Case of pediatric traditional serrated adenoma resected via endoscopic submucosal dissection.

Traditional serrated adenoma (TSA) is a type of serrated polyp of the colorectum and is thought to be a precancerous lesion. There are three types of serrated polyps, namely, hyperplastic polyps, sessile serrated adenomas/polyps, and TSAs. TSA is the least common of the three types and accounts for about 5% of serrated polyps. Here we report a pediatric case of TSA that was successfully resected by endoscopic submucosal dissection (ESD). This rare case report describes a pediatric patient with no family history of colonic polyp who was admitted to our hospital with hematochezia. On colonoscopy, we found a polypoid lesion measuring 10 mm in diameter in the lower rectum. We selected ESD as a surgical option for en bloc resection, and histopathological examination revealed TSA. The findings in this case suggest that TSA with precancerous potential can occur in children, and that ESD is useful for treating this lesion.

Lacunar Infarcts Rather than White Matter Hyperintensity as a Predictor of Future Higher Level Functional Decline: The Ohasama Study.

OBJECTIVE: We aimed to determine the associations between silent cerebrovascular lesions, characterized by lacunar infarcts and white matter hyperintensity, and future decline in higher level functional capacity in older community-dwelling adults. MATERIALS AND METHODS: For this observational study, we selected individuals from the general population of Ohasama, a rural Japanese community. Three hundred thirty-one participants who were free of functional decline at baseline and who were at least 60 years old underwent brain magnetic resonance imaging and answered a questionnaire on higher level functional capacity derived from the Tokyo Metropolitan Institute of Gerontology Index of Competence. Weassessed the relationship between silent cerebrovascular lesions with a decline in higher level functional capacity at 7 years using multiple logistic regression analysis adjusted for possible confounding factors. RESULTS: During the follow-up, 22.1% reported declines in higher level functional capacity. After adjustment for putative confounding factors, the presence of silent cerebrovascular lesions (odds ratio [95% confidence interval], 2.10 [1.05-4.21]) and both lacunar infarcts (2.04 [1.05-3.95]) and white matter hyperintensity (2.02 [1.02-3.95]) was significantly associated with the risk of functional decline at 7-year follow-up. In subscale analysis, specifically lacunar infarcts were strongly associated with the future risk of decline in intellectual activity (3.16 [1.27-7.84]). CONCLUSION: Silent cerebrovascular lesions are associated with future risk of decline in higher level functional capacity. Appropriate management of health risk factors to prevent silent cerebrovascular lesions may prevent higher level functional decline in the elderly population.

Surgery for gastroesophageal reflux disease with Gaucher disease type 2.

Gaucher disease, the most common lysosomal storage disease, is sometimes complicated with gastroesophageal reflux disease (GERD). The present patient was a 136-day-old Japanese boy with Gaucher disease type 2. Enzyme replacement therapy and chemical chaperone therapy were successful for the skin disorders, joint contractures, hepatosplenomegaly and thrombocytopenia, but he also had GERD. Accordingly, a Nissen fundoplication with gastrostomy was performed. There was no vulnerability of organs, easy bleeding or difficulty of maintaining the visual field because of hepatosplenomegaly during operation. In the perioperative period, there was no prolonged wound healing or infection. GERD was improved. In the near future, the number of long-term survivors of Gaucher disease will increase due to improvements in medical therapy. Therefore, it is expected that the number of patients requiring fundoplication will also increase. In patients with successful medical therapy, surgical fundoplication can be safely and effectively performed.

Inhibitory transcranial direct current stimulation enhances weak beta event-related synchronization after foot motor imagery in patients with lower limb amputation.

PURPOSE: Sensorimotor rhythm patterns in patients with lower limb amputations might be altered because of reorganization of the sensorimotor cortices. The authors evaluated the sensorimotor rhythm of motor imagery (MI) in healthy subjects and patients with lower limb amputations. In addition, the authors investigated whether transcranial direct current stimulation (tDCS) could modulate sensorimotor rhythm control. METHODS: Six healthy subjects and six patients with lower limb amputations were assigned to receive anodal, cathodal, or sham tDCS over the foot motor area in a randomized order. The authors evaluated event-related desynchronization and event-related synchronization (ERS) of unilateral hand and bilateral foot MI before and after tDCS. RESULTS: Beta ERS of foot MI in patients with lower limb amputations was significantly lesser than that in healthy subjects. Compared with sham stimulation, cathodal tDCS enhanced beta ERS of foot MI in patients with lower limb amputations. In contrast, anodal tDCS decreased beta ERS of foot MI in healthy subjects. CONCLUSIONS: This is the first study to demonstrate that cathodal tDCS can enhance a weak beta ERS of foot MI in patients with lower limb amputations. These findings might contribute in improving the effectiveness of sensorimotor rhythm-based brain computer interface for gait restoration after lower limb amputation.

Hepatitis B (HB) immunoglobulin plus HB vaccine for intrauterine HB virus infection.

BACKGROUND: Vaccination against hepatitis B virus (HBV) infection in infants born to hepatitis B surface antigen (HBsAg)-positive mothers using HB immunoglobulin (HBIG) and hepatitis B (HB) vaccine was launched in Japan in 1985. Infants testing positive for HBsAg at 1 month of age are considered to have prenatally acquired the infection and are usually excluded from the prevention program. Infants born to HB e antigen (HBeAg)-positive mothers are at a high risk of perinatally acquiring the infection. In this study, long-term outcome was evaluated in children with prenatal HBV infection who received the HBIG and HB vaccine in Japan. METHODS: Newborns of both HBsAg- and HBeAg-positive carrier mothers received HBIG within 48 h of birth and at 2 months of age. Subsequently, three doses of recombinant HB vaccine were given at 2, 3, and 5 months of age. Outcome was compared between the following two groups: infants who completed the vaccination program, even if they were HBsAg positive at 1 month of age (n = 15), and infants who did not (n = 51). RESULTS: Seroconversion from HBeAg to anti-HBe antibody (HBeAb) before 3 years of age was observed in five children (33%) who completed the vaccination program and in two (4%) who did not (P = 0.005). In 2/5 children who completed the vaccination program and achieved HBeAb seroconversion, seroconversion from HBsAg to anti-HBs antibody was also noted. CONCLUSION: This specific vaccination program for children with prenatal HBV infection has the potential to alter immune tolerance to HBV.

Intestinal ascariasis at pediatric emergency room in a developed country.

Ascaris lumbricoides infection is rare among children in developed countries. Although large numbers of adult Ascaris in the small intestine can cause various abdominal symptoms, this infection remains asymptomatic until the number of worms in the intestine considerably increases in most cases. Ascaris causing bilious vomiting suggesting ileus is rare, especially in developed countries. A 6-year-old boy who lived in Japan, presented with abdominal colic, bilious vomiting at the pediatric emergency room. He appeared pale, and had no abdominal distention, tenderness, palpable abdominal mass, or findings of dehydration. He experienced bilious vomiting again during a physical examination. Laboratory tests showed mild elevation of white blood cells and C-reactive protein levels. Antigens of adenovirus, rotavirus, and norovirus were not detected from his stool, and stool culture showed normal flora. Ultrasonography showed multiple, round-shaped structures within the small intestine, and a tubular structure in a longitudinal scan of the small intestine. Capsule endoscopy showed a moving worm of Ascaris in the jejunum. Intestinal ascariasis should be considered as a cause of bilious vomiting in children, even at the emergency room in industrial countries. Ultrasound examination and capsule endoscopy are useful for diagnosis of pediatric intestinal ascariasis.

Clinical utility of diffusion tensor imaging and fibre tractography for evaluating diffuse axonal injury with hemiparesis.

Although diffuse axonal injury (DAI) frequently manifests as cognitive and/or motor disorders, abnormal brain findings are generally undetected by conventional imaging techniques. Here we report the case of a patient with DAI and hemiparesis. Although conventional MRI revealed no abnormalities, diffusion tensor imaging (DTI) and fibre tractography (FT) revealed the lesion speculated to be responsible for hemiparesis. A 37-year-old woman fell down the stairs, sustaining a traumatic injury to the head. Subsequently, she presented with mild cognitive disorders and left hemiparesis. DTI fractional anisotropy revealed changes in the right cerebral peduncle, the right posterior limb of the internal capsule, and the right corona radiata when compared with the corresponding structures observed on the patient's left side and in healthy controls. On FT evaluation, the right corticospinal tract (CST) was poorly visualised as compared with the left CST as well as the CST in healthy controls. These findings were considered as evidence that the patient's left hemiparesis stemmed from DAI-induced axonal damage in the right CST. Thus, DTI and FT represent useful techniques for the evaluation of patients with DAI and motor disorders.

Safety and utility of capsule endoscopy for infants and young children.

AIM: To assess the safety and utility of capsule endoscopy (CE) for children who are unable to swallow the capsule endoscope. METHODS: The medical records of all of the children who underwent CE between 2010 and 2012 were retrospectively reviewed. The patients were divided into 2 groups: group A included patients who were unable to swallow the capsule endoscope, and group B included patients who were able to swallow it. For the patients who were unable to swallow the capsule endoscope, it was placed in the duodenum endoscopically. The small bowel transit time, endoscopic diagnosis and complications of the 2 groups were compared. RESULTS: During the study period, 28 CE procedures were performed in 26 patients. Group A included 11 patients with a median age of 2 years (range 10 mo-9 years), and group B included 15 patients with a median age of 12 years (range 8 years-16 years). The lightest child in the study weighed 7.9 kg. The detection rates did not differ between the 2 groups. The median small bowel transit time was 401 min (range 264-734 min) in group A and 227 min (range 56-512 min) in group B (P = 0.0078). No serious complications, including capsule retention, occurred. No significant mucosal trauma occurred in the pharynx, esophagus, stomach or duodenum when the capsule was introduced using an endoscope. CONCLUSION: CE is a safe and useful procedure for infants and young children who are unable to swallow the capsule endoscope.

Endoscopic papillary balloon dilation for a 7-year-old girl with choledocholithiasis.

A 7-year-old girl was referred to our hospital for severe abdominal pain and elevated serum levels of amylase and aminotransferase. Radiological examinations revealed choledocholithiasis. EPBD was performed under intravenous anesthesia using midazolam and ketamine chloride. After fluoroscopic confirmation of a bile duct stone, a dilation balloon (30 mm-long, 8 mm-diameter) was passed over the guidewire and placed across the papilla. The balloon was gradually inflated until the notch created by the papillary sphincter disappeared. At 4 atm, the notch disappeared and the pressure was maintained for 15 s. Stone extraction was performed by using a retrieval balloon catheter. Abdominal pain disappeared immediately after EPBD, and she resumed oral intake 2 days after EPBD. In conclusion, EPBD may be a safe and effective technique for the treatment of choledocholithiasis in pediatric patients. EPDB should be selected as a treatment for pediatric choledocholithiasis in view of its advantages of preserving papillary function.

Predictors of the disappearance of triad symptoms in patients with idiopathic normal pressure hydrocephalus after shunt surgery.

We identified factors that predict the disappearance of the triad of symptoms (gait disturbance, cognitive impairment and urinary incontinence) of idiopathic normal pressure hydrocephalus (iNPH) following shunt surgery in this study. We classified 71 patients with iNPH into those whose objective symptoms disappeared (disappearance group) or remained (residual group), for each of the triad symptoms 12 months after shunt surgery. Logistic regression analyses were used to identify the predictors of the disappearance of symptoms among 10 variables before shunt surgery (e.g., age, sex, severity of symptoms, Evans index, cerebrospinal fluid (CSF) pressure, CSF stasis on computerized tomographic cisternography, regional cerebral blood flow on single photon emission computed tomography, three kinds of prior diseases). For each of the triad symptoms, mild symptoms before shunt surgery were predictors of the disappearance of the symptom. Young age was also a predictor of the disappearance of gait disturbance. When the analysis was conducted using subscores of the Mini Mental State Examination, a successful visuoconstruction subtest and an absence of hypertension were predictors of the disappearance of cognitive impairment. None of the neuroimaging examinations predicted the disappearance of symptoms after shunt surgery in this study.

Association between white matter hyperintensity and lacunar infarction on MRI and subitem scores of the Japanese version of mini-mental state examination for testing cognitive decline: the Ohasama study.

We assessed whether subitem scores on the Mini-Mental State Examination (MMSE) associated independently with cerebral white matter hyperintensity (WMH) and lacunar infarction (LI). Magnetic resonance imaging (MRI) and neuropsychological evaluation (MMSE) were performed in 1008 elderly individuals from the Ohasama Study (348 men, 660 women [65.5%]; age 68.0 ± 6.0 [mean ± SD] years; MMSE score, 26.5 ± 2.9). The relationships between MRI findings and MMSE subitem scores were analyzed by logistic regression. Significant associations were observed between the MMSE subitems "Orientation to place" and WMH, and "Copy a figure" and LI. Pathological changes were detected by brain MRI associated with a decrease in cognitive function in healthy elderly individuals.

Prevalence and length of recovery of pusher syndrome based on cerebral hemispheric lesion side in patients with acute stroke.

BACKGROUND AND PURPOSE: The aim of this study was to determine if side of cerebral hemisphere lesion affects the prevalence and time course of pushing behavior (PB) after stroke. METHODS: A total of 1660 patients with acute stroke were investigated. PB was assessed using the standardized Scale for Contraversive Pushing. Risk ratios were used to evaluate the differences in the prevalence of PB between right cerebral hemisphere-damaged (RCD) and left cerebral hemisphere-damaged (LCD) patients. The differences in the time course among 35 (27 RCD and 8 LCD) patients were evaluated by analyzing Scale for Contraversive Pushing scores with the Kaplan-Meier method using a log-rank test. RESULTS: PB was observed in 156 (9.4%) patients. The prevalence of PB was significantly higher in RCD (97 of 556 [17.4%]) than in LCD (57 of 599 [9.5%]) patients; risk ratio was 1.83 (95% CI, 1.35-2.49). The log-rank test indicated that RCD patients exhibited a significantly slower recovery than LCD patients (P=0.027). CONCLUSIONS: The number of RCD patients who exhibited PB was higher than that of LCD patients. The duration of recovery from PB was longer in RCD patients than in LCD patients.

Ambulatory versus home versus clinic blood pressure: the association with subclinical cerebrovascular diseases: the Ohasama Study.

The usefulness of ambulatory, home, and casual/clinic blood pressure measurements to predict subclinical cerebrovascular diseases (silent cerebrovascular lesions and carotid atherosclerosis) was compared in a general population. Data on ambulatory, home, and casual/clinic blood pressures and brain MRI to detect silent cerebrovascular lesions were obtained in 1007 subjects aged ≥55 years in a general population of Ohasama, Japan. Of the 1007 subjects, 583 underwent evaluation of the extent of carotid atherosclerosis. Twenty-four-hour, daytime, and nighttime ambulatory and home blood pressure levels were closely associated with the risk of silent cerebrovascular lesions and carotid atherosclerosis (all P<0.05). When home and one of the ambulatory blood pressure values were simultaneously included in the same regression model, each of the ambulatory blood pressure values remained a significant predictor of silent cerebrovascular lesions, whereas home blood pressure lost its predictive value. Of the ambulatory blood pressure values, nighttime blood pressure was the strongest predictor of silent cerebrovascular lesions. The home blood pressure value was more closely associated with the risk of carotid atherosclerosis than any of the ambulatory blood pressure values when home and one of the ambulatory blood pressure values were simultaneously included in the same regression model. The casual/clinic blood pressure value had no significant association with the risk of subclinical cerebrovascular diseases. Although the clinical indications for ambulatory blood pressure monitoring and home blood pressure measurements may overlap, the clinical significance of each method for predicting target organ damage may differ for different target organs.

Influence of adrenomedullin 2/intermedin gene polymorphism on blood pressure, renal function and silent cerebrovascular lesions in Japanese: the Ohasama study.

Adrenomedullin 2/intermedin (AM2/IMD) is a novel vasodilator peptide with various effects on the renal function and cardiovascular system. An exonic insertion (I)/deletion (D) polymorphism (rs3840963) may influence generation of AM2/IMD-53, due to its location within the N-terminal sequence. We investigated the association of this polymorphism with blood pressure, renal function and the risk of silent cerebrovascular lesions in a Japanese population recruited from the Ohasama study. We recorded 24 h ambulatory blood pressure (ABP), estimated glomerular filtration rate (eGFR) and proteinuria of 1073 individuals over 40 years of age. Silent cerebrovascular lesions (lacunar infarction and white matter hyperintensity (WMH)) were recorded in 794 individuals over 55 years of age. Chronic kidney disease (CKD) was diagnosed in individuals with proteinuria and/or decreased eGFR ≤60 ml min(-1) per 1.73 m(2). DD carriers, compared with II and ID carriers, displayed significantly higher 24 h ABP (127.4 vs. 122.0 and 122.9 mm Hg, respectively, in systolic ABP, P=0.009; and 74.8 vs. 71.3 and 72.5 mm Hg, respectively, in diastolic ABP, P=0.002), and lower eGFR (75.4 vs. 82.6 and 82.9 ml min(-1) per 1.73 m(2), respectively, P=0.04). DD carriers also had a significantly higher odds ratio (OR) for prevalence of CKD (OR: 2.7, P=0.003), presence of lacunar infarction (OR: 2.4, P=0.01) and WMH (OR: 2.7, P=0.003), compared with II carriers. The AM2/IMD I/D polymorphism is associated with renal dysfunction, blood pressure regulation and asymptomatic cerebrovascular diseases in the Japanese general population.

Association of (pro)renin receptor gene polymorphisms with lacunar infarction and left ventricular hypertrophy in Japanese women: the Ohasama study.

Recent studies have revealed that (pro)renin receptor ((P)RR), a newly identified member of the renin-angiotensin system, is associated with organ damage that occurs with cardiovascular disease. We investigated the association of genetic polymorphisms in the (P)RR gene with lacunar infarction, white matter hyperintensity and left ventricular hypertrophy (LVH) in a Japanese general population recruited from the Ohasama study, a Japanese cohort study. A total of 779 subjects (men=250 and women=529) were recruited. For the association study, we selected three polymorphisms: -782A>G (rs2968915), intervening sequence (IVS)5+169C>T (rs5918007) and +1513A>G (rs6609080). In women, the prevalence of lacunar infarction and LVH was significantly higher in subjects with the +1513GG genotype than in those with the AA or AG genotypes (lacunar infarction: P=0.01, LVH: P=0.003). Plasma renin activity (PRA) levels in women with the GG genotype were significantly lower than in women with the AA or AG genotypes (P=0.01). Multiple logistic regression analysis adjusted for confounding factors demonstrated that +1513A>G polymorphism was significantly and independently associated with the risk of lacunar infarction (trend P=0.03) and LVH (trend P=0.003). In men, there were no significant differences in lacunar infarction, LVH or PRA levels among the three genotypes. The polymorphism of the (P)RR gene +1513A>G is associated with lacunar infarction and LVH in Japanese women. These results suggest that (P)RR has a role in organ damage in humans.

Association of arterial stiffness with silent cerebrovascular lesions: the Ohasama study.

BACKGROUND: Arterial stiffness is a risk factor for symptomatic stroke, and is associated with symptomatic cerebral infarction and cognitive impairment. Hence, we hypothesized that arterial stiffness would be a significant determinant of silent cerebrovascular lesions. METHODS: The subjects were 363 individuals without symptomatic cerebrovascular lesions who had their arterial stiffness assessed by brachial-ankle pulse wave velocity (baPWV) measurement. The subjects were classified into two groups by the presence or absence of lacunar infarcts, as well as into three groups by grade of white matter hyperintensity (WMH). baPWV was compared among these groups. RESULTS: Eighty-six subjects had lacunar infarcts. Of 138 subjects with WMHs, 102 were classified as having grade 1 and 36 as having grade 2 or 3 WMHs. baPWV was significantly higher in subjects with lacunar infarcts than in those without (17.3 ± 0.3 vs. 16.4 ± 0.2 m/s). baPWV tended to increase with higher WMH grade (16.2 ± 0.2, 16.9 ± 0.3, and 17.8 ± 0.5 m/s in grade 0, 1, and 2 or 3, respectively) after adjustments for confounding factors. The adjusted odds ratio (OR) for lacunar infarcts in subjects with middle-tertile baPWV was significantly higher (OR, 2.37; 95% confidence interval, CI, 1.10-5.11) and the OR in subjects with the highest-tertile baPWV tended to be higher (OR 2.26; 95% CI 0.99-5.45) compared with the lowest-tertile baPWV. The adjusted OR for WMH tended to increase with increased baPWV. CONCLUSIONS: Arterial stiffness appeared to be associated with the presence of a lacunar infarct and WMH, independently of the risks for other cerebrovascular diseases.

Vagal nerve regulation is essential for the increase in gastric motility in response to mild exercise.

It has been shown that mild to moderate exercise can accelerate gastric emptying in humans. However, understanding of the underlying mechanism is hampered by the lack of appropriate animal models. To investigate the effects of mild exercise on gastric motility, we developed an animal model, in which strain gauge transducers were surgically planted on the antral surfaces of female Sprague-Dawley rats. We continuously recorded the contractions of gastric circular muscle in unrestrained conscious rats, divided into four groups: sham-operated exercise, sham-operated sedentary, vagotomized exercise, and vagotomized sedentary. The rats were trained for 3 weeks, and gastric motility was monitored before and after exercise. Although exercise accelerates gastric antral contraction in sham-operated rats, this effect was absent in the vagotomized exercise group, indicating the involvement of the vagal nerve in the exercise-mediated increase in gastric motility. Among the four groups, daily food intake was highest in the sham-operated exercise group. In contrast, the vagotomized exercise group exhibited the smallest body weight gain. Severe gastric retention was observed in vagotomized rats, suggesting a role of the vagal nerve in facilitating food movement and digestion in the stomach. Moreover, at the end of the 3-week exercise, there were no differences in plasma levels of growth hormone, peptid YY, and ghrelin among the four groups. These results indicate that in response to a mild physical exercise challenge, the vagal nerve stimulates gastric motility and enhances the ability of the stomach to process food. Our findings highlight the significance of neuronal control of stomach function.

Changes in the volumes of the brain and cerebrospinal fluid spaces after shunt surgery in idiopathic normal-pressure hydrocephalus.

OBJECTIVES: To investigate volumetric changes of the brain and cerebrospinal fluid (CSF) spaces after shunt surgery in shunt-responsive idiopathic normal-pressure hydrocephalus (iNPH), and correlations between the changes and postoperative clinical improvements. METHODS: Twenty-one patients with shunt-responsive iNPH were studied. Magnetic resonance imaging (MRI) of the brain was performed before and 1year after surgery, and clinical symptoms were assessed by the iNPH Grading Scale, a validated assessment tool of the triad of iNPH, the Modified Rankin Scale, the Timed Up and Go Test, and neuropsychological tests including the Mini-Mental State Examination. The volumes of the left cerebral hemisphere, infratentorial brain, ventricles, and suprasylvian and infrasylvian subarachnoid CSF spaces were measured using an MRI-based volumetric technique. RESULTS: The volumes of the cerebral hemisphere and infratentorial brain did not change significantly after shunt surgery (p=0.231, 0.109, respectively). The volumes of the ventricles and infrasylvian subarachnoid CSF spaces were significantly decreased (p<0.0001, <0.05, respectively), with a mean change rate of -26.1% and -4.5%, respectively. The volumes of the suprasylvian subarachnoid CSF spaces increased significantly (p<0.0001), with a mean change rate of 43.5%. The decrease in ventricular volumes was significantly correlated with clinical improvement.