Dynamic ultrasonography for optimizing treatment position in superior mesenteric artery syndrome:Two case reports and review of literature

BACKGROUND Superior mesenteric artery(SMA)syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta(SMA-Ao).Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome,individual variations in the optimal patient position have been noted.In this report,we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient.CASE SUMMARY Case 1:A 90-year-old man with nausea and vomiting.Following diagnosis of SMA syndrome by computed tomography(CT),ultrasonography(US)revealed the SMA-Ao distance in the supine position(4 mm),which slightly improved in the lateral position(5.7–7.0 mm)without the passage of duodenal contents.However,in the sitting position,the SMA-Ao distance was increased to 15 mm accompanied by improved content passage.Additionally,US indicated enhanced passage upon abdominal massage on the right side.By day 2,the patient could eat comfortably with the optimal position and massage.Case 2:An 87-year-old woman with vomiting.After the diagnosis of SMA syndrome and aspiration pneumonia by CT,dynamic US confirmed the optimal position(SMA-Ao distance was improved to 7 mm in forward-bent position,whereas it remained at 5 mm in the supine position).By day 7 when her pneumonia recovered,she could eat with the optimal position.CONCLUSION The optimal position for SMA syndrome varies among individuals.Dynamic US appears to be a valuable tool in improving patient outcomes.

ARID1A expression in gastric adenocarcinoma:Clinicopathological significance and correlation with DNA mismatch repair status

AIM:To analyze the mismatch repair(MMR)status and the ARID1A expression as well as their clinicopathological significance in gastric adenocarcinomas.METHODS:We examined the expressions of MMR proteins and ARID1A by immunohistochemistry in consecutive 489 primary gastric adenocarcinomas.The results were further correlated with clinicopathological variables.RESULTS:The loss of any MMR protein expression,indicative of MMR deficiency,was observed in 38cases(7.8%)and was significantly associated with an older age(68.6±9.2 vs 60.4±11.7,P<0.001),a female sex(55.3%vs 31.3%,P=0.004),an antral location(44.7%vs 25.7%,P=0.021),and a differentiated histology(57.9%vs 39.7%,P=0.023).Abnormal ARID1A expression,including reduced or loss of ARID1A expression,was observed in 109 cases(22.3%)and was significantly correlated with lymphatic invasion(80.7%vs 69.5%,P=0.022)and lymph node metastasis(83.5%vs 73.7%,P=0.042).The tumors with abnormal ARID1A expression more frequently indicated MMR deficiency(47.4%vs 20.2%,P<0.001).A multivariate analysis identified abnormal ARID1A expression as an independent poor prognostic factor(HR=1.36,95%CI:1.01-1.84;P=0.040).CONCLUSION:Our observations suggest that the AIRD1A inactivation is associated with lymphatic invasion,lymph node metastasis,poor prognosis,and MMR deficiency in gastric adenocarcinomas.

Size does not determine the grade of malignancy of early invasive colorectal cancer

AIM： To clarify the clinicopathological characteristics of small and large early invasive colorectal cancers （EI-CRCs）, and to determine whether malignancy grade depends on size. METHODS： A total of 583 consecutive EI-CRCs treated by endoscopic mucosal resection or surgery at the National Cancer Center Hospital between 1980 and 2004 were enrolled in this study. Lesions were classified into two groups based on size： small （≤10 ram） and large （〉10 ram）. Clinicopathological features, incidence of lymph node metastasis （LNM） and risk factors for LNM, such as depth of invasion, lymphovascular invasion （LVI） and poorly differentiated adenocarcinoma （PDA） were analyzed in all resected specimens. RESULTS： There were 120 （21%） small and 463 （79%） large lesions. Histopathological analysis of the small lesion group revealed submucosal deep cancer （sin： 1〉1000 μm） in 90 （75%） cases, LVI in 26 （22%） cases, and PDA in 12 （10%） cases. Similarly, the large lesion group exhibited submucosal deep cancer in 380 （82%） cases, LVI in 125 （27%） cases, and PDA in 79 （17%） cases. The rate of LNM was 11.2% and 12.1% in the small and large lesion groups, respectively.CONCLUSION： Small EI-CRC demonstrated the same aggressiveness and malignant potential as large cancer.

Superior mesenteric artery syndrome:Diagnosis and management

Superior mesenteric artery(SMA)syndrome(also known as Wilkie's syndrome,cast syndrome,or aorto-mesenteric compass syndrome)is an obstruction of the duodenum caused by extrinsic compression between the SMA and the aorta.The median age of patients is 23 years old(range 0-91 years old)and predominant in females over males with a ratio of 3:2.The symptoms are variable,consisting of postprandial abdominal pain,nausea and vomiting,early satiety,anorexia,and weight loss and can mimic anorexia nervosa or functional dyspepsia.Because recurrent vomiting leads to aspiration pneumonia or respiratory depression via metabolic alkalosis,early diagnosis is required.The useful diagnostic modalities are computed tomography as a standard tool and ultrasonography,which has advantages in safety and capability of real-time assessments of SMA mobility and duodenum passage.The initial treatment is usually conservative,including postural change,gastroduodenal decompression,and nutrient management(success rates:70%-80%).If conservative therapy fails,surgical treatment(i.e.,laparoscopic duodenojejunostomy)is recommended(success rates:80%-100%).

Diagnostic value of antigenemia assay for cytomegalovirus gastrointestinal disease in immunocompromised patients

AIM:To investigate the utility of the cytomegalovirus(CMV)antigenemia assay for the diagnosis of CMV gastrointestinal disease(GID). METHODS:One hundred and thirty immunocompromised patients were enrolled in this study.Patients with a history of anti-CMV treatment and who had not undergone examination using the antigenemia assay were excluded.CMV-GID was defined as the detection of large cells with intranuclear inclusions alone or associated with granular cytoplasmic inclusions by biopsy.Biopsy sections were stained with hematoxylin and eosin and immunohistochemically stained with anti-CMV.We evaluated the association between CMV-GID and patient characteristics(symptoms,underlying disease,medication,leukocyte counts,and antigenemia assay).All patients were checked with an human immunodeficiency virus(HIV)antibody test before endoscopic examination.White blood cell(WBC)counts were obtained from medical records within 1 wk of endoscopy.Leukopenia was defined as a total WBC count<5000 cells/mm 3 . For HIV patients,we also checked CD4+counts from medical records. RESULTS:A total of 99 patients were retrospectively selected for analysis.Of the immunocompromised patients,19 had malignant disease,18 had autoimmune disease,19 had disorders of biochemical homeostasis, three had undergone transplantation,and 45 had HIV infection.A total of 50 patients had received immunosuppressive therapy.No patients had inflammatory bowel disease.Fifty-five patients were diagnosed as having CMV-GID.Univariate analysis indicated an association between HIV infection,leukopenia,and positive antigenemia and CMV-GID(P<0.05).Multivariate analysis using logistic regression revealed that HIV infection and positive antigenemia were the only independent factors related to CMV-GID(P<0.01).The sensitivity,specificity,positive predictive value,and negative predictive value of antigenemia for CMV-GID were 65.4%,93.6%, 91.9%,and 71.0%,respectively.In a subgroup analy-sis,patients with leukopenia displayed low sensitivity and high specificity.Minimal differences in accuracy were seen among patients with or without leukopenia. HIV-infected patients displayed low sensitivity and high specificity.Accuracy barely differed between HIV-positive and-negative patients.In HIV-infected patients, CD4 count<50 cells/μL resulted in low sensitivity and high specificity.Differences in accuracy among patients were minor,regardless of CD4 count.In patients who had undergone both quantitative real-time polymerase chain reaction(PCR)and antigenemia assay,real-time PCR was slightly more accurate in terms of sensitivity than the antigenemia assay;however,this difference was not statistically significant(P=0.312). CONCLUSION:If the antigenemia test is positive,endoscopic lesions are acceptable for the diagnosis of CMVGID without biopsy.The accuracy is not affected by HIV infection and leukopenia.Either PCR or the antigenemia assay are valid.

无蒂黏膜下侵犯性结肠直肠癌患者淋巴结转移的组织病理学预测因素

PURPOSE: Risk factors for lymph node metastasis in patients with nonpedunculated submucosal invasive colorectal carcinoma remain to be characterized. This study examines the relationship between lymph node metastasis and clinicopathologic factors in nonpedunculated submucosal invasive colorectal carcinoma. METHODS: The study cohort comprised 155 patients who had undergone surgical treatment for nonpedunculated submucosal invasive colorectal carcinoma. The clinicopathologic factors investigated included gender, age, tumor location, macroscopic type, tumor size, histologic type and grade, intramucosal growth pattern, lymphatic invasion, venous invasion, degree of focal dedifferentiation at the submucosal invasive front, status of the remaining muscularis mucosa, and the depth and width of submucosal invasion. RESULTS: Lymph node metastases were found in 19 patients (12.3 percent). Univariate analysis showed that lymphatic invasion, focal dedifferentiation at the submucosal invasive front, status of the remaining muscularis mucosa, and depth of submucosal invasion all had a significant influence on lymph node metastasis. Multivariate analysis showed lymphatic invasion (P = 0.014) and high-grade focal dedifferentiation at the submucosal invasive front (P = 0.049) to be independent factors predicting lymph node metastasis. No lymph node metastasis was found in tumors with a depth of submucosal invasion of < 1.3 mm. CONCLUSIONS: Lymphatic invasion and high-grade focal dedifferentiation at the submucosal invasive front are important predictors of lymph node metastasis in patients with nonpedunculated submucosal invasive colorectal carcinoma. Depth of submucosal invasion can be used as an identifying marker for patients who do not require subsequent surgery after endoscopic resection.

Endoscopic diagnosis of cytomegalovirus gastritis after allogeneic hematopoietic stem cell transplantation

AIM:To clarify the endoscopic and clinical findings of cytomegalovirus(CMV) gastritis after allogeneic hematopoietic stem cell transplantation(allo-SCT).METHODS:Between 1999 and 2005,523 patients underwent allo-SCT at our hospital,and 115 of these patients with gastrointestinal symptoms underwent esophagogastroduodenoscopy.RESULTS:CMV gastritis was diagnosed pathologically in seven patients(1.3%) with the other 108 patients serving as controls.Six of the seven patients developed positive CMV antigenemia,and five complained of abdominal pain.Development of abdominal pain preceded CMV antigenemia in four of the f ive patients.Endoscopic examination showed oozing(n=2),erosion(n=6),and redness(n=5) in the seven patients with CMV gastritis,while the control patients showed oozing(n=3),erosion(n=24),and redness(n=100).Erosion and oozing were more frequently documented in patients with CMV gastritis compared with the controls,and the differences were statistically significant(P=0.0012 and 0.029,respectively).CMV inclusion bodies were documented in 12 of 14 biopsy specimens obtained from erosive lesions,while they were identif ied in 4 of 15 biopsy specimens obtained from lesions other than erosions(P=0.0025).CONCLUSION:This study suggests that erosion and oozing,as well as abdominal pain,are useful indicators in the diagnosis of CMV gastritis following allo-SCT.

Baseline moderate-range albuminuria is associated with protection against severe COVID-19 pneumonia

BACKGROUND Diabetes mellitus is considered a leading contributor to severe coronavirus disease 2019(COVID-19).AIM To characterize differences between hospitalized diabetic patients with vs without COVID-19,and parameters associated with COVID-19 severity for prediction.METHODS This case-control study included 209 patients with type 2 diabetic mellitus hospitalized at the Galilee Medical Center(Nahariya,Israel)and recruited between September 2020 and May 2021,65 patients with COVID-19 infection in dedicated wards and 144 COVID-19-negative patients in internal medicine wards hospitalized due to other reasons.Clinical parameters-including age,type of antiglycemic medications,presence of retinopathy,smoking history,body mass index(BMI),glycosylated hemoglobin,maximum neutrophil:lymphocyte ratio(NLR_(max)),C-reactive protein(CRP),estimated glomerular filtration rate(eGFR),and albumin(blood and urine)-were compared between the two primary patient groups,and then between COVID-19-negative patients hospitalized due to infectious vs non-infectious disease.Finally,we explored which parameters were associated with severe COVID-19 pneumonia.RESULTS COVID-19-negative patients were older(63.9±9.9 vs 59.8±9.2,P=0.005),and had longer duration of diabetes(P=0.031),lower eGFR(P=0.033),higher albumin(P=0.026),lower CRP(P<0.001),greater smoking prevalence(P<0.001),and more baseline albuminuria(54.9%vs 30.8%,P=0.005)at admission;70%of COVID-19 patients with albuminuria had moderate-range albuminuria(albumin:creatinine 30-300 mg/g).Most of the patients with albuminuria had chronic kidney disease stage II(CKD II).Oral antiglycemic therapies were not significantly different between the two groups.Multivariable logistic regression showed that higher BMI was significantly associated with severe COVID-19(OR 1.24,95%CI:1.01-1.53,P=0.04),as was higher NLR_(max)(OR 1.2,95%CI:1.06-1.37,P=0.005).Surprisingly,pre-hospitalization albuminuria,mostly moderate-range,was associated with reduced risk(OR 0.09,95%CI:0.01-0.62,P=0.015).Moderate-range albuminuria was not associated with bacterial infections.CONCLUSION Moderate-range albuminuria in COVID-19-positive diabetic patients with CKD II is associated with less severe COVID-19.Further studies should explore this potential biomarker for risk of COVID-19-related deterioration and early interventions.

结肠直肠癌中CD10的表达与肝转移相关

PURPOSE: If it were possible to identify the features of primary colorectal carcinoma that were associated with liver metastasis, these features could be used as predictors of liver metastasis. METHODS: From January 1995 to December 1997, 648 consecutive cases of colorectal carcinoma were recorded at the Department of Surgery, National Cancer Center Hospital, Tokyo, Japan. We evaluated clinicopathologic and immunohistochemical factors (age, gender, tumor location, gross type, size, histologic type, dedifferentiation of invasive front, depth of invasion, lymphatic invasion, venous invasion, lymph-node metastasis, and expression of CD10, MUC2, and human gastric mucin) in 505 of these patients who had undergone resection of T2/T3/T4 colorectal carcinomas to clarify the correlation between these factors and liver metastasis. RESULTS: Liver metastases, including unresectable, were detected in 122 patients (24 percent), all of whom had been followed for at least five years. Univariate analysis revealed that liver metastasis was significantly associated with tumor size, histologic type, dedifferentiation of invasive front, depth of invasion, lymphatic invasion, venous invasion, lymph-node metastasis, and CD10 expression. Multivariate analysis revealed that invasion deeper than the subserosa, venous invasion, lymph-node metastasis, and CD10 expression were significantly associated with liver metastases. CONCLUSIONS: CD10 expression in colorectal carcinoma is a good predictor of liver metastasis.

Retrospective analysis of early COVID-19 vaccine efficacy in older individuals receiving primary cycle, first booster and second booster

Background:We analysed data garnered during the ongoing Italian nationwide coronavirus disease 2019(COVID-19)vaccination campaign for comparing early COVID-19 monovalent vaccine efficacy in older persons who received the primary vaccination cycle,the first vaccine booster,and the second vaccine booster.Methods:We conducted a retrospective analysis of early COVID-19 monovalent vaccine efficacy(i.e.,within 120 days)against COVID-19 related hospitalizations,intensive care unit(ICU)admissions and deaths in older persons(i.e.,aged≥80 years),by accessing official data of the COVID-19 national integrated surveillance program instituted by the Italian National Institute of Health.Vaccine efficacy was compared(odds ratio;OR)among cohorts receiving the primary vaccination cycle,the first vaccine booster,and the second vaccine booster.Results:A consistent decline could be seen in the rate of COVID-19 hospitalizations,ICU admissions and deaths with increasing number of monovalent immunizations.Within 120 days of administration,the first and second vaccine boosters had superior efficacy compared to the primary vaccination cycle,reducing the odds of all endpoints between 62%-71%and 69%-84%,respectively.A modestly superior early efficacy could also be noted for the second versus the first monovalent vaccine booster(ORs of all endpoints further reduced by 18%-48%).Conclusion:Since an increasing number of immunizations is associated with a lower risk of unfavourable COVID-19 outcomes,vaccine boosters may be useful for limiting the clinical burden of this infectious disease in elderly populations.

Pooled analysis of efficacy of the fourth mRNA-based COVID-19 vaccine dose in eliciting anti-SARS-CoV-2 serum antibody response in the general immunocompetent population

Objective:Since the opportunity of widespread administration of the fourth mRNA-based coronavirus disease 2019(COVID-19)vaccine dose remains controversial,this article provides a pooled analysis of the efficacy of the second COVID-19 mRNA-based homologous vaccine booster in eliciting anti-SARS-CoV-2 serum antibody response in general immunocompetent populations.Methods:We conducted a digital search in Medline using the keywords"fourth dose"or"second booster"and"antibodies"and"COVID-19"or"SARS-CoV-2"and"BNT162b2"or"mRNA-1273",to identify all clinical studies which evaluated the anti-SARS-CoV-2 serum antibody response after the fourth mRNA-based COVID-19 homologous vaccine dose administration in general immunocompetent populations compared to the response seen before its administration and after the first booster.Results:Four studies totaling 571 recipients of the second mRNA-based COVID-19 vaccine booster were finally included in our analysis.The weighted mean difference(WMD)ratio of anti-SARS-CoV-2 serum antibodies levels measured after and before administration of the fourth vaccine dose was 9.7(95%CI,6.5-12.9)in those receiving BNT162b2 and 12.0(95%CI,5.8-18.2)in those receiving mRNA-1273,respectively.The WMD ratio of anti-SARS-CoV-2 serum antibodies levels measured at the peak of the fourth and third vaccine doses was 1.4(95%CI,1.2-1.7)in those receiving BNT162b2 and 1.9(95%CI,1.5-2.4)in those receiving mRNA-1273,respectively.Conclusion:Our data confirm the efficacy of the fourth mRNA-based COVID-19 vaccine dose in restoring a satisfactory level of anti-SARS-CoV-2 serum antibodies,though such effectiveness seems only marginally superior to that of the first booster.

Monitoring humoral and cellular immunity over 6 months after mRNA-based bivalent COVID-19 vaccine administration

Dear Editor,Although the World Health Organization(WHO)has declared an end to the global emergency for coronavirus disease 2019(COVID-19)[1],the clinical burden of severe acute respiratory syndrome coronavirus disease(SARS-CoV-2)has not yet subsided[2,3],especially after the emergence of new variants such as EG.5 and BA.2.86,whose genetic leap is so large that it may contribute to increase the number of new COVID-19 cases,hospitalizations,and deaths[3].Some physical preventive measures,such as mask-wearing,hand hygiene,and isolation of positive cases,play an important role.However,widespread vaccination remains the cornerstone to contain the spread of the virus and mitigate the potential harm to human health.

Harmonization of SARS-CoV-2 antigen immunoassays:are they measuring the same“thing”?

Background:This study was planned to assess the accuracy and comparability of two commercially available,laboratory-based SARS-CoV-2(severe acute respiratory syndrome)antigen(Ag)immunoassays.Methods:We studied a cohort of subjects with acute SARS-CoV-2 infection,from whom a nasopharyngeal swab was taken and tested with a molecular assay(Altona Diagnostics RealStar SARS-CoV-2 RT-PCR Kit)and two laboratory-based,fully automated SARS-CoV-2 Ag immunoassays(Fujirebio Lumipulse G SARS-CoV-2 Ag and Roche Elecsys SARS-CoV-2 Ag).Results:The final population consisted in 93 subjects testing positive for SARS-CoV-2 RNA,34 with cycle threshold(Ct)values<29.5.The results of the two SARS-CoV-2 Ag immunoassays were significantly intercorrelated(r=0.77;P<0.001)in the entire cohort,though such correlation considerably improved in patients with high viral load(cycle threshold values<29.5:r=0.96;P<0.001).The accuracy for identifying samples with high viral load was excellent for both Lumipulse G SARS-CoV-2 Ag(AUC,0.99;P<0.001)and Elecsys SARS-CoV-2 Ag(AUC,0.99;P<0.001),with best cut-offs of 2.03 ng/mL for Lumipulse G SARS-CoV-2 Ag(1.00 sensitivity and 0.88 specificity)and 0.70 COI for Elecsys SARS-CoV-2 Ag(1.00 sensitivity and 0.80 specificity),respectively.Conclusion:The results of this study provide valuable support to usability of fully-automated,rapid,high throughput and accurate SARS-CoV-2 Ag immunoassays for complementing molecular assays.

Sarcomatoid malignant pleural mesothelioma confirmed by full-thickness biopsy

Diffuse malignant pleural mesothelioma （DMPM） is a rare thoracic malignancy, but its incidence isdramatically increasing worldwide as a result ot widespread use of asbestos. The World Health Organization classifies DMPM into three types： epithelioid, sarcomatoid, and biphasic types. DMPM remains suffering poor prognosis and the diagnosis should always be based on adequate, representative tissue samples. There still remains a considerable number of patients with DMPM who are misdiagnosed after a complete investigation including thoracoscopic biopsies.