Obesity-induced metabolic imbalance allosterically modulates CtBP2 to inhibit PPAR-alpha transcriptional activity.

Maintenance of metabolic homeostasis is secured by metabolite-sensing systems, which can be overwhelmed by constant macronutrient surplus in obesity. Not only the uptake processes but also the consumption of energy substrates determine the cellular metabolic burden. We herein describe a novel transcriptional system in this context comprised of peroxisome proliferator-activated receptor alpha (PPARα), a master regulator for fatty acid oxidation, and C-terminal binding protein 2 (CtBP2), a metabolite-sensing transcriptional corepressor. CtBP2 interacts with PPARα to repress its activity, and the interaction is enhanced upon binding to malonyl-CoA, a metabolic intermediate increased in tissues in obesity and reported to suppress fatty acid oxidation through inhibition of carnitine palmitoyltransferase 1. In line with our preceding observations that CtBP2 adopts a monomeric configuration upon binding to acyl-CoAs, we determined that mutations in CtBP2 that shift the conformational equilibrium toward monomers increase the interaction between CtBP2 and PPARα. In contrast, metabolic manipulations that reduce malonyl-CoA decreased the formation of the CtBP2-PPARα complex. Consistent with these in vitro findings, we found that the CtBP2-PPARα interaction is accelerated in obese livers while genetic deletion of CtBP2 in the liver causes derepression of PPARα target genes. These findings support our model where CtBP2 exists primarily as a monomer in the metabolic milieu of obesity to repress PPARα, representing a liability in metabolic diseases that can be exploited to develop therapeutic approaches.

Formulation of Adult Food-Protein-Induced Enterocolitis Syndrome Diagnostic Scoring System Differentiating from Immediate-type Food Allergy.

BACKGROUND: Adult food protein-induced enterocolitis syndrome (FPIES) has recently been recognized, and there are no international diagnostic criteria for this disease. Differentiating adult FPIES from immediate-type food allergy reactions and providing specific treatment for each in an emergency is important, but methods have not been developed. OBJECTIVE: To develop a diagnostic scoring system for adult FPIES by comparing it with an immediate-type food allergy (IgE-FA). METHODS: This retrospective cohort study of food-avoidant adults based on the diagnostic criteria for adult FPIES reported by Gonzalez et al. was conducted by telephone interviews. We compared the clinical profiles of the patients with FPIES and IgE-FA. Adult FPIES-associated factors were extracted using multivariate analysis, and a diagnostic scoring system was developed based on odds ratios (OR). RESULTS: Forty-eight (16.7%) of 288 adults with food allergies were diagnosed with FPIES; of these, 240 (83.3%) had IgE-FA. Seafood was the most common cause of FPIES in adults (68.8%). Multivariate analysis identified age of onset > 26, >10 episodes, a longer latency period, cold sweat, abdominal distention, and vomiting as adult FPIES-associated factors. An adult FPIES diagnostic scoring system was developed using ORs with a high area under the curve (AUC = .978), 100% sensitivity and 87.0% specificity. CONCLUSION: Clinical profiles and an adult FPIES diagnostic scoring system were developed for the first time. This scoring system can be useful in differentiating adult FPIES and IgE-FA while treating a food-related acute reactions.

Prognostic significance of C-reactive protein in unresectable hepatocellular carcinoma treated with atezolizumab and bevacizumab.

AIM: C-reactive protein (CRP) is both an inflammatory and prognostic marker in various cancers. This study aimed to elucidate the characteristics of CRP and the prognostic factors in patients who were administered with atezolizumab plus bevacizumab (ATZ + BEV) for unresectable hepatocellular carcinoma (HCC). METHODS: A total of 213 patients who received ATZ + BEV for HCC from November 2020 to March 2023 at 15 hospitals were enrolled in this retrospective study. The prognosis was analyzed by subdividing the patients based on baseline characteristics, radiologic response, and treatment lines. Accuracy of survival prediction was assessed using CRP, alpha fetoprotein (AFP), C-reactive protein and alpha fetoprotein in immunotherapy (CRAFITY), and Glasgow Prognostic Score. RESULTS: Compared with patients with baseline CRP <1 mg/dL, those with baseline CRP ≥1 mg/dL (n = 45) had a significantly higher baseline albumin-bilirubin score and AFP levels, significantly lower disease control rate (62.2%), and significantly shorter median overall survival (hazards ratios 2.292; 95% confidence interval 1.313-5.107; log-rank test, p < 0.001). Multivariate analysis identified CRP ≥1 mg/dL, AFP ≥100 ng/mL, and modified albumin-bilirubin grade as the significant prognostic factors. The baseline CRP, AFP, CRAFITY, and Glasgow Prognostic Score demonstrated higher discrimination for 1-year survival prediction after first-line ATZ + BEV administration, compared with beyond second line, with area under the receiver operating characteristic curves of 0.759, 0.761, 0.805, and 0.717, respectively. CONCLUSIONS: CRP was a significant biomarker in patients treated with ATZ + BEV for HCC. Elevated CRP levels may indicate aggressive cancer progression and potential resistance to ATZ + BEV therapy.

A detailed intake-status profiling of seafoods in adult food-protein-induced enterocolitis syndrome patients.

BACKGROUND: Adults with food-protein-induced enterocolitis syndrome (FPIES) often develop severe abdominal symptoms after eating seafood. However, no investigation of a food elimination strategy for adult FPIES patients has been performed to date. METHODS: We conducted a retrospective cohort study of seafood-avoidant adults by telephone interview, based on the diagnostic criteria for adult FPIES reported by González et al. We compared the clinical profiles, abdominal symptoms, and causative seafoods between FPIES and immediate-type food allergy (IgE-mediated FA) patients. We also profiled the detailed intake-status of seafoods in adult FPIES patients. RESULTS: Twenty-two (18.8 %) of 117 adults with seafood-allergy were diagnosed with FPIES. Compared with the IgE-mediated FA patients, FPIES patients had an older age of onset, more pre-existing gastrointestinal and atopic diseases, more episodes, longer latency and duration of symptoms, more nausea, abdominal distention, and severe abdominal pain, and more frequent vomiting and diarrhea. In particular, abdominal distention-reflecting intestinal edema and luminal fluid retention-may be the most distinctive characteristic symptom in adult FPIES (p < 0.001). Bivalves, especially oysters, were the most common cause of FPIES. Strikingly, intake-status profiling revealed that many FPIES patients can safely ingest an average of 92.6 % of seafood species other than the causative species. CONCLUSIONS: There are many differentiators between FPIES and IgE-mediated FA, which may reflect differences in the underlying immunological mechanisms. Although seafood FPIES is unlikely to induce tolerance, many patients can ingest a wide variety of seafood species after a long period from onset.

Comparison of adult food protein-induced enterocolitis syndrome to crustaceans and immediate-type food allergy.

BACKGROUND: Food protein-induced enterocolitis syndrome (FPIES) is increasingly found in adults. FPIES requires different treatment from immediate-type food allergy (FA) in emergency medicine. However, no comparison of the clinical presentations of these diseases has been reported. OBJECTIVE: To compare the clinical presentations and causative crustaceans of adult FPIES and FA using a standardized questionnaire and to thereby lay the groundwork for establishing an algorithm that distinguishes those diseases. METHODS: We conducted a retrospective cohort study of crustacean-avoidant adults by telephone interview based on the previously reported diagnostic criteria for adult FPIES to compare the clinical features and crustacean intake status between FPIES and FA. RESULTS: Of 73 adult patients with crustacean allergy, 8 (11%) were diagnosed with having FPIES and 53 (73%) FA. Compared with the patients with FA, those with FPIES had a longer latency period (P < .01), more episodes (P = .02), longer duration of symptoms (P = .04), more frequent abdominal distention (P = .02), and severe colic pain (P = .02). Half of the patients with FPIES experienced fear of death during an episode. Panulirus japonicus (Japanese spiny lobster) and Homarus weber (lobster) were significantly common FPIES-causing foods. A statistically significant 62.5% of patients with FPIES were able to ingest some type of crustacean. CONCLUSION: FPIES and FA can be clearly differentiated by the abdominal symptoms, latency period, and duration of episodes. Furthermore, some patients with FPIES do not necessarily need to avoid all crustaceans. Our findings lay the groundwork for establishing an algorithm that distinguishes FPIES from FA in adults.

Colonoscopic observation time as a predictor of stigmata of recent hemorrhage identification in colonic diverticular hemorrhage.

OBJECTIVES: The strategy of identifying stigmata of recent hemorrhage (SRH) and treating the bleeding source is important for the prevention of rebleeding in colonic diverticular hemorrhage (CDH). However, there are few known reports on SRH identification thus far. This large multicenter study evaluated factors correlated with SRH identification, including observation time during colonoscopy. METHODS: A total of 392 CDH cases were classified into presumptive CDH (n = 276) or definitive CDH with SRH (n = 116) on the basis of colonoscopy results. Multivariate Cox proportional hazards regression was employed to identify factors correlated with SRH identification. For the endoscopic treatment, endoscopic clips (EC), endoscopic band ligation (EBL) or endoscopic detachable snare ligation (EDSL) was performed. RESULTS: Longer observation time was significantly correlated with SRH identification in multivariate analysis (OR, 10.3 [95% CI: 3.84-27.9], p<.001). Receiver operating characteristic curve (ROC) analysis of the SRH identification rate by observation time indicated a high area under the curve (AUC) (0.79), and the threshold of the observation time was calculated at 19 min using Youden's index. Moreover, the patients taken endoscopic hemostasis showed significantly lower early rebleeding rate than patients without endoscopic hemostasis (16.4% vs. 31.9%, p=.001), suggesting the importance of identifying SRH and treating the bleeding source for reducing the risk of recurrent bleeding. CONCLUSIONS: Long-observation time correlated with SRH identification in this study, in which bowel preparation and water-jet scope and cap attachment are commonly used. This is the first known study to highlight the significance of observation time in the SRH identification rates.

Anticoagulation against portal vein thrombosis reduces mortality and liver cirrhosis-related complications: A propensity score-matched study.

AIM: Portal vein thrombosis (PVT) is one of the common complications of liver cirrhosis. Although anticoagulation contributes to thrombus resolution and is considered the first-choice treatment, its impact on patients' prognosis is still controversial. This study aimed to clarify the benefit of anticoagulation on mortality, liver function, and the incidence of liver cirrhosis-related complications in cirrhotic PVT patients. METHODS: We conducted a multicenter retrospective review in which we included 78 eligible patients with PVT out of 439. After propensity score matching, 21 cirrhotic PVT patients were included in each one of the untreated control and anticoagulation groups. RESULTS: Overall survival was significantly improved in the anticoagulation group compared with the control group (p = 0.041), along with PVT size reduction (53.3% vs. 108.2%, p = 0.009). At the time of CT follow-up, the anticoagulation group showed a lower ALBI score (p = 0.037) and its prevalence of massive ascites was significantly lower (p = 0.043) compared with the control group. The incidence of overt encephalopathy was also lower in the anticoagulation group (p = 0.041). The cumulative incidence of bleeding events did not differ significantly between the two groups. CONCLUSIONS: Anticoagulation improves the survival of patients with cirrhotic PVT. Preserved liver function and reduced risks of cirrhosis-related complications under the treatment may have contributed to a better prognosis. Given its efficacy and safety, anticoagulation is worth initiating in patients with PVT.

Intestinal phenotype is maintained by Atoh1 in the cancer region of intraductal papillary mucinous neoplasm.

Intraductal papillary mucinous neoplasm (IPMN) is a precancerous lesion of pancreatic cancer. Although there are 4 types of IPMN, among which intestinal-type IPMN is likely to progress into invasive cancer known as colloid carcinoma, no information regarding the involvement of the intestinal phenotype in the carcinogenesis of IPMN exists. The present study was conducted to explore how the intestinal differentiation system is maintained during the tumor progression of intestinal-type IPMN using surgical resection specimens. Results showed that Atoh1, a critical transcriptional factor for intestinal differentiation toward the secretory lineages of intestinal epithelial cells, was expressed in an invasive-grade IPMN. To determine the function of Atoh1 in pancreatic cancer, we generated a pancreatic ductal adenocarcinoma (PDAC) cell line overexpressing Atoh1. In a xenograft model, we successfully induced an IPMN phenotype in PDAC cells via Atoh1 induction. Finally, for the first time, we discovered that GPA33 is expressed in intestinal-type IPMN, thereby suggesting a novel target for cancer therapy. In conclusion, the intestinal differentiation system might be maintained during tumor progression of intestinal-type IPMN. Further analysis of the function of Atoh1 in IPMN might be useful for understanding the molecular mechanism underlying the malignant potential during the tumor progression of IPMN.

What impact does postgraduate clinical training have on empathy among Japanese trainee dentists?

BACKGROUND: Enhancing empathy in healthcare education is a critical component in the development of a relationship between healthcare professionals and patients that would ensure better patient care; improved patient satisfaction, adherence to treatment, patients' medication self-efficacy, improved treatment outcomes, and reduced patient anxiety. Unfortunately, however, the decline of empathy among students has been frequently reported. It is especially common when the curriculum transitions to a clinical setting. However, some studies have questioned the significance and frequency of this decline. Thus, the purpose of this study was to determine the impact of postgraduate clinical training on dental trainees' empathy from cognitive, behavioral, and patients' perspective. METHODS: This study included 64 trainee dentists at Okayama University Hospital and 13 simulated patients (SPs). The trainee dentists carried out initial medical interviews with SPs twice, at the beginning and the end of their clinical training. The trainees completed the Japanese version of the Jefferson Scale of Empathy for health professionals just before each medical interview. The SPs evaluated the trainees' communication using an assessment questionnaire immediately after the medical interviews. The videotaped dialogue from the medical interviews was analyzed using the Roter Interaction Analysis System. RESULTS: No significant difference was found in the self-reported empathy score of trainees at the beginning and the end of the clinical training (107.73 [range, 85-134] vs. 108.34 [range, 69-138]; p = 0.643). Considering the results according to gender, male scored 104.06 (range, 88-118) vs. 101.06 (range, 71-122; p = 0.283) and female 109.17 (range, 85-134) vs. 111.20 (range, 69-138; p = 0.170). Similarly, there was no difference in the SPs' evaluation of trainees' communication (10.73 vs. 10.38, p = 0.434). Communication behavior in the emotional responsiveness category for trainees in the beginning was significantly higher than that at the end (2.47 vs. 1.14, p = 0.000). CONCLUSIONS: Overall, a one-year postgraduate dental training program neither reduced nor increased trainee dentists' empathy levels. Providing regular education support in this area may help trainees foster their empathy.

BRAF V600E mutation is a potential therapeutic target for a small subset of synovial sarcoma.

Synovial sarcoma (SS) is an aggressive tumor that most often affects the deep soft tissues in young adults. Intrathoracic SS is rare and is associated with poor outcome, highlighting the urgent need for a novel therapeutic strategy. In the process of clinical sequencing, we identified two patients with intrathoracic SS harboring the BRAF V600E mutation. The patients were women aged 32 and 23 years, and both presented with SS18-SSX2-positive monophasic SS in the thoracic cavity. BRAF V600E mutations were detected by next generation sequencing, and validated immunohistochemically by diffuse intense positivity to BRAF V600E mutation-specific antibodies. The phosphorylated ERK (pERK) immunohistochemistry result was also positive. One patient received a combination therapy of dabrafenib and trametinib, which led to tumor shrinkage. However, the tumor growth progressed 7.5 months later with an additional NRAS Q61K mutation. Immunohistochemical screening of 67 archival SS tumor samples failed to identify additional samples with BRAF V600E mutation. However, 32% of BRAF V600E-negative cases was positive for pERK, and one of the six tumors showing the highest pERK expression harbored an FGFR2-activating mutation. This is the first report of targetable BRAF mutation in a small subset of SS. Our study suggests involvement of the mitogen-activated protein kinase pathway and the potential clinical implication of BRAF mutation screening in SS.

Impact of renal function-based anti-tuberculosis drug dosage adjustment on efficacy and safety outcomes in pulmonary tuberculosis complicated with chronic kidney disease.

BACKGROUND: Dosages of anti-tuberculosis (TB) drugs are recommended to be adjusted according to renal function for patients complicated with chronic kidney disease (CKD). However, the efficacy and safety outcomes of such renal function-based dosage adjustments are not fully elucidated. METHODS: We retrospectively reviewed cases of pulmonary TB susceptible to first-line drugs that were treated at Jikei University Daisan Hospital between 2005 and 2014 with standard regimens based on dosage adjustments according to renal function recommended by international guidelines. Patients were divided into four groups, those with no, mild, moderate or severe CKD. In-hospital TB-related mortality, the rate of sputum culture conversion at 2 months, the frequency of adverse events (AEs), for which at least the temporal discontinuation of the suspect drug was required for patient improvement, and the rate of regimen change due to AEs were assessed. RESULTS: In the 241 enrolled patients (mean age, 64.1 years; 143 men), fourteen patients (5.8%) died due to TB during their hospitalization. The rate of sputum culture conversion at 2 months was 78.0%. The frequency of in-hospital TB-related death and the conversion rate in the groups did not vary significantly according to CKD severity including those in the non-CKD group (P = 0.310 and P = 0.864). Meanwhile, a total of 70 AEs were observed in 60 patients (24.9%) and the difference between the groups in the overall frequency of AEs was almost significant (P = 0.051). Moreover, for the 154 patients with CKD, severe CKD stage was a significant risk factor for regimen change (OR = 5.92, 95% CI = 1.08-32.5, P = 0.041), as were drug-induced hepatitis and cutaneous reaction (OR = 35.6, 95% CI = 8.70-145, P < 0.001; OR = 17.4, 95% CI = 3.16-95.5, P = 0.001; respectively). CONCLUSIONS: Adjusting the dosage of TB treatment for CKD patients according to the guidelines was efficient in terms of similar therapeutic outcome to that of the non-CKD group. However, AEs warrant attention to avoid regimen change in patients with severe CKD, even if the renal function-based dosage adjustment is performed.

Development of a new device for artificial insemination in cynomolgus macaques.

In cynomolgus macaques, an important animal species for biomedical research, efficient reproduction has been hampered partly due to the difficulties of artificial insemination (AI) using straw tubes developed for humans or farm animals, because cynomolgus macaques have a complex cervical canal structure. In this study, taking into consideration the unique structure of the macaque cervical canal, we developed a novel device for AI, comprised of a syringe and an outer cylinder. At 24 and 48 h after using this device to inject semen into one female, viable sperm were observed in the oviduct where the sperm meets the oocytes. We then attempted AI using this new device on 10 females that were at pre-ovulation, and pregnancy was successful in three animals (30% pregnancy rate). These results show that the newly developed device can be used for AI in cynomolgus macaques.

Microbead-based ligase detection reaction assay using a molecular beacon probe for the detection of low-abundance point mutations.

A microbead-based ligase detection reaction (LDR) assay using a molecular beacon probe was developed for the facile and rapid detection of point mutations present in low copy numbers in a mixed population of wild-type DNA. Biotin-tagged ligation products generated in the LDR were captured on the surface of streptavidin-modified magnetic beads for purification and concentration. The resulting product-tethered microbeads were combined with a molecular beacon probe solution, and the suspension was directly flowed into a capillary. The microbeads were accumulated in a confined space within the capillary using a bar magnet. The packed bead sample was then scanned by a fluorescence scanning imager to detect the presence of any mutations. With the developed methodology, we were able to successfully detect one cancer mutation in a mixture of 400 wild-type templates (t test at 95% confidence level). Furthermore, the post-LDR processing, typically the most laborious and time-consuming step in LDR-based mutation detection assays, could be carried out much more rapidly (approximately 20 min). This was enabled by the simple bead and fluid manipulations involved in the present assay.

Intraperitoneally injected d11-11(12)-epoxyeicosatrienoic acid is rapidly incorporated and esterified within rat plasma and peripheral tissues but not the brain.

Epoxyeicosatrienoic acids (EpETrEs) are bioactive lipid mediators of arachidonic acid cytochrome P450 oxidation. In vivo, the free (unbound) form of EpETrEs regulate multiple processes including blood flow, angiogenesis and inflammation resolution. Free EpETrEs are thought to rapidly degrade via soluble epoxide hydrolase (sEH); yet, in many tissues, the majority of EpETrEs are esterified to complex lipids (e.g. phospholipids) suggesting that esterification may play a major role in regulating free, bioactive EpETrE levels. This hypothesis was tested by quantifying the metabolism of intraperitoneally injected free d11-11(12)-Epoxyeicosatrienoic acid (d11-11(12)-EpETrE) in male and female rats. Plasma and tissues (liver, adipose and brain) were obtained 3 to 4 min later and assayed for d11-11(12)-EpETrE and its sEH metabolite, d11-11,12-dihydroxyeicosatrienoic acid (d11-11,12-diHETrE) in both the free and esterified lipid fractions. In both males and females, the majority of injected tracer was recovered in liver followed by plasma and adipose. No tracer was detected in the brain, indicating that brain levels are maintained by endogenous synthesis from precursor fatty acids. In plasma, liver, and adipose, the majority (>54 %) of d11-11(12)-EpETrE was found esterified to phospholipids or neutral lipids (triglycerides and cholesteryl esters). sEH-derived d11-11,12-diHETrE was not detected in plasma or tissues, suggesting negligible conversion within the 3-4 min period post tracer injection. This study shows that esterification is the main pathway regulating free 11(12)-EpETrE levels in vivo.

Ex vivo-expanded DCs induce donor-specific central and peripheral tolerance and prolong the acceptance of donor skin grafts.

Dendritic cells (DCs) are known to regulate immune responses by inducing both central and peripheral tolerance. DCs play a vital role in negative selection of developing thymocytes by deleting T cells with high-affinity for self-peptide-major histocompatibility complexes. In the periphery, DCs mediate peripheral tolerance by promoting regulatory T-cell development, induction of T-cell unresponsiveness, and deletion of activated T cells. We studied whether allogeneic DCs, obtained from bone marrow cultured with either Flt3L (FLDCs) or granulocyte-macrophage colony-stimulating factor (GMDCs), could induce allospecific central and peripheral tolerance after IV injection; B cells were used as a control. The results showed that only FLDCs reached the thymus after injection and that these cells induced both central and peripheral tolerance to donor major histocompatibility complexes. For central tolerance, injection of FLDCs induced antigen-specific clonal deletion of both CD8 and CD4 single-positive thymocytes. For peripheral tolerance, injection of FLDCs induced donor-specific T-cell unresponsiveness and prolonged survival of donor-derived skin grafts. Tolerance induction by adoptive transfer of FLDCs could be a useful approach for promoting graft acceptance after organ transplantation.

Spin dynamics, loop formation and cooperative reversal in artificial quasicrystals with tailored exchange coupling.

Aperiodicity and un-conventional rotational symmetries allow quasicrystalline structures to exhibit unusual physical and functional properties. In magnetism, artificial ferromagnetic quasicrystals exhibited knee anomalies suggesting reprogrammable magnetic properties via non-stochastic switching. However, the decisive roles of short-range exchange and long-range dipolar interactions have not yet been clarified for optimized reconfigurable functionality. We report broadband spin-wave spectroscopy and X-ray photoemission electron microscopy on different quasicrystal lattices consisting of ferromagnetic Ni81Fe19 nanobars arranged on aperiodic Penrose and Ammann tilings with different exchange and dipolar interactions. We imaged the magnetic states of partially reversed quasicrystals and analyzed their configurations in terms of the charge model, geometrical frustration and the formation of flux-closure loops. Only the exchange-coupled lattices are found to show aperiodicity-specific collective phenomena and non-stochastic switching. Both, exchange and dipolarly coupled quasicrystals show magnonic excitations with narrow linewidths in minor loop measurements. Thereby reconfigurable functionalities in spintronics and magnonics become realistic.

Periodic and Aperiodic NiFe Nanomagnet/Ferrimagnet Hybrid Structures for 2D Magnon Steering and Interferometry with High Extinction Ratio.

Magnons, quanta of spin waves, are known to enable information processing with low power consumption at the nanoscale. So far, however, experimentally realized half-adders, wave-logic, and binary output operations are based on few µm-long spin waves and restricted to one spatial direction. Here, magnons with wavelengths λ down to 50 nm in ferrimagnetic Y3 Fe5 O12 below 2D lattices of periodic and aperiodic ferromagnetic nanopillars are explored. Due to their high rotational symmetries and engineered magnetic resonances, the lattices allow short-wave magnons to propagate in arbitrarily chosen on-chip directions when excited by conventional coplanar waveguides. Performing interferometry with magnons over macroscopic distances of 350 × λ without loss of coherency, unprecedentedly high extinction ratios of up to 26 (±8) dB [31 (±2) dB] for a binary 1/0 output operation at λ = 69 nm (λ = 154 nm) are achieved in this work. The reported findings and design criteria for 2D magnon interferometry are particularly important in view of the realization of complex neuronal networks recently proposed for interfering spin waves underneath nanomagnets.

Development of risk scores for early and late recurrence of colonic diverticular hemorrhage.

OBJECTIVES: Colonic diverticular hemorrhage (CDH) often recurs. Although several studies have suggested that early rebleeding (ER) and late rebleeding (LR) should be treated independently, and several ER/LR risk factors have been identified, an integrated system for risk evaluation is still lacking. This study aimed to develop risk scores for early and late rebleeding of CDH. METHODS: This two-center, retrospective cohort study included 218 patients between 2008 and 2021. ER and LR risk factors were identified using multivariate analysis, and risk scores were developed using the odds ratios of each risk factor. RESULTS: The ER and LR rates were 32.6 and 25.7%, respectively. High heart rate on admission, early endoscopy from the visit, no bowel preparation and no endoscopic treatment were identified as risk factors for ER. On the other hand, LR risk factors included a history of hypertension and diabetes, early endoscopy from the visit, and the use of endoscopic clips. The ER risk score [area under the curve (AUC) = 0.71] was highly sensitive (90.3%) at a cutoff point of 6 and highly specific (98.0%) at a cutoff point of 15. The LR risk score (AUC = 0.70) was highly sensitive (91.1%) at a cutoff point of 2.6 and highly specific (88.3%) at a cutoff point of 7.1. CONCLUSIONS: The ER and LR risk scores were established for the first time, and they can divide CDH patients based on their risk of rebleeding as well as provide clinicians with practical information about the CDH management.

The efficacy of dupilumab in induction and maintenance of remission in an adult patient with steroid-dependent eosinophilic enteritis (EoN).

Eosinophilic enteritis (EoN) is associated with an eosinophilic infiltrate confined to the small intestine, but treatment options other than diet and corticosteroid therapy are scarce. There is only one report of the use of dupilumab for eosinophilic gastrointestinal disease, involving three pediatric patients. We report a case of successful induction of remission with dupilumab in a 53 year-old female patient with steroid-dependent EoN. The patient presented to the emergency room with uncontrollable abdominal pain and CT revealed a thickened ileal wall and small amount of ascites. Despite no abnormalities on endoscopy, histological examination revealed numerous eosinophilic infiltrates (> 100/HPF) and degranulation in the ileal lamina propria, diagnosing the patient with EoN. The patient achieved clinical remission with prednisolone, but EoN relapsed during tapering. Long-term steroid therapy was inappropriate due to mandibular osteomyelitis and osteoporosis, and she was switched to 9 mg budesonide, an intestine-soluble topical steroid without effect. Dupilumab administration resulted in resolution of abdominal pain, and remission was maintained after discontinuation of budesonide. Histological remission was confirmed 2 months after dupilumab administration. This is the first report of remission induced and maintained with dupilumab in an adult patient with EoN.

Segmental arterial mediolysis with a ruptured visceral artery on two consecutive days.

Background: We describe a case of segmental arterial mediolysis in which a vessel ruptured on two consecutive days. Case Presentation: A 69-year-old man presented with sudden-onset abdominal pain. Computed tomography showed a hematoma in the gastric wall. The patient was discharged after the pain was relieved but returned 8 h later with abdominal pain and shock. Repeated computed tomography revealed a massive intra-abdominal hemorrhage without previous aneurysm formation. Emergency angiography and coil embolization were successfully carried out. Segmental arterial mediolysis was diagnosed after irregular vasodilated lesions were observed in multiple arteries. Conclusion: This case suggests that accurately predicting the next vessel rupture is difficult. For patients experiencing intra-abdominal bleeding with segmental arterial mediolysis, we suggest treating only ruptured aneurysms and closely following-up unruptured aneurysms.