A novel endoscopic ablation of gastric antral vascular ectasia

An 80-year-old woman was admitted to our hospital because of tarry stool with iron deficiency anemia. Her past history included autoimmune hepatitis. Esophagogastroduodenal endoscopy was performed to investigate the bleeding source and revealed multiple linear gastric vascular malformations in the antrum and cardia, compatible with Gastric antral vascular ectasia (GAVE). Endoscopic ablation was carried out with the tip of the hot biopsy forceps without opening at soft coagulation mode of 80W. The patient tolerated the procedure well and there were no complications associated with endoscopic therapies. After two sessions of endoscopic ablation her anemia improved to around 10 g/dL, an increase of 3.6 g/dL. Various endoscopic treatments have been described to manage GAVE. The most popular is argon plasma coagulation (APC), although APC is associated with over-distension induced by the argon plasma gas. To avoid over-distension and to reduce the abdominal discomfort/pain of this patient, we have used hot biopsy forceps instead of APC. Our case suggests that this procedure is effective, easy and convenient, as no special equipment or skill is necessary.

Peeling a giant ileal lipoma with endoscopic unroofing and submucosal dissection

Lipoma is relatively common in the colon but is less often in the small intestine. Most lipomas are incidentally detected at endoscopy and are usually small and asymptomatic. However, some of them can present with obstruction and/or intussusceptions. Surgical resection is commonly recommended to remove such significant lipomas with a limited pedicle and larger than 2 cm in size, as endoscopic resection may result in unfavorable complications such as intestinal perforations. We report a case of 62-year-old man presenting with hematochezia. Colonoscopy showed a submucosal tumor, about 50 mm in size, in the terminal ileum. A clinical diagnosis of lipoma was established based on the findings of colonoscopy and abdominal computed tomography (CT). As the patient complained of hematochezia and mild iron deficiency anemia associated with repeated tumor prolapse, we decided to remove his lipoma. Consequently, the lesion was completely removed en bloc. Although abdominal CT immediately after removal of the lesion showed a small amount of free air, conservative treatment was successfully carried out for the perforation. Histologically, the removed lesion was a lipoma.

Spontaneous complete regression of a rectal cancer

We report a unique case of a biopsy-proven rectal cancer exhibiting spontaneous complete regression in an extremely short period of 3 months. An 80-year-old man visited our hospital because of a positive fecal occult blood test. Colonoscopy showed a sessile polyp, about 25 mm in diameter, in the middle part of the rectum. Instead of endoscopic resection, two endoscopic biopsies were taken for histological evaluation, as an invasive cancer was endoscopically suspected.Well-differentiated invasive adenocarcinoma was revealed, and thus surgical resection was planned. At the second colonoscopy for endoscopic tattooing before surgery, the polyp was found to have unexpectedly developed into a flat lesion. Furthermore, the surgically removed specimen showed that the flat lesion had transformed to a depressed lesion, and surprisingly, no cancerous tissue was detected histologically.

Evaluation of unexpected positive results from a commercial ELISA for antibodies to PRRSV

Unexpected positive results from the widely used IDEXX ELISA for the detection of antibodies to porcine reproductive and respiratory syndrome virus (PRRSV) may confound investigations of the disease. Supplementing the ELISA with blocking agents and the use of IgG purified from serum samples had no effect on the unexpected positive results, suggesting that they were due to an antibody-antigen reaction. Simple competitive and blocking ELISAs were developed by modifying the IDEXX ELISA, and they and an indirect fluorescent antibody test (IFAT) were used to examine PRRSV antibodies in 33 antibody-negative, 88 antibody-positive and 73 unexpectedly positive sera. All the unexpectedly positive sera were negative by IFAT, and 89.0 per cent were negative by both the competitive and blocking ELISAs. The competitive ELISA (97.7 per cent) and the blocking ELISA (96.5 per cent) detected more positive sera than the IFAT (90.9 per cent). These results show that both ELISAs are capable of distinguishing positive and unexpectedly positive sera, and suggest that most of the unexpected positive signals are false-positives.

Eradication of Helicobacter pylori in hemodialysis patients

BACKGROUND

Helicobacter pylori (H. pylori) are a causative agent of digestive disease. Although a proton pump inhibitor combined with amoxicillin-clarithromycin is the accepted drug treatment for H. pylori eradication in Japan, there is no consensus treatment for hemodialysis patients.

STUDY

Seventy-seven hemodialysis patients underwent upper digestive tract endoscopy. Biopsy specimens were taken, and histological findings, culture, and rapid urease tests were performed to confirm the presence of H. pylori. H. pylori-positive patients were then administered at random either a seven-day lansoprazole (60 mg a day)-amoxicillin (750 mg a day)-clarithromycin (400 mg a day) (LAC) regimen or a seven-day lansoprazole (60 mg a day)-clarithromycin (400 mg a day) (LC) regimen. The success of H. pylori eradication was determined from histological findings, culture, and rapid urease tests.

RESULTS

In 13 of 77 patients (13.6%), ulcers and/or ulcer scars were seen by endoscopy. Thirty-one patients (40.3%) were positive for H. pylori, and 20 patients among them were randomized to one of two regimens: one is seven-day LAC regimen (eleven patients) and the other is seven-day LC regimen (nine patients). Eradication was successful in nine of the eleven patients (72.7%) receiving the LAC regimen, but in only three of the nine patients (33.3%) who underwent the LC regimen. No serious adverse effects were observed with either regimen, and 95% of the patients reported complete compliance.

CONCLUSION

A seven-day low dose LAC regimen is safe and effective and recommended for treatment of H. pylori infection in hemodialysis patients.

Effect of high fat diet on NKT cell function and NKT cell-mediated regulation of Th1 responses

Diet is one of the important factors that modulate immune responses. In the present study, we have examined the capacity of dietary lipids to modify immune responses in mice and we have investigated the contribution of glycolipid-reactive natural killer T (NKT) cells in this process. Mice fed, high fat diet (HFD; 21.2% fat, 0.20% cholesterol) for 3 weeks, as compared with mice fed standard fat diet (SFD; 4.3% fat, 0.03% cholesterol), showed significantly reduced interferon-gamma production in sera at 6 or 12 h after intraperitoneal injection of an NKT cell ligand, alpha-galactosylceramide. In contrast, production of interleukin-13 was significantly higher at 2 and 6 h in HFD fed mice compared with mice on SFD. No difference was detected in the serum interleukin-4 levels between these two groups of animals. The proportion of NKT cells in spleen and liver was reduced in mice fed HFD compared with those on SFD. In addition, activation of NKT cells assessed by up-regulation of CD69 was suppressed specifically in liver from mice fed HFD. Recall responses of conventional T cells and delayed-type hypersensitivity (Th1 type) against ovalbumin were significantly suppressed in mice fed HFD in comparison with those fed SFD. This suppression was not observed in CD1d-/- mice, suggesting that NKT cells in mice fed HFD played a role in suppressing Th1 responses. Taken together, our findings suggest a critical link between NKT cells, dietary lipid and adaptive immune responses.

Crystal Structure and Physical Properties of Conducting Molecular Antiferromagnets with a Halogen-Substituted Donor: (EDO-TTFBr2)2FeX4 (X = Cl, Br)

The crystal structure and physical properties of radical ion salts (EDO-TTFBr2)2FeX4 (X = Cl, Br) based on halogen-substituted organic donor and magnetic anions are investigated, including the comparison with the isomorphous compounds (EDO-TTFBr2)2GaX4 with nonmagnetic anions. The crystal structure of these four salts consists of uniformly stacked donor molecules and tetrahedral counter anions, and the Br substituents of the donor molecules are connected to halide ligands of anions with remarkably short intermolecular atomic distances. These salts show metallic behavior around room temperature and undergo a spin-density-wave transition in the low-temperature range, as confirmed with the divergence of the electron spin resonance (ESR) line width. Although close anion-anion contacts are absent in these salts, the FeCl4 salt undergoes an antiferromagnetic transition at TN = 4.2 K, and the FeBr4 salt shows successive magnetic transitions at TN = 13.5 K and TC2 = 8.5 K with a helical spin structure as a candidate for the ground state of the d-electron spins. The magnetoresistance of the FeCl4 salt shows stepwise anomalies, which are explained qualitatively using a pi-d interaction-based frustrated spin system model composed of the donor pi-electron and the anion d-electron spins. Although on the ESR spectra of the FeX4 salts signals from the pi- and d-electron spins are separately observed, the line width of the pi-electron spins broadens under the temperature where the susceptibility deviates from the Curie-Weiss behavior, showing the presence of the pi-d interaction.

Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection

Although many reports have described laparoscopic minor liver resections, major hepatic resection, including right or left lobectomy, has not been widely developed because of technical difficulties. This article describes a new technique for performing laparoscopy-assisted right or left hepatic lobectomy using hilar Glissonean pedicle transection. Laparoscopic mobilization of the right or left hepatic lobe is performed, including dissection of the round, faliciform, triangular, and coronary ligaments. The right or left Glissonean pedicle is encircled and divided laparoscopically. A parenchymal dissection is then performed though the upper median or right subcostal incision, through which the resected liver is removed. We successfully performed this procedure in 6 patients without blood transfusion or serious complications. Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection can be feasible and safe in highly selected patients.

Blood Flow Redistribution During Exercise Contributes to Exercise Tolerance in Patients With Chronic Heart Failure

BACKGROUND

It is widely known that blood flow redistribution is impaired in patients with chronic heart failure (CHF). However, the relationship between exercise tolerance and the degree of blood flow redistribution is not fully understood. Whole-body thallium-201 chloride ((201)Tl) scintigraphy can estimate blood flow distribution. This study will evaluate the relationship between exercise tolerance and blood flow redistribution using whole-body scintigraphy in patients with CHF.

METHODS AND RESULTS

Exercise stress whole-body thallium scintigraphy was performed in 19 patients with CHF (mean ejection fraction: 33.0%; peak oxygen uptake: 15.5 ml x min(-1) x kg(-1)). Blood flow redistribution was quantified by comparing the regional thallium count (count/pixel) in the thigh and arm. We then assessed the relationship between these parameters and parameters obtained from cardiopulmonary exercise testing. (201)Thallium-chloride uptake in the thigh increased during exercise compared to rest (p<0.05), while its uptake in the arm was not different between exercise and rest. Increased (201)Tl uptake in the thigh during exercise was positively correlated with exercise tolerance (r=0.689). In contrast, (201)Tl uptake in the arm was not correlated with exercise tolerance.

CONCLUSIONS

By using this method, it is concluded that blood flow redistribution to the exercising muscle increases as the exercise tolerance increases in patients with CHF.

Successful catheter ablation of atrial tachycardia originating near the atrioventricular node from the noncoronary sinus of Valsalva

This report describes a patient who underwent RF catheter ablation of atrial tachycardia. Two applications of RF energy near the His-bundle region transiently terminated the tachycardia. With detailed mapping at the aortic sinus of Valsalva using a retrograde transaortic approach, the earliest atrial activation was found in the noncoronary sinus of Valsalva. Complete elimination of the tachycardia was achieved with RF energy application from this site.

Second-line treatment for Helicobacter pylori infection in Japan: proton pump inhibitor-based amoxicillin and metronidazole regimen

BACKGROUND

Recent studies have reported that proton pump inhibitor (PPI)/amoxicillin (A) metronidazole (M) therapy for Helicobacter pylori infection provides a sufficient cure rate in Japan in patients who have failed first-line treatment with PPI/amoxicillin and clarithromycin (AC). To validate the efficacy of this regimen as second-line therapy, our experience with second-line treatment using a PPI/AM regimen was reviewed.

METHODS

We analyzed data on 151 patients who had been prescribed a 10-day PPI/AM re-treatment regimen after eradication failure of 1 to 2 weeks' first-line PPI/AC therapy. The PPI/AM regimen was given according to results of susceptibility testing (S+) in 31 patients. The group that had undergone susceptibility testing was further divided into two subgroups according to dosage: standard dose of omeprazole (O)/AM (n = 11) and double dose of lansoprazole (L)/AM (n = 20). The PPI/AM regimen was given without susceptibility testing (S-) to 120 patients. These patients were also divided into two subgroups according to whether they received omeprazole or lansoprazole: OAM (n = 61) and LAM (n = 59). Cure rates and adverse effects in each group were analyzed.

RESULTS

The intention-to-treat (ITT)-based cure rate with/without susceptibility testing was 93.5% (95% confidence interval [CI], 79%-99%) and 87.5% (95% CI, 80%-93%), respectively (not significant [NS]). The ITT-based cure rate in S+/S- for OAM and S+/S- for LAM was 90.9% (95% CI, 59%-100%)/82% (95% CI, 70%-91%), and 95% (95% CI, 75%-100%)/93.2% (95% CI, 84%-98%), respectively (NS). Adverse effects were seen in 26.3% and 32.5% of patients in the OAM group and the LAM group, respectively (NS).

CONCLUSIONS

The 10-day PPI/AM re-treatment regimen is safe and effective, suggesting its usefulness as second-line treatment in Japan in patients who have failed initial treatment with the PPI/AC regimen.

Case report: fatal ventricular tachycardia exacerbated by fever in a child

Primary ventricular tachycardia (VT) is rare in children. We report a child with VT exacerbated by fever which was ultimately fatal. His first episode occurred at 5 months old and recurred with fever, occasionally causing syncope. Episodes were difficult to control with antiarrhythmic agents during fever but remitted with antipyretics. He was admitted to hospital 23 times because of VT and died suddenly with fever when he was 17 years old. At autopsy, severe fatty replacement of the bundle of His and interstitial fibrosis of the sinus node was found.