Unilateral chronic subdural hematoma due to spontaneous intracranial hypotension: a report of four cases.

Background: Chronic subdural hematoma (CSDH) is a common neurosurgical disease. A subset of patients with CSDH may exhibit underlying spontaneous intracranial hypotension (SIH). Bilateral CSDH has a causal relationship with SIH, but there is no known causal relationship between unilateral CSDH and SIH.Case description: We encountered four cases of unilateral CSDH due to SIH. The patients' age ranged between 44 and 64 years; there were three males and one female. All patients presented with headache as their initial symptom, and then became comatose. Computed tomography demonstrated unilateral CSDH and transtentorial herniation in all patients. Treatments were emergency epidural blood patch (EBP) and evacuation of CSDH. The site of cerebrospinal fluid leak could not be identified in three patients; therefore, EBP was performed at upper and lower spine. All patients recovered from SIH; however, one patient experienced poor outcome due to Duret hemorrhage and ischemic complications of transtentorial herniation. Cranial asymmetry was present in all four patients, and unilateral CSDH was located on the side of the most curved cranial convexity.Conclusions: Unilateral CSDH, asymmetric cranial morphology, and transtentorial herniation in relatively young patients may indicate underlying SIH.

[Temporal Profiles of Neuroimaging Features of Non-haemorrhagic and Non-ischemic Vertebral Artery Dissections for Conservative Treatment].

Most patients with non-hemorrhagic and non-ischemic vertebral artery dissections(VADs)are likely to recover with good outcomes. In contrast, some cases of uneventful outcomes have also been reported. Therefore, whether surgical treatment or prolonged follow-up should be utilized for each case remains controversial. In this study, we retrospectively investigated the radiological features and changes in non-hemorrhagic and non-ischemic VADs during the follow-up period. We reviewed the medical records of 15 consecutive patients with VADs without hemorrhage or ischemic lesions diagnosed between 2008 and 2017; all patients reported severe occipital headache. All hemorrhagic and ischemic lesions were categorized into morphological types according to the initial radiological findings. The following morphological types of dissections were observed: six cases, pearl and string type; six cases, dilatation type; two cases, stenosis type; and one case, occlusion type. We observed morphological aggravation in four cases, and among them, three underwent surgical interventions. Seven patients recovered during the follow-up period, and five of them showed marked radiological changes within 2 months. One patient died fromethe clinical onset. Therefore, careful follow-up radiological imaging is presumably necessary for patients with non-hemorrhagic and non-ischemic VADs, within at least 2 months of the clinical onset because of the tendency of VADs for rapid morphological changes during that period.

Individual Step Characteristics During Sprinting in Unilateral Transtibial Amputees.

To understand the step characteristics during sprinting in lower-extremity amputees using running-specific prosthesis, each athlete should be investigated individually. Theoretically, sprint performance in a 100-m sprint is determined by both step frequency and step length. The aim of the present study was to investigate how step frequency and step length correlate with sprinting performance in elite unilateral transtibial amputees. By using publicly-available Internet broadcasts, the authors analyzed 88 races from 7 unilateral transtibial amputees. For each sprinter's run, the average step frequency and step length were calculated using the number of steps and official race time. Based on Pearson's correlation coefficients between step frequency, step length, and official race time for each individual, the authors classified each individual into 3 groups: step-frequency reliant, step-length reliant, and hybrid. It was found that 2, 2, and 3 sprinters were classified into step-frequency reliant, step-length reliant, and hybrid, respectively. These results suggest that the step frequency or step length reliance during a 100-m sprint is an individual occurrence in elite unilateral transtibial amputees using running-specific prosthesis.

Transplantation of Unique Subpopulation of Fibroblasts, Muse Cells, Ameliorates Experimental Stroke Possibly via Robust Neuronal Differentiation.

OBJECTIVE: Muse cells reside as pre-existing pluripotent-like stem cells within the fibroblasts, are nontumorigenic, exhibit differentiation capacity into triploblastic-lineage cells, and replenish lost cells when transplanted in injury models. Cell fate and function of human skin fibroblast-derived Muse cells were evaluated in a rat stroke model. METHODS: Muse cells (30,000), collected by pluripotent surface marker stage-specific embryonic antigen-3, were injected stereotaxically into three deposits within the rat ischemic cortex at 2 days after transient middle cerebral artery occlusion, and the cells' biological effects were examined for more than 84 days. RESULTS: Muse cells spontaneously and promptly committed to neural/neuronal-lineage cells when cocultured with stroke brain slices. Muse-transplanted stroke rats exhibited significant improvements in neurological and motor functions compared to control groups at chronic days 70 and 84, without a reduction in the infarct size. Muse cells survived in the host brain for up to 84 days and differentiated into NeuN (∼ 65%), MAP-2 (∼ 32%), calbindin (∼ 28%), and GST-π (∼ 25%)-positive cells in the cortex, but glial fibrillary acidic protein-positive cells were rare. Tumor formation was not observed. Muse cells integrated into the sensory-motor cortex, extended their neurites into cervical spinal cord, and displayed normalized hind limb somatosensory evoked potentials. INTERPRETATION: Muse cells are unique from other stem cells in that they differentiate with high ratio into neuronal cells after integration with host brain microenvironment, possibly reconstructing the neuronal circuit to mitigate stroke symptoms. Human fibroblast-derived Muse cells pose as a novel source of transplantable stem cells, circumventing the need for gene manipulations, especially when contemplating autologous cell therapy for stroke.

Navigation-guided clipping of a de novo aneurysm associated with superficial temporal artery-middle cerebral artery bypass combined with indirect pial synangiosis in a patient with moyamoya disease.

De novo aneurysms associated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass are an extremely rare complication of direct revascularization surgery for moyamoya disease (MMD). The basic pathology of MMD includes fragility of the intracranial arterial wall characterized by medial layer thinness and waving of the internal elastic lamina. However, the incidence of newly formed aneurysms at the site of anastomosis currently remains unknown. Among 317 consecutive direct/indirect combined revascularization surgeries performed for MMD, we encountered a 52-year-old woman manifesting a de novo aneurysm adjacent to the site of anastomosis 11 years after successful STA-MCA bypass with encephalo-duro-myo-synangiosis (EDMS). Although the patient remained asymptomatic, the aneurysm gradually increased in diameter to more than 6 mm with the formation of a daughter sac, and a computational fluid dynamic study revealed low wall shear stress at the aneurysm dome. The patient underwent microsurgical clipping of the aneurysm using a neuro-navigation system that permitted the minimally invasive dissection of the temporal muscle flap used for EDMS at the site of the aneurysm without affecting pial synangiosis. The aneurysm was successfully occluded using a titanium clip without complications. The postoperative course was uneventful, and the patient was discharged without neurological deficits. De novo aneurysms associated with STA-MCA bypass for MMD may be safely treated with microsurgical clipping, even in cases initially managed by a combined revascularization procedure that includes complex pial synangiosis. We recommend the application of the neuro-navigation system for the maximum preservation of pial synangiosis during this procedure.

Uneven cerebral hemodynamic change as a cause of neurological deterioration in the acute stage after direct revascularization for moyamoya disease: cerebral hyperperfusion and remote ischemia caused by the 'watershed shift'.

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is the standard surgical treatment for moyamoya disease (MMD). The main potential complications of this treatment are cerebral hyperperfusion (CHP) syndrome and ischemia, and their managements are contradictory to each other. We retrospectively investigated the incidence of the simultaneous manifestation of CHP and infarction after surgery for MMD. Of the 162 consecutive direct revascularization surgeries performed for MMD, we encountered two adult cases (1.2%) manifesting the simultaneous occurrence of symptomatic CHP and remote infarction in the acute stage. A 47-year-old man initially presenting with infarction developed CHP syndrome (aphasia) 2 days after left STA-MCA anastomosis, as assessed by quantitative single-photon emission computed tomography (SPECT). Although lowering blood pressure ameliorated his symptoms, he developed cerebral infarction at a remote area in the acute stage. Another 63-year-old man, who initially had progressing stroke, presented with aphasia due to focal CHP in the left temporal lobe associated with acute infarction at the tip of the left frontal lobe 1 day after left STA-MCA anastomosis, when SPECT showed a paradoxical decrease in cerebral blood flow (CBF) in the left frontal lobe despite a marked increase in CBF at the site of anastomosis. Symptoms were ameliorated in both patients with the normalization of CBF, and there were no further cerebrovascular events during the follow-up period. CHP and cerebral infarction may occur simultaneously not only due to blood pressure lowering against CHP, but also to the 'watershed shift' phenomenon, which needs to be elucidated in future studies.

De Novo Development of Moyamoya Disease in an Adult Female with a Genetic Variant of the RNF-213 Gene: Case Report.

BACKGROUND: The de novo development of moyamoya disease (MMD) in adults is extremely rare, with only 2 cases being previously reported. Furthermore, the mechanisms underlying the progression of adult MMD have not been elucidated yet. CASE REPORT: A transient ischemic attack occurred in a 46-year-old woman, owing to progressive MMD. Magnetic resonance (MR) angiography performed 7 years before the diagnosis of MMD did not detect any steno-occlusive changes in the major intracranial vessels, including the internal carotid artery (ICA) and the middle cerebral artery (MCA). However, during the last 2 years, serial MR angiography revealed the gradual progression of left MCA stenosis and ultimately showed apparent stenosis of the bilateral terminal ICA to proximal MCA. Catheter angiography confirmed the definitive diagnosis of MMD. A genetic analysis of RING-finger protein (RNF)-213, an MMD susceptibility gene, revealed that not only the patient, but also her sister, brother, and daughter had the heterozygous variant of the RNF-213 gene. Because of hemodynamic compromise with ischemic symptoms, the patient underwent revascularization surgery on the affected hemisphere, without complications. She had no cerebrovascular event in the postoperative follow-up period of 8 months, and there was no evidence of the further progression of MMD. CONCLUSION: We herein present the entire clinical course of the de novo development of MMD in a female adult. Newly developed MMD in an adult patient with a characteristic variant of the RNF-213 gene appears to be unique.

Transient Global Cerebral Ischemia Induces RNF213, a Moyamoya Disease Susceptibility Gene, in Vulnerable Neurons of the Rat Hippocampus CA1 Subregion and Ischemic Cortex.

The RING finger protein 213 (RNF213) is an important susceptibility gene for moyamoya disease (MMD) and is also implicated in other types of intracranial major artery stenosis/occlusion (ICAS); however, the role of RNF213 in the development of ICAS including MMD is unclear. The constitutive expression of the RNF213 gene is relatively weak in brain tissue, while information regarding the expression patterns of the RNF213 gene under cerebral ischemia, which is one of characteristic pathologies associated with ICAS, is currently limited. Our objective was to address this critical issue, and we investigated Rnf213 mRNA expression in rat brains after 5 minutes of transient global cerebral ischemia (tGCI) by occluding the common carotid arteries coupled with severe hypotension. Rnf213 gene expression patterns were investigated with in situ RNA hybridization and a real-time polymerase chain reaction (PCR) from 1 to 72 hours after tGCI. In situ RNA hybridization revealed a significant increase in Rnf213 mRNA levels in the hippocampus CA1 sub-region 48 hours after tGCI. The significant induction of the Rnf213 gene was also evident in the ischemic cortex. Double staining of Rnf213 mRNA with NeuN immunohistochemistry revealed Rnf213 hybridization signal expression exclusively in neurons. The real-time PCR analysis confirmed the induction of the Rnf213 gene after tGCI. The up-regulation of the Rnf213 gene in vulnerable neurons in the hippocampus CA1 after tGCI suggests its involvement in forebrain ischemia, which is an underlying pathology of MMD. Further investigations are needed to elucidate its exact role in the pathophysiology of ICAS including MMD.

Improvement of Subjective Symptoms and Eye Complications When Changing From 2-Week Frequent Replacement to Daily Disposable Contact Lenses in a Subscriber Membership System.

PURPOSE: Subjective symptoms and other eye complications were assessed and retrospectively compared in patients belonging to a proprietary membership system who switched from 2-week frequent replacement (2WFR) wear to daily disposable (DD) lens use. METHODS: Questionnaire responses were completed by all patients for a 5-year interval between October 2008 and September 2013 from 83 wearers in three Japanese clinics (59 female and 24 male; average age: 33.4±10.9 years). Complications were recorded for each patient at times of reexamination. RESULTS: Over the 5-year observation period, the 83 patients wore lenses for more than 26 months. The average duration of use of 2WFR lenses was 14.5±2.7 days/lens (n=83) and subsequently 1.03±0.12 days/lens (n=83) for DD lenses. Compliance with the duration of use was consistently good as monitored by requests for lens resupply in both wearing modalities. The subjective complaint of dryness tended to consistently show improvement by the change to DD wear: 18.1% vs. 30.1% (P=0.10, Fisher exact test). Among eye complications noted in each group, the occurrence of superficial punctate keratitis (SPK) was significantly decreased in DD wear: 9.6% vs. 26.5% (P=0.008, Fisher exact test). The main reasons given by patients for changing to DD wear were (1) "DD lens wear was more hygienic" (78.6%) and (2) "DD lens use is more convenient for travel/business trips" (64.3%). Comments after the switch in wear were (1) "easy and convenient" (95.7%) and (2) "I don't have to worry about expiration dates" on solutions (57.1%). Overall, 95.7% of wearers making the change answered as "satisfied" and "mostly satisfied." CONCLUSIONS: In the subscription membership program, which provided free lens replacement and/or reexamination, individual compliance with duration of wear in 2WFR wear cycles was good; however, these patients switching to DD wear tended to have improvement in their subjective complaints of dryness and objectively demonstrated a significant reduction of SPK at follow-up examinations.

Preparation and Characterization of Four Stereoisomers of Monatin.

Monatin is a naturally occurring, sweet amino acid comprising four stereoisomers due to its two asymmetric centers at C2 and C4. However, the characteristics of each stereoisomer have not yet been fully investigated. To obtain a sufficient amount of racemic monatin for optical resolution, a synthetic method was developed by modifying a possible biosynthetic pathway, i.e., a cross-aldol reaction and subsequent transamination. The key intermediate, 4-hydroxy-4-(3-indolylmethyl)-2-ketoglutaric acid, was obtained via the cross-aldol reaction of pyruvic acid and indole-3-pyruvic acid. Subsequently, the carbonyl group was converted to a hydroxyimino group through reaction with hydroxylamine and then to an amino group via hydrogenation to produce monatin. Next, the racemic monatin was divided into mixtures of two pairs of enantiomers through recrystallization. Finally, both enantiomers of the N-carbobenzoxy-γ-lactone derivatives of monatin were separated by preparative HPLC and deprotected. It was found that all optically pure stereoisomers exhibited a sweet taste. The isomer that displayed the most intense sweetness was the (2R,4R)-isomer, as determined by single crystal X-ray structure analysis of the monatin potassium salt, whereas the least sweet isomer was the (2S,4S)-isomer, which demonstrated a far lower sweetness than was previously reported.

Development of Abnormal Hemispheric Vascular Networks Mimicking Cerebral Proliferative Angiopathy in a Child Originally Diagnosed with Deep-Seated Arteriovenous Fistula.

Cerebral proliferative angiopathy (CPA), which is characterized by diffuse vascular abnormalities with intermingled normal brain parenchyma, is a rare clinical entity distinct from classical cerebral arteriovenous malformations. Its pathology at initial state and subsequent course of progression has totally been undetermined. We herein presented a case of a child who was initially diagnosed with deep-seated arteriovenous fistula (AVF), and ultimately developed symptomatic CPA-like vascular lesion over a long period of clinical follow-up. A 7-month-old boy was incidentally found to have an AVF in the right basal ganglia and conservatively followed up. Serial magnetic resonance angiograms revealed the gradual proliferation and enlargement of pial and medullary vessels surrounding the AVF. Seven years later, he had a transient ischemic attack followed by intraventricular hemorrhage. A catheter angiogram showed a diffuse large vascular malformation composed of 2 distinct structures, including AVF in the right basal ganglia and the surrounding proliferated pial and medullary arteries in the right hemisphere. Single-photon emission computed tomography with N-isopropyl[123I]-p-iodoamphetamine revealed apparent hemodynamic compromise on the right hemisphere. Targeted embolization of the pseudoaneurysm originating from the right A1 perforator was performed to prevent rebleeding without complications. The patient had no further cerebrovascular events. Perinidal hypoperfusion induced by a deep-seated AVF could be one of the underlying pathologies of progressive angiogenic activity. This is the first case showing the development of abnormal hemispheric vascular networks mimicking CPA, which offers insight into the pathogenesis of this new entity.

Characteristics of patients with non-variceal upper gastrointestinal bleeding taking antithrombotic agents.

BACKGROUND AND AIM: The present study aimed to clarify the features and management of non-variceal upper gastrointestinal bleeding (UGIB) in Japanese patients taking antithrombotic agents. METHODS: We retrospectively investigated the medical records of 560 patients who underwent emergency endoscopy for UGIB from 2002 to 2013. The patients were divided into two groups: group A, antithrombotic agent use; and group NA, no antithrombotic agent use. We compared clinical characteristics, comorbidities, and causes of UGIB between the groups. We also investigated management with antithrombotics. RESULTS: Of 560 patients with UGIB, 27.5% were taking antithrombotics, and this proportion gradually increased during the study period. Mean hemoglobin levels on admission were significantly lower in group A (8.0 ± 1.7 g/dL) than in group NA (8.9 ± 2.9 g/dL) (P < 0.001). Patients in group A developed more gastric ulcers and multiple ulcers than did patients in group NA. Incidence of Forrest Ia-type bleeding was lower in group A than in group NA (P < 0.001), and the rate of endoscopic hemostasis was significantly higher in group A (98.7%) than in group NA (94.3%) (P = 0.022). After the release of the 2012 Japan Gastroenterological Endoscopy Society guidelines, the antithrombotic agent cessation periods were significantly shortened (P < 0.001). CONCLUSIONS: Among patients with UGIB, those taking antithrombotics exhibited more severe clinical signs. However spurting hemorrhage was rare. Antithrombotics may be resumed early after endoscopic hemostasis.

Local Vasogenic Edema without Cerebral Hyperperfusion after Direct Revascularization Surgery for Moyamoya Disease.

Superficial temporal artery-middle cerebral artery anastomosis is generally used as the standard surgical treatment for moyamoya disease to prevent cerebral ischemic attacks. Although the main potential complications associated with this treatment are cerebral hyperperfusion and ischemia, the adverse impacts of revascularization surgery remain unclear. Of the 142 consecutive surgeries for moyamoya disease at our hospital from 2008, we herein presented 2 cases of adult-onset moyamoya disease that manifested local vasogenic edema at the site of anastomosis without cerebral hyperperfusion; 1 in a 31-year-old woman presented with transient ischemic attack and the other in a 22-year-old man manifested as minor completed stroke. Both patients underwent superficial temporal artery-middle cerebral artery anastomosis, resulting in the formation of a reversible high-signal-intensity lesion at the site of anastomosis on T2-weighted images along with an increase in apparent diffusion coefficient values, whereas diffusion-weighted images showed no changes. Neither hyperperfusion nor hypoperfusion, as assessed by single-photon emission computed tomography with N-isopropyl[123I]-p-iodoamphetamine, was observed postoperatively. In light of the increased risk of the further progression of vasogenic edema to intracerebral hemorrhage, these patients were treated with prophylactic blood pressure lowering and the intravenous infusion of a free radical scavenger. They did not have any further cerebrovascular events during the follow-up period. Regional vasogenic edema without cerebral hyperperfusion, possibly due to cerebral ischemia/reperfusion injury, may be another novel entity that needs to be considered as a potential complication after extracranial-intracranial bypass for moyamoya disease. Strict postoperative management should be used to avoid hemorrhagic transformation.

[A case of akin moyamoya disease associated with type-I diabetes mellitus managed by extracranial-intracranial bypass].

Moyamoya disease is characterized by idiopathic steno-occlusion at the terminal portion of the internal carotid artery with concomitant abnormal vascular networks that can lead to transient ischemic attacks and hemorrhagic stroke with symptoms of headache, confusion, dizziness, ataxia, seizure, and cognitive and personality changes. Because these symptoms also occur in patients with type 1 diabetes mellitus(T1DM), patients with both diseases might go unnoticed and without the less common diagnosis of akin moyamoya disease, accurate diagnosis and treatment could be delayed. Here, we report the case of a 32-year-old woman with past history of T1DM for 26 years presenting with right amaurosis, which was diagnosed as akin moyamoya disease even though she had suffered right incomplete hemiparesis 2 years ago. She underwent superficial temporal artery-middle cerebral artery anastomosis with pial synangiosis in the left hemisphere without complication. She had no cerebrovascular events postoperatively. Although akin moyamoya disease associated with T1DM is rare in Japan, we recommend that clinicians consider the coexistence of both diseases when evaluating patients with T1DM who have neurologic signs or symptoms and not overlook the possibility of cerebrovascular diseases, such as akin moyamoya disease.

[A case of atherothrombotic embolization developing with slowly progressive symptoms and requiring differential diagnosis from metastatic tumor recurrence].

We report a case of atherothrombotic embolization that developed with slowly progressive symptoms and required differential diagnosis from metastatic tumor recurrence. A 64-year-old man with a history of lung cancer and metastatic brain tumor was carefully followed at our outpatient department for tumor recurrence. Five years after surgery for brain metastasis and whole brain radiation therapy, he had no recurrence and systemic disease was well controlled. At a routine follow up in October 2013, he complained of slight right arm dysesthesia. Follow up brain magnetic resonance (MR) imaging revealed no lesion. Two months later, he developed right hemiparesthesia and gait disturbance. Spinal MR imaging was unremarkable. However, at a routine follow up in January 2014, multiple enhancements were detected near the resection cavity and regions delineating the sulci. At first, this was diagnosed as tumor recurrence. However, 3 days later, additional MR imaging detected new multiple small infarctions after worsening right hemiparesis and dysarthria. With the diagnosis of embolic stroke, we searched for an embolic source. Cardiogenic embolization and carotid bifurcation stenosis studies were negative, but severe stenosis and thrombosis were detected near the left common carotid artery origin. This site was in the field of radiation the patient received as treatment for primary lung cancer.

Nkx2.5 is involved in myeloid cell differentiation at anterior ventral blood islands in the Xenopus embryo.

We have shown previously that two populations of myeloid cells emerge in the anterior and posterior ventral blood islands (aVBI and pVBI) at the different stages in Xenopus laevis embryo. In order to elucidate the regulatory mechanism of myeloid cell differentiation in the aVBI, we examined the role of Nkx2.5, an essential transcription factor for heart differentiation, in regulation of the myeloid cell differentiation in this region. Knockdown of endogenous Nkx2.5 by introducing MO into the dorsal marginal zone (DMZ) suppressed the expression of MHCα as well as that of mpo and spib in the resultant embryos and in DMZ explants made from the injected embryos. Expression of c/ebpα was less affected in the embryos injected with Nkx2.5 MO. The effect of Nkx2.5 MO in myeloid cell differentiation was recovered by coinjection of nkx2.5 or c/ebpα mRNA, indicating that Nkx2.5 functions at the same or the upper level of C/EBPα for the specification of myeloid cells. An attempt to identify transcription factors for myeloid cell differentiation in ventral marginal zone (VMZ) explants demonstrated that coinjection of two transcription factors out of three factors, namely C/EBPα, Nkx2.5 and GATA4, was sufficient to induce a certain amount of mpo expression. We suggest that C/EBPα is an unequivocal factor for myeloid cell differentiation in the aVBI and that Nkx2.5 and GATA4 cooperate with C/EBPα for promotion of myeloid cell differentiation.

Upper Gastrointestinal Bleeding in Japanese Patients Prescribed Antithrombotic Drugs: Differences in Trends over Time.

BACKGROUND/AIMS: We studied the features of upper gastrointestinal bleeding (UGIB) in patients taking antithrombotic drugs. METHODOLOGY: The records of 430 patients taking antithrombotic drugs who underwent emergency endoscopy for UGIB in Saga Medical School Hospital between 2002 and 2011 were studied. We also compared the characteristics of our cohort of 11,919 patients prescribed antithrombotic drugs in our hospital between 2002 and 2011. UBGI patients of variceal bleeding were not included in this study. RESULTS: 186 patients presented with UGIB in the first period (2002-2006) and 244 in the second period (2007-2011). The proportion of patients infected with Helicobacter pylori was lower in the second period, while the proportion taking antithrombotic drugs rose significantly. Peptic ulcer disease was responsible for the majority of bleeding episodes; however, bleeding from other sources is increasing. In the whole cohort, the risk of UGIB was 1.08%; however, of the 31.8% who also took an acid-secretion inhibitor only 18 (0.28%) developed bleeding. In contrast, 102 (1.87%) of those not taking an acid-secretion inhibitor developed UGIB, a statistically significant difference. CONCLUSION: Risk of UGIB in Japanese patients taking antithrombotics was 1.01% and the incidence is increasing. Acid-secretion inhibitors reduced the risk of antithrombotic drug-related UGIB.

Repeated screening with fecal immunochemical tests reduced the incidence of colorectal cancers in Saga, Japan.

BACKGROUND/AIMS: Screening with fecal occult blood test has reduced mortality from colorectal cancer (CRC), with fecal immunochemical tests (FIT) widely utilized for CRC screening in Japan. To evaluate the importance of repeated FIT screening, the incidence of CRC was compared in patients undergoing initial and repeated screening. METHODOLOGY: Participants aged ≥40 years in Saga, Japan, were invited to undergo a 2-day FIT. FIT positive subjects were verified by colonoscopy to evaluate the CRC incidence rates. RESULTS: From 2005 to 2007, 55,595 individuals were invited to undergo CRC screening, including 47,168 undergoing repeated and 8,427 undergoing initial screening. Of the 5,832 FIT-positive subjects, 4,615 were assessed by colonoscopy, with 114 diagnosed as having CRC. Of these 114 patients, 67 had early and 47 had advanced CRC. The risk of CRC was 63% lower in the repeated than in the initial screening group (p<0.0001). Of the 67 patients with early CRC, 42 underwent endoscopic resection, with the rate significantly higher in the repeated than in the initial screening group (p = 0.01). Overall survival was longer in screened subjects than in those who visited hospitals with clinical symptoms. CONCLUSIONS: Repeated CRC screening with FIT reduced the incidence of CRC in Saga, Japan.

Compliance study of contact lens wearers in Japan--part 2: evaluation of a subscribed membership system.

OBJECTIVE: To examine the hypothesis that membership in a contact lens (CL) supply system is associated with better compliance for regular wearers (members) who belong to the subscription membership system. METHODS: Subjects were 104 members and 100 nonmember wearers of 2-week frequent replacement silicone hydrogel CLs whose clinical information was retrospectively available for 1.5 to 2 years in the interval between September 2010 and August 2012. The average duration of use of a single lens was calculated from the number of lenses supplied during the observation period and surveyed using questionnaires. Subjective symptoms and eye complications were also documented and compared. RESULTS: The average duration of use of a lens was significantly longer in nonmembers (17.8±5.6 days/lens; n=91) than in members (14.2±3.5 days/lens; n=98) (P<0.001, Mann-Whitney U test). The number of wearers who replaced their lenses within 15.4 days per lens wear was significantly higher in members (74.5%) as compared with nonmembers (45.1%) (P<0.001, Fisher exact test). Levels of compliance reported by wearers did not match with those indicated in clinical records. In recorded eye complications, the rate of incidence of allergic and giant papillary conjunctivitis tended to be higher in nonmembers as compared with members. CONCLUSIONS: The hypothesis that a membership system could be associated with better compliance was found to be supported by clinical records. It is suggested that a membership system is useful for identifying wearers who want to be more compliant and that better compliance may reduce long-term complications of lens wear.

Efficacy of extracranial-intracranial bypass for progressive middle cerebral artery occlusion associated with active Sjögren's syndrome: case report.

Sjögren syndrome affecting the major cerebral arteries is rare, and an optimal therapeutic strategy to counteract such a lesion has not yet been established. We herein report a case of a 39-year-old woman with a history of primary Sjögren syndrome, which had previously been treated with immunosuppressive therapy, manifesting with a crescendo transient ischemic attack because of left middle cerebral artery stenosis. Despite the administration of high doses of prednisolone and azathioprine for active Sjögren syndrome, the frequency of crescendo transient ischemic attacks increased with the progression of stenosis and magnetic resonance imaging showed the development of subacute cerebral infarction. Single-photon emission computed tomography with N-isopropyl[(123)I]-p-iodoamphetamine revealed apparent hemodynamic compromise in the affected cerebral hemisphere. In light of the increased risk of further progression of cerebral infarction, we decided to perform surgical revascularization in spite of her active inflammatory condition. The patient underwent extracranial-intracranial bypass without complications and was treated with intensive immunosuppressive therapy during the perioperative period. Based on our findings, we recommend surgical revascularization for occlusive cerebrovascular disease with hemodynamic compromise in combination with intensive immunosuppressive therapy, even in the active inflammatory state of autoimmune diseases, if ischemic symptoms are medically uncontrollable.