Development of a new classification for in vivo diagnosis of duodenal epithelial tumors with confocal laser endomicroscopy: A pilot study.

BACKGROUND AND AIM: Confocal laser endomicroscopy (CLE) has been established for in vivo diagnosis of various gastrointestinal diseases. However, validated criteria for confocal diagnosis of duodenal tumors do not exist. Therefore, the aim of the present pilot study was to develop a novel classification for in vivo optical diagnosis of duodenal tumors using CLE. METHODS: Consecutive patients with duodenal tumorous lesions were included. First, an initial classification system was developed which was then validated. Histopathology was used as a reference standard. RESULTS: A simple classification system for in vivo diagnosis of duodenal epithelial tumors using CLE was developed. Sensitivity, specificity, and accuracy were 90%, 100%, and 97%, respectively. Positive and negative predictive values were calculated as 100% and 96%. The kappa coefficient representing consistency was 1 between observers and within each observer. CONCLUSION: A new classification for in vivo diagnosis of duodenal epithelial tumors using confocal imaging has been developed. The new classification system allows adequate prediction of histology and could therefore be used to guide subsequent therapy of duodenal lesions.

Is narrow-band imaging useful for histological evaluation of gastric mucosa-associated lymphoid tissue lymphoma after treatment?

BACKGROUND AND AIM: Endoscopic diagnosis of stomach mucosa-associated lymphoid tissue (MALT) lymphoma is often difficult because few specific findings are indicated. Even when MALT lymphoma is suspected by endoscopy, it is still difficult to make a definitive diagnosis by biopsy because lymphoma cells sometimes distribute unevenly. We previously reported that a tree-like appearance (TLA) is a characteristic finding of MALT lymphoma by narrow-band imaging (NBI) magnifying endoscopy and it is valuable in the selection of an optimal biopsy site in MALT lymphoma. Here, we study the frequency of TLA and evaluate the relationship between the response to eradication therapy and TLA in MALT lymphoma. METHODS: We retrospectively examined the clinical background, endoscopic findings, response to eradication therapy, and Helicobacter pylori infection status of 16 patients diagnosed with MALT lymphoma who were referred to our hospital from April 2007 to August 2012. The regimen for eradicationtherapy consisted of rabeprazole, with amoxicillin and clarithromycin, all given for 7 days. RESULTS: TLA was found in 75% (12/16) and H. pylori infection in 75% (12/16) of patients diagnosed with MALT lymphoma by NBI magnifying endoscopy. In all complete regression (CR) patients after eradication treatment, the TLA finding had disappeared (100%); however, in the non-CR patients, TLA remained the same as before the eradication therapy (P=0.002). CONCLUSION: These results suggest that NBI magnifying endoscopy may be useful not only in the diagnosis but also in the evaluation of the response to eradication therapy of MALT lymphoma of the stomach.

Usefulness of cross-table lateral view radiograph for the diagnosis of cam-type femoroacetabular impingement.

The purpose of this study was to examine the usefulness of cross-table view in the clinical diagnosis of cam-type femoroacetabular impingement (FAI). We measured the α angles on radiographs taken in cross-table lateral view in 39 hips with cam-type FAI and compared with those measured in 45 control hips. Alpha angles ranged from 30° to 78° (mean 56°) in the control group and from 47° to 120° (mean 81.1°) in the FAI group. From a canonial discriminant analysis, the cutoff value of α angle was 68.2°. Sensitivity analysis showed a sensitivity of 87.18 %, specificity of 88.89 %, and accuracy of 88.3 %. Cross-table lateral view is useful for the diagnosis of cam-type FAI.

Reliability and validity of the Japanese Orthopaedic Association hip disease evaluation questionnaire (JHEQ) for patients with hip disease.

BACKGROUND: The Japanese Orthopaedic Association hip disease evaluation questionnaire (JHEQ) was developed to evaluate the quality of life (QOL) in patients with hip disease. This questionnaire consists of three subscales: pain; movement; and mental. The purpose of this study was to assess the reliability and validity of the JHEQ for use as a clinical evaluation tool. METHODS: We investigated patients who visited the outpatient department at our hospital and affiliated hospital between April and May 2010. The study population comprised 286 patients (239 women) with a mean age of 56.8 years. The diagnosis was osteoarthritis of the hip in 230 patients, avascular osteonecrosis of the femoral head in 49 patients, and other conditions in 7 patients. The JHEQ questionnaire, the SF-36 questionnaire as a generic QOL scale, and the Oxford hip score (OHS) as a disease-specific scale, were filled out by the patient while waiting in the outpatient department. RESULTS: Pearson's correlation coefficients of 0.6 were observed between JHEQ pain and SF-36 bodily pain (BP) subscales, and between JHEQ movement and SF-36 physical functioning (PF) subscales. The JHEQ mental subscale correlated with SF-36 social functioning (SF) and BP subscales. A strong negative correlation was seen between JHEQ pain and OHS pain subscales (r = -0.817). JHEQ movement subscale also showed a strong negative correlation with the OHS function subscale (r = -0.715). These results indicated the convergent validity of JHEQ. The internal consistency of pain, movement, and mental subscales of JHEQ was satisfactory, indicated by Cronbach's α coefficients of 0.92, 0.91, and 0.94, respectively. Each subscale also showed high test-retest reliability with intra-class correlation coefficients of 0.89, 0.93, and 0.85, respectively. CONCLUSIONS: We determined the reliability and validity of JHEQ as a self-administered questionnaire that evaluates hip disease. JHEQ is useful as a tool for evaluating patients with hip disease.

Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ): a patient-based evaluation tool for hip-joint disease. The Subcommittee on Hip Disease Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association.

BACKGROUND: The Japanese Orthopaedic Association Hip Score is widely used in Japan, but this tool is designed to reflect the viewpoint of health-care providers rather than that of patients. In gauging the effect of medical therapies in addition to clinical results, it is necessary to assess quality of life (QOL) from the viewpoint of patients. However, there is no tool evaluating QOL for Japanese patients with hip-joint disease. METHODS: With the aim of more accurately classifying QOL for Japanese patients with hip-joint disease, we prepared a questionnaire with 58 items for the survey derived from 464 opinions obtained from approximately 100 Japanese patients with hip-joint disease and previously devised evaluation criteria. In the survey, we collected information on 501 cases, and 402 were subjected to factor analysis. From this, we formulated three categories-movement, mental, and pain-each comprising 7 items, for a total of 21 items to be used as evaluation criteria for hip-joint function. RESULTS: The Cronbach's α coefficients for the three categories were 0.93, 0.93, and 0.95, respectively, indicating the high reliability of the evaluation criteria. The 21 items included some related to the Asian lifestyle, such as use of a Japanese-style toilet and rising from the floor, which are not included in other evaluation tools. CONCLUSIONS: This self-administered questionnaire may become a useful tool in the evaluation of not only Japanese patients, but also of members of other ethnic groups who engage in deep flexion of the hip joint during daily activities.

A comparison of three different concentrations of ropivacaine with fentanyl for patient-controlled epidural analgesia.

BACKGROUND: The optimal concentration of ropivacaine in combination with fentanyl for patient-controlled epidural analgesia focusing on preservation of bowel function, analgesia, and motor function remains unclear. METHODS: Three hundred-twelve women scheduled to undergo gynecologic lower abdominal surgery, were randomly allocated to receive ropivacaine 0.05, 0.075, or 0.1% in combination with fentanyl 4 mug/mL and droperidol 25 microg/mL. The settings of patient-controlled epidural analgesia were as follows: initial loading volume 5 mL, background infusion 2 mL/h during night-time, no background infusion during daytime, bolus volume 2 mL, and lockout interval 10 min. Bowel function was evaluated by the first passage of flatus and feces. Pain was assessed with a visual analog scale, and motor function was examined by modified Bromage scale. Data were collected in the evening on the day of surgery, in the morning and in the evening on the first postoperative day, and in the morning on the second postoperative day. RESULTS: Gastrointestinal motility was not different among the three groups. All three solutions produced equivalent analgesia and no motor blockade. CONCLUSION: We conclude that ropivacaine 0.05% is sufficient to preserve gastrointestinal motility, and provides excellent postoperative pain relief without motor blockade.

Lower limits of hematocrit and mixed venous oxygen saturation ensuring sufficient cerebral oxygenation during hemodilution in rabbits.

OBJECTIVES: We have assessed clinically systemic tissue oxygenation by monitoring mixed venous oxygen saturation (SvO2) in addition to hematocrit (Hct) during cardiopulmonary bypass. Based on results of experimental studies together with clinical experience, we previously defined the lower limits of the critical range as an Hct of 12% and an SvO2 of 46%. However, these values do not provide direct information about cerebral oxygenation. This study was performed to identify critical values for these variables that would be able to ensure sufficient jugular venous oxygen saturation (SjO2), which reflects global cerebral oxygenation. METHODS: Normovolemic hemodilution was performed in ten rabbits. Hct, SvO2 and SjO2 were measured every 7 minutes. The safety limit for cerebral oxygenation was defined as an SjO2 of 50% based on studies of Croughwell et al. and Cook et al. The limit point was defined as 7 minutes before the time that the SjO2 decreased below 50% for the first time. RESULTS: Minimal values for Hct and SvO2 to maintain SjO2 at 50% or more during normovolemic normothermic hemodilution, expressed as the 95% confidence interval, were Hct of 7.4% to 10.0% and SvO2 of 41.8% to 51.4%. CONCLUSION: Adopting the higher values of these pairs, safety limits for cerebral oxygenation would be an Hct of 10.0% and an SvO2 of 51.4%. In conclusion, our experiments in rabbits suggest new safety limits during normovolemic normothermic hemodilution of Hct of 12% and SvO2 of 52%, taking both whole-body and cerebral oxygenation into consideration.

Usefulness of training using animal models for colorectal endoscopic submucosal dissection: is experience performing gastric ESD really needed?

BACKGROUND AND STUDY AIMS: Despite the clinical advantages of colorectal endoscopic submucosal dissection (ESD), an effective training system, especially for Western endoscopists, has been challenging to establish. Herein, we propose a novel training program using ex vivo animal models and evaluate the learning curve of colorectal ESD trainees without gastric ESD experience. PATIENTS AND METHODS: A total of 80 colorectal lesions were prospectively collected and removed by two novice operators. Before human ESD procedures, they received ESD training using an ex vivo porcine "proximal colon" model, which simulates a lumen with many folds and flexions. To assess the validity of our training system, the self-completion and en bloc R0 resection rates, the operation time, and prevalence of complications were compared between the first and latter period. Moreover the factors associated with prolonged operation time were evaluated. RESULTS: The overall rates of self-completion and en bloc R0 resection were 98 % (78/80) and 100 % (80/80), respectively. The operation time during the first period was significantly longer than that during the latter period (86 ±â€Š50 minutes vs. 60 ±â€Š36 minutes, P = 0.01). Regarding complications, only two cases of perforations and delayed hemorrhage were observed during the first period; however, all of the complications were successfully managed endoscopically. The presence of fibrosis was identified as a significant independent predictor of a prolonged operation time during the first period (coefficient, 5.90; 95 %CI, 2.36 - 9.44, P = 0.002). CONCLUSIONS: Our trainees achieved high rates of self-completion and R0 resection without severe complications even during the first 20 cases, suggesting that our training programs using ex vivo animal models are useful for trainees without gastric ESD experience. STUDY REGISTRATION: UMIN000013566.

Distinct diagnostic criteria for ultrasonographic examination of papillary thyroid carcinoma: a multicenter study.

Recent advances permitting high-resolution ultrasonography have made ultrasonographic examination of nodular thyroid diseases an accessible examination for routine practice. However, diagnostic criteria for ultrasonographic examination of thyroid nodules are not surely established. To identify the optimal strategy for well standardized differential diagnosis of papillary thyroid carcinoma and benign nodules, we evaluated the significance of individual ultrasonographic characteristics of thyroid nodules in a multicenter study. Ten characteristics in ultrasonograms from 53 patients scored by 17 investigators from 15 centers were analyzed by t tests and logistic regression analyses. Between benign and papillary thyroid cancer groups, all characteristics but not size or multiplicity of strong echoes, which suggest calcifications, were significant parameters. Logistic regression analyses showed that border character, shape, and internal echo level are highly significant parameters (p < 0.0005). A multiple logistic regression showed to be the most important predictors of pathologic diagnosis. The diagnostic criterion with border character and internal echo level yielded 93% sensitivity and 92% specificity. In conclusion, univariate and multivariate analyses identified border character, shape, internal echo level, but not strong echoes (calcifications), as important characteristics in differentiating papillary thyroid carcinoma from benign nodules. These results will contribute to standardization of accurate ultrasonographic diagnosis of papillary thyroid carcinoma.

Clinical assessment after total hip arthroplasty using the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire.

AIMS: The aim of this study was to evaluate clinical outcomes using the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ). METHODS: 100 consecutive patients at 6 months after total hip arthroplasty (THA) were evaluated. RESULTS: The improvement rate for the pain subscale was significantly higher than that for the movement and mental subscales. Preoperative scores on the JHEQ movement and mental subscales were positively correlated to scores on the same subscales at 6 months after surgery. CONCLUSION: We conclude that the most predictable aspect of THA is pain relief and preoperative hip-joint ROM and mental status influence 6-month postoperative outcomes.

Methylenetetrahydrofolate reductase genotype, vitamin B12, and folate influence plasma homocysteine in hemodialysis patients.

Hyperhomocysteinemia, a well-recognized cardiovascular risk factor, is frequent in hemodialysis (HD) patients. A common polymorphism in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, C-->T substitution at nucleotide 677, is associated with homocysteine (Hcy) level elevation. We examined whether three factors involved in the methionine cycle could influence plasma Hcy concentrations in HD patients: MTHFR polymorphism; vitamin B12, an essential cofactor; and folate, the substrate. In a cross-sectional study, serum vitamin B12, folate, and plasma Hcy were measured and MTHFR genotyping was performed in 534 HD patients. Effects of MTHFR genotypes, vitamin B12, and folate on plasma Hcy levels were examined in 450 HD patients not administered vitamin B12 or folate. To examine the effect of vitamin B12 on plasma Hcy concentrations, we compared plasma Hcy concentrations in HD patients with and without vitamin B12 supplementation. To examine whether functional vitamin B12 deficiency exists even in HD patients with normal vitamin B12 concentrations, 15 HD patients (serum vitamin B12 concentrations, 250 to 2,100 pg/mL) were treated with vitamin B12 (mecobalamin, 1.5 mg/d) for 8 weeks. Serum concentrations of methylmalonic acid (MMA) and vitamin B12 were measured. Hcy levels were higher and folate levels were lower in patients with the TT and CT genotypes compared with patients with the CC genotype. Analysis of covariance to determine independent predictors of high Hcy levels identified low serum vitamin B12 and folate levels and high albumin (Alb) levels in CC-genotype patients, low folate levels and high Alb levels in CT-genotype patients, and low folate levels in TT-genotype patients. Plasma Hcy levels were lower in CC- and CT-genotype patients with vitamin B12 supplementation than in those without supplementation. Vitamin B12 supplementation for 8 weeks significantly reduced MMA concentrations in HD patients with normal serum vitamin B12 concentrations. These results indicate that MTHFR genotype influences the correlation of Hcy level with vitamin B12 and folate levels in HD patients. Functional vitamin B12 deficiency may exist, even in HD patients with normal vitamin B12 concentrations. The efficacy of vitamin B12 and folate supplementation on plasma Hcy levels may depend on MTHFR genotype.

Effects of 10-day confinement on the immune system and psychological aspects in humans.

We investigated the changes in percentages of leukocyte subpopulations, natural killer (NK) cells, CD69-expressing lymphocytes, and psychological aspects in 10 subjects who participated in a 10-day confinement study. Suppression of lymphocyte proliferative reaction and changes in leukocyte distribution are known to occur in space. These responses are similar to those induced by psychological stress. Ground-based confinement studies are suitable for validating the effects of stress arising only due to confinement. Two groups, consisting of five male subjects (ages 20-27 yr, mean 22.8 yr) each, participated in a 10-day confinement study. Blood samples were taken once before, three times during, and once after the confinement and activated with an anti-CD2 agonistic antibody cocktail. The percentages of leukocyte subpopulations, NK (CD45(+)CD56+) cells, and activated lymphocytes (CD45(+)CD69+) were measured by flow cytometric assay. The face scale test was used to measure psychological aspects. The percentage of CD69+ lymphocytes decreased during the period of confinement. This was mostly caused by changes in the ratio between NK and non-NK lymphocytes. The face scale showed that the subjects' moods improved toward the postconfinement period. Consistent with the face scale, the percentages of innate immune cells, such as NK cells and granulocytes, increased during the postconfinement period. We concluded that the changes in the distribution of immune cells caused by stress plays an important role in suppression of proliferative reactivity. The observed physiological reactions were specific to the confined environment, and the stress caused by confinement plays a role in the immune changes observed in space.

Status of the gastric mucosa with endoscopically diagnosed gastrointestinal stromal tumor.

Background. Since gastrointestinal stromal tumor (GIST) is a mesenchymal submucosal tumor, the endosonographic, CT, and MRI features of gastric GISTs have been widely investigated. However, the GIST-bearing gastric mucosa status has not been reported. Objective. To characterize the GIST-bearing gastric mucosa status in terms of the degree of inflammation and atrophy, assessed endoscopically. Subjects and Methods. The subjects were 46 patients with submucosal tumors (histologically proven gastric GISTs) who had undergone upper gastrointestinal endoscopy in our hospital between April 2007 and September 2012. They were retrospectively evaluated regarding clinicopathological features, the endoscopically determined status of the entire gastric mucosa (presence or absence and degree of atrophy), presence or absence and severity of endoscopic gastritis/atrophy (A-B classification) at the GIST site, and presence or absence of H. pylori infection. Results. Twenty-three patients had no mucosal atrophy, but 17 and 6 had closed- and open-type atrophy, respectively. Twenty-six, 5, 12, 1, 1, and 1 patients had grades B0, B1, B2, B3, A0, and A1 gastritis/atrophy at the lesion site, respectively, with no grade A2 gastritis/atrophy. Conclusion. The results suggest that gastric GISTs tend to arise in the stomach wall with H. pylori-negative, nonatrophic mucosa or H. pylori-positive, mildly atrophic mucosa.

Development of an evaluation system for foot arch types in the elderly using foot pressure distribution data.

The foot arch serves important functions related to shock absorption and the action of walking. Simple and quantitative classifications of foot arch types, such as flat feet and high arches, help to provide health support services for the elderly. To develop an evaluation system for foot arch types using foot pressure distribution data, discriminant analyses were conducted using data from healthy elderly persons. The midfoot pressure ratio was selected and discriminants were derived. For evaluating the performance of the classification method, the derived discriminants were applied to the data from the other group of healthy elderly persons. Results indicate that both sensitivity and specificity of the classified foot arch types were sufficiently high.

Chlamydia pneumoniae: comparison with findings of Mycoplasma pneumoniae and Streptococcus pneumoniae at thin-section CT.

PURPOSE: To retrospectively compare thin-section computed tomographic (CT) findings of Chlamydia pneumoniae pneumonia with those of Streptococcus pneumoniae pneumonia and Mycoplasma pneumoniae pneumonia. MATERIALS AND METHODS: Institutional review board and patient informed consent were not required. Twenty-four patients with C pneumoniae pneumonia (17 men, seven women; age range, 19-89 years) underwent thin-section CT; 41 patients with S pneumoniae pneumonia (28 men, 13 women; age range, 19-91 years) and 30 patients with M pneumoniae pneumonia (20 men, 10 women; age range, 16-67 years) were also enrolled. Thin-section CT scans of each patient were retrospectively and independently assessed by two chest radiologists for consolidation, ground-glass opacity (GGO), bronchovascular bundle thickening, nodules, pleural effusion, lymphadenopathy, reticular or linear opacity, airway dilatation, pulmonary emphysema, and bilateral lung involvement. Consensus was reached for disagreements. The frequency of each finding was compared among the three types of pneumonia by using the chi2 test. RESULTS: For C pneumoniae pneumonia, CT demonstrated consolidation in 20 patients, GGO in 13, bronchovascular bundle thickening in 17, nodules in 18, pleural effusion in six, lymphadenopathy in eight, reticular or linear opacity in 15, airway dilatation in nine, pulmonary emphysema in 11, and bilateral lung involvement in 12. Bronchovascular bundle thickening (P = .022) and airway dilatation (P = .034) were significantly more frequent in patients with C pneumoniae pneumonia than in those with S pneumoniae pneumonia. Reticular or linear opacity (P = .017), airway dilatation (P = .016), and associated pulmonary emphysema (P = .003) were significantly more frequent in patients with C pneumoniae pneumonia than in those with M pneumoniae pneumonia. CONCLUSION: C pneumoniae pneumonia demonstrates a wide spectrum of thin-section CT findings that are similar to those of S pneumoniae pneumonia and M pneumoniae pneumonia; airway dilatation and bronchovascular thickening were significantly more frequent in patients with C pneumoniae pneumonia.

Eating disorders with binge-eating behaviour are associated with the s allele of the 3'-UTR VNTR polymorphism of the dopamine transporter gene.

OBJECTIVE: The dopaminergic system is associated with feelings of pleasure and reward and with positive hedonic processes related to food, sexual activity and certain substances. Because it is recognized that patients who have eating disorders with binge-eating behaviour have a high comorbidity of substance dependence, we examined the association between the variable number of tandem repeats (VNTR) polymorphism in the 3; untranslated region of the dopamine transporter gene (DAT1) and eating disorders with binge-eating behaviour. METHODS: The subjects were 90 female Japanese patients with eating disorders diagnosed using DSM-IV; they were compared with 115 healthy female controls. Genomic DNA was extracted from whole blood, and standard polymerase chain reaction testing was performed. We compared the frequencies of a short allele (7 or 9 repeats) and a long allele (10 or 11 repeats) in both groups. RESULTS: In the group who had an eating disorder with binge-eating behaviour, the frequency of a short allele was significantly higher compared with the control group. CONCLUSION: It seems plausible that the association between the DAT1 VNTR and binge-eating behaviour indicates that dysregulation of dopamine reuptake may act as a common pathophysiologic mechanism in eating disorders with binge-eating behaviour and in disorders related to substance use.