and/or endoscopic submucosal dissection (ESD). The main outcomes involved rates of en bloc resection, R0 resection, adverse events and recurrence. Results: A total of 20 studies were finally included in the present study. The total number of lesions were 3,903 (EMR: 1,230, ESD: 2,673). EMR-en bloc resection was obtained in 395/591 (66.8%), with ESD-en bloc resection reported in 2,020/2,265 (89.2%) [odds ratio (OR) 0.244, P<0.0001, 95% confidence interval (CI): 0.197-0.304]. EMR-R0 resection was achieved in 409/547 (74.8%), which was lower than that of ESD (1,895/2,241, 84.6%) (OR 0.541, P<0.0001, 95% CI: 0.432-0.677). Bleedings occurred more frequently in EMR than in ESD group (10.4% vs. 3.1%, OR 3.559, P<0.0001, 95% CI: 2.618-4.836). Rates of perforations in EMR and ESD were 0.4% and 4.1% (OR 0.099, P<0.0001, 95% CI: 0.036-0.27). Recurrence of EMR was higher than ESD group (6.3% vs. 1.0%, OR 6.732, P<0.0001, 95% CI: 3.751-12.082). Discussion: Endoscopic resections of colorectal LSTs are safe and effective. ESD leads to higher rates of en bloc and R0 resection, as well as lower rates of bleeding and recurrence, but it has a high risk of perforation, compared with EMR.

Novel approaches to minimize intraoperative bleeding during endoscopic submucosal dissection of a large rectal lateral spreading tumor extended to the dentate line with internal hemorrhoids.

Video 1Endoscopic submucosal dissection (ESD) of large rectal lateral spreading tumors (LSTs) that extend to the dentate line with internal hemorrhoids is a challenging procedure because of the increased risk of bleeding from penetrating and hemorrhoidal vessels and the reduced visual field caused by the dilated venous packages and the narrow anal lumen.This video describes novel technical approaches to minimize the risk of intraoperative bleeding.The described approaches are indicated in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. The described selective-vessel approach is also indicated in any vascularized superficial lesion amenable to endoscopic treatment.ESD was performed in the retroflex view using an Evis Exera II video processor, an H180 gastroscope, an ERBE ICC 200, and CO2 insufflation. As tools, IT-nano, needle knife, hook knife, hemostatic forceps, and a distal cap were used. The lifting solution was a mixture of normal saline, hyaluronic acid, epinephrine, and indigo carmine.A hemicircumferential superficial granular lateral spreading tumor was observed in the lower rectum. Indigo carmine dye spray facilitated the identification of the lesion's margin and demonstrated no ulcer, converging folds, or large nodules. After the submucosal (SM) injection, a shallow mucosal incision was made in the retroflex view using a conventional needle knife, followed by the circumferential incision at the proximal side using an IT-nano. The SM layer was dissected at a superficial level to avoid large SM vessels, thus preventing intraoperative bleeding and maintaining a clean surgical field. Small vessels were selectively coagulated mainly by using the small disc located at the back of the insulated tip as the SM later was superficially dissected. To facilitate precise coagulation, a stepwise dissection technique was used for larger vessels. After identification, the vessel was first exposed by dissecting the surrounding SM layer at the left and right sides using the long blade of IT-nano, with blunt dissection of the surrounding tissue at the vessels' posterior aspect using a Hook knife. Double-vessel sealing using a hemostatic forceps was performed both at the rectal and tumor sides. Lastly, the vessel was transected between sealed segments using the IT-nano, without major bleeding. The circumferential incision was completed at the left side and distally extended to the anal canal where large hemorrhoidal bundles were seen. A needle knife was used to complete the SM dissection and, here, the final cut. En bloc resection was successfully achieved without intraoperative bleeding.The en bloc resected specimen was 85 mm in size, and squamous epithelium of the anal canal was observed at the distal margin. Colonoscopy 5 months post-ESD revealed adequate healing, no stenosis and no hemorrhoids.Coagulation and hemostasia should be promptly carried out whenever inadvertent injury to large vessels and subsequent bleeding occurs during lateral exposure, posterior blunt dissection, double coagulation, and transection of vessels.Curative ESD can be achieved in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. Strategies to minimize intraoperative bleeding during ESD should be considered and include the following:•An SM dissection from the proximal tumor margin in the retroflex view to circumvent contact with hemorrhoids.•A differential level of dissection to prevent inadvertent vessel injury-shallow first to avoid large SM vessels and deeper above the muscular layer closer to the dentate line to shut off blood supply by penetrating hemorrhoidal vessels.•Last but not least, a selective approach to vessels to reduce the risk of bleeding, with direct coagulation for small vessels and with lateral exposure, posterior blunt dissection, double-vessel sealing, and transection between sealed segments for larger vessels.

Evaluation of different strategies to minimize the matrix effects on LC-MS/MS analysis of multiple lipophilic shellfish toxins in both acidic and alkaline chromatographic conditions.

Lipophilic shellfish toxins (LSTs) accumulated by shellfish pose a potential threat to consumer health. A mandatory routine monitoring of LSTs has been adopted for seafood products by liquid chromatography-mass spectrometry (LC-MS) in many countries. In this study, two methods developed on liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) under acidic and alkaline chromatographic conditions were assessed for the determination of multiple LSTs. Different strategies including matrix solid-phase dispersion (MSPD), solid phase extraction (SPE) and sample dilution were applied and evaluated the matrix effects of mussel, scallop, clam, and oyster samples on the signal response of mass spectrometry. Results showed that the alkaline method achieved a lower limit of detection (LOD) and more robust compared to the acidic method. The obvious signal suppression of OA and DTX1 (55%-76%) and signal enhancement of PTX2 (27%-34%) occurred in the crude extracts of shellfish under acidic chromatography. In the alkaline method, no remarkable matrix effects of crude extracts were found except for the scallop matrix on the signal intensity of DTX1, AZA3 and GYM-A (121%-130%). Clean-up methods MSPD, SPE and sample dilution obviously reduced the inhibition of shellfish matrices on the signal response of OA and DTX1, however, which were still subject to signal inhibition under acidic condition. Sample dilution was more effective than SPE and MSPD in minimizing the matrix interference in both acidic and alkaline methods. Furthermore, sample dilution in combination with the alkaline chromatography was the most effective method. Bivalve mollusks harvested from Beibu Bay, South China Sea, were generally contaminated by GYM-A and SPX1 at low concentrations.

Occurrence and variation of lipophilic shellfish toxins in phytoplankton, shellfish and seawater samples from the aquaculture zone in the Yellow Sea, China.

Lipophilic shellfish toxins (LSTs) produced by diverse microalgae have become a potential threat to the marine aquaculture industry in coastal regions throughout the world. In this study, phytoplankton, scallop, and seawater samples were collected and monitored in the aquaculture zone of Liuqing Bay located in the coast of Qingdao, Yellow Sea, in 2014 and 2015. Dissolved LSTs in seawater were adsorbed by solid phase adsorption toxin tracking (SPATT) bags and solid phase extraction (SPE) cartridges, respectively. PTX2 was found to be the predominant LSTs, while OA and DTX1 were detected at trace levels in the three species of Dinophysis and Phalacroma genera picked from the investigation zone. The highest quota of PTX2 occurred in D. fortii (0.28 pg cell-1), followed by D. acuminata complex (0.08 pg cell-1) and P. rotundatum (=D. rotundata) (0.02 pg cell-1). PTX2 (nd∼5.7 µg kg-1), OA (nd∼2.8 µg kg-1) and DTX1 (nd∼1.6 µg kg-1) were also observed in cultivated scallops, but in addition to the former, PTX2sa, 7-epi-PTX2sa and an isobaric form of DTX1 suspected as DTX1b were also found in the SPATT bags. The isobaric compound of DTX1 only appeared in the SPATT bags deployed in field samples of seawater. A significant higher quantity of OA was adsorbed by SPATT bags compared to DTX1, although similar concentrations of both toxins were adsorbed by SPE cartridges from the aquaculture zone. AZA2 was also found in the concentrated phytoplankton cells, which demonstrated that AZA-producing microalgae were present in this investigated area. The variation in concentrations of PTX2 adsorbed by SPATT bags could reflect the change of Dinophysis density in seawater, but there was a time lag behind the peaks of Dinophysis density. Comparative results did not support the SPATT technology as a useful warning tool for toxic algal blooms and toxin accumulation in bivalves. The data suggest that the contamination of LSTs was prevalent in the coast of Qingdao and the environmental behavior of LSTs should be explored further.

Advanced polypectomy and resection techniques.

Most colorectal cancer arises from adenomatous polyps. This gradual process may be interrupted by screening and treatment using colonoscopy and polypectomy. Advances in imaging platforms have led to classification systems that facilitate prediction of histologic type and both stratification for and prediction of the risk of invasion. Endoscopic treatment should be the standard of care even for extensive advanced mucosal neoplasm. Technique selection is influenced by lesion features, location, patient factors, and local expertise. Postprocedural complications are more common following advanced resection and endoscopists should be familiar with risk factors, early detection methods, and management.

El pólipo plano: un desafío / Flat polyp: a real challenge

The relevance and interest in discussing on flat polyps is mainly due to the various challenges involved in its diagnosis and therapeutical difficulties, being the endoscopic route the state of the art nowadays, as well as their follow up and subsequent controls. Available diagnostic technologies have improved significantly and are widespread among digestive endoscopy units. Endoscopy treatment includes EMR(endoscopic mucosal resection), ESD(endoscopic submucosal dissection), ablation and even transmural resections. Prevention and treatment of complications is a major issue in these endoscopic solutions. Multiple variables related with flat lesions are analysed in this review, such as serrated lesions, laterally spreading tumors, and flat lesions meaning dysplasia and cancer in inflammatory bowel disease patients, among others. Complete resections should be ensured in order to avoid interval colon polyps and cancer, preventing the development of colon cancer, which is our major goal.

El interés actual y la relevancia de discutir sobre el pólipo planoestá en los desafíos que se enfrentan tanto en el terreno del diagnóstico como en su resolución terapéutica, mayormente endoscópica, su seguimiento y controles posteriores. Los medios diagnósticos endoscópicos se han perfeccionado y se encuentran disponibles en muchos centros. Las armas disponibles en esta terapia incluyen hoy la EMR (endoscopic mucosal resection), ESD (endoscopic submucosal dissection), la ablación y terapias transmurales. Se cuenta con elementos para prevenir y tratar complicaciones de su manejo. Múltiples variables de las lesiones planas se discutirán en esta revisión, como las lesiones serradas, los tumores de extensión lateral (laterally spreading tumors; LSTs) y las lesiones planas que significan displasia y cáncer en pacientes portadores de enfermedad inflamatoria intestinal, entre otros. Debemos preocuparnos de su resección completa, evitando así recidivas y cáncer colorrectal de intervalo, avanzando en nuestra lucha en la prevención de esta patología.