Increased Detection of Colorectal Polyps in Screening Colonoscopy Using High Definition i-SCAN Compared with Standard White Light

Background/Aims:

The aim of this study was to evaluate the efficacy of high definition (HD) i-SCAN for colorectal polyp detection in screening colonoscopy.

Methods:

We retrospectively analyzed the records of 501 patients who had undergone screening colonoscopy performed by three endoscopists with either HD i-SCAN (n=149) or standard white light (n=352) from January 2, 2014 through June 30, 2014. Patient information and inter-endoscopist variation as well as polyp number, endoscopic findings, and pathologic characteristics were reviewed.

Results:

The detection rates of colorectal and neoplastic polyps were significantly higher using HD i-SCAN than standard white light colonoscopy (52% vs. 38.1%, p=0.004 for colorectal polyps; and 37.2% vs. 27.9%, p=0.041 for neoplastic polyps). Analysis of endoscopic findings revealed no difference in detected polyp size between HD i-SCAN and standard white light colonoscopy (4.59±2.35 mm vs. 4.82±2.81 mm, p=0.739), but non-protruding polyps were more commonly detected by i-SCAN than by standard white light colonoscopy (24.6% vs. 13.5%, p=0.007).

Conclusions:

Colonoscopy using HD i-SCAN had a significantly higher detection rate of colorectal polyps, including neoplastic polyps, because of improved sensitivity for detecting non-protruding lesions.

Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea

PURPOSE

Cholecystectomy in patients with an intact gallbladder after endoscopic removal of stones from the common bile duct (CBD) remains controversial. We conducted a case-control study to determine the risk of recurrent CBD stones and the benefit of cholecystectomy for prevention of recurrence after endoscopic removal of stones from the CBD in Korean patients.

MATERIALS AND METHODS

A total of 317 patients who underwent endoscopic CBD stone extraction between 2006 and 2012 were included. Possible risk factors for the recurrence of CBD stones including previous cholecystectomy history, bile duct diameter, stone size, number of stones, stone composition, and the presence of a periampullary diverticulum were analyzed.

RESULTS

The mean duration of follow-up after CBD stone extraction was 25.4±22.0 months. A CBD diameter of 15 mm or larger [odds ratio (OR), 1.930; 95% confidence interval (CI), 1.098 to 3.391; p=0.022] and the presence of a periampullary diverticulum (OR, 1.859; 95% CI, 1.014 to 3.408; p=0.045) were independent predictive factors for CBD stone recurrence. Seventeen patients (26.6%) in the recurrence group underwent elective cholecystectomy soon after endoscopic extraction of CBD stones, compared to 88 (34.8%) in the non-recurrence group; the difference was not statistically significant (p=0.212).

CONCLUSION

A CBD diameter of 15 mm or larger and the presence of a periampullary diverticulum were found to be potential predictive factors for recurrence after endoscopic extraction of CBD stones. Elective cholecystectomy after clearance of CBD stones did not reduce the incidence of recurrent CBD stones in Korean patients.

Conventional versus Analgesia-Oriented Combination Sedation on Recovery Profiles and Satisfaction after ERCP: A Randomized Trial

Background

The importance of providing effective analgesia during sedation for complex endoscopic procedures has been widely recognized. However, repeated administration of opioids in order to achieve sufficient analgesia may carry the risk of delayed recovery after propofol based sedation. This study was done to compare recovery profiles and the satisfaction of the endoscopists and patients between conventional balanced propofol sedation and analgesia-oriented combination sedation for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

Methods

Two hundred and two adult patients scheduled for ERCP were sedated by either the Conventional (initial bolus of meperidine with propofol infusion) or Combination (repeated bolus doses of fentanyl with propofol infusion) method. Recovery profiles, satisfaction levels of the endoscopists and patients, drug requirements and complications were compared between groups.

Results

Patients of the Combination Group required significantly less propofol compared to the Conventional Group (135.0 ± 68.8 mg vs. 165.3 ± 81.7 mg, P = 0.005). Modified Aldrete scores were not different between groups throughout the recovery period, and recovery times were also comparable between groups. Satisfaction scores were not different between the two groups in both the endoscopists and patients (P = 0.868 and 0.890, respectively).

Conclusions

Considering the significant reduction in propofol dose, the non-inferiority of recovery profiles and satisfaction scores of the endoscopists and patients, analgesia oriented combination sedation may be a more safe yet effective sedative method compared to conventional balanced propofol sedation during ERCP.

Intramuscular diclofenac for the prevention of post-ERCP pancreatitis: a randomized trial

BACKGROUND AND STUDY AIMS

Rectal nonsteroidal anti-inflammatory drugs have been shown to reduce the incidence of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The aim of this study was to determine whether intramuscular diclofenac reduces the risk of PEP.

PATIENTS AND METHODS

Patients who underwent ERCP were randomized to receive either 90 mg of diclofenac or placebo by intramuscular injection immediately after the procedure. PEP was defined as elevated serum amylase levels (at least three times the upper limit of normal 24 hours after the procedure) associated with new or worsened upper abdominal, epigastric, or back pain.

RESULTS

In total, 380 patients were randomized, and 343 were eligible for analysis. The two groups were similar regarding clinical and demographic factors, as well as patient- and procedure-related risk factors for PEP. PEP developed in 20/170 patients (11.8 %) in the placebo group and in 22/173 patients (12.7 %) in the diclofenac group (P = 0.87). Multivariate regression analysis failed to illustrate that intramuscular diclofenac prevented PEP (odds ratio 0.79; 95 % confidence interval 0.39 - 1.25; P = 0.51).

CONCLUSION

Prophylactic intramuscular diclofenac had no beneficial preventive effect on PEP.Clinicaltrials.gov NCT01717599.

Validation of group B borderline resectable pancreatic cancer: retrospective analysis

Background/Aims

Among borderline resectable pancreatic cancer (BRPC), group B BRPC patients have findings that are suggestive but not diagnostic of metastasis. In this study, we attempted to validate whether group B could truly be categorized as a borderline resectable group.

Methods

We placed the BRPC patients into group A or group B. The survival outcomes were compared between the groups.

Results

A total of 53 patients with pancreatic adenocarcinoma was classified as either group A or B borderline resectable. In group A, 23 (60.5%) of 38 patients underwent pancreatectomy after concurrent chemoradiotherapy or chemotherapy, but in group B, only five (33.3%) of 15 patients underwent pancreatectomy, mainly because of the progression of suspected distant metastasis. There was a significant difference in overall survival (OS) between group A and B patients (median OS, 21.2 months vs 10.2 months, respectively; p=0.007). Of the patients who underwent pancreatectomy, group B had a higher recurrence rate compared to group A (recurrence rate: 11 of 23 patients [47.8%] vs five of five patients [100%], respectively; p=0.033).

Conclusions

This report is the first to validate the definition of BPRC. Group B had much worse outcomes, and whether group B BRPC can be categorized as BRPC together with group A is questionable.

Full-Dose Gemcitabine Is a More Effective Chemotherapeutic Agent Than 5-Fluorouracil for Concurrent Chemoradiotherapy as First-Line Treatment in Locally Advanced Pancreatic Cancer

<b><i>Objectives:</i></b> To compare the efficacy of full-dose gemcitabine-based concurrent chemoradiotherapy (FG-CCRT) and conventional 5-fluorouracil CCRT (5FU-CCRT) for locally advanced pancreatic cancer (LAPC). <b><i>Methods:</i></b> 109 LAPC cases treated with FG-CCRT (n = 89) or 5FU-CCRT (n = 20) were reviewed retrospectively. The FG-CCRT group was composed of a full-dose gemcitabine monotherapy (1,000 mg/m²) arm and a combination therapy with cisplatin (70 mg/m²) arm. The 5FU-CCRT group used a radiosensitizing dose of 5-FU (500 mg/m²) plus leucovorin (20 mg/m²). Concurrent radiotherapy was targeted at the tumor with a 5-mm margin without lymph node irradiation. <b><i>Results:</i></b> Objective response rate (ORR) and disease control rate (DCR) was significantly higher in the FG-CCRT group (ORR: 32.6 vs. 5%, p = 0.013; DCR: 79.8 vs. 50.0%, p = 0.006). FG-CCRT showed remarkable superiority to 5FU-CCRT for suppressing distant metastasis (18.0 vs. 45.0%, p = 0.017). Neutropenia (34.8 vs. 10%, p = 0.032) and thrombocytopenia (21.3 vs. 0.0%, p = 0.021) were more frequent in the FG-CCRT group as originally expected. When dividing the FG-CCRT group to gemcitabine monotherapy (GEM) and gemcitabine plus cisplatin, toxicities of the GEM subgroup were not different than those of the 5FU-CCRT group. <b><i>Conclusion:</i></b> FG-CCRT, especially full-dose gemcitabine monotherapy-based CCRT was more effective for the initial control of LAPC than 5FU-CCRT, and also relatively safe.

The use of health functional foods in gastrointestinal cancer patients

As an adjunct to cancer treatment, the use of health functional foods (HFFs) seems to be increasing. However, little is known for the use of HFFs among cancer patients in Korea. The aims of this study were to investigate the exposure rate of HFF use among gastrointestinal (GI) cancer patients and to examine the relationship of socio-demographic and disease-related characteristics with the use of HFFs. A total of 126 patients diagnosed with GI cancer participated in the study. A cross-sectional survey was conducted using a questionnaire. Over a half of all the patients surveyed (n = 67; 53.2%) used HFFs. Patients who were younger, had higher income, or longer duration of disease showed a trend to use HFFs more frequently, even though the tendency was not statistically significant. The most commonly used HFF was vitamin complex (n = 20; 16%), followed by red ginseng (n = 15; 12%), and sweet wormwood (Artemisia annua) (n = 11; 8.8%). About 26% of all responders expressed concerns for using HFFs. The primary concern was 'going against physician's recommendations' (36.8%). About 63% of respondents expressed a desire to consult with their physicians and follow their recommendations. More basic scientific data and educational materials regarding HFFs are required for both health-care professionals and cancer patients. A larger sample and size-controlled groups representing each cancer type will continue to be recruited for participation in this survey.

Prognostic factors and characteristics of pancreatic neuroendocrine tumors: single center experience

PURPOSE

Pancreatic neuroendocrine tumors (PNET) are a rare subgroup of tumors. For PNETs, the predictive factors for survival and prognosis are not well known. The purpose of our study was to evaluate the predictive factors for survival and disease progression in PNETs.

MATERIALS AND METHODS

We retrospectively analyzed 37 patients who were diagnosed with PNET at Severance Hospital between November 2005 and March 2010. Prognostic factors for survival and disease progression were evaluated using the Kaplan-Meier method.

RESULTS

The mean age of the patients was 50.0±15.0 years. Eight cases (21.6%) were described as functioning tumors and 29 cases (78.4%) as non-functioning tumors. In univariate analysis of clinical factors, patients with liver metastasis (p=0.002), without resection of primary tumors (p=0.002), or American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) stage III/IV (p=0.002) were more likely to demonstrate shorter overall survival (OS). Patients with bile duct or pancreatic duct invasion (p=0.031), sized-lesions larger than 20 mm (p=0.036), liver metastasis (p=0.020), distant metastasis (p=0.005), lymph node metastasis (p=0.009) or without resection of primary tumors (p=0.020) were more likely to demonstrate shorter progression-free survival (PFS). In multivariate analysis of clinical factors, bile duct or pancreatic duct invasion [p=0.010, hazard ratio (HR)=95.046] and tumor location (non-head of pancreas) (p=0.036, HR=7.381) were confirmed as independent factors for predicting shorter PFS.

CONCLUSION

Patients with liver metastasis or without resection of primary tumors were more likely to demonstrate shorter OS. Patients with bile duct or pancreatic duct invasion or tumors located at body or tail of pancreas were more likely to demonstrate shorter PFS.

Primary intestinal lymphangiectasia diagnosed by capsule endoscopy and double balloon enteroscopy

Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lymphatics and the development of protein-losing enteropathy. Patients with PIL develop hypoalbuminemia, hypocalcemia, lymphopenia and hypogammaglobulinemia, and present with bilateral lower limb edema, fatigue, abdominal pain and diarrhea. Endoscopy reveals diffusely elongated, circumferential and polypoid mucosae covered with whitish enlarged villi, all of which indicate intestinal lymphangiectasia. Diagnosis is confirmed by characteristic tissue pathology, which includes dilated intestinal lymphatics with diffusely swollen mucosa and enlarged villi. The prevalence of PIL has increased since the introduction of capsule endoscopy. The etiology and prevalence of PIL remain unknown. Some studies have reported that several genes and regulatory molecules for lymphangiogenesis are related to PIL. We report the case of a patient with PIL involving the entire small bowel that was confirmed by capsule endoscopy and double-balloon enteroscopy-guided tissue pathology who carried a deletion on chromosome 4q25. The relationship between this deletion on chromosome 4 and PIL remains to be investigated.

Molecular cloning of the arylsulfate sulfotransferase gene and characterization of its product from Enterobacter amnigenus AR-37

The gene encoding the Enterobacter amnigenus AR-37 arylsulfate sulfotransferase (ASST) was cloned, sequenced, and expressed in Escherichia coli NM522. Sequencing led to the identification of three contiguous open reading frames (ORFs) on the same strand. Based on amino acid sequence homology, ORF1, ORF2, and ORF3 are designated astA, dsbA, and dsbB, respectively. A multiple sequence alignment revealed conserved regions in ASST. An N-terminal amino acid sequence analysis of the purified ASST from E. coli NM522 (pEAST72) showed that it is subject to N-terminal processing. The specific activity of purified ASST is 436.5 U/mg of protein. The enzyme is a monomeric protein with a molecular mass of 64 kDa. Using phenol as an acceptor substrate, 4-methylumbelliferyl sulfate is the best donor substrate, followed by beta-naphthyl sulfate, p-nitrophenyl sulfate (PNS), and alpha-naphthyl sulfate. For PNS, alpha-naphthol is the best acceptor substrate, followed by phenol, resorcinol, p-acetaminophen, tyramine, and tyrosine. The enzyme has a different acceptor specificity than the enzyme purified from Eubacterium A-44. It is similar to Klebsiella K-36 and Haemophilus K-12. The apparent K(m) values for PNS using phenol as an acceptor and for phenol using PNS as a donor are 0.163 and 0.314 mM, respectively. The pI and optimum pH are 6.1 and 9.0, respectively.

The relationship between stress and absenteeism

BACKGROUND OF STUDY: Three hundred and sixty three subjects from various civil service organisations were administered the SCOPE-i (Stress, Coping and Personality Inventory) as part of the Institute of Mental Health's efforts to promote mental health in the workplace.

AIM OF STUDY

This study examines the relationship between stress-related factors and absenteeism. Absenteeism is measured by the number of days of medical leave taken (MC) and self-report of minor illnesses (MI) which are not severe enough to warrant the coverage of a medical certificate.

RESULTS

In this study, we are interested in the differences between MI and MC, and their respective relationships with stress-related factors. We hypothesised that MI, rather than MC, is more related to poor workplace conditions. The findings of this study support this hypothesis. Thus if workplace environment is stressful, people are still likely to come to work despite their illness. An interesting observation in this study is the different ways in which environmental stressors and psychosocial aspects of the workplace environment affect the MC variable. Individuals are more likely to take MC when the environmental stressors are high (i.e., poor lighting, uncomfortable temperatures, etc) as compared to poor psychosocial environmental conditions (e.g., work overload, high organisational tension, career limitations and high personal constraints). On the other hand, when faced with poor psychosocial environmental conditions, MI increases instead of MC.

CONCLUSION

These findings have implications on the types of changes in a workplace which employers should make in order to decrease MC and improve physical well-being. In addition, the study shows the usefulness of MI in future studies as a dependent variable.

Induction of ermAMR from a clinical strain of Enterococcus faecalis by 16-membered-ring macrolide antibiotics

We cloned the MLSB resistance determinant by PCR from a clinical isolate of Enterococcus faecalis 373, which is induced more strongly by a 16-membered-ring macrolide, tylosin, than by erythromycin. To elucidate the molecular basis of resistance of E. faecalis 373, we analyzed the cloned gene, designated ermAMR, by site-directed mutagenesis and reporter gene assay. Our results showed that an arginine-to-cysteine change in the seventh codon of the putative leader peptide endowed tylosin with resistance inducibility and that TAAA duplication enabled the control region to express the downstream methylase gene at a drastically increased level.

Overexpression of arylsulfate sulfotransferase as fusion protein with glutathione S-transferase

A procedure has been developed for the overexpression and purification of milligram quantities of the Klebsiella K-36 arylsulfate sulfotransferase (ASST). The structural gene was amplified by means of a polymerase chain reaction (PCR) technique and inserted into the plasmid vector pGEX-3X. The plasmid pGEX-100, carrying the Klebsiella K-36 astA structural gene under the control of the Escherichia coli tac promoter, was transformed into the E. coli strain BL21 (DE3). The ASST was produced in E. coli as a fusion with glutathione S-transferase. Conditions for protein production, isolation on glutathione Sepharose 4B, and Xa cleavage to generate active ASST were developed. The purification yielded approximately 0.7 mg of pure enzyme per liter of bacterial culture. Kinetic analysis of the overexpressed enzyme indicated that it had kinetic properties almost the same as those of the enzyme purified from Klebsiella K-36 cells. The purification procedure was very rapid and is suitable for obtaining considerable amounts of enzyme at a relatively high yield compared with its purifying method from the culture of the Klebsiella K-36 strain.

Role of mRNA termination in regulation of ermK

To study the role of mRNA termination in the regulation of ermK, we introduced mismatches into terminators by in vitro mutagenesis. In wild-type ermK, only truncated transcription products were detected in the absence of induction. In contrast, only the full-length transcript was synthesized in the terminator 1 and terminator 2 double mutants, even in the absence of erythromycin. These results indicate that the expression of ermK is primarily regulated by transcriptional attenuation rather than translational attenuation. We also tested the possible contribution of translational attenuation control to the regulation of ermK by constructing a triple mutant (terminator 1 plus terminator 2 plus the methylase Shine-Dalgarno region). A higher level of beta-galactosidase synthesis was seen in the triple mutant. Therefore, unlike with previously described attenuators, it can be concluded that both transcriptional and translational attenuation contribute to the regulation of ermK, although transcriptional attenuation plays a larger role.

Relationships between angiotensin I converting enzyme gene polymorphism and renal complications in Korean IDDM patients

OBJECTIVES

The prognosis of IDDM is mainly dependent on complicated diabetic nephropathy which is probably determined by both metabolic abnormalities and genetic predisposition. Angiotensin I converting enzyme (ACE) regulates systemic and renal circulations through angiotensin II formation and kinins metabolism. The insertion(i)/deletion(D) polymorphism in intron 16 of ACE gene is strongly associated with ACE levels, and subjects homozygote for deletion (genotype DD) have the highest plasma values. Recently, it was reported that I/D polymorphism of ACE gene is associated with diabetic nephropathy in Caucasian IDDM patients. We studied the relationship between the ACE gene polymorphism and diabetic nephropathy in Korean IDDM patients.

METHODS

The study population consisted of 59 IDDM patients (duration > 5 yrs) and 107 control subjects. IDDM subjects were divided into 2 groups according to the presence or absence of diabetic nephropathy (with nephropathy: n = 31, without nephropathy: n = 28). After extraction of genomic DNA from peripheral blood leukocytes, PCR was performed using the sense primer (5' -GCC CTG CAG GTG TCT GCA GC-3') and anti-sense primer (3'-TGC CCA TAA CAG TGC TTC ATA -5'), respectively. The PCR products were electrophoresed in 2% agarose gels, and DNA was visualized directly with ethidium bromide staining.

RESULTS

Frequencies for II, ID and DD genotypes were similar in IDDM subjects and controls (23: 19:17 vs 49:41:17, p = 0.142) and derived allele frequencies for I and D alleles were similar in both groups (0.551:0.449 vs 0.649:0.351, p = 0.098). The ACE genotype distributions were not different in diabetic subjects with or without nephropathy (12:9:10 vs 11:10:7, p = 0.78) and derived allele frequencies were also similar (0.532:0.468 vs 0.571:0.429, p = 0.81).

CONCLUSION

The I and D allele frequency in our controls was different compared to ACE allele frequencies of Caucasian populations, but very similar compared to those of Chinese or Japanese subjects. We found that I/D polymorphism of ACE gene is not implicated in the diabetic nephropathy of Korean IDDM patients and may be explained by ethnic differences.

Psychiatric referrals in the general hospital

Psychiatric disorders and physical illnesses often coexist. Although there is evidence of high psychiatric morbidity in general hospital patients, only a small percentage are referred to the consultation-liaison psychiatrist. The paper describes and discusses the common psychiatric conditions encountered and referred in general hospitals. They include attempted suicides, psychiatric disorders presenting with physical symptoms, organic psychiatric disorders presenting with psychiatric symptoms and the psychiatric consequences of physical illness. The major diagnostic categories of these referrals are organic psychotic disorders, functional psychoses and neurotic disorders. Some broad guidelines are listed for the referring physician. Patients presenting with suicidal ideations or attempts, suspected emotional psychiatric disturbance, a history of psychiatric illness, an apparent incompetence in giving consent for medical procedures and those with diagnostic and management problems could be referred to the psychiatrist.

Psychological and psychiatric investigations of HIV infection in Singapore

A psychosocial study was carried out on 10 out of the 18 HIV positive persons who were under surveillance and receiving counselling at either Middle Road Hospital or the Communicable Disease Centre in February 1988. The results of the psychological testing and psychiatric findings are presented. All 10 were male: 9 of them were homosexual and 1 heterosexual. Only one had significant depressive symptoms at the time of study. All had fears about their infection being found out by others and of the stigma that this might bring to their families. Psychometric tests on memory function did not show any signs of visuo-verbal memory impairment but did reveal a possible indication of audio-verbal memory dysfunction.