Standards of diagnostic colonoscopy for early-stage neoplasia: Recommendations by an Asian private group

BACKGROUND AND AIM

In recent years, the incidence of colorectal cancer has been increasing, and it is now becoming the major cause of cancer death in Asian countries. The aim of the present study was to develop Asian expert-based consensus to standardize the preparation, detection and characterization for the diagnosis of early-stage colorectal neoplasia.

METHODS

A professional group was formed by 36 experts of the Asian Novel Bio-Imaging and Intervention Group (ANBI2 G) members. Representatives from 12 Asia-Pacific countries participated in the meeting. The group organized three consensus meetings focusing on diagnostic endoscopy for gastrointestinal neoplasia. The Delphi method was used to develop the consensus statements.

RESULTS

Through the three consensus meetings with debating, reviewing the literature and regional data, a consensus was reached at third meeting in 2016. The consensus was reached on a total of 10 statements. Summary of statements is as follows: (i) Adequate bowel preparation for high-quality colonoscopy; (ii) Antispasmodic agents for lesion detection; (iii) Image-enhanced endoscopy (IEE) for polyp detection; (iv) Adenoma detection rate for quality indicators; (v) Good documentation of colonoscopy findings; (vi) Complication rates; (vii) Cecal intubation rate; (viii) Cap-assisted colonoscopy (CAC) for polyp detection; (ix) Macroscopic classification using indigocarmine spray for characterization of colorectal lesions; and (x) IEE and/or magnifying endoscopy for prediction of histology.

CONCLUSION

This consensus provides guidance for carrying out endoscopic diagnosis and characterization for early-stage colorectal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early-stage colorectal neoplasia.

Pleiotropic effects of moonlighting glyceraldehyde-3-phosphate dehydrogenase (GAPDH) in cancer progression, invasiveness, and metastases

Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) may represent the quintessential example of a moonlighting protein. The latter are a new, intriguing class of cell proteins which exhibit multiple activities in different subcellular locales apart from their initially, well-characterized function. As such, apart from its classical role in energy production, membrane-bound GAPDH is required for membrane fusion, endocytosis and, intriguingly, for iron transport. Cytoplasmic GAPDH regulates mRNA stability and is required for ER to Golgi trafficking. Nuclear GAPDH is involved in apoptosis, transcriptional gene regulation, the maintenance of DNA integrity, as well as nuclear tRNA export. Paradoxically, the etiology of a number of human pathologies is dependent upon GAPDH structure and function. In particular, recent evidence indicates a significant role for moonlighting GAPDH in tumorigenesis. Specifically, these include its role in the survival of tumor cells, in tumor angiogenesis, as well as its control of tumor cell gene expression and posttranscriptional regulation of tumor cell mRNA. Each of these activities correlates with increased tumor progression and, unfortunately, a poor prognosis for the afflicted individual.

SopB activates the Akt-YAP pathway to promote Salmonella survival within B cells

B cells are a target of Salmonella infection, allowing bacteria survival without inducing pyroptosis. This event is due to downregulation of Nlrc4 expression and lack of inflammasome complex activation, which impairs the secretion of IL-1β. YAP phosphorylation is required for downregulation of Nlrc4 in B cells during Salmonella infection; however, the microorganism’s mechanisms underlying the inhibition of the NLRC4 inflammasome in B cells are not fully understood. Our findings demonstrate that the Salmonella effector SopB triggers a signaling cascade involving PI3K, PDK1 and mTORC2 that activates Akt with consequent phosphorylation of YAP. When we deleted sopB in Salmonella, infected B cells that lack Rictor, or inhibited the signaling cascade using a pharmacological approach, we were able to restore the function of the NLRC4 inflammasome in B cells and the ability to control the infection. Furthermore, B cells from infected mice exhibited activation of Akt and YAP phosphorylation, suggesting that Salmonella also triggers this pathway in vivo. In summary, our data demonstrate that the Salmonella effector inositide phosphate phosphatase SopB triggers the PI3K-Akt-YAP pathway to inhibit the NLRC4 inflammasome in B cells. This study provides further evidence that Salmonella triggers cellular mechanisms in B lymphocytes to manipulate the host environment by turning it into a survival niche to establish a successful infection.

Performance of a Novel Blood-Based Early Colorectal Cancer Screening Assay in Remaining Serum after the Blood Biochemical Test

Background

Combination of multiple biomarkers was an effective strategy to improve sensitivity in cancer diagnosis and screening. However, the performance of the combination of methylated SEPT9 and SDC2 for detection of colorectal cancer (CRC) has yet to be reported.

Methods

A new qPCR-based assay combining the detection of methylated SEPT9 and SDC2 was used. Methylation statuses of SEPT9 and SDC2 were examined in 19 sets of cancer tissues and paired adjacent tissues and further evaluated with 225 serum samples, including 111 CRC patients and 114 no evidence of disease individuals.

Results

SEPT9 and SDC2 methylation levels were higher in 94.7% and 100.0% of cancer tissues than in their paired adjacent tissues. The sensitivities for detecting CRC by SEPT9 methylation alone and SDC2 methylation alone were 73.0% (95% CI: 63.6–80.8%) and 71.2% (95% CI: 61.8–79.2%), respectively, with the same specificity of 95.6% (95% CI: 89.6–98.4%). However, when SEPT9 methylation was combined with SDC2 methylation to detect CRC, the sensitivity was improved to 86.5% (95% CI: 78.4–92.0%) with a specificity of 92.1% (95% CI: 85.1–96.1%).

Conclusion

The combination of methylated SEPT9 and SDC2 detection in serum has the potential to be a noninvasive strategy for CRC screening.

Less barium enema, more colonoscopy: A 12-year nationwide population-based study in Taiwan

BACKGROUND

Colorectal cancer (CRC) is the second most common and third most fatal cancer in Taiwan. To reduce incidence and mortality rates from cancer, including CRC, the Health Promotion Administration in Taiwan initiated the National Program on Cancer Prevention in 2005. For patients who have a positive fecal occult blood test, colonoscopy is recommended, and double-contrast barium enema (BE) is reserved as an alternative for those who cannot receive colonoscopy. In addition, single-contrast BE is sometimes used in pediatrics to evaluate colonic condition. This study evaluated the usage trends of BE and colonoscopy in Taiwan.

METHODS

Data from the National Health Insurance Research Database from 2001 to 2013 were used in this study. Patients who received BE and colonoscopy were identified using the procedure codes of the National Health Insurance program. Age-standardized, yearly rates of BE and colonoscopy procedures were calculated.

RESULTS

According to the data, the total number of colonoscopies increased 3.7-fold from 2001 to 2013. The compound annual growth rates for BE and colonoscopy were -5.36% and 10.47%, respectively, during the same period. The compound annual growth rates for BE and colonoscopy were -3.89% and 11.64% from 2005 to 2009, and -11.36% and 9.82% from 2010 to 2013, respectively. BE was conducted significantly more frequently than colonoscopy in patients who were aged <12 years and in female patients.

CONCLUSION

Professional association guidelines, national cancer prevention programs, patient and physician preferences, and increasing awareness and knowledge of CRC may all contribute to the increasing use of colonoscopy and the dramatic decline in the use of BE in Taiwan.

CT and MRI features of undifferentiated carcinomas with osteoclast-like giant cells of the pancreas: a case series

PURPOSE

The purpose of this case series was to describe computed tomography (CT) and magnetic resonance imaging (MRI) features of undifferentiated carcinoma with osteoclast-like giant cells of the pancreas.

METHODS

Institutional ethics review board approval was obtained, and informed consent was waived for this case series. We reviewed CT and MRI of patients with pathologically confirmed undifferentiated carcinoma with osteoclast-like giant cells of the pancreas found in the medical records of our hospital between 2006 and 2016.

RESULTS

Seven patients (3 males and 4 females; age, 59-82 years (mean, 71)) with confirmation by surgical resection (n = 3) or biopsy (n = 4) were identified. They underwent CT (n = 7) and MRI (n = 6). The tumors 26-83 mm in diameter (mean, 44 mm) were located in the head (n = 4) or body (n = 3) of the pancreas. They were demonstrated as lower attenuation areas relative to the adjacent pancreas on CT images obtained in both pancreatic and portal vein phases (n = 7) with a well-defined smooth margin (n = 5). They were demonstrated as hypointense areas relative to the pancreas on T2-weighted images (n = 4) and T2*-weighted images (n = 4) and diffusion-weighted images (n = 3). They contained hemosiderin deposits on histology (n = 7).

CONCLUSIONS

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas might be present as low attenuation areas with a well-defined smooth margin on CT images obtained in pancreatic and portal vein phases, and hypointense areas on T2-, T2*-, and diffusion-weighted images caused by hemosiderin deposits.

The First Screening Program for Colorectal Cancer in the North of Iran

PURPOSE

Colorectal cancer (CRC) is the second leading cause of cancer deaths. This screening aimed to determine the positivity of the fecal occult blood test (FOBT) and the results of colonoscopy among a medium-risk population in the northern regions of Iran.

METHODS

This cross-sectional study was conducted in 2016 on 924 eligible samples from people over the age of 50. After completing the questionnaire, participants were referred to a laboratory for three immunochemical fecal occult blood tests (IFOBTs). If the result of at least one test was found to be positive, they were submitted to the state hospital for colonoscopy. Results were recorded according to the number of people with CRC, polyps, and other diseases.

RESULTS

Among a total number of 897 (97.1%) cases, at least two acceptable samples were sent to the laboratory and in 229 (25.5%) cases, at least one case was IFOBT-positive. Finally, 118 (64.1%) cases were referred to the hospital for colonoscopy; among these, 5 colonoscopies were incomplete, while 113 had complete colonoscopies with 42 healthy subjects, 3 cases of cancer, 28 cases of polyps, and other diseases identified in the remaining patients.

CONCLUSIONS

Based on the results, the prevalence of positive IFOBT, polyps, and cancer was high. The results of this study will play an important role in establishing a CRC screening program in the country. With reference to the status of the general population, the target group in the country should be reviewed and not limited to the first-degree relatives of patients.

Performance of a MethyLight assay for methylated SFRP2 DNA detection in colorectal cancer tissue and serum

BACKGROUND

Colorectal cancer is one of the five most common cancers in China, and its incidence is steadily increasing. An accurate and non-invasive screening method is needed to increase the population uptake of colorectal cancer screening. Secreted frizzled-related protein 2 ( SFRP2) has been found to be hypermethylated in most colorectal cancer patients, and it may fulfill the role of a non-invasive biomarker for colorectal cancer screening.

METHODS

Methylation status of SFRP2 was examined in 17 cancer tissues and paired adjacent paracancer tissues by a new SFRP2 MethyLight assay, which was also used to test the serum of 62 patients with colorectal cancer and 55 normal individuals.

RESULTS

The limit of detection of the SFRP2 MethyLight assay was about 200 pg per reaction. The SFRP2 methylation level was higher in 94.1% colorectal cancer tissues than in paired adjacent paracancer tissues ( P<0.001). The sensitivity and specificity of SFRP2 for detecting colorectal cancer in serum were 69.4% (95% confidence interval (CI) 56.2, 80.1%) and 87.3% (95% CI 74.9, 94.3%), respectively.

CONCLUSION

SFRP2 methylation in serum has the potential to be a non-invasive biomarker for colorectal cancer screening.

Clinical and endoscopic characteristics of sessile serrated adenomas/polyps with dysplasia/adenocarcinoma in a Korean population: A Korean Association for the Study of Intestinal Diseases (KASID) multicenter study

Sessile serrated adenomas/polyps (SSA/Ps) are precancerous lesions that account for one-third of colorectal cancers. The endoscopic and pathologic differentiation between SSA/Ps without dysplasia (SSA/POs) and SSA/Ps with dysplasia or adenocarcinoma (SSA/PDAs) can be difficult. This study aimed to assess the clinical characteristics of SSA/PDs. This multicenter retrospective cohort study included 532 patients who underwent endoscopic resection and were pathologically diagnosed with SSA/POs and SSA/PDAs. Initially, medical, endoscopic, and histopathological records of patients who underwent endoscopic resection of SSA/POs and SSA/PDAs at eight university hospitals in Korea between January 2005 and December 2015 were reviewed. A total of 307 (57.7%) patients were detected in men and 319 (60.0%) were located in the proximal colon. Most SSA/Ps had a flat, slightly elevated, or sessile morphology. The most prevalent endoscopic findings of SSA/Ps were nodular surface (244, 45.9%), disrupted vascular pattern (232, 43.6%), altered fold contour (141, 26.5%), dome-shaped morphology (135, 25.4%), and pale color (115, 21.6%). SSA/POs were more commonly found in the proximal colon, compared to SSA/PDAs. SSA/PDAs displayed 0-Ip, Isp, IIb or IIa + IIc morphologies more frequently, while SSA/POs displayed 0-Is or IIa morphology more frequently. The frequency of a rim of debris/bubbles was significantly higher in SSA/POs, while nodular surface and disrupted vascular pattern were significantly higher in SSA/PDAs. In the univariate analysis of endoscopic features, SSA/PDAs were significantly associated with the distal colon location, 0-Isp and IIb morphologies, nodular surface, and disrupted vascular pattern. In the multivariate analysis, 0-IIb, nodular surface, and disrupted vascular pattern were significantly associated with SSA/PDAs. SSA/Ps with 0-IIb morphology, nodular surface and disrupted vascular pattern are associated with an increased risk of dysplasia or adenocarcinoma.

Increasing Trend in Young-Onset Colorectal Cancer in Asia: More Cancers in Men and More Rectal Cancers

BACKGROUND

The incidence of young-onset colorectal cancer (CRC) is reported to be increasing in the Western world. There are no population-based studies assessing the trend across Asia.

METHODS

We performed a multinational cohort study involving four Asian countries/regions, namely Taiwan, Korea, Japan, and Hong Kong. The magnitude and direction of trend in the incidence of young-onset CRC (age < 50) were quantified using Joinpoint Regression Program to estimate average annual percentage change (AAPC).

RESULTS

In Taiwan (1995-2014), incidence of young-onset CRC significantly increased in both men (colon cancer: 4.9-9.7 per 100,000; rectal cancer: 4.0-8.3 per 100,000) and women (colon cancer: 5.1-9.7 per 100,000; rectal cancer: 3.8-6.4 per 100,000). In Korea (1999-2014), incidence of young-onset CRC significantly increased in both men (colon cancer: 5.0-10.4 per 100,000; rectal cancer: 4.9-14.0 per 100,000) and women (colon cancer: 4.1-9.6 per 100,000; rectal cancer: 4.1-9.1 per 100,000). The most pronounced change was observed with male rectal cancer, increasing by 3.9% per year in Taiwan (AAPC + 3.9, 95% confidence interval + 3.3 to +4.5, P < 0.05) and 6.0% per year in Korea (AAPC +6.0, 95% confidence interval + 4.5 to +7.6, P < 0.05). Only a significant increase in rectal cancer was noted in Japan (male rectal cancer: 7.2-10.1 per 100,000, female rectal cancer 4.7-6.7 per 100,000) and Hong Kong (male rectal cancer: 4.4-7.0 per 100,000).

CONCLUSIONS

Increasing trend in young-onset CRC is not limited to the Western world. This finding may have implications on screening program for CRC in these countries/regions.

Cross-national analysis about the difference of histopathological management in Tis and T1 colorectal cancer between Japan and Korea

OBJECTIVES

There are differences in each country with regards to histopathological managements of colorectal cancer (CRC), such as definition of Tis and lymphatic and venous invasion. In this study, we compared Tis and T1 CRC in Japan and Korea.

METHODS

We retrospectively compared various clinical characteristics of consecutive patients who had Tis and T1 CRCs and who were newly diagnosed between 2010 and 2014 at the Kyoto Prefectural University of Medicine (Japan) and the Konkuk University (Korea).

RESULTS

Three hundred and sixty-five cases of T1 cancer and 510 cases of Tis cancer from 726 Japanese and 149 Korean patients were included. The rate of Tis in Japan was higher than in Korea (59.8% vs. 51.0%, P = 0.047), according to the difference of definition of Tis. In the analyses of 365 T1 CRCs, median age was higher in Japan than Korea (67.8 ± 10.6 vs. 62.2 ± 10.1, P < 0.001). Right-sided lesions were more frequent in Japan than they were in Korea (38.7% vs. 22.2%, P < 0.001). The rates of venous and lymphatic invasion were higher in Japan than they were in Korea (venous: 18.6% vs. 1.4%, P < 0.001, lymphatic: 25.3% vs. 13.7%, P = 0.042), according to the different methods of immunohistochemical examinations used (Japan: E-HE and D2-40, Korea: ERG).

CONCLUSIONS

Our study of T1 CRC showed that there were differences between Japan and Korea in tumor location, elderly incidence, and histopathological lymphatic and venous invasion. Additionally, rates of Tis were different between the two countries. In this international study for CRC, it is considered that we have to pay attention regarding the difference of histopathological definition and method in each country.

Role of Aldehyde Dehydrogenases in Physiopathological Processes

Many different diseases are associated with oxidative stress. One of the main consequences of oxidative stress at the cellular level is lipid peroxidation, from which toxic aldehydes may be generated. Below their toxicity thresholds, some aldehydes are involved in signaling processes, while others are intermediaries in the metabolism of lipids, amino acids, neurotransmitters, and carbohydrates. Some aldehydes ubiquitously distributed in the environment, such as acrolein or formaldehyde, are extremely toxic to the cell. On the other hand, aldehyde dehydrogenases (ALDHs) are able to detoxify a wide variety of aldehydes to their corresponding carboxylic acids, thus helping to protect from oxidative stress. ALDHs are located in different subcellular compartments such as cytosol, mitochondria, nucleus, and endoplasmic reticulum. The aim of this review is to analyze, and highlight, the role of different ALDH isoforms in the detoxification of aldehydes generated in processes that involve high levels of oxidative stress. The ALDH physiological relevance becomes evident by the observation that their expression and activity are enhanced in different pathologies that involve oxidative stress such as neurodegenerative disorders, cardiopathies, atherosclerosis, and cancer as well as inflammatory processes. Furthermore, ALDH mutations bring about several disorders in the cell. Thus, understanding the mechanisms by which these enzymes participate in diverse cellular processes may lead to better contend with the damage caused by toxic aldehydes in different pathologies by designing modulators and/or protocols to modify their activity or expression.

Serrated Lesions of the Colon-Rectum: A Focus on New Diagnostic Tools and Current Management

Prompt diagnosis and correct management of the so called "serrated lesions" (SLs) of the colon-rectum are generally considered of crucial importance in the past years, mainly due to their histological heterogeneity and peculiar clinical and molecular patterns; sometimes, they are missed at conventional endoscopy and are possibly implicated in the genesis of interval cancers. The aim of this review is to focus on the diagnostic challenges of serrated lesions, underlying the role of both conventional endoscopy and novel technologies. We will show how an accurate and precise diagnosis should immediately prompt the most appropriate therapy other than defining a proper follow-up program. It will be emphasized how novel endoscopic techniques may provide better visualization of mucosal microsurface structures other than enhancing the microvascular architecture, in order to better define and characterize specific patterns of mucosal lesions of the gastrointestinal tract. Standard therapy of SLs of the colon-rectum is still very debated, also due to the relatively lack of studies focusing on treatment issues. The high risk of incomplete resection, together with the high rate of postcolonoscopy interval cancers, suggests the need of an extra care when facing this kind of lesions. Given this background, we will outline useful technical tips and tricks in the resection of SLs, taking aspects such as the size and location of the lesions, as well as novel available techniques and technologies, other than future perspectives, including confocal laser endomicroscopy into consideration. Follow-up of SLs is another hot topic, also considering that their clinical impact has been misunderstood for a long time. The incidence of the so called interval colorectal cancer underlines how some weaknesses exist in current screening and follow-up programs. Considering the lack of wide consensus for the management of some SLs, we will try to summarize and clarify the best strategies for their optimal management.

Protein kinase C: perfectly balanced

Protein kinase C (PKC) isozymes belong to a family of Ser/Thr kinases whose activity is governed by reversible release of an autoinhibitory pseudosubstrate. For conventional and novel isozymes, this is effected by binding the lipid second messenger, diacylglycerol, but for atypical PKC isozymes, this is effected by binding protein scaffolds. PKC shot into the limelight following the discovery in the 1980s that the diacylglycerol-sensitive isozymes are "receptors" for the potent tumor-promoting phorbol esters. This set in place a concept that PKC isozymes are oncoproteins. Yet three decades of cancer clinical trials targeting PKC with inhibitors failed and, in some cases, worsened patient outcome. Emerging evidence from cancer-associated mutations and protein expression levels provide a reason: PKC isozymes generally function as tumor suppressors and their activity should be restored, not inhibited, in cancer therapies. And whereas not enough activity is associated with cancer, variants with enhanced activity are associated with degenerative diseases such as Alzheimer's disease. This review describes the tightly controlled mechanisms that ensure PKC activity is perfectly balanced and what happens when these controls are deregulated. PKC isozymes serve as a paradigm for the wisdom of Confucius: "to go beyond is as wrong as to fall short."

Narrow-Band Imaging: Clinical Application in Gastrointestinal Endoscopy

Narrow-band imaging is an advanced imaging system that applies optic digital methods to enhance endoscopic images and improves visualization of the mucosal surface architecture and microvascular pattern. Narrow-band imaging use has been suggested to be an important adjunctive tool to white-light endoscopy to improve the detection of lesions in the digestive tract. Importantly, it also allows the distinction between benign and malignant lesions, targeting biopsies, prediction of the risk of invasive cancer, delimitation of resection margins, and identification of residual neoplasia in a scar. Thus, in expert hands it is a useful tool that enables the physician to decide on the best treatment (endoscopic or surgical) and management. Current evidence suggests that it should be used routinely for patients at increased risk for digestive neoplastic lesions and could become the standard of care in the near future, at least in referral centers. However, adequate training programs to promote the implementation of narrow-band imaging in daily clinical practice are needed. In this review, we summarize the current scientific evidence on the clinical usefulness of narrow-band imaging in the diagnosis and characterization of digestive tract lesions/cancers and describe the available classification systems.

Image-Enhanced Endoscopy in Lower Gastrointestinal Diseases: Present and Future

From dye-assisted conventional chromoendoscopy to novel virtual chromoendoscopy, image-enhanced endoscopy (IEE) is continuously evolving to meet clinical needs and improve the quality of colonoscopy. Dye-assisted chromoendoscopy using indigo carmine or crystal violet, although slightly old-fashioned, is still useful to emphasize the pit patterns of the colonic mucosa and predict the histological structures of relevant lesions. Equipment-based virtual chromoendoscopy has the advantage of being relatively easy to use. There are several types of virtual chromoendoscopy that vary depending on the manufacturer and operating principle. IEE plays distinctive roles with respect to histologic characterization of colorectal polyps and prediction of the invasion depth of colorectal cancers. In addition, the newest models of IEE have the potential to increase adenoma and polyp detection rates in screening colonoscopy.

Complete polypectomy and early detection and management of residual disease to reduce the risk of interval colorectal cancers

Advances in colorectal polyp detection and resection methods aim to reduce interval cancer rates. Complete polypectomy is essential to reduce the risk of early recurrence and the development of interval cancers. To achieve this, polyps must first be correctly identified and then completely excised. This article reviews current adenoma detection methods in use and the management of residual disease.

Don't Sugar Coat It: Glycemic Control in the Intensive Care Unit

Stress hyperglycemia is the transient increase in blood glucose as a result of complex hormonal changes that occur during critical illness. It has been described in the critically ill for nearly 200 years; patient harm, including increases in morbidity, mortality, and lengths of stay, has been associated with hyperglycemia, hypoglycemia, and glucose variability. However, there remains a contentious debate regarding the optimal glucose ranges for this population, most notably within the past 15 years. Recent landmark clinical trials have dramatically changed the treatment of stress hyperglycemia in the intensive care unit (ICU). Earlier studies suggested that tight glucose control improved both morbidity and mortality for ICU patients, but later studies have suggested potential harm related to the development of hypoglycemia. Multiple trials have tried to elucidate potential glucose target ranges for special patient populations, including those with diabetes, trauma, sepsis, cardiac surgery, and brain injuries, but there remains conflicting evidence for most of these subpopulations. Currently, most international organizations recommend targeting moderate blood glucose concentration to levels <180 mg/dL for all patients in the intensive care unit. In this review, the history of stress hyperglycemia and its treatment will be discussed including optimal glucose target ranges, devices for monitoring blood glucose, and current professional organizations' recommendations regarding glucose control in the ICU.

Prevention of Bortezomib-Related Peripheral Neuropathy With Docosahexaenoic Acid and α-Lipoic Acid in Patients With Multiple Myeloma: Preliminary Data

Background and Aims: Peripheral neuropathy is a common complication of chemotherapy that can induce marked disability that negatively affects the quality of life in patients with multiple myeloma (MM). The aim of this study was to prevent the onset or the worsening of peripheral neuropathy in MM patients treated with bortezomib (BTZ), using a new nutritional neuroprotective compound. We report preliminary results of 18 out of 33 patients who completed the study. Methods: We administered a tablet of Neuronorm to patients, containing docosahexaenoic acid 400 mg, α-lipoic acid 600 mg, vitamin C 60 mg, and vitamin E 10 mg bid for the whole follow-up period. Neurological visit assessment, electroneurography, and evaluation scales were performed at baseline and after 6 months. Results: At 6 months, 8 patients had no chemotherapy-induced peripheral neuropathy, while 10 patients experienced chemotherapy-induced peripheral neuropathy of grade 1 according to the Common Terminology Criteria for Adverse Events, one of them with pain. Seventeen patients did not report painful symptoms; no limitation of functional autonomy and stability in quality of life domains explored was observed. Conclusions: Our results seem to indicate that early introduction of a neuroprotective agent in our patients with MM treated with BTZ could prevent the onset or the worsening of neuropathic pain, avoiding the interruption of the therapy with BTZ, and maintaining a good functional autonomy to allow normal daily activities. Despite the limitations due to the fact that this is a preliminary study, in a small population, with short follow-up, our data seem to indicate that the nutraceutical may have some potential to be considered for a future trial.

The Complex Puzzle of Interactions Among Functional Food, Gut Microbiota, and Colorectal Cancer

Colorectal cancer exerts a strong influence on the epidemiological panorama worldwide, and it is directly correlated to etiologic factors that are substantiated by genetic and environmental elements. This complex mixture of factors also has a relationship involving the structural dependence and composition of the gut microbiome, leading to a dysbacteriosis process that may evolve to serious modifications in the intestinal lining, eventually causing the development of a neoplasm. The gastrointestinal tract presents defense strategies and immunological properties that interfere in intestinal permeability, inhibiting the bacterial translocation, thus maintaining the integrity of intestinal homeostasis. The modulation of the intestinal microbiome and the extinction of risk factors associated with intestinal balance losses, especially of environmental factors, make cell and defense alterations impossible. This modulation may be conducted by means of functional foods in the diet, especially soluble fibers, polyunsaturated fatty acids, antioxidants and prebiotics that signal immunomodulatory effects in the intestinal microbiota, with preventive and therapeutic action for colorectal cancer. In summary, this review focuses on the importance of dietary modulation of the intestinal microbiota as an instrument for dysbacteriosis and, consequently, for the prevention of colorectal cancer, suggesting anticarcinogenic, and antiangiogenic properties. Among the intestinal modulating agents considered here are functional foods, especially flaxseed, oat and soy, composing a Bioactive Food Compound.

Magnifying Endoscopy for Esophageal Ectopic Sebaceous Glands

Ectopic sebaceous glands are found very rarely in the esophagus; heretofore, several cases have been reported. The sebaceous gland is originally a source of an endodermal origin; however, there have been controversies regarding whether the origin of the esophageal ectopic sebaceous gland is ectodermal or endodermal. Ectopic sebaceous glands of the esophagus usually do not cause symptoms; thus, they are often found incidentally on endoscopy for routine health screening. Endoscopic findings are characterized by single or multiple yellow patches or nodular lesions of various sizes, sometimes with small central openings. We report two cases of esophageal ectopic sebaceous glands found incidentally during endoscopy with magnifying endoscopic findings. The lesions were in the mid-esophagus and lower esophagus, respectively, and both endoscopic findings were similar as multiple yellowish patches or plaques. Magnifying endoscopy revealed the openings of the excretory ducts surrounded by circular microvessels in both cases.

Demographic characteristics and the first program of colorectal cancer (CRC) screening in north of Iran (2016)

Background

Colorectal cancer (CRC) is one of the most common types of gastrointestinal cancers. This study aimed to determine the demographic characteristics and their relationships with the results of the first screening program for CRC in people over 50 years old in northern Iran.

Methods

This cross-sectional study was conducted in 2016 on 924 eligible people over 50 years old. Initial screening was done by IFOBT and then colonoscopy was performed if the results were positive. The demographic characteristics of individuals including age, sex, place of residence, marital status, body mass index (BMI) and education level were investigated with the results of the colonoscopy and the test results.

Results

The mean age of participants was 59.38 years, and the participation of women (57.0%) and rural residents (54.2%) were higher in the screening program. According to the demographic variables, age was considered as a strong independent predictor variable, so that the prevalence of positive test results was more than 2 times higher in subjects older than 70 compared with subjects aged ≤60 (OR =2.05; 95% CI, 1.18-3.55, P=0.010). Also, the chance of positive test result in the age group ≤55 years old was 23%, with an increase of 64% in the age group above 75 years (P<0.001). Among the positive test subjects, 118 cases underwent colonoscopy.

Conclusions

The prevalence of IFOBT positivity was increased with age. Therefore, given the aging population of the country, it is recommended to emphasize on the screening of older people in the general population.

Hydrogen Sulfide and Glucose Homeostasis: A Tale of Sweet and the Stink

SIGNIFICANCE

Among many endogenous mediators, the gasotransmitter hydrogen sulfide (H₂S) plays an important role in the regulation of glucose homeostasis. In this article we discuss different functional roles of H₂S in several metabolic organs/tissues required in the maintenance of glucose homeostasis. Recent Advances: New evidence has emerged revealing the insulin sensitizing role of H₂S in adipose tissue and skeletal muscle biology. In addition, H₂S was demonstrated to be a potent stimulator of gluconeogenesis via the induction and stimulation of various glucose-producing pathways in the liver.

CRITICAL ISSUES

Similar to its other physiological effects, H₂S exhibits paradoxical characteristics in the regulation of glucose homeostasis: (1) H₂S stimulates glucose production via activation of gluconeogenesis and glycogenolysis in hepatocytes, yet inhibits lipolysis in adipocytes; (2) H₂S stimulates glucose uptake into adipocytes and skeletal muscle but inhibits glucose uptake into hepatocytes; (3) H₂S inhibits insulin secretion from pancreatic β cells, yet sensitizes insulin signaling and insulin-triggered response in adipose tissues and skeletal muscle. It is also unclear the impact H₂S may have on glucose metabolism and utilization by other vital organs, such as the brain.

FUTURE DIRECTIONS

Recent reports and ongoing studies lay the foundation for a general, although highly incomplete, understanding of the effect of H₂S on regulating glucose homeostasis. In this review, we describe the molecular mechanisms and physiological outcomes of the gasotransmitter H₂S on organs and tissues required for homeostatic maintenance of blood glucose. Future directions highlighting the H₂S-mediated homeostatic control of glucose metabolism under physiological and insulin-resistant conditions are also discussed. Antioxid. Redox Signal. 28, 1463-1482.

Endoscopic submucosal dissection (ESD) for anal high-grade intraepithelial neoplasia: a case report

Anal intraepithelial neoplasia (AIN) is a precursor of anal carcinoma. Conventional therapy is based on topical and local ablative approaches. However, the recurrence rates are very high, leading to repetitive treatment sessions and need for long-term surveillance. Endoscopic submucosal dissection (ESD) is an established treatment for malignant early neoplasias of the gastrointestinal tract, especially in the esophagus, stomach, and colorectum. Japanese centers have reported few cases of ESD for early anal carcinoma. We report a case of high-grade AIN diagnosed with magnifying narrow-band imaging and chromoendoscopy that was resected R0 with ESD en bloc.

Canonical PI3Kγ signaling in myeloid cells restricts Trypanosoma cruzi infection and dampens chagasic myocarditis

Chagas disease is caused by infection with the protozoan Trypanosoma cruzi (T. cruzi) and is an important cause of severe inflammatory heart disease. However, the mechanisms driving Chagas disease cardiomyopathy have not been completely elucidated. Here, we show that the canonical PI3Kγ pathway is upregulated in both human chagasic hearts and hearts of acutely infected mice. PI3Kγ-deficient mice and mutant mice carrying catalytically inactive PI3Kγ are more susceptible to T. cruzi infection. The canonical PI3Kγ signaling in myeloid cells is essential to restrict T. cruzi heart parasitism and ultimately to avoid myocarditis, heart damage, and death of mice. Furthermore, high PIK3CG expression correlates with low parasitism in human Chagas’ hearts. In conclusion, these results indicate an essential role of the canonical PI3Kγ signaling pathway in the control of T. cruzi infection, providing further insight into the molecular mechanisms involved in the pathophysiology of chagasic heart disease.

Trypanosoma cruzi infection causes Chagas disease, but mechanisms underlying pathogenesis are unclear. Here, Silva et al. show that canonical PI3Kγ signaling in myeloid cells restricts T. cruzi infection in mice and that high PIK3CG expression correlates with low parasite levels in human Chagas’ hearts.

Combined Hyperglycemia- and Hyperinsulinemia-Induced Insulin Resistance in Adipocytes Is Associated With Dual Signaling Defects Mediated by PKC-ζ

A hyperglycemic and hyperinsulinemic environment characteristic of type 2 diabetes causes insulin resistance. In adipocytes, defects in both insulin sensitivity and maximum response of glucose transport have been demonstrated. To investigate the molecular mechanisms, freshly isolated rat adipocytes were incubated in control (5.6 mM glucose, no insulin) and high glucose (20 mM)/high insulin (100 nM) (HG/HI) for 18 hours to induce insulin resistance. Insulin-resistant adipocytes manifested decreased sensitivity of glucose uptake associated with defects in insulin receptor substrate (IRS)-1 Tyr phosphorylation, association of p85 subunit of phosphatidylinositol-3-kinase, Akt Ser473 and Thr308 phosphorylation, accompanied by impaired glucose transporter 4 translocation. In contrast, protein kinase C (PKC)-ζ activity was augmented by chronic HG/HI. Inhibition of PKC-ζ with a specific cell-permeable peptide reversed the signaling defects and insulin sensitivity of glucose uptake. Transfection of dominant-negative, kinase-inactive PKC-ζ blocked insulin resistance, whereas constitutively active PKC-ζ recapitulated the defects. The HG/HI incubation was associated with stimulation of IRS-1 Ser318 and Akt Thr34 phosphorylation, targets of PKC-ζ. Transfection of IRS-1 S318A and Akt T34A each partially corrected insulin signaling, whereas combined transfection of both completely normalized insulin signaling. In vivo hyperglycemia/hyperinsulinemia in rats for 48 hours similarly resulted in activation of PKC-ζ and increased phosphorylation of IRS-1 Ser318 and Akt Thr34. These data indicate that impairment of insulin signaling by chronic HG/HI is mediated by dual defects at IRS-1 and Akt mediated by PKC-ζ.

Diagnostic Accuracy of NICE Classification System for Optical Recognition of Predictive Morphology of Colorectal Polyps

The NICE classification is an international endoscopic classification of colorectal neoplasia through a narrowband spectrum that on the basis of lesion colors, vascular pattern, and structure of the surface of the mucous membrane classifies colorectal neoplasms in three categories: type 1 as hyperplastic lesions, type 2 as adenomas, and type 3 as invasive tumors. The aim of this study was to verify diagnostic accuracy of the NICE classification system compared to the reference standard: histopathological analysis. This retrospective study was conducted by ten physicians on a sequential sample of 418 patients and 735 polyps. The total diagnostic accuracy of the NICE classification system is found to be 76.7%. Optical recognition is significantly better with larger polyps, high-risk lesions (HGIEN), and neoplastic lesions. This research has shown that the NICE classification system is at the moment inferior to histopathological analysis. However, it is noticed that some physicians achieve significantly better results, with the accuracy of diagnosis ranging from 59.5% to 84.2%. These results show that with proper training of physicians and the use of endoscope enhancements to improve image quality, the NICE classification system could in the future potentially replace the histopathological diagnosis process.

Short-term heat stress altered metabolism and insulin signaling in skeletal muscle

Heat-related complications continue to be a major health concern for humans and animals and lead to potentially life-threatening conditions. Heat stress (HS) alters metabolic parameters and may alter glucose metabolism and insulin signaling. Therefore, the purpose of this investigation was to determine the extent to which 12 h of HS-altered energetic metabolism in oxidative skeletal muscle. To address this, crossbred gilts (n = 8/group) were assigned to one of three environmental treatments for 12 h: thermoneutral (TN; 21 °C), HS (37 °C), or pair-fed to HS counterparts but housed in TN conditions (PFTN). Following treatment, animals were euthanized and the semitendinosus red (STR) was recovered. Despite increased relative protein abundance of the insulin receptor, insulin receptor substrate (IRS1) phosphorylation was increased (P = 0.0005) at S307, an inhibitory site, and phosphorylated protein kinase B (AKT) (S473) was decreased (P = 0.03) likely serving to impair insulin signaling following 12 h of HS. Further, HS increased phosphorylated protein kinase C (PKC) ζ/λ (P = 0.02) and phosphorylated PKCδ/θ protein abundance (P = 0.02), which are known to regulate inhibitory serine phosphorylation of IRS1 (S307). Sarcolemmal glucose transporter 4 (Glut4) was decreased (P = 0.04) in the membrane fraction of HS skeletal muscle suggesting diminished glucose uptake capacity. HS-mediated increases (P = 0.04) in mechanistic target of rapamycin (mTOR) were not accompanied by phosphorylation of eukaryotic translation initiation factor 4E-binding protein 1 (4EBP1). HS decreased (P = 0.0006) glycogen synthase (GS) and increased (P = 0.02) phosphorylated GS suggesting impaired glycogen synthesis. In addition, HS altered fatty acid metabolic signaling by increasing (P = 0.02) Acetyl-CoA carboxylase (ACC), decreasing (P = 0.005) phosphorylated ATP-citrate lyase (pATPCL) and fatty acid synthase (P = 0.01) (FAS). These data suggest that 12 h of HS blunted insulin signaling, decreased protein synthesis, and altered glycogen and fatty acid metabolism.

Effects of surgery and anesthetic choice on immunosuppression and cancer recurrence

Background

The relationship between surgery and anesthetic-induced immunosuppression and cancer recurrence remains unresolved. Surgery and anesthesia stimulate the hypothalamic–pituitary–adrenal (HPA) axis and sympathetic nervous system (SNS) to cause immunosuppression through several tumor-derived soluble factors. The potential impact of surgery and anesthesia on cancer recurrence was reviewed to provide guidance for cancer surgical treatment.

Methods

PubMed was searched up to December 31, 2016 using search terms such as, “anesthetic technique and cancer recurrence,” “regional anesthesia and cancer recurrence,” “local anesthesia and cancer recurrence,” “anesthetic technique and immunosuppression,” and “anesthetic technique and oncologic surgery.”

Results

Surgery-induced stress responses and surgical manipulation enhance tumor metastasis via release of angiogenic factors and suppression of natural killer (NK) cells and cell-mediated immunity. Intravenous agents such as ketamine and thiopental suppress NK cell activity, whereas propofol does not. Ketamine induces T-lymphocyte apoptosis but midazolam does not affect cytotoxic T-lymphocytes. Volatile anesthetics suppress NK cell activity, induce T-lymphocyte apoptosis, and enhance angiogenesis through hypoxia inducible factor-1α (HIF-1α) activity. Opioids suppress NK cell activity and increase regulatory T cells.

Conclusion

Local anesthetics such as lidocaine increase NK cell activity. Anesthetics such as propofol and locoregional anesthesia, which decrease surgery-induced neuroendocrine responses through HPA-axis and SNS suppression, may cause less immunosuppression and recurrence of certain types of cancer compared to volatile anesthetics and opioids.

The value of narrow band imaging in diagnosis of head and neck cancer: a meta-analysis

Head and neck cancer is difficult to diagnose early. We aimed to estimate the diagnosis value of narrow band imaging(NBI) in head and neck cancers. We identified relevant studies through a search of PubMed, Embase and the Cochrane Library. We used a random effect model. Subgroup analysis and meta-regression analysis were performed to estimate the factors which may influence the sensitivity and specificity of the NBI. We included 25 studies with total 6187 lesions. The pooled sensitivity, specificity, positive likelihood rate, negative likelihood rate and diagnostic odds ratios of NBI were 88.5%, 95.6%, 12.33, 0.11 and 121.26, respectively. The overall area under the curve of SROC was 96.94%. The location, type of assessment, type of endoscope system and high definition were not significant sources of heterogeneity (P > 0.05). However, magnification may be related to the source of heterogeneity (P = 0.0065). Therefore, NBI may be a promising endoscopic tool in the diagnosis of head and neck cancer.

Atypical PKC, PKCλ/ι, activates β-secretase and increases Aβ1-40/42 and phospho-tau in mouse brain and isolated neuronal cells, and may link hyperinsulinemia and other aPKC activators to development of pathological and memory abnormalities in Alzheimer's disease

Hyperinsulinemia activates brain Akt and PKC-λ/ι and increases Aβ1-40/42 and phospho-tau in insulin-resistant animals. Here, we examined underlying mechanisms in mice, neuronal cells, and mouse hippocampal slices. Like Aβ1-40/42, β-secretase activity was increased in insulin-resistant mice and monkeys. In insulin-resistant mice, inhibition of hepatic PKC-λ/ι sufficient to correct hepatic abnormalities and hyperinsulinemia simultaneously reversed increases in Akt, atypical protein kinase C (aPKC), β-secretase, and Aβ1-40/42, and restored acute Akt activation. However, 2 aPKC inhibitors additionally blocked insulin's ability to activate brain PKC-λ/ι and thereby increase β-secretase and Aβ1-40/42. Furthermore, direct blockade of brain aPKC simultaneously corrected an impairment in novel object recognition in high-fat-fed insulin-resistant mice. In neuronal cells and/or mouse hippocampal slices, PKC-ι/λ activation by insulin, metformin, or expression of constitutive PKC-ι provoked increases in β-secretase, Aβ1-40/42, and phospho-thr-231-tau that were blocked by various PKC-λ/ι inhibitors, but not by an Akt inhibitor. PKC-λ/ι provokes increases in brain β-secretase, Aβ1-40/42, and phospho-thr-231-tau. Excessive signaling via PKC-λ/ι may link hyperinsulinemia and other PKC-λ/ι activators to pathological and functional abnormalities in Alzheimer's disease.

Insulin-Like Growth Factor (IGF) Binding Protein-2, Independently of IGF-1, Induces GLUT-4 Translocation and Glucose Uptake in 3T3-L1 Adipocytes

Insulin-like growth factor binding protein-2 (IGFBP-2) is the predominant IGF binding protein produced during adipogenesis and is known to increase the insulin-stimulated glucose uptake (GU) in myotubes. We investigated the IGFBP-2-induced changes in basal and insulin-stimulated GU in adipocytes and the underlying mechanisms. We further determined the role of insulin and IGF-1 receptors in mediating the IGFBP-2 and the impact of IGFBP-2 on the IGF-1-induced GU. Fully differentiated 3T3-L1 adipocytes were treated with IGFBP-2 in the presence and absence of insulin and IGF-1. Insulin, IGF-1, and IGFBP-2 induced a dose-dependent increase in GU. IGFBP-2 increased the insulin-induced GU after long-term incubation. The IGFBP-2-induced impact on GU was neither affected by insulin or IGF-1 receptor blockage nor by insulin receptor knockdown. IGFBP-2 significantly increased the phosphorylation of PI3K, Akt, AMPK, TBC1D1, and PKCζ/λ and induced GLUT-4 translocation. Moreover, inhibition of PI3K and AMPK significantly reduced IGFBP-2-stimulated GU. In conclusion, IGFBP-2 stimulates GU in 3T3-L1 adipocytes through activation of PI3K/Akt, AMPK/TBC1D1, and PI3K/PKCζ/λ/GLUT-4 signaling. The stimulatory effect of IGFBP-2 on GU is independent of its binding to IGF-1 and is possibly not mediated through the insulin or IGF-1 receptor. This study highlights the potential role of IGFBP-2 in glucose metabolism.

Antiobesity potential of Piperonal: promising modulation of body composition, lipid profiles and obesogenic marker expression in HFD-induced obese rats

BACKGROUND

Black pepper or Piper nigrum is a well-known spice, rich in a variety of bioactive compounds, and widely used in many cuisines across the world. In the Indian traditional systems of medicine, it is used to treat gastric and respiratory ailments. The purpose of this investigation is to study the antihyperlipidemic and antiobesity effects of piperonal in high-fat diet (HFD)-induced obese rats.

METHODS

Piperonal, an active constituent of Piper nigrum seeds, was isolated and confirmed by HPLC, 1H and 13C NMR spectroscopy. Male SD rats were fed on HFD for 22 weeks; Piperonal was supplemented from the 16th week as mentioned in the experimental design. Changes in body weight and body composition were measured by TOBEC, bone mineral composition and density were measured by DXA, and adipose tissue distribution was measured by 7 T-MRI. Plasma levels of glucose, insulin, insulin resistance and lipid profiles of plasma, liver and kidney, adipocyte hormones and liver antioxidants were evaluated using standard kit methods. Expression levels of adipogenic and lipogenic genes, such as PPAR-γ, FAS, Fab-4, UCP-2, SREBP-1c, ACC, HMG-COA and TNF-α were measured by RT-PCR. Histopathological examination of adipose and liver tissues was also carried out in experimental rats.

RESULTS

HFD substantially induced body weight, fat%, adipocyte size, circulatory and tissue lipid profiles. It elevated the plasma levels of insulin, insulin resistance and leptin but decreased the levels of adiponectin, BMC and BMD. Increased expression of PPAR-γ, FAS, Fab-4, UCP-2, SREBP-1c, ACC, and TNF-α was noticed in HFD-fed rats. However, supplementation of piperonal (20, 30 and 40 mg/kg b.wt) for 42 days considerably and dose-dependently attenuated the HFD-induced alterations, with the maximum therapeutic activity being noticed at 40 mg/kg b.wt.

CONCLUSIONS

Piperonal significantly attenuated HFD-induced body weight and biochemical changes through modulation of key lipid metabolizing and obesogenic genes. Our findings demonstrate the efficacy of piperonal as a potent antiobesity agent, provide scientific evidence for its traditional use and suggest the possible mechanism of action.

Community-based survey of knowledge of, attitudes to and practice of colorectal cancer screening in Hong Kong

OBJECTIVE

We aimed to investigate the knowledge, attitudes and practice of colorectal cancer (CRC) and screening in the community to complement the introduction of population-based CRC screening in Hong Kong SAR, China.

METHODS

Clients attending the Family Planning Association of Hong Kong clinics from March to June 2016 were randomly invited to participate in this questionnaire survey.

RESULTS

Knowledge of CRC and screening for it was still deficient in the community. Respondents scored less than half on their knowledge of the symptoms and screening methods of CRC as well as on the local screening policy. Fewer than 30% knew that CRC can be asymptomatic and they had insufficient knowledge of primary lifestyle prevention of CRC. However, most (86.0%) would like to participate in CRC screening. The cost and trouble involved were the two main reasons given for not wanting to do so. Only 14.0% of the whole sample and 27.0% of those aged 50 years or above had undergone CRC screening irrespective of screening method. One-fifth of those who had been screened had some abnormality, with a cancer detection rate of 2.2%. Employment, income, knowledge and perception of risk were major determinants of their decision to undergo screening.

CONCLUSIONS

To reduce the morbidity and mortality of CRC significantly, average risk and high-risk groups should be encouraged to come forward for screening even if they are asymptomatic. Educating the population, simplifying the screening procedure and offering financial support by the government are keys to success.

Diagnostic performance of Japan NBI Expert Team classification for differentiation among noninvasive, superficially invasive, and deeply invasive colorectal neoplasia

BACKGROUNDS AND AIMS

The Japan NBI Expert Team (JNET) classification is the first universal narrow-band imaging magnifying endoscopic classification of colorectal tumors. Considering each type in this classification, the diagnostic ability of Type 2B is the weakest. Generally, clinical behavior is believed to be different in each gross type of colorectal tumor. We evaluated the differences in the diagnostic performance of JNET classification for each gross type (polypoid and superficial) and examined whether the diagnostic performance of Type 2B could be improved by subtyping.

METHODS

We analyzed 2933 consecutive cases of colorectal lesions, including 136 hyperplastic polyps/sessile serrated polyps, 1926 low-grade dysplasias (LGDs), 571 high-grade dysplasias (HGDs), and 300 submucosal (SM) carcinomas. We classified lesions as polypoid and superficial type and compared the diagnostic performance of the classification system in each type. Additionally, we subtyped Type 2B into 2B-low and 2B-high based on the level of irregularity in surface and vessel patterns, and we evaluated the relationship between the subtypes and histology, as analyzed separately for polypoid and superficial types. We also estimated interobserver and intraobserver variability.

RESULTS

The diagnostic performance of JNET classification did not differ significantly between polypoid and superficial lesions. Ninety-nine percent of Type 2B-low lesions were LGDs, HGDs, or superficial submucosal invasive (SM-s) carcinomas. In contrast, 60% of Type 2B-high lesions were deep submucosal invasive (SM-d) carcinomas. The results were not different between each gross type. Interobserver and intraobserver agreements for Type 2B subtyping were good, with kappa values of .743 and .786, respectively.

CONCLUSIONS

Type 2B subtyping may be useful for identifying lesions that are appropriate for endoscopic resection. JNET classification and Type 2B sub classification are useful criteria, regardless of gross type.

Mulberry branch bark powder significantly improves hyperglycemia and regulates insulin secretion in type II diabetic mice

This experiment, based on the previous study on R. mori, introduces whole mulberry branch powder into the diet to treat diabetic mice. Mulberry branch bark powder (MBBP) was administered orally to streptozotocin (STZ)-induced type II diabetic (T2D) mice to investigate hypoglycemic effects. After a 4-week period of diet consumption containing 5%, 10% and 20% MBBP, the fasting blood glucose, body weight and the related western blotting were measured, pathologic and immunohistochemical were observed. The 20% MBBP group showed a significant reduction in hyperglycemia and hyperinsulinemia; fasting blood glucose and insulin decreased from 25.0 to 14.8 mmol/L and 26.5 to 16.0 mU/L, respectively. Pathologic and immunohistochemical observation showed that MBBP administration lead to the repair of pancreas cells and restoration of insulin secretion. Dietary MBBP was associated with the decrease in the contents of 3, 4-methylenedioxeamphetamine, 8-OHdG, aspartate aminotransferase, and alanine aminotransferase, and the increase in antioxidative ability and glucose tolerance. Western blotting (WB) analysis suggested that MBBP decreased the TNF-α levels, thus relieving inflammation and improving liver function. It also led to the downregulation of apoptosis factor expression. WB also confirmed that MBBP enhanced the gene expression of the key enzymes: insulin receptor, insulin receptor substrate, p-AKT, GSK3β, glycogen synthase, G6Pase and phosphoenolpyruvate carboxykinase, which are related to glucose metabolism in the liver, and increase the expression of the genes PDX-1, GLUT2, MafA, and glucokinase, related to insulin secretion. Thus, oral administration of MBBP regulated insulin secretion and effectively maintained normal levels of glucose metabolism in mice, which may be done by improving the antioxidant capacity and activating insulin signaling with T2D..

Global perspective on colonoscopy use for colorectal cancer screening: A multi-country survey of practicing colonoscopists

OBJECTIVES

To examine colorectal cancer screening practices among colonoscopy specialists from 5 countries and inform public health needs in improvement of the ongoing global crisis in colorectal cancer.

METHODS

An online survey among colonoscopy specialists was conducted in France, Germany, the United Kingdom, Japan, and the United States. The survey covered topics on colonoscopy practices in the screening as well as in the treatment setting, as well as expected trends.

RESULTS

Participating colonoscopy specialists included 114 physicians from the United States, 81 from France, 80 from Germany, 80 from the United Kingdom, and 156 from Japan. Survey results revealed that 59%-73% of colonoscopies were performed in patients aged 50-75 years old, with 15%-23% performed in patients <50 years old. The proportion of patients with age-based versus symptom-based first colorectal cancer screening varied by country and age. Sedation protocols varied by country; however, rate of incomplete colonoscopy was low in all countries. The proportion of negative first colonoscopies decreased with age in all countries.

CONCLUSIONS

This multi-country survey of real-world clinical practices suggests a need for improved participation in population age-based colorectal cancer screening and possibly younger age of screening initiation than currently recommended by guidelines. The variation among countries in the proportion of patients who received their first colonoscopy due to age-based colorectal cancer screening versus symptom-based initial colonoscopy indicates that population-based screening initiatives and improved health outcomes will benefit from public health awareness programs.

Current standards and new developments of colorectal polyp management and resection techniques

Colonoscopy and endoscopic removal of precancerous polyps play an important role in colorectal cancer (CRC) prevention. Improved endoscopes and quality standards have led to an increasing polyp and adenoma detection rate. Optimal polyp resection techniques and management strategies are key for an effective colonoscopy practice. Areas covered: Strategies for how to improve diminutive polyp (polyps up to 5 mm in size) management are discussed because of their high prevalence. Systematic removal of diminutive polyps leads to increasing costs of colonoscopy practice, while the effect on colorectal cancer prevention might be negligible. Furthermore, polypectomy recommendations for mid-size and large polyps are provided. For all larger polyps larger, complete and safe resection is mandatory to avoid post colonoscopy cancers. The focus for managing such larger polyps is to use new techniques (i.e. cold snares) and to attempt complete removal and to reduce post-polypectomy complications. Expert commentary: The resect-and-discard strategy is a promising management strategy for diminutive polyps. However, modification of this approach might be required in order to make widespread adoption feasible. Cold snare polypectomy is a promising new approach for small polyp resection. For resection of large polyps adequate treatment recommendations with regard to endoscopic mucosal resection and complication prevention are provided.

Colorectal Cancer Screening in Asia

PURPOSE OF REVIEW

Colorectal cancer (CRC) is increasing in Asia, especially in regions with higher levels of economic development. Several Asian countries have launched population CRC screening programs to combat this devastating disease because previous studies have demonstrated that either fecal occult blood test or lower gastrointestinal endoscopy can effectively reduce CRC mortality.

RECENT FINDINGS

Screening includes engaging the population, testing, administering a confirmation examination, and treating screening-detected neoplasms; thus, monitoring the whole process using measurable indicators over time is of utmost importance. Only when the quality of every step is secured can the effectiveness of CRC screening be maximized. Screening and verification examination rates remain low in Asian countries, and important infrastructure, including cancer or death registry systems, colonoscopy capacity, and reasonable subsidization for screening, is lacking or insufficient. Future research should identify potential local barriers to screening. Good communication and dialog among screening organizers, clinicians, professional societies, and public health workers are indispensible for successful screening programs.

RORα controls hepatic lipid homeostasis via negative regulation of PPARγ transcriptional network

The retinoic acid receptor-related orphan receptor-α (RORα) is an important regulator of various biological processes, including cerebellum development, circadian rhythm and cancer. Here, we show that hepatic RORα controls lipid homeostasis by negatively regulating transcriptional activity of peroxisome proliferators-activated receptor-γ (PPARγ) that mediates hepatic lipid metabolism. Liver-specific Rorα-deficient mice develop hepatic steatosis, obesity and insulin resistance when challenged with a high-fat diet (HFD). Global transcriptome analysis reveals that liver-specific deletion of Rorα leads to the dysregulation of PPARγ signaling and increases hepatic glucose and lipid metabolism. RORα specifically binds and recruits histone deacetylase 3 (HDAC3) to PPARγ target promoters for the transcriptional repression of PPARγ. PPARγ antagonism restores metabolic homeostasis in HFD-fed liver-specific Rorα deficient mice. Our data indicate that RORα has a pivotal role in the regulation of hepatic lipid homeostasis. Therapeutic strategies designed to modulate RORα activity may be beneficial for the treatment of metabolic disorders.Hepatic steatosis development may result from dysregulation of lipid metabolism, which is finely tuned by several transcription factors including the PPAR family. Here Kim et al. show that the nuclear receptor RORα inhibits PPARγ-mediated transcriptional activity by interacting with HDAC3 and competing for the promoters of lipogenic genes.

Association between CYP24A1 polymorphisms and the risk of colonic polyps and colon cancer in a Chinese population

AIM

To determine the pathogenesis and potential single nucleotide polymorphisms (SNPs) as screening sites for colonic polyps, colon cancer and ulcerative colitis, and to analyze the possible association between these genetic polymorphisms and the three diseases.

METHODS

We evaluated genetic polymorphisms in 144 newly diagnosed colonic polyp patients, 96 colon cancer patients and 44 ulcerative colitis patients. The four SNPs genotyped were rs4809957, rs6068816, rs6091822 and rs8124792. The control group consisted of 504 East Asians enrolled in the 1000 Genomes Project. Correlations between CYP24A1 SNPs and the diseases were analyzed by Fisher’s exact probability test.

RESULTS

CYP24A1 polymorphisms rs4809957 A/G and rs6068816 C/T showed a statistically significant association with risk of the three diseases, when both the genotypes and allele frequencies were considered. With regard to rs6091822 G/T, all three diseases were related to risk allele carriers (GT + TT) vs wild-type (GG), but the associations between the allele frequencies and the diseases were not significant. The risk of colonic polyps and colon cancer was related to the allele frequencies of rs8124792 G/A, and this association remained for genotype frequencies of this SNP.

CONCLUSION

Four SNPs are related to the risk of colonic polyps and colon cancer. G allele in rs6091822 G/T may play an anti-cancer role only if it is homozygous. The A allele, which is a minor component of rs8124792, may be indicated in the diagnosis of colonic polyps or colon cancer rather than ulcerative colitis.

Approaching the Hard-to-Reach in Organized Colorectal Cancer Screening: an Overview of Individual, Provider and System Level Coping Strategies

BACKGROUND

Despite the proven effectiveness of colorectal cancer (CRC) screening on reduction of CRC mortality, the uptake of CRC screening remains low. Participation rate is one of determinants for the success of organized population-based screening program. This review aims to identify those who are hard-to-reach, and summarize the strategies to increase their screening rate from individual, provider and system levels.

METHODS

A systematic search of electronic English databases was conducted on the factors and strategies of uptake in CRC screening for the hard-to-reach population up to May 2017.

DISCUSSION

The coverage rate and participation rate are two indexes to identify the hard-to-reach population in organized CRC screening program. However, the homeless, new immigrants, people with severe mental illness, the jail intimates, and people with characteristics including lower education levels and/or low socioeconomic status, living in rural/remote areas, without insurance, and racial minorities are usually recognized as hard-to-reach populations. For them, organized screening programs offer a better coverage, while novel invitation approaches for eligible individuals and multiple strategies from primary care physicians are still needed to enhance screening rates among subjects who are hard-to-reach. Suggestions implied the effectiveness of interventions at the system level, including linkages to general practice; use of decision making tools; enlisting supports from coalition; and the continuum from screening to diagnosis and treatment.

CONCLUSION

Organized CRC screening offers a system access to approach the hard-to-reach populations. To increase their uptake, multiple and novel strategies from individual, provider and system levels should be applied. For policymakers, public healthcare providers and community stakeholders, it is a test to tailor their potential needs and increase their participation rates through continuous efforts to eliminate disparities and inequity in CRC screening service.

Omega-3 supplementation in patients with sepsis: a systematic review and meta-analysis of randomized trials

BACKGROUND

Nutritional supplementation of omega-3 fatty acids has been proposed to modulate the balance of pro- and anti-inflammatory mediators in sepsis. If proved to improve clinical outcomes in critically ill patients with sepsis, this intervention would be easy to implement. However, the cumulative evidence from several randomized clinical trials (RCTs) remains unclear.

METHODS

We searched the Cochrane Library, MEDLINE, and EMBASE through December 2016 for RCTs on parenteral or enteral omega-3 supplementation in adult critically ill patients diagnosed with sepsis or septic shock. We analysed the included studies for mortality, intensive care unit (ICU) length of stay, and duration of mechanical ventilation, and used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the quality of the evidence for each outcome.

RESULTS

A total of 17 RCTs enrolling 1239 patients met our inclusion criteria. Omega-3 supplementation compared to no supplementation or placebo had no significant effect on mortality [relative risk (RR) 0.85; 95% confidence interval (CI) 0.71, 1.03; P = 0.10; I ² = 0%; moderate quality], but significantly reduced ICU length of stay [mean difference (MD) -3.79 days; 95% CI -5.49, -2.09; P < 0.0001, I ² = 82%; very low quality] and duration of mechanical ventilation (MD -2.27 days; 95% CI -4.27, -0.27; P = 0.03, I ² = 60%; very low quality). However, sensitivity analyses challenged the robustness of these results.

CONCLUSION

Omega-3 nutritional supplementation may reduce ICU length of stay and duration of mechanical ventilation without significantly affecting mortality, but the very low quality of overall evidence is insufficient to justify the routine use of omega-3 fatty acids in the management of sepsis.

A 15-year-old Nepali boy with metastasised colorectal cancer

Nepal suffers from vast inequalities in modern healthcare. The low-income country wrestles with far-reaching insufficiencies in minimal preventative medicine, health awareness, limited infrastructure and difficult topography-all of which contribute to poor access and poor care-seeking behaviour. Our patient came from rural Nepal, where primary healthcare outposts are frequently understaffed and underequipped. He received supportive treatment in his village from the time symptoms presented until he was diagnosed 2 years later, at a tertiary medical centre, with colorectal cancer. An examination of the relevant literature indicates that younger patients often present in later stages of the disease due to initial misdiagnosis or overlooking colorectal cancer as a possibility. Beyond the rarity of the patient's condition, the logistical and financial obstacles he faced in Nepal, particularly outside of the capital of Kathmandu, deterred his access to a higher level of care and delayed his correct diagnosis and treatment.