Source of Energetic Protons in the 2014 September 1 Sustained Gamma-ray Emission Event.

We report on the source of > 300 MeV protons during the SOL2014-09-01 sustained gamma-ray emission (SGRE) event based on multi-wavelength data from a wide array of space- and ground-based instruments. Based on the eruption geometry we provide concrete explanation for the spatially and temporally extended γ -ray emission from the eruption. We show that the associated flux rope is of low inclination (roughly oriented in the east-west direction), which enables the associated shock to extend to the frontside. We compare the centroid of the SGRE source with the location of the flux rope's leg to infer that the high-energy protons must be precipitating between the flux rope leg and the shock front. The durations of the SOL2014-09-01 SGRE event and the type II radio burst agree with the linear relationship between these parameters obtained for other SGRE events with duration ≥ 3 hrs . The fluence spectrum of the SEP event is very hard, indicating the presence of high-energy (GeV) particles in this event. This is further confirmed by the presence of an energetic coronal mass ejection with a speed > 2000 km s - 1 , similar to those in ground level enhancement (GLE) events. The type II radio burst had emission components from metric to kilometric wavelengths as in events associated with GLE events. All these factors indicate that the high-energy particles from the shock were in sufficient numbers needed for the production of γ -rays via neutral pion decay.

Long-term Solar Activity Studies using Microwave Imaging Observations and Prediction for Cycle 25.

We use microwave imaging observations from the Nobeyama Radioheliograph at 17 GHz for long-term studies of solar activity. In particular, we use the polar and low-latitude brightness temperatures as proxies to the polar magnetic field and the active-regions, respectively. We also use the location of prominence eruptions as a proxy to the filament locations as a function of time. We show that the polar microwave brightness temperature is highly correlated with the polar magnetic field strength and the fast solar wind speed. We also show that the polar microwave brightness at one cycle is correlated with the low latitude brightness with a lag of about half a solar cycle. We use this correlation to predict the strength of the solar cycle: the smoothed sunspot numbers in the southern and northern hemispheres can be predicted as 89 and 59, respectively. These values indicate that cycle 25 will not be too different from cycle 24 in its strength. We also combined the rush to the pole data from Nobeyama prominences with historical data going back to 1860 to study the north-south asymmetry of sign reversal at solar poles. We find that the reversal asymmetry has a quasi-periodicity of 3-5 cycles.

Two-step forecast of geomagnetic storm using coronal mass ejection and solar wind condition.

To forecast geomagnetic storms, we had examined initially observed parameters of coronal mass ejections (CMEs) and introduced an empirical storm forecast model in a previous study. Now we suggest a two-step forecast considering not only CME parameters observed in the solar vicinity but also solar wind conditions near Earth to improve the forecast capability. We consider the empirical solar wind criteria derived in this study (Bz ≤ -5 nT or Ey ≥ 3 mV/m for t≥ 2 h for moderate storms with minimum Dst less than -50 nT) and a Dst model developed by Temerin and Li (2002, 2006) (TL model). Using 55 CME-Dst pairs during 1997 to 2003, our solar wind criteria produce slightly better forecasts for 31 storm events (90%) than the forecasts based on the TL model (87%). However, the latter produces better forecasts for 24 nonstorm events (88%), while the former correctly forecasts only 71% of them. We then performed the two-step forecast. The results are as follows: (i) for 15 events that are incorrectly forecasted using CME parameters, 12 cases (80%) can be properly predicted based on solar wind conditions; (ii) if we forecast a storm when both CME and solar wind conditions are satisfied (∩), the critical success index becomes higher than that from the forecast using CME parameters alone, however, only 25 storm events (81%) are correctly forecasted; and (iii) if we forecast a storm when either set of these conditions is satisfied (∪), all geomagnetic storms are correctly forecasted.

The hepatorenal syndrome.

HRS occurs frequently in patients with advanced cirrhosis of the liver and fulminant hepatitis. The pathogenesis of HRS is not clearly understood; reduced effective plasma volume and intense renal cortical vasoconstriction seem to have important roles. The HRS is a diagnosis by exclusion, and it [table: see text] is often difficult to differentiate this entity from prerenal azotemia and ATN. The HRS is characterized by its relentless progression and usually fatal outcome. The essential steps in the management of HRS are to identify and correct the precipitating factors leading to HRS and avoidance of potential hepatotoxic and nephrotoxic drugs. Patients with potentially reversible liver diseases should be treated aggressively. Volume expansion is important and should be tried first, even though hypovolemia may be not clinically evident. Dialysis may benefit patients with fluid overload and electrolyte imbalance or those awaiting liver transplantation. In selective cases, peritoneovenous shunt may be of value. Liver transplantation is the only curative therapy available at present.

Cardiac arrhythmias and electrocardiographic changes during upper and lower gastrointestinal endoscopy.

Ninety-two patients undergoing upper and lower gastrointestinal endoscopy were monitored with holter recording for electrocardiographic changes during the procedures. The electrocardiographic changes were seen in 20.6% of the patients. These included cardiac arrhythmias in 16.2% and ischemic ST-T changes in 4.4% of the patients. The incidence of these changes was more in patients with cardiac (36%) or pulmonary disease (25%) than in patients with no clinical cardiac or pulmonary problem (16%). The patients with baseline electrocardiographic abnormalities also showed higher incidence of such electrocardiographic changes during the endoscopic procedures when compared with patients with normal baseline electrocardiograms (32% vs. 16%).

Prostaglandin E1 binds to Z protein of rat liver.

Z protein or fatty-acid-binding protein is abundant in the cytosol of many cell types including liver cells. It is considered to play an important role in intracellular transport and metabolism of long-chain fatty acids and other organic anions. We studied the role of Z protein in the metabolism of prostaglandin E1 (PGE1). Binding of tritiated prostaglandin E1 to this fatty-acid-binding protein (Z protein) purified from rat liver was determined. The binding of [3H]prostaglandin E1 to Z protein is rapid, saturable and reversible. Scatchard analysis of [3H]PGE1 binding to Z protein showed a single class of binding sites with a dissociation constant (Kd) of 37 nM. The binding capacity is 110 nmol/mg Z protein. Optimal [3H]PGE1 binding occurred at pH 7.4. The presence of 3 mM MgCl2 stimulated the prostaglandin E1 binding to Z protein. Competition experiments show that the binding of this autacoid to Z protein is highly specific. It could not be displaced by other prostaglandins (PGA1, PGA2, PGE2, PGB1, PGI2, PGD2, PGF2 alpha, and 6-keto PGF1 alpha). Z protein might be involved in the metabolism of prostaglandins in the cytosol.

Upper gastrointestinal bleeding in acute mesenteric thrombosis.

We report an unusual case of upper gastrointestinal bleeding secondary to superior mesenteric vein thrombosis and review the literature to assess the frequency of upper GI bleeding in patients with superior mesenteric vascular disease. Clinical features and laboratory and radiological findings are nonspecific; endoscopy and abdominal angiograms are helpful to rule out the common causes of GI bleeding and to suspect the diagnoses of superior mesenteric vein thrombosis. Without early surgical intervention, mortality is close to 100%.

Risks of intra-abdominal nonshunt surgery in cirrhotics.

We have reviewed the risks of various nonshunt intra-abdominal operations in cirrhotic patients. Most of these studies are retrospective reviews with limitations. Among various risk stratifications in cirrhosis, Child-Pugh classification is sufficiently informative. Elective surgery can be done safely in patients with Child's A or B class. Operations in Child's C patients and emergent surgery carry formidably high mortality. Limiting the extent of surgery, controlling ascites, correcting coagulation abnormality and malnutrition and aggressively treating infection, might reduce mortality. Laparoscopic cholecystectomy and endoscopic sphincterotomy in cirrhotics seem to be promising in reducing mortality and morbidity.

Hepatobiliary complications of inflammatory bowel disease.

Clinically significant liver and biliary disorders occur in approximately 5 percent of persons with inflammatory bowel disease. The most common hepatobiliary disorders encountered in patients with inflammatory bowel disease are fatty liver, sclerosing cholangitis and gallstones. In addition, chronic hepatitis, cirrhosis, biliary cancer and amyloidosis sometimes occur. Family physicians should be alert for these gastrointestinal problems in patients with inflammatory bowel disease.

Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding.

BACKGROUND: It has been customary to initiate feeding through percutaneous endoscopic gastrostomy (PEG) tubes 24 hours or more after placement of these tubes. Recent changes in practice environment and emphasis on early discharge of hospitalized patients prompted us to evaluate early PEG feeding in a randomized prospective manner. METHODS: Forty-one patients were included in the study. After an informed consent, the patients were randomly assigned to two groups. Groups I (21 patients) received tube feedings 3 hours and Group II (20 patients) received feedings 24 hours after PEG placement. All patients received an Iso-osmolar formula by continuous infusion at 30 ml/hour for the first 24 hours of feeding. The rates were then increased to 70 ml/hour. Residual volumes, tube length, peristomal leakage, and vital signs were checked, and a global assessment was done every 4 hours. Evaluation by a physician was done every 24 hours for 72 hours. If the residual volume was more than 60 ml (significant residual volume), the tube feedings were held for 2 hours. Patients exited the study at 72 hours from the time of procedure. All deaths were recorded to calculate 30-day mortality. RESULTS: One patient (Group 2) died during the study period. Three patients (two in Group 1 and one in Group 2) had a significant residual volume. One patient (Group 1) had local skin infection requiring treatment. None of the patients had any signs of peritonitis or systemic infection. CONCLUSION: Early PEG tube feeding (3 hours after tube placement) is as safe as next day feeding in elderly patients.

Double-lumen esophagus: formation of a new lumen or septation of the existing one?

Presented here are two cases in which two esophageal lumens were identified at endoscopy. One patient had a history of antireflux surgery and both patients had received esophageal dilations. Both patients have done poorly with standard esophageal dilation and are not considered likely to gain from surgery. The mechanism of formation of the second lumen is not certain in Case 1, but in Case 2 a self-contained perforation appears to be the likely mechanism. There is no clear definition of "double-lumen esophagus" in the literature. The term is used at times interchangeably with esophagogastric fistula. We propose that the phrase "double-lumen esophagus" is a morphologic description and should be used only when the two lumens are of nearly equal diameter. The term "fistula" should be used whenever that is the likely mechanism. Hence, Case 1 of our report is the true double-lumen esophagus, while Case 2 is an esophagogastric fistula. Since patients do poorly with standard dilation, newer endoscopic modalities may have a role in the management of these rare but difficult cases.

Length of esophageal cancer and degree of luminal stenosis during upper endoscopy predict T stage by endoscopic ultrasound.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) is considered to be the most accurate modality for T staging of esophageal cancer. This study attempted to determine whether endoscopic features such as the length and degree of luminal stenosis in esophageal cancer can predict the T stage on EUS. PATIENTS AND METHODS: Thirty-five patients with newly diagnosed esophageal adenocarcinoma or squamous-cell carcinoma undergoing EUS prior to initiation of any treatment were included in the study. The length of the tumor was assessed prospectively during esophagogastroduodenoscopy (EGD) before EUS in 22 patients. Radial EUS was then performed in these patients. The other 13 patients had sufficient luminal stenosis to prevent complete advancement of the echo endoscope through the tumor. In these 13 patients, the length of the esophageal cancer was not examined, but the T and N stage up to the level of maximum advancement of the echo endoscope through the tumor were noted. RESULTS: All 13 patients with luminal stenosis had at least a T3 (n = 12) or T4 (n = 1) lesion up to the level of maximum advancement of the echo endoscope. Among the 22 patients in whom the length of the esophageal cancer was measured, the mean length in the 13 patients with a T1 or T2 lesion on EUS was 2.6 cm. The mean length in the nine patients with T3 esophageal cancer was 7.1 cm. The difference in the mean length of T1 or T2 lesions (2.6 cm) was significantly different ( P < 0.001) from the mean length of T3 lesions (7.1 cm). Using a clinical diagnostic testing approach, when > or = 5 cm length was used as a criteria for diagnosing T3 lesions, the sensitivity was 89 %, specificity 92 %, positive predictive value 89 %, and negative predictive value 92 %. There was also a suggestion of increased chances of lymph-node metastases with increasing length of esophageal cancer. CONCLUSIONS: In esophageal carcinoma, endoscopic features such as the length of the cancer and the degree of luminal stenosis correlate with T staging on EUS. Esophageal cancers that are > or = 5 cm in length, or are sufficiently stenotic to prevent passage of an endoscope, are much more likely to be T3 or higher-stage lesions, while those that are < 5 cm in length have a greater chance (92 %) of being T1 or T2.

Retrospective analysis of missed advanced adenomas on surveillance colonoscopy.

OBJECTIVE: Miss rates of large polyp/cancer during colonoscopy are reported from tertiary centers where experts do the colonoscopies. This information is important for determining surveillance intervals for repeat colonoscopy, patient safety, and malpractice issues. We evaluated retrospectively the miss rates of advanced adenomas in the setting of a GI fellowship training where most colonoscopies are done by closely supervised fellows. METHODS: We reviewed the 235 patients who had at least one repeat colonoscopy after initial polypectomy, between 1992 and 1999, at the Dayton Veterans Affairs Medical Center. Advanced adenomas were defined as polyps 10 mm or greater in size with or without a villous component or high-grade dysplasia. Data of missed advanced adenomas on 122 patients who had complete colonoscopy with satisfactory preparation and the excluded patients are reported. RESULTS: Four advanced adenomas (one had intramucosal cancer) on second colonoscopy and two advanced adenomas on third colonoscopy were missed. The miss rate of advanced adenoma for 232 patients was 1.7%, and the miss rate for the 122 patients with complete colonoscopy and satisfactory colon preparation was 2.5% and 3.3% on second and third repeat colonoscopy, respectively. No cancer was missed. CONCLUSIONS: The present study shows an advanced polyp miss rate that is comparable with other studies even in a fellowship training setting. Prospective studies with tandem surveillance colonoscopy are needed to confirm our findings.

Is in vivo measurement of size of polyps during colonoscopy accurate?

BACKGROUND: Accurate measurement of polyp size during colonoscopy is important because of the direct correlation of size with colon cancer. Major studies of colorectal neoplasms have measured polyp size differently. It is also well documented that endoscopists underestimate polyp size frequently. The goal of this prospective study was to determine which one of the five methods of estimating polyp size during colonoscopy is most accurate. METHODS: One hundred colon polyps were measured by means of visual estimation, open biopsy forceps methods, linear probe, a ruler immediately after excision, and after fixation in formalin. The size of the polyps measured outside the body immediately after excision was considered the "gold standard" against which all measurements were compared. RESULTS: Forty-seven polyps were 5 mm or less in diameter, 33 polyps were 5.01 mm to 10 mm, and 20 polyps were more than 10 mm in size. For all polyps the mean difference versus the actual size of the polyps was 3.4% for linear probe, 6.4% for visual estimation, and 12.3% for the forceps. CONCLUSION: Measurement of polyp size by linear probe agreed best with the actual polyp size, followed closely by visual estimation. The open biopsy forceps method was the least accurate.

Intraoperative endoscopic ultrasonography in Zollinger-Ellison syndrome.

In a 46-year-old man with Zollinger-Ellison syndrome, multiple imaging studies were negative for a primary gastrinoma. Preoperative endoscopic ultrasonography (EUS) revealed a 3.3-cm mass which appeared to be in the pancreatic head. During surgery, a celiac lymph node of the size of the mass seen by EUS was found, but the pancreatic head also felt firm and was suspicious for a mass. After resection of the celiac node, intraoperative EUS revealed no mass in the pancreatic head. Based upon intraoperative EUS findings, the pancreatic head was not resected. Histologic evidence of gastrinoma was found in the celiac lymph node and a 4 to 5 mm nodule in the duodenal wall. Postoperatively serum gastrin levels returned to normal.

Endoscopic ultrasound miniprobe-guided steroid injection for treatment of refractory esophageal strictures.

Local injection of corticosteroids into refractory esophageal strictures to decrease the restenosis rate has been reported. Here we report our efforts in three patients to render the delivery of steroids more precise, by injecting them in the thickest segment of the stricture with the guidance of a high frequency ultrasound miniprobe passed through a regular upper endoscope. Steroid injection under ultrasound miniprobe guidance may be indicated for patients who do not respond to a "blind" steroid injection without miniprobe guidance.

A comparative study of eight fecal occult blood tests and HemoQuant in patients in whom colonoscopy is indicated.

BACKGROUND AND OBJECTIVE: Some studies suggest that immunochemical fecal occult blood tests (FOBTs) and HemoQuant are more efficient at detecting fecal occult blood than the commonly employed Hemoccult II (guaiac) test. We undertook this study to determine whether an immunochemical test either alone or in combination with a guaiac test gives efficiency superior to the Hemoccult II test in predicting significant gastrointestinal tract disease. DESIGN: Criterion standard, prospective, blinded. SETTING: Referral population of ambulatory patients at an institutional and a private hospital. PATIENTS: Eight-one patients referred to a gastroenterologist and in whom colonoscopy was indicated. INTERVENTIONS: While on a restricted diet, patients made preparations for FOBTs from three consecutive bowel movements. Patients then underwent colonoscopy. Polyps larger than 1 cm in size, carcinoma of the colon, peptic ulcers, gastric erosions, and angiodysplasia were considered to be likely causes of occult gastrointestinal tract bleeding. MAIN OUTCOME MEASURES: Using colonoscopy results as the reference standard, sensitivity, specificity, and positive and negative predictive values for each of eight tests or pair of tests were compared with those of Hemoccult II. RESULTS: Of 81 patients, 10 had significant lower gastrointestinal tract lesions and six had significant upper gastrointestinal tract lesions. Hemoccult SENSA, Heme-Select, and FECA-EIA were shown to be more sensitive than Hemoccult II but slightly less specific. Paired tests showed less efficiency than Hemoccult II alone. CONCLUSIONS: We did not find an ideal test or pair of tests; however, Hemoccult SENSA exhibited higher sensitivity than Hemoccult II and many other tests. The sensitivity, specificity, and positive predictive values of many of the FOBTs were believed to be low. We recommend that physicians consider FOBTs only as adjuncts to history and physical examination findings in deciding how to proceed in diagnosing gastrointestinal tract disease.

A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease.

BACKGROUND: In view of controversy about the association of aortic stenosis and angiodysplasia of the gut, we performed a prospective, controlled study to evaluate the relationship between aortic valve disease and gastrointestinal angiodysplasia. METHODS: Forty patients who had endoscopy for clinical indications such as gastrointestinal bleeding, anemia, polyps, colon cancer, and dyspepsia, and who were found to have angiodysplasia of the gastrointestinal tract, underwent two-dimensional and Doppler echocardiography. Thirty-seven controls matched for age, sex, indication, and nature of endoscopic examination, but without angiodysplasia, underwent similar echocardiographic examination. RESULTS: None of the patients in either group had aortic stenosis. The prevalence of aortic sclerosis, aortic insufficiency, and low left ventricular ejection fraction was similar in patients with and without angiodysplasia. CONCLUSIONS: This study does not support the role of aortic valve disease as the cause of angiodysplasia of the gastrointestinal tract. A subgroup of patients with angiodysplasia with aortic sclerosis, with or without other valvular disease (but none with aortic stenosis), had increased prevalence of gastrointestinal bleeding when compared with controls. When aortic valve disease or decreased left ventricular ejection fraction were analyzed as independent predictors, none of them in and of itself appeared to be a factor in bleeding from these gastrointestinal lesions.

Stromal eosinophilia in colonic epithelial neoplasms.

OBJECTIVE: The purpose of this retrospective study was to determine the frequency and intensity of eosinophilic infiltration (or tissue eosinophilia) in the stroma of colonic adenomas, hyperplastic polyps, and colorectal adenocarcinomas. Eosinophilic infiltration in various malignancies has been reported but has not been evaluated in benign colorectal adenomas and hyperplastic polyps. METHODS: We analyzed 488 colonic neoplasms: 176 tubular adenomas, 55 tubulovillous adenomas, 82 villous adenomas, 15 early carcinomas in polyps, 95 invasive adenocarcinomas, and 65 hyperplastic polyps for the presence of eosinophilic infiltration. The eosinophilic infiltration was graded as negative (< or =5%), mild to moderate (>5-40%), or marked (>40%), depending on the percentage of eosinophils relative to total inflammatory cells in the stroma. RESULTS: Mild to moderate eosinophilia was noted in 75% of all adenomas. The transitional zone in all cases of invasive adenocarcinoma (zone between normal tissue and adenocarcinoma) revealed a high percentage of tissue eosinophilia. There was a striking absence of TE in the stroma of invasive adenocarcinomas. Only 5% of hyperplastic polyps had any eosinophilic infiltration. CONCLUSIONS: These data suggest that, in the spectrum of colonic neoplasms, stromal eosinophilia is most prominent in adenomas and seems to decrease with progression through the adenoma-carcinoma sequence. The ramifications of this study may alter management plans and provide some prognostic information for clinical evaluation.

Hepatobiliary dysfunction as the initial manifestation of disseminated cryptococcosis.

A case of hepatobiliary dysfunction as the initial manifestation of disseminated cryptococcosis is described. The patient was admitted with symptoms of hepatitis with cholestatic jaundice. Antibody tests for hepatitis B and C and human immunodeficiency virus were negative. The patient continued to deteriorate clinically. Eventually, the patient succumbed to hepatic failure. Autopsy disclosed systemic cryptococcosis that caused extensive necrosis of the liver. In review of the literature, only nine cases of cryptococcal infection presenting as hepatitis, cholangitis, and cholecystitis as initial manifestation were reported. Four of these patients had been subjected to exploratory laparotomy for clinical suspicion of acute abdomen. One patient developed cirrhosis as a result of cryptococcal hepatitis. Two patients succumbed to hepatic failure. Cryptococcosis is known to occur commonly in immunocompromised patients, yet only two reported cases presenting as hepatitis were associated with immunocompromised status.