Cold snare defect protrusion and incomplete polyp resection after forced cold snare polypectomy: a prospective observational study.

BACKGROUND: Cold snare defect protrusions (CSDPs) that occur after cold snare polypectomy (CSP) are considered indicators of incomplete polyp resection (IPR). We have sometimes experienced difficulty resecting polyps with snaring alone; in such cases, a forcible pull on the snare by the endoscopist is necessary. We call this procedure "forced CSP (FCSP)." However, no previous studies have evaluated this procedure. METHODS: This was a prospective observational study. From November 2020 to June 2021, the frequency, safety, and validity of FCSP were evaluated at our hospital. We distinguished CSP with snaring alone performed by the assistant as conventional CSP, and CSP requiring a forcible pull on the snare by the endoscopist as FCSP. RESULTS: Of 1315 polyps removed, 105 underwent FCSP (8%). The perforation rate was 0% in both groups. The rate of CSDP after the procedure was 96.2% (101/105) with FCSP and 6.4% (77/1210) with conventional CSP (P<0.001). The rate of IPR was 12.5% (13/104) with FCSP and 6.2% (75/1208) with conventional CSP (P=0.02). Multivariable analysis identified polyps located in the cecum (risk ratio [RR], 1.13; 95%CI 1.050-1.179; P=0.003) and polyps ≥6mm in diameter (RR, 2.37; 95%CI 2.146-2.542; P<0.001) as independent risk factors for FCSP. CONCLUSIONS: FCSP was performed on 105 polyps (8%) in this study. FCSP may be associated with the occurrence of CSDP and IPR. Further studies are necessary to confirm our results.

Co-Catalyzed atom transfer radical addition of bromodifluoroacetamides, expanding the scope of radical difluoroalkylation.

The atom transfer radical addition (ATRA) of bromodifluoroacetamides to arylalkynes and terminal alkenes was conducted using von Wangelin's Co catalyst system (CoBr2/1,2-bis(diphenylphosphino)benzene/Zn) in acetone/H2O at 30 °C to afford the corresponding functionalized difluoroacetamides in 33-89% yields. Moreover, the Co catalyst was successfully applied to the tandem addition/cyclization of 1,6-diene and -enyne substrates and intramolecular ATRA of N-allyl and N-propargyl bromodifluoroacetamides, significantly expanding the scope of radical difluoroalkylation.

The feasibility and safety of endoscopic submucosal dissection of gastric lesions larger than 5 cm.

BACKGROUND: As the indications for endoscopic submucosal dissection (ESD) for early gastric cancer have been revised, diagnostic ESD has increased. However, despite the technical difficulty of ESD for large lesions, the degree to which curative resection can be achieved has not been clarified. This study investigated the feasibility and safety of ESD for gastric lesions larger than 5 cm. METHODS: This retrospective multicenter study included 3474 gastric lesions treated by ESD from April 2012 to December 2021. We compared clinicopathological characteristics and treatment outcomes between lesions ≥ 5 cm and lesions < 5 cm. RESULTS: There were 128 lesions in the ≥ 5 cm group and 3282 lesions in the < 5 cm group. In the ≥ 5 cm group, upper location and fibrosis during ESD were more common, with a lower rate of 0-IIc type. Both en bloc resection rate and R0 resection rate were comparable, but there was a difference in curative resection rate (65.6% in the ≥ 5 cm group and 91.5% in the < 5 cm group). The frequency of adverse events (post-ESD bleeding, perforation, or stenosis) was almost similar, but delayed perforation was significantly more common (1.6% in the ≥ 5 cm group vs. 0.1% in the < 5 cm group). CONCLUSIONS: About two-thirds of curative resections were obtained with ESD for early gastric lesions larger than 5 cm, but delayed complications should be noted (Number: UMIN000047725).

The feasibility of endoscopic submucosal dissection for colorectal lesions larger than 10 cm.

BACKGROUND: Although endoscopic submucosal dissection (ESD) enables en bloc removal of colorectal neoplasms, its effectiveness for larger lesions (≥ 10 cm in diameter) is undetermined. We aimed to investigate the feasibility and safety of ESD for colorectal lesions ≥ 10 cm wide. METHODS: This retrospective study included 3591 consecutive colorectal lesions managed with ESD from June 2012 through December 2020. Clinicopathological characteristics and treatment outcomes were compared between lesions ≥ 10 cm wide and lesions 5-10 cm wide. RESULTS: There were 50 patients in the ≥ 10 cm group and 270 patients in the 5-10 cm group. Among patients in the ≥ 10 cm group, lesions were most often in the rectum (50.0%), and the laterally spreading tumor-granular nodular mixed type (LST-G-M) was most prevalent (41/50, 82%). Although patients in the ≥ 10 cm group a longer mean ESD procedure time (186.0 vs. 94.4 min, p < 0.001), the dissection speed was significantly higher in this group (0.50 vs. 0.41 cm2/min, p = 0.003). The en bloc and curative resection rates were comparable between the ≥ 10 cm and 5-10 cm groups (100% vs. 99.6% and 86.0% vs. 88.5%, respectively). Although the stenosis rate was higher in the ≥ 10 cm group (4% vs. 0%), the delayed bleeding and perforation rates were similar between the two groups. CONCLUSIONS: ESD for colorectal lesions ≥ 10 cm wide is feasible and curative, even though it is associated with higher technical difficulty and longer procedure times compared with ESD for smaller lesions (Number: UMIN 000044313).

Safety and efficacy of a new cold snare technique with clipping for colorectal angioectasia.

Colorectal angioectasia is a major cause of lower gastrointestinal bleeding. Use of antithrombotic agents is expected to increase with aging of the population, and bleeding from angioectasia is an important issue. Although the effectiveness of endoscopic mucosal resection for colorectal angioectasia has been reported, there are no reports of cold snare technique for angioectasia (CSA). From February 2018 to February 2022, the safety of CSA was evaluated at Omori Red Cross Hospital. We investigated the incidence of bleeding (delayed post-polypectomy bleeding (DPPB) and immediate bleeding) after CSA and the incidence of rebleeding requiring repeated endoscopic treatment. During the study period, 106 angioectasias were identified during colonoscopy. We only targeted patients with bloody stools and/or anemia requiring treatment for bleeding from angioectasia. Finally, we included 11 angioectasias in this study. Rates of DPPB and rebleeding after CSA were 0 %. The rate of immediate bleeding during CSA was 27.3 % (3/11). Dilated capillaries could be observed pathologically in nine of 11 lesions (81.8 %). CSA was safe and can be a new treatment option in the future. To confirm our results and verify the long-term safety and efficacy of CSA, further studies are desirable.

Synthesis of Benzo-Fused Cyclic Ketones via Metal-Free Ring Expansion of Cyclopropanols Enabled by Proton-Coupled Electron Transfer.

The metal-free ring expansion of cyclopropanols containing a pendant styrene moiety was successfully achieved using a proton-coupled electron transfer enabled by an organic photoredox catalyst. Through this, variants of 1-tetralone and 1-benzosuberone bearing a substituent at the benzylic position were selectively obtained through the regioselective ring closure of alkyl radical intermediates depending on the substitution pattern of the alkene moiety.

Surgical repair of unroofed coronary sinus with severe mitral regurgitation in an elderly patient.

An unroofed coronary sinus (URCS) is a rare anomaly that produces communication between the left atrium (LA) and the coronary sinus (CS), resulting in a left-to-right shunt. Due to the lack of symptoms and particular anatomical characteristics, this disease is difficult to diagnose, and prone to be overlooked. An 85-year-old man was admitted to our hospital because of anorexia and shortness of breath. On physical examination, a systolic murmur was heard at the apex, and pitting edema was present in both legs. Transthoracic echocardiography showed severe regurgitation of the mitral valve and tricuspid valve. Transesophageal echocardiography confirmed a shunt between the LA and the CS. Because of uncontrolled heart failure, we performed surgical repair 50 days after admission. Under cardiopulmonary bypass and heart arrest, the URCS was detected in the LA and directly sutured. Repair of the mitral and tricuspid valves and the Maze procedure were also performed. The patient had a good postoperative course, and has been doing well for 2 years. Transesophageal echocardiography is helpful for diagnosis of URCS. Mitral regurgitation might raise the left atrial pressure and result in increase in shunt flow, causing left and right heart failure in elderly patients. .

Morphological prediction of glaucoma by quantitative analyses of ocular shape and volume using 3-dimensional T2-weighted MR images.

Elongated axial length of the eye increases the morbidity of glaucoma. Myopia also associates with elongated axial length, and such ellipsoid shape of the eyeball strongly contributes its pathogenesis. Morphological features of the eyeballs, which could be important factors for developing glaucoma, have not been well described. The aim of this study was to investigate the three-dimensional (3D) topographic features of glaucomatous eyeballs with/without myopia to evaluate the potential of those features for predicting glaucoma. Using a 3.0-tesla MRI, volume-isotropic turbo-spin-echo acquisition T2-weighted images were obtained from 55 patients with glaucoma and 22 controls to delineate the eyeballs. Eyeball volumes, axial lengths and transverse lengths were semi-automatically calculated and compared between four groups: normal, myopia, glaucoma, and glaucoma with myopia. Both glaucoma and myopia increased the eyeball volume compared to the normal eyes. An increased anisotropy ratio (axial/transversus length) was observed in myopic eyes compared to normal, whereas in the glaucomatous eyes, with or without myopia, no increase in anisotropy ratio was observed. Increasing volume of eyes can be caused by myopia and glaucoma. Myopic eyes were ellipsoid in shape, but there was less anisotropy and a near-spherical shape in glaucomatous eyes, even in glaucomatous myopic eyes.

Functional importance of charged residues within the putative intracellular loops in pH regulation by Na+/ H+ exchanger NHE1.

The plasma membrane Na+/H+ exchanger 1 is activated in response to various extrinsic factors, and this process is regulated by an intracellular pH-sensing mechanism. To identify the candidate residues responsible for intracellular pH regulation, we analyzed the functional properties of engineered Na+/H+ exchanger 1 mutants with charge-reversal mutations of charged residues located in the intracellular loops. Na+/H+ exchanger 1 mutants with mutations at 11 positions were well expressed in the plasma membrane, but that with E247R was not, suggesting that Glu247 is important for the functional expression of Na+/H+ exchanger 1. Charge-reversal mutations of Glu131 (E131R, E131K) and Arg327 (R327E) resulted in a shift in the intracellular pH dependence of the exchange activity measured by 22Na+ uptake to the acidic side, and it abolished the response to growth factors and a hyperosmotic medium; however, mutations of Asp448 (D448R) and Arg500 (R500E) slightly shifted it to the alkaline side. In E131R, in addition to the change in intracellular pH dependence, the affinities for extracellular Na+, Li+ and the inhibitor 5-(N-ethyl-N-isopropyl)amiloride significantly increased. Furthermore, charge-conserved mutation of E131 (E131D) was found to have no effect, whereas charge neutralization (E131Q) resulted in a slight acidic shift of exchange. These results support the view that the multiple charged residues identified in this study, along with several basic residues reported previously, participate in the regulation of the intracellular pH sensing of Na+/H+ exchanger 1. In addition, Glu131 may also be important for cation transport.

An increase in the coronary calcification score is associated with an increased risk of heart failure in patients without a history of coronary artery disease.

BACKGROUND: The presence of coronary artery calcification (CAC) and its severity predict future cardiovascular events and is used for risk stratification. However, the association of CAC with heart failure (HF) in patients without a history of coronary artery disease (CAD) remains unclear. This study aimed to determine the correlations of CAC with N-terminal pro-B-type natriuretic peptide (NT-proBNP) and HF events in patients without a history of CAD or HF. METHODS: From June 2010 to June 2013, a total of 487 patients without a history of CAD and HF were enrolled. All of the patients underwent plane multi-detector computed tomography. They were divided into four categories according to CAC scores: ≤10, 11-100, 101-400, and ≥401. RESULTS: The proportion of patients with high NT-proBNP levels increased with CAC categories (p<0.0001). The CAC score was associated with NT-proBNP levels ≥400pg/ml, with an odds ratio of 2.901 (95% confidence interval: 1.368-6.151, p=0.0055) for CAC scores ≥401 compared with CAC scores of 0-10 after adjustment for confounding factors. During the follow-up period of 497±315 days, nine patients were admitted for HF. Kaplan-Meier analysis showed that patients with CAC scores ≥401 had a lower rate of freedom from admission for HF with cumulative incidences of 0.4%, 1%, 2%, and 8% for CAC scores of 0-10, 11-100, 101-400, and ≥401, respectively (p<0.0001). Increasing CAC scores were associated with an increase in incidence of admission for HF, with a hazard ratio of 10.371 for CAC scores ≥401 (95% CI: 1.062-101.309, p=0.0443) compared with CAC scores of 0-10 after adjustment for risk factors. CONCLUSION: Severe CAC is an independent determinant of high NT-proBNP levels and a predictor of admission for HF in a population without a history of CAD or HF.

Serum cystatin C level is associated with left atrial enlargement, left ventricular hypertrophy and impaired left ventricular relaxation in patients with stage 2 or 3 chronic kidney disease.

BACKGROUND: Cystatin C is an endogenous marker of kidney function that overcomes the limitations of serum creatinine. High serum cystatin C levels have been associated with increased cardiovascular mortality and morbidity. In this cross-sectional study, we aimed to determine the associations between serum cystatin C levels and structural and functional cardiac changes in patients with stage 2 or 3 chronic kidney disease (CKD). METHODS AND RESULTS: We enrolled 429 consecutive patients (aged 24-97 years) with CKD stage 2 or 3 and left ventricular (LV) ejection fraction (LVEF)>40%. Echocardiographic parameters, including LV mass index (LVMI), early diastolic mitral annulus velocity (e' velocity), left atrial volume index (LAVI), and N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) were measured. Patients were categorized into quartiles according to serum cystatin C levels. Cystatin C was associated with LAVI (p=0.0055), LVEF (p=0.0432), LVMI (p=0.0409), e' (p=0.0051), E/e' (p=0.0027), and log-transformed NT-proBNP (p<0.0001) according to multivariate linear regression analysis, after adjustment for confounding factors including creatinine-based estimated glomerular filtration rate (eGFRcreat) and urinary albumin to creatinine ratio. Incidence of eccentric and concentric hypertrophy increased with increasing cystatin C (Q1, 38%; Q2 49%; Q3, 51%; Q4, 66%, p=0.0008), mainly because of increasing concentric hypertrophy (Q1, 30%; Q2, 39%; Q3, 39%; Q4, 51%, p=0.0187). CONCLUSION: A high serum cystatin C is strongly associated with structural cardiac abnormalities such as LVH and left atrial enlargement, impaired LV relaxation, and an increased NT-proBNP, independently of eGFRcreat in patients with stage 2 or 3 CKD.