Outcomes of peroral endoscopic myotomy in patients with achalasia and prior bariatric surgery: A multicenter experience.

Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.

p11 in Cholinergic Interneurons of the Nucleus Accumbens Is Essential for Dopamine Responses to Rewarding Stimuli.

A recent study showed that p11 expressed in cholinergic interneurons (CINs) of the nucleus accumbens (NAc) is a key regulator of depression-like behaviors. Dopaminergic neurons projecting to the NAc are responsible for reward-related behaviors, and their function is impaired in depression. The present study investigated the role of p11 in NAc CINs in dopamine responses to rewarding stimuli. The extracellular dopamine and acetylcholine (ACh) levels in the NAc were determined in freely moving male mice using in vivo microdialysis. Rewarding stimuli (cocaine, palatable food, and female mouse encounter) induced an increase in dopamine efflux in the NAc of wild-type (WT) mice. The dopamine responses were attenuated (cocaine) or abolished (food and female mouse encounter) in constitutive p11 knock-out (KO) mice. The dopamine response to cocaine was accompanied by an increase in ACh NAc efflux, whereas the attenuated dopamine response to cocaine in p11 KO mice was restored by activation of nicotinic or muscarinic ACh receptors in the NAc. Dopamine responses to rewarding stimuli and ACh release in the NAc were attenuated in mice with deletion of p11 from cholinergic neurons (ChAT-p11 cKO mice), whereas gene delivery of p11 to CINs restored the dopamine responses. Furthermore, chemogenetic studies revealed that p11 is required for activation of CINs in response to rewarding stimuli. Thus, p11 in NAc CINs plays a critical role in activating these neurons to mediate dopamine responses to rewarding stimuli. The dysregulation of mesolimbic dopamine system by dysfunction of p11 in NAc CINs may be involved in pathogenesis of depressive states.

Development of Oropharyngeal Scope Type II with Integrated Tongue Depressor for Examination of the Oropharynx: NTOP2016 Study.

The oropharynx is examined by focusing an electric light, penlight, or forehead mirror on a desired visual field using a tongue depressor. However, it is extremely difficult to obtain objective recorded evidence for display with these methods, and the tools for examination have remained virtually unchanged for the past century. Treatment of the pharynx/oral cavity is exceedingly difficult, particularly in elderly patients and children. Therefore, there is an increasing need to develop a method for displaying the visual field during oropharyngeal examinations which is acceptable to patients, which can easily be applied at all medical institutions, which can be displayed to third parties, and which can be used by doctors for recording data and determining treatment. We earlier developed a dedicated device for this purpose (Improved Type I) and have now made further improvements. This study aims to evaluate the utility of the improved type II oropharyngeal endoscope as a tool for objective examination.

Effects of bifemelane hydrochloride on cortical neuronal activity in cats.

The effects of bifemelane hydrochloride on neuronal activity in the visual cortex of the cat were studied by microiontophoretic application under methoxyflurane anesthesia. Of 195 neurons examined with both acetylcholine (ACh) and bifemelane, 67 cells (34%) were excited and 7 cells (4%) were inhibited by ACh. The effect of bifemelane was excitatory on 122 neurons (63%), inhibitory on 20 (10%) and unchanged on the rest. In 60 cells out of the above 122 neurons, bifemelane showed a similar discharge pattern to ACh with a slow onset and delayed termination. The bifemelane-induced excitation was, in 18 out of 22 cells, antagonized by atropine (30-40 nA). Also, a potentiation in bifemelane-induced discharges by physostigmine (30-50 nA) was observed in 14 of the 32 cells tested. The firing evoked by ACh (80-100 nA) was potentiated during of after the application of bifemelane (30-40 nA) in 9 out of 29 neurons, which were not excited by bifemelane alone. These results suggest that neuronal discharges produced by bifemelane are induced at least in part, through a muscarinic ACh receptor, although other mechanisms may possibly be involved.

Hyperostosis associated with meningioma of the cranial base: secondary changes or tumor invasion.

OBJECTIVE: Hyperostosis associated with intracranial meningiomas is a well-described entity. The cause, management, and prognosis of these bony changes have long been a point of controversy. Some authors have postulated that hyperostotic changes are secondary to the formation of the tumor and do not constitute invasion of the tumor into the bone. Determining this point has direct implications in the treatment of these patients, especially regarding surgical considerations. To more thoroughly evaluate this question, a study correlating the morphology to the radiology is necessary. METHODS: In this study, 51 patients underwent resection for meningiomas involving the cranial base. Preoperative radiographic evaluation using magnetic resonance imaging and/or computed tomography was performed, and areas of hyperostosis were identified. During the resection of the tumor, biopsies from these hyperostotic regions were sent for histological evaluation regarding the presence or absence of tumor invasion of the bone. RESULTS: Preoperative neuroradiological assessment identified 26 patients with radiographic evidence of hyperostosis. Histological examination of the resected bone showed tumor invasion in 35 patients, including the area of radiographically identified hyperostosis in 25 of the 26 patients. The floor of the middle fossa was a specific area of low sensitivity for preoperative assessment of associated hyperostosis. CONCLUSION: These results indicate that hyperostosis associated with meningiomas involving the cranial base are caused by tumor invasion of the bone histologically.

The severity of residual coronary stenosis immediately after thrombolytic therapy does not influence the size of later left ventricular asynergic area.

To determine whether the severity of residual coronary artery stenosis immediately after thrombolytic therapy influences the size of later left ventricular (LV) asynergic area, we reviewed coronary angiograms (CAGs) and left ventriculograms (LVGs) of 31 patients with acute myocardial infarction (AMI). All patients received intracoronary urokinase therapy within 6 h after onset of AMI due to total occlusion of the proximal left anterior descending coronary artery (LAD). A dose of 960,000 IU urokinase was infused into the ostium of the left coronary artery over 40 min. Patients in whom antegrade blood flow without delayed distal filling was restored received rigorous anticoagulation. The patients were divided into three groups according to the severity of the coronary lesion immediately after urokinase therapy: 9 patients with complete occlusion in Group 1, 15 with > 90% stenosis in Group 2, and 7 with < 90% stenosis in Group 3. There were no significant differences in the baseline clinical characteristics among the patients in the three groups. The LADs in Group 1 were also totally occluded 1 month after urokinase therapy, the treated vessels in both Groups 2 and 3 were still patent, and patients in Group 2 showed a further reduction in residual stenosis. When LV asynergic area, regional wall motion, and global ejection fraction (EF) were compared among the three groups, no significant differences were demonstrated. In comparison with the data immediately after urokinase therapy, all parameters 1 month after therapy were significantly improved in both Groups 2 and 3.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic regurgitation secondary to diastolic prolapse of a tubular intimal flap into the left ventricle in a patient with anuloaortic ectasia.

A 32-year-old man with distal skeletal manifestations of Marfan's syndrome had experienced shortness of breath and orthopnea for one month. Physical examination showed the presence of severe aortic regurgitation. Both noninvasive and invasive studies revealed that the aortic regurgitation was induced by previously undescribed peculiar and unusual etiology: diastolic prolapse of a circumferentially dissected tubular intimal flap into the left ventricle. The patient underwent surgical repair with striking clinical improvement.

Intracerebral ring-enhancing lesions in a patient with multiple sclerosis: a case report.

BACKGROUND Intracerebral cystic lesions can easily be identified by computed tomography (CT) and magnetic resonance imaging (MRI). Cystic gliomas, brain abscesses, or metastatic carcinoma are the usual underlying causes for this neuroradiologic finding. CASE PRESENTATION We report here the case of a patient with multiple sclerosis who has two intracerebral cystic lesions. CONCLUSIONS Central nervous system (CNS) tissue destruction, necrosis, and cyst formation are very unusual in multiple sclerosis. Diagnostic difficulty therefore arises when patients suspected of having multiple sclerosis have radiologic evidence of cystic CNS lesions.

Acute acalculous cholecystitis in a patient on total parenteral nutrition: case report and review of the Japanese literature.

Acute acalculous cholecystitis (AAC) is a rare and dangerous complication of various medical and surgical conditions. We report on a male patient with bile panperitonitis caused by gangrenous AAC, which developed while he was on total parenteral nutrition (TPN) for ileus related to obstructive colon cancer. We also review the relevant Japanese literature on AAC associated with TPN. Our patient suddenly developed right hypochondrial pain after 3 days of TPN while waiting for colon cancer surgery. We diagnosed acute AAC by ultrasonography, and salvaged the patient by cholecystectomy plus left colectomy. Early diagnosis by ultrasound is important for this critical condition. Knowledge of the risk of acute gangrenous cholecystitis during TPN may allow the physician to provide an appropriate diagnosis and treatment.

Polypropylene mesh substitute for the fascial defect after using for the dural repair--technical note.

Use of the anterior sheath of the rectus abdominis muscle (anterior sheath) as a dural substitute and patching of the large defect of the anterior sheath with polypropylene mesh are described. Five patients were treated using the anterior sheath and the mesh. No postoperative complications such as cerebrospinal fluid leakage, infection, or abdominal wall hernia occurred. The mesh is useful as a patch for the sheath defect.

Functional disabilities of disabled workers in vocational aid facilities and a social welfare factory.

We evaluated functional disabilities of disabled workers at vocational aid facilities and a social welfare factory to reveal whether evaluation of the functional disabilities is useful for occupational health care activities. Subjects were 121 persons with a physical disability working at Fukuoka Colony (FC workers) and 35 persons with mental retardation working at Nanomi Kogei (NK workers). The Self-Rating Barthel Index, Self-Rating Frenchay Activities Index, and Satisfaction in Daily Life (SDL) were used for the evaluation of basic activities of daily living (ADL), lifestyle, and subjective domain of quality of life, respectively. The FC workers were almost independent in basic ADL: had a high capability in self-care activities and moderately disturbed capability in mobility activities, and had a more active lifestyle than the NK workers. The total SDL score indicated that the FC workers were less satisfied with overall daily life, although not significant, and were less satisfied with the SDL items of physical health, gait, house facilities, and having a job than the NK workers. Because these results indicated the features of disabled workers and gave an occupational health physician valuable information about disabilities, the evaluations used in this study can be regarded as useful for occupational health care activities.

Circadian rhythms in synaptic excitability of the dorsal lateral geniculate nucleus in the rat.

Excitability changes of the dorsal lateral geniculate nucleus were recorded in male albino rats (Wistar strain) with chronically implanted electrodes. Both averaged postsynaptic and presynaptic evoked responses showed clear circadian rhythms under a constant dark condition. The circadian rhythmicity of the evoked responses was not as a result of motor activity or due to the sleep-wakefulness changes which might show circadian rhythms independently. Circadian rhythms of antidromic and orthodromic evoked responses were abolished after bilateral suprachiasmatic nucleus lesions. These results suggest that the circadian rhythm generated in the suprachiasmatic nucleus significantly affects visual information transmission in the lateral geniculate nucleus.

Coronary angiographic findings in infarct-related arteries following 1 month of medical treatment.

PURPOSE: We undertook the present study to determine first whether coronary angiographic (CAG) features, suggestive of ruptured atherosclerotic plaque, develop in infarct-related arteries of patients receiving conventional medical therapy without thrombolytic agents, and if they develop, what the incidence is, and second whether the sites where the CAG features develop are specific to infarct-related lesions. METHODS: We reviewed the CAG findings of 127 consecutive patients one month after myocardial infarction (MI), including 72 consecutive patients who received medical therapy (Group I) and 55 patients who underwent intracoronary urokinase infusion (Group II). RESULTS: Angiographic evidence of ruptured plaque was present in 24/44 (54.5%) patent infarct-related arteries in Group I and in 27/43 (62.8%) in Group II. Similar findings were only noted in 2/52 (3.8%) patent non-infarct-related arteries with significant stenosis in Group I, and in 0/45 (0.0%) in Group II. CONCLUSION: On angiography, ruptured plaque was commonly found in patent infarct-related arteries in both groups, and was highly specific for the site of infarction. Thrombolytic therapy seemed to have no apparent effect on lesion morphology 1 month after MI.

Angiographic features in the infarct-related artery after intracoronary urokinase followed by prolonged anticoagulation. Role of ruptured atheromatous plaque and adherent thrombus in acute myocardial infarction in vivo.

To unravel sequential morphological features in infarct-related coronary arteries (IRCA), we performed coronary angiography (CAG) before, during, and immediately after intracoronary urokinase infusion in 43 consecutive patients. After 1 month of rigorous anticoagulation by intravenous heparin and subsequent oral warfarin or after the same period of treatment by antiplatelet agents, we repeated CAG in all patients except for one, who died 6 days after thrombolytic therapy. Thirty-two IRCAs were totally occluded, and 11 were severely occluded at baseline. With recanalization and/or reduction in luminal narrowing at the site of the occlusion by progressive removal of the overlying thrombus and plaque content, we recognized the development of extraluminal contrast pooling in an ellipsoid shape (type A), single or paired linear radiolucency(ies) with or without outpouching (type B), and definite outpouching (type C). The development of type A, B, and C lesions occurred in 4, 6, and 0 IRCAs immediately after thrombolytic therapy and in 0, 18, and 3 IRCAs 1 month later, respectively. Throughout the study, at least one of type A-C lesions developed in 23 of 43 (53.5%) IRCAs. Lesion development proceeded from total or severe occlusion to type A, then to type B or C, both accompanied by progressive reduction in luminal narrowing and frequent enlargement of outpouching. A postmortem study in one patient whose CAG immediately after thrombolytic therapy was interpreted as a type B lesion demonstrated a ruptured plaque with paired ridges. Serial observations in vivo indicate that many IRCAs are associated with a complex underlying spatial structure, probably composed of some part of ruptured atheromatous plaque with or without adherent thrombus. Recognition and identification of such complex structures beneath the accumulated thrombus are of great importance in both CAG interpretation and elucidation of the pathophysiological sequence of acute myocardial infarction in vivo and may enable prevention or more effective therapy of acute coronary events.

Intravenous injection of caerulein or cholecystokinin increases the parotid-type and pancreatic-type amylase in the serum of rats.

Caerulein and cholecystokinin (CCK) injection (i.v.) into rats caused about a 2.3- and 1.9-fold increase in serum amylase activity within 2 h, respectively. The increase of amylase activity in the serum caused by pilocarpine or isoproterenol injection (i.p.) was only of parotid-type amylase. Caerulein or CCK markedly increased pancreatic-type amylase, and significantly increased parotid-type amylase in the serum.

[Physiologically active substances in the oral excreta produced by honey bee--effects of royal jelly on silkworm].

The effect of royal jelly on the growth, development, weight of a cocoon and the number of eggs of the silkworm, Bombyx mori, was tested by the use of artificial diets. The growth and developmental speed of the silkworm were quickened by addition of royal jelly. The number of eggs increased markedly by the feeding of raw royal jelly but not of boiled royal jelly.

Simultaneous Determination of Lipid Hydroperoxides by HPLC-Post Column Systems.

Two HPLC-post column systems, a conventional-size system and a semi-micro system, for the simultaneous determination of lipid hydroperoxides were developed. The hydroperoxides of free fatty acids, phosphatidylcholines, triacylglycerols and cholesterol esters were individually determined at the pmol level with good reproducibility by using gradient elution and post-column detection with diphenyl-1-pyrenylphosphine.