Ivy Sign in Moyamoya Disease: A Comparative Study of the FLAIR Vascular Hyperintensity Sign Against Contrast-Enhanced MRI.

BACKGROUND AND PURPOSE: The ability of the ivy sign on contrast-enhanced T1-weighted MR imaging (CEMR) to reflect cerebral perfusion and postoperative revascularization in Moyamoya disease remains largely unknown. We aimed to compare the capabilities of CEMR and FLAIR. MATERIALS AND METHODS: CEMR, FLAIR, arterial spin-labeling, and DSA were performed in 44 patients with Moyamoya disease. The ivy sign was scored separately on CEMR and FLAIR using the Alberta Stroke Program Early CT Score. The status of leptomeningeal collaterals was scored on DSA. The postoperative Matsushima grade was evaluated at least 3 months after surgical revascularization. RESULTS: Scoring of the ivy sign on CEMR showed excellent interrater reliability, and FLAIR vascular hyperintensity showed moderate interrater reliability. Correlation analyses revealed that DSA scores were more consistent with the CEMR-based ivy sign score (r = 0.25, P = .03) than with FLAIR vascular hyperintensity (r = 0.05, P = .65). The CEMR-based ivy sign score was significantly correlated with CBF in late-Suzuki stage Moyamoya disease (t = -2.64, P = .02). The CEMR-based ivy sign score at baseline was significantly correlated with the postoperative Matsushima grade (r = 0.48, P = .03). CONCLUSIONS: In this study, CEMR outperformed FLAIR in capturing the ivy sign in Moyamoya disease. In addition, the CEMR-based ivy sign score provided adequate information on hemodynamic status and postoperative neovascularization. The current study suggested that CEMR could be considered as an alternative to FLAIR in future studies investigating leptomeningeal collaterals in Moyamoya disease.

Validation of two prognostic models for recurrence and survival after radical gastrectomy for gastric cancer.

BACKGROUND: Prognostic models from Korea and Italy have been developed that predict overall survival and cancer recurrence respectively after radical gastrectomy for gastric cancer. The aim of this study was to validate the two models in independent patient cohorts, and to evaluate which factors may explain differences in prognosis between Korean and Italian patients with gastric cancer. METHODS: Patients who underwent radical gastrectomy for gastric cancer between January 2000 and December 2004 at Seoul National University Hospital and at eight centres in Italy were included. Discrimination of the models was tested with receiver operating characteristic (ROC) curves and calculation of area under the curve (AUC). Calibration was evaluated by plotting actual survival probability against predicted survival probability for the Korean nomogram, and actual against predicted risk of recurrence for the Italian score. RESULTS: Some 2867 and 940 patients from Korea and Italy respectively were included. The Korean nomogram achieved good discrimination in the Italian cohort (AUC 0·80, 95 per cent c.i. 0·77 to 0·83), and the Italian model performed well in the Korean cohort (AUC 0·87, 0·85 to 0·89). The Korean nomogram also achieved good calibration, but this was not seen for the Italian model. Multivariable analyses confirmed that Italian ethnicity was an independent risk factor for cancer recurrence (odds ratio (OR) 1·72, 1·31 to 2·25; P < 0·001), but not for overall survival (OR 1·20, 0·95 to 1·53; P = 0·130). CONCLUSION: Both prognostic models performed fairly well in independent patient cohorts. Differences in recurrence rates of gastric cancer may be partially explained by ethnicity.

Bladder stone formation on permanent suture material ten years after laparoscopic high uterosacral ligament suspension.

The present authors describe an uncommon case of iatrogenic bladder stone formation in a patient who underwent surgery for pelvic organ prolapse. A female patient who underwent high uterosacral ligament suspension ten years ago presented with pyuria and irritable bladder symptoms that did not respond to treatment. She had not experienced any specific urinary symptoms during the previous ten years. Patient evaluation revealed bladder stone formation on the non-absorbable suture material used during the previous operation. Cystoscopy during the previous operation did not find the suture material, and the suture knot that was tied extravesically during the operation was found inside the bladder. These strongly suggest delayed migration and rotation of the'suture knot after surgery rather than direct penetration of the bladder during operation. Delayed suture migration is a long-term complication that clinicians should consider in a patient who suffers from recurrent urinary symptoms after pelvic surgery around the bladder.

Incidence and clinical features of Clostridium difficile infection in Korea: a nationwide study.

The incidence and severity of Clostridium difficile infections (CDI) have increased in Western countries. However, there are limited data regarding the epidemiology of CDI in Eastern countries. This nationwide study was conducted in 17 hospitals to determine temporal trends in CDI incidence (from 2004 to 2008) in South Korea. The total incidence of CDI in Korea was 1·7 cases/1000 adult admissions in 2004, and 2·7/1000 cases in 2008 (P = 0·028). When analysing the clinical features of 1367 CDI patients diagnosed in 2008, oral metronidazole was effective as a first-line treatment for CDI (61·9%). Relapse rate was 8·9% and complicated CDI was only observed in 3·6%. The incidence of CDI increased significantly in Korea from 2004 to 2008. Although the clinical features were milder than in Western countries, the increasing burden of CDI needs ongoing surveillance systems.

Stomach hanging technique using gauze during laparoscopic gastrectomy.

INTRODUCTION: Lifting the stomach using laparoscopic instruments during laparoscopic gastrectomy is difficult and increases the risk of crushing the tumor. In this study, we present a stomach hanging technique using gauze pieces that reduces the risk to the tumor. MATERIALS AND SURGICAL TECHNIQUE: After a partial omentectomy and the opening of the lesser sac, the antrum was wrapped with a 15-20-cm gauze piece. Next, a straight needle with 2-0 monofilament suture material pierced the abdominal cavity through the right subcostal area on the mid-clavicular line, and the gauze was then sutured twice in a figure of eight manner. The needle was removed percutaneously through the right middle quadrant of the abdomen. Another suture was applied to wrap the left side of the stomach. The stomach was easily lifted and positioned by pulling the four suture strings in different directions. After the suture materials were fastened to the abdominal wall using hemostat forceps, the surgical field was sufficiently exposed, facilitating lymph node dissection on the superior surface of the pancreas. This method freed the assistant from holding the stomach and enabled this individual to assist the operation in other ways. DISCUSSION: This stomach lifting technique using gauze is a good option for exposing the surgical field, enables the assistant to perform other tasks, and reduces the risk of crushing the tumor during laparoscopic gastrectomy.

Translationally controlled tumour protein is associated with podocyte hypertrophy in a mouse model of type 1 diabetes.

AIMS/HYPOTHESIS: Translationally controlled tumour protein (TCTP) is thought to be involved in cell growth by regulating mTOR complex 1 (mTORC1) signalling. As diabetes characteristically induces podocyte hypertrophy and mTORC1 has been implicated in this process, TCTP may have a role in the pathogenesis of diabetes-induced podocyte hypertrophy. METHODS: We investigated the effects and molecular mechanisms of TCTP in diabetic mice and in high glucose-stimulated cultured podocytes. To characterise the role of TCTP, we conducted lentivirus-mediated gene silencing of TCTP both in vivo and in vitro. RESULTS: Glomerular production of TCTP was significantly higher in streptozotocin induced-diabetic DBA/2J mice than in control animals. Double-immunofluorescence staining for TCTP and synaptopodin revealed that podocyte was the principal cell responsible for this increase. TCTP knockdown attenuated the activation of mTORC1 downstream effectors and the overproduction of cyclin-dependent kinase inhibitors (CKIs) in diabetic glomeruli, along with a reduction in proteinuria and a decrease in the sizes of podocytes as well as glomeruli. In addition, knockdown of TCTP in db/db mice prevented the development of diabetic nephropathy, as indicated by the amelioration of proteinuria, mesangial expansion, podocytopenia and glomerulosclerosis. In accordance with the in vivo data, TCTP inhibition abrogated high glucose-induced hypertrophy in cultured podocytes, which was accompanied by the downregulation of mTORC1 effectors and CKIs. CONCLUSIONS/INTERPRETATION: These findings suggest that TCTP might play an important role in the process of podocyte hypertrophy under diabetic conditions via the regulation of mTORC1 activity and the induction of cell-cycle arrest.

Criteria for decision making after endoscopic resection of well-differentiated rectal carcinoids with regard to potential lymphatic spread.

BACKGROUND AND STUDY AIM: Rectal carcinoids are low-grade malignancies that are usually treated by endoscopic resection. However, on pathologic examination, resection margins that are positive for carcinoid cells are frequently found. Patient outcomes were reviewed after endoscopic resection of rectal carcinoids and the clinical significance of possible residual disease, as defined by pathologic and endoscopic examination, was evaluated. PATIENTS AND METHODS: The medical records and endoscopic findings of 347 patients presenting with rectal carcinoids to 14 university hospitals in Korea between January 1999 and June 2007 were retrospectively analyzed. RESULTS: A total of 304 patients were treated with endoscopic resection, and 43 patents were treated with surgery. In the endoscopic resection group, the complete resection rate was 88.2% based on endoscopic appearance (CR-E) and 60.2% based on pathologic evaluation (CR-P). The agreement between CR-E and CR-P was low (κ=0.192). No residual tumors were found in 77 of 85 patients (90.6%) who were CR-E but not CR-P and who had endoscopic biopsy taken at 24-month follow-up. The receiver-operating characteristic curve identified an optimal cut-off value of 10.5 mm, at which the sensitivity and the specificity for metastasis were 100% and 89%, respectively. The risk factors for metastasis by multivariate analysis were tumor size, increased mitotic rate, and lymphovascular invasion. CONCLUSIONS: Endoscopic resection is a safe and effective modality for treating well-differentiated rectal carcinoids smaller than 10 mm in diameter. Discrepancies were observed between CR-E and CR-P. The risk factors for metastasis were tumor size, increased mitotic rate, and lymphovascular invasion.

A case of acute phosphate nephropathy in a patient with nephrotic syndrome and decreased serum fetuin-A.

We report a case of APN after OSP use in a patient with nephrotic syndrome (NS). Renal biopsy revealed minimal change disease with multifocal calcium phosphate deposits within the tubules and in the interstitium. The serum level of fetuin-A, a systemic calcification inhibitor, was low during severely proteinuric state but normalized after remission of NS. To verify whether fetuin-A levels are low in NS patients, serum fetuin-A levels were determined in 10 patients with NS and 10 with asymptomatic microscopic hematuria (H). The mean serum fetuin-A levels were significantly lower in the NS group compared to the H group (p < 0.01). This finding suggests that a lower serum fetuin-A level may be associated with APN after OSP use in patients with NS, thus careful attention should be paid when colonoscopy using OSP is scheduled in this population.

Lactobacillus casei prevents the development of dextran sulphate sodium-induced colitis in Toll-like receptor 4 mutant mice.

Probiotics, defined as live or attenuated bacteria or bacterial products, confer a significant health benefit to the host. Recently, they have been shown to be useful in the treatment of chronic inflammatory bowel disease and infectious colitis. In this study, we investigated the effect of probiotics on the development of experimental colitis using Toll-like receptor 4 (TLR-4) mutant (lps-/lps-) mice. TLR-4(lps-/lps-) and wild-type (WT) mice were given 2.5% dextran sulphate sodium (DSS) in drinking water to induce colitis with or without Lactobacillus casei pretreatment. Clinical and histological activity of DSS-colitis was attenuated markedly both in TLR-4(lps-/lps-) and WT mice pretreated with L. casei. Interestingly, histological activity was less severe in TLR-4(lps-/lps-) mice than in WT mice. The levels of myeloperoxidase activity and interleukin (IL)-12p40 were attenuated in pretreated TLR-4(lps-/lps-) mice after DSS administration. By contrast, transforming growth factor (TGF)-beta and IL-10 mRNA and protein expressions were increased markedly in pretreated TLR-4(lps-/lps-) mice. The current results suggest that L. casei has a preventive effect in the development of acute DSS-induced colitis and its action depends largely upon TLR-4 status. L. casei modulates the expression of inflammatory cytokines and down-regulates neutrophilic infiltration in the case of incomplete TLR-4 complex signalling.

Podocyte biology in diabetic nephropathy.

Glomerular visceral epithelial cells, namely podocytes, are highly specialized cells and give rise to primary processes, secondary processes, and finally foot processes. The foot processes of neighboring podocytes interdigitate, leaving between them filtration slits. These are bridged by an extracellular substance, known as the slit diaphragm, which plays a major role in establishing size-selective barrier to protein loss. Furthermore, podocytes are known to synthesize matrix molecules to the glomerular basement membrane (GBM), including type IV collagen, laminin, entactin, and agrin. Because diabetic nephropathy is clinically characterized by proteinuria and pathologically by glomerular hypertrophy and GBM thickening with foot process effacement, podocytes have been the focus in the field of research on diabetic nephropathy. As a result, many investigations have demonstrated that the diabetic milieu per se, hemodynamic changes, and local growth factors such as transforming growth factor-beta and angiotensin II, which are considered mediators in the pathogenesis of diabetic nephropathy, induce directly and/or indirectly hypertrophy, apoptosis, and structural changes, and increase type IV collagen synthesis in podocytes. This review explores some of the structural and functional changes of podocytes under diabetic conditions and their role in the development and progression of diabetic nephropathy.

Patient factors predictive of pain and difficulty during sedation-free colonoscopy: a prospective study in Korea.

BACKGROUND: Successful colonoscopy depends on insertion of the instrument to the cecum, precise observation, and minimal patient discomfort during the procedure. This prospective study was designed to identify factors, apart from the endoscopist's skill, that predict patient pain and technical difficulty during sedation-free colonoscopy. METHODS: A total of 426 sedation-free colonoscopies performed by one experienced endoscopist were evaluated in a prospective manner. Factors were recorded, including patient pain level, intubation time, demographic data, history of abdominal surgery, bowel preparation status, diverticular disease, bowel habits, anxiety level, and number of previous colonoscopies. These factors were analysed to determine their association with difficulty and pain during the procedure. RESULTS: Four hundred six colonoscopies were completed to the cecum (95.3%). Mean insertion time for complete colonoscopy was 6.5+/-3.5 min. Multivariate logistic regression analyses revealed that older age, lower body mass index, previous hysterectomy, diarrhoea, 1st time colonoscopy and anxiety were predictors of patient pain. Older age, lower body mass index and previous hysterectomy were predictors of difficulty of intubation. CONCLUSIONS: This prospective study identified several factors that may predict patient pain and technical difficulty associated with the procedure. These findings have implications for the practice and teaching of colonoscopy.

Activation of the renin-angiotensin system within podocytes in diabetes.

The autocrine and paracrine activation of the renin-angiotensin system (RAS) within cells of the kidney plays a role in the overall pathophysiology of the renal disease due to diabetes. In this study, we focus on components of the RAS in the podocyte as these cells are important in the pathogenesis of glomerulosclerosis and proteinuria. Immortalized mouse podocytes were exposed to media containing normal glucose (NG) or high glucose (HG) for in vitro studies. In vivo studies utilized kidney tissue obtained from rats treated for 3 months with streptozotocin to induce diabetes. Angiotensinogen (AGT) and the angiotensin II (AII) type 1 receptor mRNA and protein were significantly increased in the podocytes cultured under the high glucose conditions. Both angiotensins I and II levels were significantly higher in cell lysates and the conditioned media of cells grown in high glucose. There were no differences in renin activity, angiotensin-converting enzyme level, or AII type 2 receptor level. Glomerular AGT and AII type 1 receptor assessed by means of immunohistochemistry were increased in diabetic rats compared with the control rats. Other measured components of the RAS within the glomeruli were not different. We suggest that increased AGT, an attendant increase in AII and increased AII type 1 receptor in podocytes experiencing diabetic conditions play an important role in the pathogenesis of diabetic nephropathy.

New insight of amino acid-based dialysis solutions.

Malnutrition is a major complication of peritoneal dialysis (PD) and is associated with increased morbidity and mortality. Daily losses of proteins and amino acids (AAs) into dialysate contribute to this problem. Previous metabolic balance study demonstrated that treatment with 1.1% AA-based dialysis solution is safe and may improve protein malnutrition in continuous ambulatory peritoneal dialysis (CAPD) patients ingesting low protein intake. Other prospective studies also showed that AA solution can provide nutritional benefit for malnourished PD patients resulting in a significant improvement in some biochemical and/or anthropometric nutritional parameters. However, there are other studies showing no particular improvement in nutritional parameters after long-term use of AA solution. This may be related to the differences in the study design, sample size, methods used to assess nutritional status, and other factors such as dietary intake and comorbidities of study subjects. Published data will be reviewed to further emphasize the nutritional benefit of long-term use of AA solution in malnourished PD patients along with a brief discussion on the various reasons that may partly explain the different study results. We will also present the results of a longitudinal observational study evaluating changes in nutritional parameters following use of one exchange of 1.1% AA solution in malnourished Korean PD patients. A significant improvement of somatic protein status such as lean body mass (LBM) and hand grip strength was observed. No significant change in serum albumin level was noted. Patients with a positive estimated coefficient for LBM in the fitted regression model to the repeated observations over 1 year were classified as responders and patients with neutral or negative coefficient were considered as non-responders. Thirty-one out of 43 malnourished patients (72%) showed nutritional benefit based on the change of LBM. Hand grip strength and back lift strength were significantly higher in responders at baseline. Other baseline parameters did not differ between the two groups.

Diagnostic yield of advanced colorectal neoplasia at colonoscopy, according to indications: an investigation from the Korean Association for the Study of Intestinal Diseases (KASID).

BACKGROUND AND STUDY AIMS: The factors that more accurately predict the detection of colorectal cancers and adenomas at colonoscopy are different. We conducted a prospective multicenter study to evaluate which indications were most closely associated with advanced colorectal neoplasm (CRN), including colorectal cancer, in a group of patients undergoing colonoscopy. PATIENTS AND METHODS: The 17 468 patients were enrolled in this study between July 2003 and March 2004, from 11 tertiary medical centers in Korea. They were recruited according to 11 itemized colonoscopic indications. The term "advanced adenoma" refers here to tubular adenomas of diameter of 11 mm or more, or to tubulovillous, villous, or severely dysplastic adenomas, irrespective of their size. Cancer was defined as the invasion of malignant cells beyond the muscularis mucosa. Advanced CRN was defined as advanced adenoma or invasive cancer. RESULTS: Advanced CRN was found in 1227/17 307 patients (1176 advanced adenomas plus 51 carcinomas, 7.1 %). According to univariate and multivariate analysis, the factors associated with advanced CRN included age >60 years (odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.8 - 2.4, P < 0.0001), male gender (OR 2.1, 95 %CI 1.7 - 2.7, P < 0.0001), referral for colonoscopy from primary care physician (OR 3.1, 95 %CI 2.5 - 3.7, P < 0.0001), and several other indications (OR 1.8, 95 %CI 1.5 - 2.3, P < 0.001). The yield of colonoscopy for advanced CRN was lower (2.2 %) than expected in patients with iron-deficiency anemia (OR 0.5, 95 %CI 0.2 - 0.9, P = 0.03). CONCLUSIONS: Age, gender, and referral for colonoscopy from primary care physician constituted important independent predictors of advanced CRN in patients undergoing colonoscopy.

Association of obesity, serum glucose and lipids with the risk of advanced colorectal adenoma and cancer: a case-control study in Korea.

BACKGROUND: Previous studies on colorectal cancer risk suggest that obesity, serum lipids and glucose might be related to colorectal carcinogenesis. This case-control study was conducted to investigate the association between obesity, serum lipids and glucose, and the risk of advanced colorectal adenoma and cancer. METHODS: Patients with histologically confirmed colorectal cancers (n=105), same number of patients with advanced colorectal adenomas matched by age and sex, and the same number of controls matched by age and sex were selected in Hanyang University Guri Hospital between January 2002 and June 2004. RESULTS: Adenoma and cancer group showed significantly higher levels of mean body mass index and serum glucose. Cancer group also showed significantly lower mean serum lipids levels than controls. We used an unordered polytomous logistic model to calculate multivariate odds ratios for advanced adenoma and cancer relative to controls. Higher serum glucose level was more strongly associated with increased risk of cancer relative to controls (odds ratio, 3.0; 95% confidence interval, 0.9-9.8) than with increased risk of advanced adenoma (odds ratio, 2.1; 95% confidence interval, 0.9-5.4). Higher body mass index was strongly associated with increased risk of advanced adenoma (odds ratio, 10.8; 95% confidence interval, 4.6-25.3), but associated with attenuated risk of cancer (odds ratio, 2.3; 95% confidence interval, 0.9-5.8). Serum triglycerides and cholesterol levels were strongly associated with reduced risk of cancer (odds ratio, 0.3; 95% confidence interval, 0.1-0.8 and odds ratio, 0.2; 95% confidence interval, 0.1-0.6, respectively). CONCLUSIONS: Obesity and hyperglycaemia are positively related to advanced colorectal adenoma formation. Furthermore, hyperglycaemia plays an important role in progression to cancer. Findings on an inverse relationship between serum triglyceride and cholesterol levels and the risk of colorectal cancer may be the secondary results from metabolic or nutritional changes in advanced colorectal cancer patients and should be clarified in further studies.

Huge gastric diospyrobezoars successfully treated by oral intake and endoscopic injection of Coca-Cola.

A diospyrobezoar is a type of phytobezoar that is considered to be harder than any other types of phytobezoars. Here, we describe a new treatment modality, which effectively and easily disrupted huge gastric diospyrobezoars. A 41-year-old man with a history of diabetes mellitus was admitted with lower abdominal pain and vomiting. Upper gastrointestinal endoscopy revealed three huge, round diospyrobezoars in the stomach. He was made to drink two cans of Coca-Cola every 6 h. At endoscopy the next day, the bezoars were partially dissolved and turned to be softened. We performed direct endoscopic injection of Coca-Cola into each bezoar. At repeated endoscopy the next day, the bezoars were completely dissolved.