Diagnostic value of nonenhanced multidetector computed tomography for ruling out acute aortic dissection in patients presenting with chest or back pain

Background

Multidetector computed tomography (MDCT) is widely used for diagnosing acute aortic dissection (AAD). However, the diagnostic value of nonenhanced MDCT for AAD remains unknown. We evaluated the usefulness of nonenhanced 64-slice MDCT for ruling out AAD in patients presenting with chest or back pain.

Methods

Of 107 patients with clinical suspicion of AAD who underwent MDCT, AAD was confirmed in 47 and ruled out in 60. Nonenhanced MDCT data of all patients were retrospectively assessed by 2 independent observers unaware of clinical information and contrast-enhanced MDCT data. The diagnostic performance of nonenhanced MDCT parameters to detect AAD was calculated.

Results and conclusion

Among the parameters, positive intimal flap, defined as the clear presence of a high-density membrane-like structure in the aorta on serial axial images, had a sensitivity of 87%, a specificity of 100%, a positive predictive value (PPV) of 100%, and a negative predictive value (NPV) of 91%, respectively. The addition of equivocal intimal flap, defined as the ambiguous presence of a high-density membrane-like structure in the aorta on at least one axial image, increased both the sensitivity and NPV to 96%. Furthermore, the combination of intimal flap (positive + equivocal or positive alone) and high-density area in the aorta showed the highest sensitivity (98%) and NPV (98%). Combination of the nonenhanced MDCT parameters intimal flap and high-density area in the aorta provides excellent sensitivity and NPV, suggesting that nonenhanced MDCT is an effective modality for ruling out AAD in patients with chest or back pain.     

Novel serine/threonine kinase 11 gene mutations in Peutz-Jeghers syndrome patients and endoscopic management

AIM: To explore mutations in serine/threonine kinase 11 (STK11) gene in Peutz-Jeghers syndrome (PJS) with gastrointestinal (GI) hamartomatous polyps.METHODS: Six Japanese PJS patients in 3 families were enrolled in this study. Each of the cases had hamartomatous polyposis in the gastrointestinal tract, including the small intestine, along with mucocutaneous hyperpigmentation. Narrow-band imaging (NBI)-magnification endoscopy was employed to detect microvascular and microsurface irregularities in the GI lesions. NBI magnification findings could be classified into three groups (type A, type B, or type C). Endoscopic polypectomy was performed using double-balloon enteroscopy or colonoscopy. Genomic DNA was extracted from a whole blood sample from each subject. All of the coding exons of STK11 gene, its boundary regions, and the promoter region containing the polymorphic regions were amplified by polymerase chain reaction, and direct sequencing was performed to assess the germline mutations.RESULTS: NBI-magnification endoscopic observation could detect the abnormalities in microvessels and microsurface structures of GI polyps. Overall, we found 5 cases of type A and one case without the examination for the gastric polyps, while there were 4 cases of type B and 2 case of type A for the colorectal polyps. Seventy-nine small-bowel and 115 colorectal polyps over 27 sessions for each were resected endoscopically without significant complications. The only delayed complication included the occurrence of bleeding in a case, and this was successfully managed with hemoclips. Resected polyps contained no malignant components. Based on mutation analysis, all 3 cases in Family I exhibited the +658C>T nonsense mutation in exon 5, which resulted in the production of a truncated protein (Q220X). In Family II, a case had -252C>A and -193C>A in the promoter region. In Family III, a case was found to have the +1062C>G (F342L) mutation in exon 8.CONCLUSION: We found two novel mutations of STK11 in association with PJS. Endoscopic polypectomy of GI polyps in PJS patients appears to be useful to prevent emergency laparotomies and reduce the cancer risk.     

Endoscopic approach through the minor papilla for the management of pancreatic diseases

AIM: To clarify the efficacy and safety of an endoscopic approach through the minor papilla for the management of pancreatic diseases.METHODS: This study included 44 endoscopic retrograde cholangiopancreatography (ERCP) procedures performed in 34 patients using a minor papilla approach between April 2007 and March 2012. We retrospectively evaluated the clinical profiles of the patients, the endoscopic interventions, short-term outcomes, and complications.RESULTS: Of 44 ERCPs, 26 were diagnostic ERCP, and 18 were therapeutic ERCP. The most common cause of difficult access to the main pancreatic duct through the major papilla was pancreas divisum followed by distortion of Wirsung’s duct. The overall success rate of minor papilla cannulation was 80% (35/44), which was significantly improved by wire-guided cannulation (P = 0.04). Endoscopic minor papillotomy (EMP) was performed in 17 of 34 patients (50%) using a needle-knife (13/17) or a pull-type papillotome (4/17). EMP with pancreatic stent placement, which was the main therapeutic option for patients with chronic pancreatitis, recurrent acute pancreatitis, and pancreatic pseudocyst, resulted in short-term clinical improvement in 83% of patients. Mild post-ERCP pancreatitis occurred as an early complication in 2 cases (4.5%).CONCLUSION: The endoscopic minor papilla approach is technically feasible, safe, and effective when the procedure is performed in a high-volume referral center by experienced endoscopists.     

IL‐28B (IFN‐λ3) and IFN‐α synergistically inhibit HCV replication

Genetic variation in the IL‐28B (interleukin‐28B; interferon lambda 3) region has been associated with sustained virological response (SVR) rates in patients with chronic hepatitis C treated with peginterferon‐α and ribavirin. However, the mechanisms by which polymorphisms in the IL‐28B gene region affect host antiviral responses are not well understood. Using the HCV 1b and 2a replicon system, we compared the effects of IFN‐λs and IFN‐α on HCV RNA replication. The anti‐HCV effect of IFN‐λ3 and IFN‐α in combination was also assessed. Changes in gene expression induced by IFN‐λ3 and IFN‐α were compared using cDNA microarray analysis. IFN‐λs at concentrations of 1 ng/mL or more exhibited concentration‐ and time‐dependent HCV inhibition. In combination, IFN‐λ3 and IFN‐α had a synergistic anti‐HCV effect; however , no synergistic enhancement was observed for interferon‐stimulated response element (ISRE) activity or upregulation of interferon ‐ stimulated genes (ISGs). With respect to the time course of ISG upregulation, the peak of IFN‐λ3‐induced gene expression occurred later and lasted longer than that induced by IFN‐α. In addition, although the genes upregulated by IFN‐α and IFN‐λ3 were similar to microarray analysis, interferon‐stimulated gene expression appeared early and was prolonged by combined administration of these two IFNs. In conclusion, IFN‐α and IFN‐λ3 in combination showed synergistic anti‐HCV activity in vitro. Differences in time‐dependent upregulation of these genes might contribute to the synergistic antiviral activity.     

Regular insulin,rather than rapid‐acting insulin,is a suitable choice for premeal bolus insulin in lean patients with type 2 diabetes mellitus

The aim of the present study was to compare the usefulness of premeal rapid‐acting and regular insulin in type 2 diabetes patients. A total of 56 type 2 diabetic patients were investigated during hospitalization. Premeal rapid‐acting insulin was applied instead of other medications. Premeal insulin was titrated to adjust premeal and bedtime blood glucose levels to 81–120 mg/dL. Premeal rapid‐acting insulin was changed to regular insulin just before a meal at the same dosage if the postmeal blood glucose level was lower than the premeal blood glucose level. A total of 15 patients changed to regular insulin, and 41 patients continued rapid‐acting insulin. The blood glucose level was comparable between these two groups. Body mass index was significantly lower in the patients using regular insulin. According to the multivariate logistic regression analysis, low body mass index was an independent variable accounting for the usefulness of regular insulin. Regular insulin, rather than rapid‐acting insulin, is a suitable choice for premeal insulin in lean type 2 diabetic patients.     

Asthma Phenotypes in Japanese Adults - Their Associations with the CCL5 ADRB2 Genotypes

BackgroundCluster analyses were previously performed to identify asthma phenotypes underlying asthma syndrome. Although a large number of patients with asthma develop the disease later in life, these previous cluster analyses focused mainly patients with younger-onset asthma.MethodsCluster analysis examined the existence of distinct phenotypes of late-onset asthma in Japanese patients with adult asthma. We then associated genotypes at the CCL5, TSLP, IL4, and ADRB2 genes with the clusters of asthma identified.ResultsUsing the 8 variables of age, sex, age at onset of the disease, smoking status, total serum IgE, %FEV1, FEV1/FVC, and specific IgE responsiveness to common inhaled allergens, two-step cluster analysis of 880 Japanese adult asthma patients identified 6 phenotypes: cluster A (n = 155): older age at onset, no airflow obstruction; cluster B (n = 170): childhood onset, normal-to-mild airflow obstruction; cluster C (n = 119): childhood onset, the longest disease duration, and moderate-to-severe airflow obstruction; cluster D (n = 108): older age at onset, severe airflow obstruction; cluster E (n = 130): middle-age at onset, no airflow obstruction; and cluster F (n = 198): older age at onset, mild-to-moderate airflow obstruction. The CCL5-28C>G genotype was significantly associated with clusters A, B and D (OR 1.65, p = 0.0021; 1.67, 0.018; and 1.74, 0.011, respectively). The ADRB2 Arg16Gly genotype was also associated with clusters B and D (OR 0.47, p = 0.0004; and 0.63, 0.034, respectively).ConclusionsThe current cluster analysis identified meaningful adult asthma phenotypes linked to the functional CCL5 and ADRB2 genotypes. Genetic and phenotypic data have the potential to elucidate the pheno- typic heterogeneity and pathophysiology of asthma.     

How often should we perform surveillance colonoscopy after surgery for colorectal cancer?

Purpose

Surveillance colonoscopy is undertaken after resection of colorectal cancer to detect and treat local recurrence and metachronous lesions, with the aim of improving survival. This study aimed to clarify the current timing of surveillance colonoscopies and evaluate the rates of local recurrence and metachronous tumors.

Methods

We retrospectively analyzed data from 459 patients who underwent surveillance colonoscopy at our institution after curative resection of colorectal cancer. The number and timing of surveillance colonoscopies, incidence of local recurrence and metachronous lesions, pathological findings of lesions, treatment of lesions, and outcomes were recorded.

Results

The first surveillance colonoscopy was undertaken at 6–18 months after surgery in 73 % of patients. Local recurrence was detected in three cases (0.7 %), all during the first surveillance colonoscopy, which was performed >1 year after surgery. These three patients all underwent additional surgery and were alive 5 years later. Invasive metachronous cancers were detected in six patients (1.3 %) at 18–57 months after surgery, and advanced adenomas were detected in 30 patients.

Conclusion

Considering the low incidence of postoperative lesions and the timing of lesion detection, reducing the number of surveillance colonoscopies after surgery for colorectal cancer may be appropriate.     

Infliximab administration prior to surgery does not increase surgical site infections in patients with ulcerative colitis

Purpose

The high incidence of infectious complications in ulcerative colitis (UC) is generally recognized to be due to several factors related to a compromised host. In our previous study, a high dose of corticosteroid was shown to be a risk factor for surgical site infection (SSI). Recently, infliximab (IFX) has been used for refractory UC. In this study, the effect of IFX on the occurrence of infectious postoperative complications for UC was evaluated, because it remains controversial.

Method

A total of 196 UC patients who underwent laparotomy between January 2010 and September 2012 were included. Possible factors related to complications were analyzed to identify significant predictors.

Results

Twenty-two patients had IFX before surgery. The overall incidence of SSI was 47/196 (24.0 %). The incidence of infections, including SSI and other infections, was 69/196 (35.2 %). On multivariate analysis, national nosocomial infection surveillance (NNIS) risk index ≥2 (p<0.01) and preoperative prednisolone dose ≥0.2 mg/kg/day (p?=?0.01) were identified as independent risk factors for overall SSI; NNIS risk index ≥2 (p <0.01) and duration from onset of UC ≥6.3 years (p?=?0.045) were identified as independent risk factors for incisional SSI; contaminated wound class (p <0.01), preoperative hospital stay ≥6 days (p?=?0.048), severe/fulminant disease activity (p?=?0.04), and pancolitis (p?=?0.02) were identified as independent risk factors for organ/space SSI; and contaminated wound (p?<?0.01), severe/fulminant disease activity (p?=?0.02), and age at surgery ≥43 years (p?=?0.047) were identified as independent risk factors for total infectious complications.

Conclusion

IFX administration was not associated with infectious complications for UC surgery.     

Rarity of Severe Bleeding and Perforation in Endoscopic Ultrasound-Guided Fine Needle Aspiration for Submucosal Tumors

Background

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established procedure for the pathological diagnosis of gastrointestinal submucosal tumors (SMTs). Although bleeding and perforation are potentially severe complications of EUS-FNA, the incidences and severities of these complications have not yet been fully evaluated because of their relative rarity.

Aim

The purpose of this study was to evaluate the incidences and mortality of severe bleeding and perforation in patients who underwent EUS-FNA for SMTs.

Methods

The records of 1,135 consecutive patients who underwent EUS-FNA for SMTs at 219 hospitals, with low- to high-volume, were reviewed using a Japanese nationwide administrative database.

Results

Of the targeted lesions 73.5 % were located in the stomach, 13.4 % in the esophagus, 8.2 % in the duodenum, and 4.9 % at other sites. Five patients (0.44 %) experienced severe bleeding requiring red blood cell transfusion or endoscopic treatment, with none experiencing perforation. Only one patient (0.09 %) died in-hospital within 30 days of EUS-FNA (0.09 %), with death not associated with bleeding or perforation.

Conclusions

EUS-FNA is safe in evaluating SMTs, with low risks of bleeding and perforation.     

Japanese severity score for acute pancreatitis well predicts in-hospital mortality: a nationwide survey of 17,901 cases

Background

Early identification of severe cases of acute pancreatitis is necessary to reduce mortality. The Japanese severity score, which consists of nine prognostic factors, is reported to be useful for assessment of acute pancreatitis severity, but has not been validated by large-scale data.

Methods

Data on adult patients with acute pancreatitis were collected between July 1, 2010, and September 30, 2011, from a national administrative database covering 1,032 Japanese hospitals. In-hospital mortality was analyzed to evaluate the predictive value of the Japanese severity score.

Results

A total of 17,901 patients were included. Total in-hospital mortality was 2.6 %, and mortality rates of non-severe and severe acute pancreatitis were 1.1 and 7.0 %, respectively (P < 0.001). In multivariate analysis with adjustment for other baseline characteristics, the odds ratio for mortality significantly increased according to an increase in prognostic factor score. The odds ratio for mortality of computed tomography grade 3 was significantly higher than that of grade 1 (P < 0.001), but that of grade 2 was not (P = 0.149). In receiver operating characteristic curve analysis of the prognostic factor score for prediction of in-hospital mortality, the area under the curve was 0.798 (95 % confidence interval 0.775–0.821), and the optimum cutoff level of the prognostic factors was 2, in accordance with the definition of the current scoring system.

Conclusions

The prognostic factor score has good predictive value for in-hospital mortality of acute pancreatitis, and thus is useful for severity assessment of acute pancreatitis at the early stage of hospital admission.