Current Treatment Strategy for Superficial Nonampullary Duodenal Epithelial Tumors

Endoscopic submucosal dissection (ESD) is the standard treatment method for esophageal, gastric, and colorectal cancers. However, it has not been standardized for duodenal lesions because of its high complication rates. Recently, minimally invasive and simple methods such as cold snare polypectomy and underwater endoscopic mucosal resection have been utilized more for superficial nonampullary duodenal epithelial tumors (SNADETs). Although the rate of complications associated with duodenal ESD has been gradually decreasing because of technical advancements, performing ESD for all SNADETs is unnecessary. As such, the appropriate treatment plan for SNADETs should be chosen according to the lesion type, patient condition, and endoscopist’s skill.

Present Status of Endoscopic Submucosal Dissection for Non-Ampullary Duodenal Epithelial Tumors

Prediction of histology by endoscopic examination is important in the clinical management of non-ampullary duodenal epithelial tumors (NADETs), including adenoma and adenocarcinoma. The use of a simple scoring system based on the findings of white-light endoscopy or magnified endoscopy with narrow-band imaging is useful to differentiate between Vienna category 3 (C3) and C4/5 lesions. Less invasive endoscopic resection procedures, such as cold snare polypectomy, are quick to perform and convenient for small (<10 mm) C3 lesions. Neoplasms with higher grade histology, such as C4/5 lesions, should be treated by endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgery. Although EMR often requires piecemeal resection, the complication rate is acceptable. Excellent complete resection rates could be achieved by ESD; however, it remains a challenging method considering the high risk of complications. Shielding or closure of the ulcer after ESD is effective at decreasing the risk of delayed bleeding and perforation. Laparoscopic endoscopic cooperative surgery is an ideal treatment with a high rate of en bloc resection and a low rate of complications, although it is limited to high-volume centers. Patients with NADETs could benefit from a multidisciplinary approach to stratify the optimal treatment based on endoscopic diagnoses.

Present Status of Endoscopic Submucosal Dissection for Non-Ampullary Duodenal Epithelial Tumors

Prediction of histology by endoscopic examination is important in the clinical management of non-ampullary duodenal epithelial tumors (NADETs), including adenoma and adenocarcinoma. The use of a simple scoring system based on the findings of white-light endoscopy or magnified endoscopy with narrow-band imaging is useful to differentiate between Vienna category 3 (C3) and C4/5 lesions. Less invasive endoscopic resection procedures, such as cold snare polypectomy, are quick to perform and convenient for small (<10 mm) C3 lesions. Neoplasms with higher grade histology, such as C4/5 lesions, should be treated by endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgery. Although EMR often requires piecemeal resection, the complication rate is acceptable. Excellent complete resection rates could be achieved by ESD; however, it remains a challenging method considering the high risk of complications. Shielding or closure of the ulcer after ESD is effective at decreasing the risk of delayed bleeding and perforation. Laparoscopic endoscopic cooperative surgery is an ideal treatment with a high rate of en bloc resection and a low rate of complications, although it is limited to high-volume centers. Patients with NADETs could benefit from a multidisciplinary approach to stratify the optimal treatment based on endoscopic diagnoses.

Comparison of the Diagnostic Yield of the Standard 22-Gauge Needle and the New 20-Gauge Forward-Bevel Core Biopsy Needle for Endoscopic Ultrasound-Guided Tissue Acquisition from Pancreatic Lesions

BACKGROUND/AIMS: To compare the diagnostic yield of 20-gauge forward-bevel core biopsy needle (CBN) and 22-gauge needle for endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of solid pancreatic masses. METHODS: The use of 20-gauge CBN was prospectively evaluated for 50 patients who underwent EUS-FNA from June 2016 to December 2016. Data were compared with those obtained by a retrospective study of 50 consecutive patients who underwent EUS-FNA using standard 22-gauge needles between December 2016 and April 2017. At least two punctures were performed for each patient; the sample from the first pass was used for cytology with or without histology and that from the second pass was used for histology. Sample quantity was evaluated using the sample obtained from the second pass. RESULTS: There was no significant difference in the diagnostic accuracy rate between the first and second passes (20-gauge CBN: 96% [48/50]; standard 22-gauge needle: 88% [44/50]). Samples >10× power fields in length were obtained from 90% (43/48) and 60% (30/50) of patients using the 20-gauge CBN and standard 22-gauge needle, respectively (p=0.01). Technical failure occurred for two patients with the 20-gauge CBN. CONCLUSIONS: Diagnostic accuracy of the 20-gauge CBN was comparable to that of the 22-gauge needle. However, two passes with the 20-gauge CBN yielded a correct diagnosis for 100% of patients when technically feasible. Moreover, the 20-gauge CBN yielded core tissue for 90% patients, which was a performance superior to that of the 22-gauge needle.

Natural History of Early Gastric Cancer: a Case Report and Literature Review

Early detection and treatment decrease the mortality rate associated with gastric cancer (GC). However, the natural history of GC remains unclear. An 85-year-old woman was referred to our hospital for evaluation of a gastric tumor. Esophagogastroduodenoscopy identified a 6 mm, flat-elevated lesion at the lesser curvature of the antrum. A biopsy specimen showed a well-differentiated tubular adenocarcinoma. The depth of the lesion was estimated to be intramucosal. Although the lesion met the indications for endoscopic resection, periodic endoscopic follow-up was performed due to the patient's advanced age and comorbidities. The mucosal GC invaded into the submucosa 3 years later, and finally progressed to advanced cancer 5 years after the initial examination. The patient died of tumor hemorrhage 6.4 years after the initial examination. In this case, mucosal GC progressed to advanced GC, eventually leading to the patient's death from GC. Early and appropriate treatment is required to prevent GC-related death.

Factors associated with serum total homocysteine level in type 2 diabetes

<p><b>OBJECTIVES</b>The aim of this study was to investigate the determinants of serum total homocysteine level (tHcy) in patients with type 2 diabetes mellitus (DM) according to sex.</p><p><b>METHODS</b>A total of 1,276 Japanese, diabetics (n = 280) with a control group of non-diabetics (n = 996), were enrolled into the study from 2003 to 2005. This cross-sectional study was conducted for all the subjects, using personal data regarding clinical characteristics and lifestyle. Multiple regression analysis was performed to analyze the association of tHcy with selected factors.</p><p><b>RESULTS</b>In diabetic subjects, estimated glomerular filtration rate (eGFR) and serum creatinine levels (Cre), even those within the normal range, were strongly associated with tHcy after adjustment in both sexes; the standardized partial regression coefficient of eGFR for tHcy was -0.251, (p = 0.001) in diabetic men and -0.523, (p < 0.001) in diabetic women. Furthermore, the eGFR of the diabetics, except patients with nephropathy, also had significant association with tHcy in both sexes. Fasting plasma glucose levels and serum triglyceride levels were strongly associated with tHcy in diabetic men only. HbA1c was also associated with tHcy in diabetic men only, though not as significantly. Age and presence of hypertension were significantly associated with tHcy in women.</p><p><b>CONCLUSIONS</b>This study suggests that there are some differences in the factors associated with tHcy between diabetics and non-diabetics, and between the sexes. There is, therefore, circumstantial evidence that elevated tHcy should be evaluated clinically. Because tHcy was strongly associated with eGFR and Cre, even within the normal ranges, tHcy may have important implications regarding the microangiopathy of the kidney and atherosclerosis.</p>

Personal features and dropout from diabetic care

<p><b>OBJECTIVE</b>To investigate the personal features associated with dropout from regular outpatient care among persons with type 2 diabetes mellitus (DM).</p><p><b>METHODS</b>A total of 160 DM patients were enrolled in the study. As a retrospective analysis, outpatient's clinical characteristics, lifestyle, or social features were gathered from their medical records or interview sheets. All the subjects were divided into two groups by adherence to diabetic care, namely, 'dropout case' (DC), or 'ongoing case' (OC), and were subjected to comparative analysis. We called the patients who did not receive outpatient treatment from the clinic on a regular basis, including treatment from other clinics or dropout of diabetic care, as DC. In contrast, patients who regularly visited the clinic were defined as OC. An unconditional multiple logistic regression analysis was performed to analyze the association of a dherence to diabetic care with several personal features.</p><p><b>RESULTS</b>Sixty-eight of 160 subjects (42.5%) were recognized as DC. The remaining 92 subjects (57.5%) were considered as OC. Young age (p=0.045), low plasma glucose (p=0.005) and hemoglobin A1c (HbA1c) levels (p=0.005), nonmedication (p<0.001) and no past history of DM (p=0.007) at the initial visit were the features related to dropout by crude analysis. Even after adjustment for age and gender by multivariate analysis, there remained significant inverse associations of dropout with HbA1c level, medical treatment (oral agents or insulin) and previous DM history. Neither occupation, distance from residence to clinic, smoking habit nor drinking habit was associated with dropout. Dropout mostly occurred after the initial or second visit.</p><p><b>CONCLUSIONS</b>A mild condition of DM may be related to dropout from regular outpatient care. It may be necessary to clearly show the objectives and importance of regular visit to an outpatient clinic for diabetic care, particularly for screened mild DM cases in public health activities.</p>

Personal Features and Dropout from Diabetic Care

Objective: To investigate the personal features associated with dropout from regular outpatient care among persons with type 2 diabetes mellitus (DM). Methods: A total of 160 DM patients were enrolled in the study. As a retrospective analysis, outpatient’s clinical characteristics, lifestyle, or social features were gathered from their medical records or interview sheets. All the subjects were divided into two groups by adherence to diabetic care, namely, ‘dropout case’ (DC) or ‘ongoing case’ (OC), and were subjected to comparative analysis. We called the patients who did not receive outpatient treatment from the clinic on a regular basis, including treatment from other clinics or dropout of diabetic care, as DC. In contrast, patients who regularly visited the clinic were defined as OC. An unconditional multiple logistic regression analysis was performed to analyze the association of adherence to diabetic care with several personal features. Results: Sixty-eight of 160 subjects (42.5%) were recognized as DC. The remaining 92 subjects (57.5%) were considered as OC. Young age (p=0.045), low plasma glucose (p=0.005) and hemoglobin A1c (HbA1c) levels (p=0.005), nonmedication (p<0.001) and no past history of DM (p=0.007) at the initial visit were the features related to dropout by crude analysis. Even after adjustment for age and gender by multivariate analysis, there remained significant inverse associations of dropout with HbA1c level, medical treatment (oral agents or insulin) and previous DM history. Neither occupation, distance from residence to clinic, smoking habit nor drinking habit was associated with dropout. Dropout mostly occurred after the initial or second visit. Conclusions: A mild condition of DM may be related to dropout from regular outpatient care. It may be necessary to clearly show the objectives and importance of regular visit to an outpatient clinic for diabetic care, particularly for screened mild DM cases in public health activities.

Interrelations among smoking habits, casual blood pressure and intraocular pressure in middle and old-aged Japanese residents

<p><b>OBJECTIVES</b>To investigate the association of smoking habits with blood pressure (BP) and intraocular pressure (IOP), and to examine whether the smoking-BP association is related to the IOP level.</p><p><b>METHODS</b>This study was conducted on the basis of a cross-sectional design using annual health check-up data during one-year between August, 1999 and August, 2000 for 611 middle and old-aged Japanese residents living in Ibaraki prefecture, Japan.</p><p><b>RESULTS</b>After adjustment for age, gender, body mass index and alcohol intake score, the proportion of hypertensives, and the mean systolic and diastolic blood pressure (SBP and DBP) of the subjects without antihypertensive medications were the highest (50.4%, 129.6 mmHg and 75.9 mmHg, respectively) in the "smokers of 25 or more cigarettes per day with intraocular pressure (IOP)≥15 mmHg" of six subgroups crossed by three smoking categories (non-smokers, 1 to 24 cigarettes per day, and 25 or more cigarettes per day) and two IOP categories (less than 15 mmHg, and 15mmHg or greater). On the other hand, the adjusted proportion of hypertensives, and the adjusted mean SBP and DBP decreased with increasing smoking category in the individuals with less than 15 mmHg of the IOP (p for trend=0.028 for proportion of hypertensives 0.008 for the SBP, and 0.001 for the DBP, respectively).</p><p><b>CONCLUSIONS</b>Heavy smoking may be specifically related to 'high BP accompanied by high IOP', although the BP may be inversely associated with smoking under the condition without high IOP.</p>

Interrelations among Smoking Habits, Casual Blood Pressure and Intraocular Pressure in Middle and Old-Aged Japanese Residents

Objectives: To investigate the association of smoking habits with blood pressure (BP) and intraocular pressure (IOP), and to examine whether the smoking-BP association is related to the IOP level. Methods: This study was conducted on the basis of a cross-sectional design using annual health check-up data during one-year between August, 1999 and August, 2000 for 611 middle and old-aged Japanese residents living in Ibaraki prefecture, Japan. Results: After adjustment for age, gender, body mass index and alcohol intake score, the proportion of hypertensives, and the mean systolic and diastolic blood pressure (SBP and DBP) of the subjects without antihypertensive medications were the highest (50.4%, 129.6 mmHg and 75.9 mmHg, respectively) in the “smokers of 25 or more cigarettes per day with intraocular pressure (IOP) >15 mmHg” of six subgroups crossed by three smoking categories (non-smokers, 1 to 24 cigarettes per day, and 25 or more cigarettes per day) and two IOP categories (less than 15 mmHg, and 15 mmHg or greater). On the other hand, the adjusted proportion of hypertensives, and the adjusted mean SBP and DBP decreased with increasing smoking category in the individuals with less than 15 mmHg of the IOP (p for trend=0.028 for proportion of hypertensives, 0.008 for the SBP, and 0.001 for the DBP, respectively). Conclusions: Heavy smoking may be specifically related to ‘high BP accompanied by high IOP’, although the BP may be inversely associated with smoking under the condition without high IOP.

Exposure of Workers to TPN during Application Using Different Spraying Methods / 日本農村医学会雑誌

When workers were applying the same volume of a TPN formulation to asparagus fields of the same acreage by a speed sprayer or a conventional power sprayer, their exposure levels to the pesticide were compared. The estimated body exposure level of workers using power sprayer was more than 10 times higher than that of workers using a speed sprayer. The fate of TPN residues in the fields was also assayed. The foliar residues reduced rapidly in one day, but thereafter its reduction rate was very slow, and TPN was expected to remain on the foliage for a long period. However, the airborne TPN concentration was reduced to nil at 1 day after application.

Exposure to Pesticide in Greenhouses / 日本農村医学会雑誌

Exposure of applicators to metalaxyl was assessed during the spraying to greenhouse cucumbers by power sprayers. Of four applicators wearing work clothes with a hood, a mask and gloves, two moved forward holding the nozzle in their hands so that they passed through the area sprayed by them. The other two went backward and sprayed both sides. Each of the applicators sprayed 14 to 18 g of metalaxyl during one hour of application. The estimated systemic expoure level in the forward moving group was 1 to 10 mg, 3 to 40 times higher than the exposure level of 0.25 to 0.29 mg in the backward group. But, skin exposure was insignificant or not detected in both groups. Also it was suggested that respiratory exposure was higher in the forward moving group than that in the backward group. In conclusion, when applying metalaxyl by any spraying techniques, the risk of poisoning was thought to be negligible under this research condition. However, the workers should employ the spraying technique moving backward, and be protected with suitable protective gear for preventing acute or chronic pesticide intoxications.

A study on the physical work load of farmers and dust conditions in the harvesting process of the chrysanthemums / 日本農村医学会雑誌

The physical work load of farmers and dust conditions in the harvesting process of chrysanthemums were investigated for two households (seven workers for A and three for B household, respectively) at mid March in 1984.<BR>The total working hours a day of each household were 3225 min (460 min as average per a worker) for A and 1954 min (652 min) for B, being allotted more times to males than females. However, all of the house keeping hours were carried out only by females.<BR>The intensity of each working load of farmers was not so heavy, as “light” and “moderately heavy” by Christesen's criteria and energy expenditure a day was calculated 2895-3604 kcal for males and 2155-2295 kcal for females.<BR>In this working process farmers were enforced to keep careful handling with chrysanthemums and fixed body posture for 4 to 6 hours a day. Particulary, the working posture of sorting and bundling chrysanthemums may cause over strained load to the muscle and joint of the lower back and legs.<BR>The dust concentrations of the sorting room were not so high. However, the farmers were exposed a large quantity of cilia of chrysanthemum leaves, calculated 37-259 pieces/cm<SUP>2</SUP> on the slide grass a day. The numbers of cilia varied with amounts of handling chrysathemums.<BR>It was suggested that the cilia of chrysanthemums may be the most important allergen to the immediate type of allergy of the chrysanthemum growers.

Exposure of spray-operators to Fenitrothion in apple orchards / 日本農村医学会雑誌

The exposure levels of nine spray-operators in apple orchards to Fenitrothion (MEP) was measured. The pesticide was sprayed in the form of a 1, 000-fold diluted solution of a 40% MEP wettable powder by using power sprayers.<BR>The operators were wearing protective non-woven clothes, masks (Sumitomo 3M 1780) and rubber gloves.<BR>The estimated exposure amount of MEP per operator was 217mg on average when a sprayer with a short rod (50-70 cm) was used. In the case of using a long rod (100-120 cm), the amount was less, indicating 44mg on average.<BR>The estimated amount of MEP penetrating the operator's clothing was 7.6mg on average, ranging from 1.2 to 23.9mg.<BR>The penetration rate averaged 6.3%.<BR>We calculated the MEP concentration in the air around the worker's mouth estimated from the amounts of MEP on the masks and from those in the sampling columns. The results averaged 0.258 mg/m<SUB>3</SUB> and 0.022 mg/m<SUB>3</SUB>, respectively.<BR>MEP was detected in blood samples from all the operators (0.0004-0.0222 ppm) immediately after the spray work and in blood samples from four of the nine operators (0.0004-0.0009 ppm) after one day, but not detected in any of the nine blood samples after three days.<BR>A decrease in blood ChE activities of the operators was not observed.<BR>The amount of MEP absorbed into the operator's body was calculated to be 0.34 to 2.59 mg. These calculations were based on the amount of the metabolites (converted into nitro-m-cresol) in the urine samples collected from the operators over a period of 24 hours after the spray work. However, the metabolites were detected in the spot urine samples of only one of the nine operators after three days and in none of the spot samples after seven days.<BR>These results show that a small amount of MEP was absorbed into the operator's body, suggesting that the spray-operator should not do the spray work day after day. However, from the point of view of the percutaneous and inhalation toxicity of MEP, we concluded that the sprayoperators were not affected by MEP exposure in this case.