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Gastric subepithelial lesions (SEL) are usually found incidentally during esophagogastroduodenoscopy. Most gastric SELs are benign lesions, such as leiomyoma and pancreatic rests. However, neoplastic lesions including neuroendocrine tumors, gastrointestinal stromal tumors, and certain types of gastric adenocarcinoma (GA), such as the recently WHO-classified fundic gland type adenocarcinoma, may be found. The lack of simple and established diagnostic methods for SEL remains a clinical challenge. Standard biopsy is suboptimal for diagnosis due to the subepithelial location of lesions and is therefore often omitted. Furthermore, guideline-based algorithmic approaches for diagnosing SEL also differ between Japan and the USA. In this case series, we describe three cases of gastric SEL that were subsequently diagnosed as GA. Case 1 was a fundic gland type (chief cell predominant type) adenocarcinoma; Case 2 was a poorly differentiated GA; Case 3 was an advanced GA, found after 4 serial years of endoscopic follow-up for SEL. While standard biopsy led to successful diagnosis in the first 2 cases, no standard biopsy was performed during surveillance in Case 3, making its diagnostic effectiveness unclear. The third case highlights the importance of longitudinal observation for endoscopic mucosal alterations that may suggest certain types of GA. Clinicians should be aware that standard biopsy may play an important role in the evaluation of malignant gastric SEL-like lesions. It is crucial to remain vigilant for surface changes in SEL and not to summarily omit standard biopsy.

BACKGROUND AND AIM Long-term cumulative incidence of and risk factors for metachronous advanced colorectal neoplasia, including both advanced colorectal adenoma (≥10 mm, or with villous or high-grade dysplasia) and colorectal cancer, are critical for surveillance strategies. The aim of this study was to determine the cumulative incidence of metachronous advanced colorectal neoplasia and its risk factors. METHODS A retrospective cohort study was conducted on 6720 consecutive individuals who underwent general health check-ups and colonoscopy. Colorectal adenomas at initial colonoscopy were categorized as low-risk (1-2 small [

This study aimed to reevaluate the effectiveness of fluoroscopy and endoscopy in reducing gastric cancer mortality at the population level.Crude and age-adjusted mortality rates of gastric cancer and the introduction rates of gastric cancer screening were extracted from the Cancer Registry and Statistics database. The population-attributable risk (PAR) percent of no screening for gastric cancer mortality was calculated using Levin's equation. The PAR of each mortality rate in the no-screening group was estimated as follows: mortality × PAR%. The Jonckheere-Terpstra test for trends and linear regression were performed to compare the PAR of gastric cancer mortality rates among the decades.The PAR of crude and age-adjusted mortality rates in the no-screening group significantly decreased in the total population ( P for trendlt;0.001), as well as individually in the male ( P for trendlt;0.001) and female ( P for trendlt;0.001) populations. The PAR of the crude mortality rate in the female population significantly decreased in 2000-2009 and 2010-2019, compared with that in 1980-1989. There was no significant difference in the PAR of crude mortality rate in the male population among the decades. The PAR of the age-adjusted mortality rate significantly decreased in 2000-2009 and 2010-2019, compared with that in 1980-1989, in the male and female populations.PAR% and PAR of no screening for gastric cancer mortality could be estimated using Levin's equation, and the effectiveness of the present gastric cancer screenings with fluoroscopy and endoscopy has been decreasing, especially in the female population.

We aimed to determine the optimal timing of colonoscopy and factors that benefit patients who undergo early colonoscopy for acute lower GI bleeding.We identified 10,342 patients with acute hematochezia (CODE BLUE-J study) admitted to 49 hospitals in Japan. Of these, 6270 patients who underwent a colonoscopy within 120 hours were included in this study. The inverse probability of treatment weighting method was used to adjust for baseline characteristics among early (≤24 hours, n = 4133), elective (24-48 hours, n = 1137), and late (48-120 hours, n = 1000) colonoscopy. The average treatment effect was evaluated for outcomes. The primary outcome was 30-day rebleeding rate.The early group had a significantly higher rate of stigmata of recent hemorrhage (SRH) identification and a shorter length of stay than the elective and late groups. However, the 30-day rebleeding rate was significantly higher in the early group than in the elective and late groups. Interventional radiology (IVR) or surgery requirement and 30-day mortality did not significantly differ among groups. The interaction with heterogeneity of effects was observed between early and late colonoscopy and shock index (shock index 1, odds ratio [OR], 2.097; shock index ≥1, OR, 1.095; P for interaction = .038) and performance status (0-2, OR, 2.481; ≥3, OR, .458; P for interaction = .022) for 30-day rebleeding. Early colonoscopy had a significantly lower IVR or surgery requirement in the shock index ≥1 cohort (OR, .267; 95% confidence interval, .099-.721) compared with late colonoscopy.Early colonoscopy increased the rate of SRH identification and shortened the length of stay but involved an increased risk of rebleeding and did not improve mortality and IVR or surgery requirement. Early colonoscopy particularly benefited patients with a shock index ≥1 or performance status ≥3 at presentation.

Outcomes of acute lower gastrointestinal bleeding have not been compared according to hospital capacity. We aimed to perform a propensity score-matched cohort study with path and mediation analyses for acute hematochezia patients. Hospitals were divided into high- versus low-volume hospitals for emergency medical services. Rebleeding and death within 30 days were compared. Computed tomography, early colonoscopy (colonoscopy performed within 24 h), and endoscopic therapies were included as mediators. A total of 2644 matched pairs were yielded. The rebleeding rate within 30 days was not significant between high- and low-volume hospitals (16% vs. 17%, P = 0.44). The mortality rate within 30 days was significantly higher in the high-volume cohort than in the low-volume cohort (1.7% vs. 0.8%, P = 0.003). Treatment at high-volume hospitals was not a significant factor for rebleeding (odds ratio [OR] = 0.91; 95% confidence interval [CI], 0.79–1.06; P = 0.23), but was significant for death within 30 days (OR = 2.03; 95% CI, 1.17–3.52; P = 0.012) on multivariate logistic regression after adjusting for patients’ characteristics. Mediation effects were not observed, except for rebleeding within 30 days in high-volume hospitals through early colonoscopy. However, the direct effect of high-volume hospitals on rebleeding was not significant. High-volume hospitals did not improve the outcomes of acute hematochezia patients.

Background: Optimal timing of colonoscopy for acute lower gastrointestinal bleeding is controversial, and it is unclear which patients benefit from early colonoscopy. The reported proportion of hemodynamically unstable patients is lower in randomized controlled trials than in observational studies. Methods: We studied 6,311 patients admitted for acute hematochezia in 49 Japanese hospitals, named the CODE-BLUE J Study. One propensity score-matched cohort comprised patients who underwent early (

Summary Background Anti-tumour necrosis factor (TNF) agents are the mainstay of long-term treatment for refractory ulcerative colitis. However, long-term use of anti-TNF therapy might lead to an increased risk of malignancy or infection. To date, no randomised controlled trial has evaluated whether anti-TNF agents can be safely discontinued in patients with ulcerative colitis in remission. We therefore aimed to compare outcomes in these patients who continued infliximab with those who discontinued infliximab. Methods We did a multicentre, open-label randomised controlled trial at 24 specialist centres in Japan. We enrolled patients with ulcerative colitis who were in remission, had been treated with intravenous infliximab (5 mg/kg) every 8 weeks, and had started infliximab at least 14 weeks before study enrolment. No restrictions regarding age and comorbidities were used to exclude participation. Patients who were confirmed to be in remission for more than 6 months, to be corticosteroid-free, and to have a Mayo Endoscopic Subscore (MES) of 0 or 1 were centrally randomised. An independent organisation randomly assigned patients (1:1) into either the infliximab-continued group or infliximab-discontinued group, using a computer-generated stratified randomisation procedure. The stratified factors were the use of immunomodulators (yes or no) and MES (0 or 1). Neither patients nor health-care providers were masked to the randomisation. The primary endpoint was the remission rate at week 48 in the full analysis set, which was based on the intention-to-treat principle and excluded participants with no efficacy data after randomisation. This study was registered with the University Hospital Medical Information Network Center Trials registry, UMIN000012092. Findings Between June 16, 2014, and July 28, 2017, 122 patients were eligible for screening and a total of 95 patients were randomly assigned to the infliximab-continued group (n=48) or the infliximab-discontinued group (n=47). 92 patients (n=46 for both groups) were included in the full analysis set. 37 (80·4% [95% CI 66·1–90·6]) of 46 patients in the infliximab-continued group and 25 (54·3% [39·0–69·1]) of 46 patients in the infliximab-discontinued group were in remission at week 48. The between-group difference was 26·1% (95% CI 7·7–44·5; p=0·0076) before adjustment and 27·3% (95% CI 8·0–44·1; p=0·0059) after adjustment for stratification factors. Eight (17%) of 48 patients in the infliximab-continued group and six (13%) of 47 in the infliximab-discontinued group developed adverse events (between-group difference 3·9% [95% CI −10·3 to 18·1]; p=0·59). In the infliximab-continued group, one patient had an infusion reaction and two patients had psoriatic skin lesions. Eight (66·7%, 95% CI 34·9–90·1) of the 12 patients in the infliximab-discontinuation group who were re-treated with infliximab after relapsing were in remission within 8 weeks of re-treatment; none had infusion reactions. Interpretation Maintenance of remission was significantly more common in patients who continued infliximab than in those who discontinued. Discontinuing infliximab should therefore be discussed with caution, taking both risk of relapse and efficacy of re-treatment into account. Funding Mitsubishi Tanabe Pharma Corporation and the Intractable Disease Project of the Ministry of Health, Labour and Welfare of Japan. Translation For the Japanese translation of the abstract see Supplementary Materials section.

BACKGROUND AND AIM Either clipping or band ligation will become the most common endoscopic treatment for colonic diverticular bleeding (CDB). Rebleeding is a significant clinical outcome of CDB, but there is no cumulative evidence comparing reduction of short-term and long-term rebleeding between them. Thus, we conducted a systematic review and meta-analysis to determine which endoscopic treatment is more effective to reduce recurrence of CDB. METHODS A comprehensive search of the databases PubMed/MEDLINE and Embase was performed through December 2019. Main outcomes were early and late rebleeding rates, defined as bleeding within 30 days and 1 year of endoscopic therapy for CDB. Initial hemostasis, need for transcatheter arterial embolization, or surgery were also assessed. Overall pooled estimates were calculated. RESULTS Sixteen studies fulfilled the eligibility criteria, and a total of 790 participants were included. The pooled prevalence of early rebleeding was significantly lower for band ligation than clipping (0.08 vs 0.19; heterogeneity test, P = 0.012). The pooled prevalence of late rebleeding was significantly lower for band ligation than clipping (0.09 vs 0.29; heterogeneity test, P = 0.024). No significant difference of initial hemostasis rate was noted between the two groups. Pooled prevalence of need for transcatheter arterial embolization or surgery was significantly lower for band ligation than clipping (0.01 vs 0.02; heterogeneity test, P = 0.031). There were two cases with colonic diverticulitis due to band ligation but none in clipping. CONCLUSION Band ligation therapy was more effective compared with clipping to reduce recurrence of colonic diverticular hemorrhage over short-term and long-term durations.

Background Antispasmodics, such as scopolamine, are widely used in several countries prior to diagnostic and screening esophagogastroduodenoscopy (EGD), with the goal of optimizing the detection of minute lesions, typically early gastric cancer (T1 lesions). The aim of this study was to determine whether scopolamine facilitates detection of gastric cancer in the screening setting. Methods A propensity score-matched retrospective study was conducted in a tertiary referral medical center in Tokyo, Japan. Consecutive individuals (n = 40 776) underwent screening EGD between January 2011 and May 2016. All outcome lesions were diagnosed with histopathological confirmation. Detection of esophageal cancer, gastric adenoma, duodenal adenoma, and upper gastrointestinal neoplasia (UGIN) were investigated as secondary outcomes. Results Scopolamine was used in 31 130 patients (76.3 %) and propensity score matching yielded 6625 pairs. Bivariate analysis revealed no significant association between possible confounders (age, sex, overweight, atrophic gastritis, alcohol history, smoking history, midazolam use, endoscopist biopsy rate grade, and gastric cancer in first-degree relatives) and scopolamine use. Lesions detected were 18 gastric cancers, 11 esophageal cancers, 19 gastric adenomas, 6 duodenal adenomas, and 54 UGINs, with no significant association between scopolamine use and lesion detection. Conclusions Scopolamine use did not appear to effectively facilitate detection of gastric or esophageal cancer, gastric or duodenal adenoma, and UGIN during screening EGD. Scopolamine should be avoided until its efficacy is confirmed by a randomized controlled trial.

Background and Aims Several endoscopic modalities have been used for the treatment of colonic diverticular bleeding (CDB). The aim of this study was to evaluate the effectiveness of endoscopic treatment for CDB. Methods We performed a systematic review and meta-analysis of the English literature. Main outcomes were initial hemostasis, early recurrent bleeding (recurrent bleeding within 30 days after endoscopic treatment), and need for transcatheter arterial embolization (TAE) or surgery. Proportions were collected from each study and were used to calculate pooled estimates. Heterogeneity was evaluated by I2. Results Sixteen studies (384 patients with CDB) were included. Pooled estimates of initial hemostasis were coagulation, 1.00 (95% CI, .91-1.00) (I2 = .0%); clipping, .99 (95% CI, .97-1.00) (I2 = .0%); and ligation, .99 (95% CI, .95-1.00) (I2 = .0%). Pooled estimates of early recurrent bleeding were coagulation, .21(95% CI, .01-.51) (I2 = 61.2%); clipping, .19 (95% CI, .07-.35) (I2 = 77.3%); and ligation, .09 (95% CI, .04-.15) (I2 = .0%). Pooled estimates of need for TAE or surgery were coagulation, .18 (95% CI, .00-.61) (I2 = 68.9%); clipping, .08 (95% CI, .03-.16) (I2 = 36.8%); and ligation, .00 (95% CI, .00-.01) (I2 = .0%). The proportion of need for TAE or surgery in the ligation group was significantly lower than that in the clipping group (P = .003) and marginally lower than in the coagulation group (P = .086). No significant difference was found between coagulation and clipping groups (P = .44). Conclusions Ligation therapy was more effective compared with clipping to avoid TAE or surgery. Coagulation, clipping, and ligation were equivocal in terms of effectiveness for initial hemostasis and preventing early recurrent bleeding.

Background and study aims Positive horizontal margins in resected specimens are sometimes encountered after endoscopic submucosal dissection (ESD) for early gastric cancers, and appropriate treatment strategies for these cases are not established. The aim of this study was to evaluate current empirical treatments for patients with positive horizontal or indeterminable margins after ESD. Patients and methods We performed a multicenter survey and data from 14 hospitals were collected. The pooled proportions of positive horizontal or indeterminable margins and those of patients followed up without early intervention were calculated using a logistic-normal random-effects model. For calculating pooled estimates, subgroup analyses of high- and non-high-volume centers were conducted. Results A total of 11,796 ESD cases were enrolled and 229 patients (2 %) had positive horizontal or indeterminable margins. Ninety-eight cases were treated within 30 days of ESD and 131 cases were followed up without early treatments. Pooled estimates of positive margins in high- and non-high-volume centers were 1 % (95 % CI: 1 % – 2 %) and 2 % (95 % CI: 1 % – 4 %), respectively, and were not heterogeneous (P = 0.191). The proportion of patients followed up without early intervention ranged from 30 % to 100 %. The pooled estimate was 68 % (95 % CI: 50 % – 83 %). The pooled estimates of high- and non-high-volume centers were 65 % (95 % CI: 38 % – 85 %) and 72 % (95 % CI: 44 % – 89 %), respectively, and were not heterogeneous (P = 0.692). Conclusion There was insufficient consensus regarding treatment strategies used for early gastric cancer with positive horizontal or indeterminable margins after ESD. Further studies are required to establish a consensus.

Background and aim The risk factors for early rebleeding following the management of colonic diverticular bleeding (CDB) are unclear. This study aimed to determine the risk factors for early rebleeding following initial colonoscopy. Methods Overall, 370 patients with CDB were divided as having presumptive (229) or definite CDB with stigmata of recent hemorrhage (141) on the basis of initial colonoscopy. Definite CDB cases were treated by either endoscopic clipping (EC) or endoscopic band ligation (EBL) as a first-line treatment. Time-to-event analysis for early rebleeding was performed by Kaplan-Meier methods with log-rank test between the three groups (presumptive, EC, and EBL). Multivariate Cox proportional hazards regression was used to identify risk factors for early rebleeding. Results There were 38 and 103 patients in the EC and EBL groups, respectively. Early rebleeding developed in 61 cases (16.5%). The cumulative incidence rates of early rebleeding at 1, 5, and 30 days were 7.7%, 16.4%, and 17.9% in the presumptive group; 1.9%, 7.0%, and 9.5% in the EBL group; and 2.6%, 34.9%, and 37.7% in the EC group, respectively (log-rank test, P = 0.00059). Moreover, 90.2% of early rebleeding occurred within 5 days. Adjusted hazard ratio (HR) was marginally lower in the presumptive group (HR = 0.50; 95% confidence interval, 0.26-1.01; P = 0.052) and significantly lower in the EBL-treated group than in the EC group (HR = 0.21; 95% confidence interval, 0.09-0.50; P = 0.0004). Conclusions Most early rebleeding occurred within 5 days after initial colonoscopy. EC was less effective than EBL in terms of early rebleeding.

Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn’s disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.

Background and study aims: Endoscopic band ligation (EBL) has been used for hemostasis of colonic diverticular hemorrhage. However, early rebleeding (

Background and Aim Helicobacter pylori (H. pylori) infection is a strong risk factor for the development of gastric cancer. In 2013, the Japanese government approved H. pylori eradication therapy in patients with chronic gastritis as well as peptic ulcer. However, the continuing decline in eradication rates for first-line H. pylori eradication therapies is an urgent problem. In this study, we investigated changes in the first-line eradication rate from 2001 to 2010. Methods Eradication rates for 7-day triple therapy [proton pump inhibitor (rabeprazole 20 mg, lansoprazole 60 mg, or omeprazole 40 mg) + amoxicillin 1500 mg + clarithromycin (CAM) 400 or 800 mg, daily] were collated from 14 hospitals in the Tokyo metropolitan area. The urea breath test was used for the evaluation of eradication. The cut-off value was less than 2.5%. Results The yearly eradication rates (intention to treat/per protocol) were 78.5/79.5% (2001, n = 242), 71.2%/72.9% (2002, n = 208), 67.8%/70.5% (2003, n = 183), 75.6%/84.6% (2004, n = 131), 56.4%/70.5% (2005, n = 114), 70.5%/75.8% (2006, n = 271), 67.4%/82.0% (2007,n = 135), 64.0%/76.3% (2008, n = 261), 60.5%/74.3% (2009, n = 329), and 66.5%/78.8% (2010, n = 370), respectively. Examination of eradication rates according to CAM dosage revealed an eradication rate of 65.6% (383/584) for CAM 400 mg daily, and 68.5% (1124/1642) for CAM 800 mg daily, with no significant difference seen between dosages. Conclusion In recent years, eradication rates for first-line triple therapy have obviously decreased, but no noticeable decrease has occurred after 2001.

Studies on ecology of medical care can provide valuable information on how people seek healthcare in a specific geographic area. The objective of this study was to update a 2003 report on the ecology of medical care in Japan, identifying relevant changes in healthcare patterns. We collected information based on a prospective health diary recorded for a month in 2013 (n = 4548; 3787 adults and 797 children) using a population-weighted random sample from a nationally representative panel. We compared our overall and stratified findings with a similar study conducted in 2003. During a one-month period, per 1000 adults and children living in Japan, we estimated that 794 report at least one symptom, 447 use an over-the-counter (OTC) drug, 265 visit a physician’s office, 117 seek help from a professional provider of complementary or alternative medicine (CAM), 70 visit a hospital outpatient clinic (60 community-based and 10 university-based), 6 are hospitalized, and 4 visit a hospital emergency department. After adjusting for demographic variables, we found that healthcare seeking behaviors were influenced by age, gender and area of living. Compared with the 2003 study, participants in this study had fewer symptoms, fewer physician and emergency room visits, and less OTC use, but reported higher frequency of CAM use (p

Background: The environment surrounding Helicobacter pylori eradication treatment is dramatically changing. Recently, vonoprazan, a first-in-class potassium-competitive acid blocker (P-CAB), was introduced onto the market in 2015. The aging of Japan’s demographic structure is becoming pronounced. In this study, we examined the trend of the eradication rate of H. pylori in the metropolitan area and examined factors concerning successful eradication. Methods: We collected data from 20 hospitals in the Tokyo metropolitan area on patients who received first-line eradication therapy with a proton-pump inhibitor (PPI)/P-CAB, amoxicillin, and clarithromycin for 1 week and second-line eradication therapy with a PPI/P-CAB, amoxicillin, and metronidazole for 1 week from 2013 to 2018. The annual eradication rate and associated factors for successful eradication were analyzed. Results: We collected data of 4097 and 3572 patients in the first- and second-line eradication therapies, respectively. The eradication rate decreased from 2013 to 2014 and increased again from 2015 to 2018 with the first-line therapy [the eradication rates in 2013, 2014, 2015, 2016, 2017 and 2018 were 71.8%, 63.7%, 78.5%, 84.6%, 89.7 and 90.1%, respectively, in the per protocol (PP)]. The second-line eradication rates were 90.0%, 82.6%, 88.8%, 87.5%, 91.8% and 90.1% in 2013, 2014, 2015, 2016, 2017 and 2018, respectively, in PP. Vonoprazan was an independent factor for successful eradication in not only first-line, but also second-line eradication. Age over 75 years was an independent factor for eradication failure in both first- and second-line eradication therapies. Conclusion: The eradication rate improved from 2015 to 2018 with the first-line therapy because of the introduction of vonoprazan in the market. The eradication rates with first- and second-line regimens in elderly patients were lower than those in younger patients.

The effectiveness of narrow band imaging (NBI), chromoendoscopy (CE), and cap-assisted colonoscopy (CAC) on adenoma detection rate (ADR) has been investigated in previous meta-analyses; however, there have been no meta-analyses of autofluorescence imaging (AFI) or flexible spectral imaging color enhancement (FICE) or i-scan. The aim of this study was to determine whether AFI and FICE/i-scan was more effective than standard/high-definition white light endoscopy to improve ADR and to update previous meta-analyses of NBI, CE, and CAC.A systematic review and meta-analysis was conducted. Four investigators selected appropriate randomized controlled trials (RCT) using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. All RCTs in which colonoscopy were performed with AFI, FICE, i-scan, NBI, CE, and CAC were included. The risk ratios (RRs) calculated from adenoma/neoplasia detection rate were used as the main outcome measurement.A total of 42 studies were included in the analysis. Pooled estimates of RR (95%confidence interval [CI]) using AFI, FICE/i-scan, NBI, CE, and CAC were 1.04 (95% CI: 0.87-1.24) (I² = 0%) (fixed effects model [FEM]); 1.09 (95% CI: 0.97-1.23) (I² = 5%) (FEM); 1.03 (95% CI: 0.96-1.11) (I² = 0%) (FEM); 1.36 (95% CI: 1.23-1.51) (I² = 16%) (FEM); and 1.03 (95% CI: 0.93-1.14) (I² = 48%) (random effects model [REM]), respectively. The pooled estimate of RR (95%CI) using indigo carmine in non-ulcerative colitis (UC) patients and methylene blue in UC patients was 1.33 (95% CI: 1.20-1.48) (I² = 14%) (FEM) and 2.39 (95% CI: 1.18-4.84) (I² = 0%) (FEM), respectively.In contrast to AFI, FICE/i-scan, NBI, and CAC, only CE improves ADR. CE with methylene blue, though not NBI, is effective for surveillance of neoplasia in chronic UC patients.

Background In Japan, the eradication rate of first-line therapy for Helicobacter pylori (H. pylori) with a proton pump inhibitor (PPI), amoxicillin (AMPC) and clarithromycin (CAM) has been decreasing because of a high prevalence of CAM resistance. A possible decrease of the eradication rate for second-line therapy with a PPI, AMPC and metronidazole (MNZ) is of concern. The aim of this study is to assess the trends in second-line eradication therapy for H. pylori in Japan. Materials and Methods We accumulated data retrospectively on patients administered second-line eradication therapy for Helicobacter pylori with a PPI, AMPC, and MNZ for 1 week after failure of first-line eradication therapy with a PPI, AMPC and CAM at 15 facilities in the Tokyo metropolitan area in Japan from 2007 to 2011. Trends for second-line eradication rates in modified intention-to-treat (ITT) analyses were investigated. Second-line eradication rates were categorized by three PPIs (rabeprazole (RPZ), lansoprazole (LPZ) or omeprazole (OMZ)) and evaluated. Results We accumulated data on 1373 patients. The overall second-line eradication rate was 92.4%. Second-line eradication rates in 2007, 2008, 2009, 2010 and 2011 were 97.7, 90.6, 94.5, 91.8 and 91.8%, respectively, with no significant trends revealed. Second-line eradication rates categorized by three PPIs for the entire 5-year period were 91.6, 93.4 and 92.4% (RPZ, LPZ and OPZ, respectively) with no significant differences among the three PPIs. Conclusions From 2007 to 2011, there were no significant trends in the second-line eradication rates and the rates remained consistently high. From the viewpoint of high prevalence of CAM resistance in Japan, triple therapy with PPI, AMPC and MNZ may be a better strategy for first-line therapy compared to triple therapy with PPI, AMPC and CAM.

Background and aims In the Western world, 10–20 % of patients with GERD complain of at least weekly episodes of heartburn and/or acid regurgitation, while the corresponding value for GERD patients in Asia is

Background The number of sample cases of colonic diverticular hemorrhage treated with endoscopic band ligation (EBL) has been small to date. Objective To elucidate the safety and efficacy of EBL for colonic diverticular hemorrhage. Design Retrospective study. Setting General hospital. Patients A total of 29 patients with 31 colonic diverticula with stigmata of recent hemorrhage (SRH). Interventions Urgent colonoscopy was performed after bowel preparation. When diverticula with SRH were identified, marking with hemoclips was done near the diverticula. The endoscope was removed and reinserted after a band-ligator device was attached to the tip of endoscope. At first, EBL was attempted. In patients who could not be treated with EBL, epinephrine injection or endoscopic clipping was performed. Main Outcome Measurements Procedure time, rate of hemostasis and rebleeding, complications. Results The mean procedure time was 47 ± 19 minutes. EBL was successfully completed in 27 colonic diverticula (87%); except in 3 diverticula with a small orifice and large dome and 1 diverticula in which the orifice was too large. Early rebleeding after EBL occurred in 3 of 27 cases (11%). Although 2 cases of sigmoid rebleeding could be managed by repeat EBL or conservatively, right hemicolectomy was performed in 1 ascending diverticulum, in which the bleeding source was not identified on repeat colonoscopy. Scar formation at previously banded diverticula was identified in 7 of 11 patients who underwent follow-up colonoscopy. There were no complications after EBL in any of the patients. Limitations Retrospective study. Conclusions EBL is a safe and effective treatment for colonic diverticular hemorrhage, and colonic diverticula resolve after EBL.

Endoscopic mucosal resection (EMR) is a therapy for early gastric cancer (EGC) that can be provided relatively easily and safely in any institution. Identification of the resection margin is a problem in EMR, especially in cases of piecemeal EMR. Despite the long-standing widespread use of piecemeal EMR for EGC, its limitation and long-term outcomes in clinical practice have not been fully evaluated. This study aimed to determine the risk factors of piecemeal EMR, the local recurrence rates, and the mortality rate.A cross-sectional, retrospective cohort study was performed to investigate the risks of piecemeal EMR for patients with the diagnosis of differentiated adenocarcinoma localized to the mucosa. Local recurrence of EGC was investigated by annual follow-up esophagogastroduodenoscopy (EGD) for 10 years. EMR was performed with snare electrocautery using a two-channel scope. When a resection margin was clearly positive for cancer, additional surgery was performed soon after the initial EMR.For the 149 EGC patients (mean age, 68.8 ± 9.8; male, 77%) who underwent EMR between 1995 and 2001, EMR was performed en bloc in 66 cases and piecemeal in 83 cases. The comorbid conditions existing in 34 of the 149 patients included other malignancies (n = 12), heart failure (n = 5), pulmonary disease (n = 7), liver cirrhosis (n = 4), and other illness (n = 6). However, EMR was completed without complication. The mean area (length × width) of the lesions was 404 ± 289 mm(2) in the piecemeal group and 250 ± 138 mm(2) in the en bloc groups. The en bloc and piecemeal EMR groups differed significantly in terms of unclear horizontal margins but not in terms of unclear vertical margins. Multiple logistic regression suggested that the adjusted odds ratio for maximum diameters exceeding 20 mm for piecemeal EMR was 2.71 (95% confidence interval [CI], 1.30-5.64). According to Kaplan-Meier estimates, the local recurrence rate was 30% (95% CI, 20-40%) at both 5 and 10 years. No recurrence was observed in the en bloc group. The adjusted hazard ratio of unclear horizontal margins for local recurrence was 1.63 (95% CI, 1.12-2.36). A total of 24 patients died after EMR because of comorbid conditions, including other malignancies (n = 11), cardiovascular disease (n = 6), pulmonary disease (n = 4), liver cirrhosis (n = 2), and traffic accident (n = 1). However, no patient died of gastric cancer during the 10-year follow-up period.An evaluation of horizontal margins in terms of local recurrence after piecemeal EMR is important, and en bloc resection is recommended. Close follow-up assessment is warranted, especially within 5 years in cases of unclear margin resection after piecemeal EMR. The use of EMR is safe even for patients with severe comorbid conditions.

Objective: We aimed to develop a prognostic prediction model for 2-week survival among patients with terminal cancer in a palliative care unit (PCU). Methods: A prospective cohort study was conducted on terminal cancer patients in the PCU for 11 months at a general hospital in Tokyo, Japan. We collected data regarding demographics, treatment history, performance status, symptoms, and laboratory results. Patients who survived more than 2 weeks were labeled ‘long survivors’ and those who died within 2 weeks were grouped as ‘short survivors’. Stepwise logistic regression model was constructed for the model development and bootstrapping was used for the internal model validation. Results: In 158 subjects whose data were available for the analysis, 109 (69%) subjects were categorized as long survivors and 49 (31%) subjects as short survivors. A prognostic prediction model with a total score of 8 points was constructed as follows: 2 points each for anorexia, dyspnea, and edema; 1 point each for blood urea nitrogen >25 mg/dl and platelets 3. Area under the receiver operating characteristic (ROC) curve of this model was 83.2% (95% CI: 75.3–91.0%). Bootstrapped validation beta coefficients of the predictors were similar to the original cohort beta coefficients. Conclusion: Our prognostic prediction model for estimating 14-day survival for patients with terminal cancer on the PCU ward included five clinical predictors that are readily available in the clinical setting and showed a relatively high accuracy. External validation is needed to confirm the model’s generalizability.

Objectives: The greater satisfaction of residents in nonuniversity hospitals in Japan found in a previous survey may reflect a better educational environment in these hospitals compared to university hospitals. We aimed to compare the educational environment of university hospitals and nonuniversity hospitals. Methods: A cross-sectional survey was sent to 6725 1styear resident physicians. The Postgraduate Hospital Educational Environment Measure (PHEEM) was used as a reliable and validated instrument to evaluate the educational environment of teaching hospitals. Results: A total of 2429 PGY-1 physicians-in-training (38% women) completed the questionnaire (response rate, 36%). The mean total scores on the PHEEM ranged from 77 to 125 (mean, 99) for 80 university hospitals, and from 46 to 149 (mean, 102) for 255 non-university hospitals. The PHEEM score was significantly higher for non-university hospitals compared to university hospitals (p=0.001). Among the top ten of hospitals with the greatest scores, there were nine non-university hospitals but only one university hospital. Conclusions: The difference in educational environment may explain the greater satisfaction of non-university residents in Japan and account for the massive shift of residents from university to non-university hospitals after

Objective: Health locus of control (HLC) is associated with health behaviours. We aimed to investigate the difference of HLC to understand the potential gap in health beliefs between physicians and the general public. Design and setting: Physicians and the general public were surveyed in Japan using a cross-sectional survey. Data on the Japanese version of the HLC scale (HLCS-J) from 2194 members of the general public and 895 physicians were available. Method: Multi-group structural equation modelling analysis was used for examining differential item functioning (DIF) in the HLCS-J between the groups. Results: Uniform DIF was identified for the dimensions of internal, professional control and control by spiritual powers. Mean score for chance control (17.2) among physicians was greater than that (14.9) among the general public (adjusted p Conclusion: Physicians are more likely to have a higher chance control but lower family control than the general public. Further studies are needed to evaluate the relationships between individual physicians’ HLC and their health behaviours.

The Ministry of Health, Labour and Welfare of Japan has been promoting participation in scholarly activities for physicians during residency training. However, there is debate regarding whether this is worthwhile for residents.To evaluate residents' opinions of engaging in scholarly activities and identify factors associated with overall satisfaction with their training program.Cross-sectional national survey.1,124 second-year residents in teaching hospitals in Japan in 2007Collected data included demographics, teaching hospital characteristics and resources, residents' research experiences, including type of activities, barriers to performing scholarly activities, residents' opinions of scholarly requirements, and resident satisfaction with their residency program.1,124 residents/1,500 responded for a response rate of 74.9%. Our data showed that 60.2% of Japanese residents engaged in some type of scholarly activity. Barriers included: "No resident time"; "No mentor;" and "No resident interest." Sixty-three percent of residents thought that research should be a residency requirement. In multivariate logistic analysis, residents' overall satisfaction with their residency program was significantly associated with participation in research activity (odds ratio (OR), 1.5; 95% confidence interval (CI), 1.1-2.1); male gender (OR, 1.5; 95% CI: 1.1-2.2); satisfaction with residency compensation (OR, 3.8; 95% CI, 2.6-5.0), and satisfaction with the residency curriculum (OR, 19.5; 95% CI, 13.7-27.7).The majority of residents surveyed thought that research activity was worthwhile. Residents' participation in research activity was associated with higher levels of satisfaction with residency training. Implementing measures to overcome existing barriers may have educational benefits for residents.

Summary Objectives: Personal digital assistants (PDAs) are in widespread use by resident physicians in many countries, reaching as high as 95% in some reports. Uses are varied and include clinical decision support and support of evidence-based practice. Utilization by resident doctors in Japan has not been characterized. This study was conducted to determine practice patterns of PDA use by Japanese resident physicians. Methods: A nationwide cohort survey study was distributed to all 1070 residency teaching programs in Japan. The survey included questions pertaining to use of PDAs in clinical practice. Results: 1124 surveys were returned (response rate of approximately 75%). 297 (30.7%) respondents reported currently using PDAs, while 971 (86.4%) reported having used a PDA in the past. PDA users were more likely to be male (p < 0.05), but no other significant differences were found when examining the following variables: age, training site (university hospital versus community teaching hospital), satisfaction with existing information technology access. Conclusions: Use of PDAs among Japanese resident physicians is much lower than their counterparts in other countries. In light of this, further research on patient outcomes in Japan and the impact of PDA usage on patient outcomes is urgently needed. If demonstrated to improve outcomes, barriers to adoption need to be identified and overcome.

Background and aims: Endoscopic band ligation (EBL) has been used to achieve hemostasis in patients with colonic diverticular bleeding. The safety and effectiveness of EBL when performed by non-expert endoscopists have not been sufficiently verified. This study aimed to elucidate the feasibility of the EBL technique when performed by non-expert endoscopists and of considering EBL as a standard treatment for colonic diverticular bleeding. Patients and methods: A retrospective cohort study was conducted in a tertiary referral center in Tokyo, Japan, between June 2009 and October 2014. A total of 95 patients treated with EBL were included in the study and were divided into two groups according to whether they had been treated by expert or non-expert endoscopists. Comorbidities, medications, shock index, hemoglobin level on admission, location of the bleeding diverticula, rate of bowel preparation, procedure time, and EBL-associated adverse events were evaluated in each group. Multivariate linear regression analyses were used to investigate factors related to EBL procedure time, which is the time elapsed between marking the site of bleeding with hemoclips and completion of the band release. Results: A total of 47 (49.5 %) procedures were performed by expert endoscopists. In a bivariate analysis, the median EBL procedure times in the expert and non-expert groups were 15 minutes (range 4 – 45) and 11 minutes (range 4 – 36), respectively (P = 0.03). When a multivariate linear regression model was used, EBL for right-sided diverticula was the factor most significantly affecting EBL procedure time. No adverse events were encountered. Conclusion: EBL can be safely and effectively performed by non-expert endoscopists. A right-sided location of diverticula was the factor most significantly affecting EBL procedure time.

Helicobacter pylori (H. pylori) infection is a strong risk factor for the development of gastric cancer. In 2013, the Japanese government approved H. pylori eradication therapy in patients with chronic gastritis as well as peptic ulcer. However, the continuing decline in eradication rates for first-line H. pylori eradication therapies is an urgent problem. In this study, we investigated changes in the first-line eradication rate from 2001 to 2010.Eradication rates for 7-day triple therapy [proton pump inhibitor (rabeprazole 20 mg, lansoprazole 60 mg, or omeprazole 40 mg)+amoxicillin 1500 mg + clarithromycin (CAM) 400 or 800 mg, daily] were collated from 14 hospitals in the Tokyo metropolitan area. The urea breath test was used for the evaluation of eradication. The cut-off value was less than 2.5%.The yearly eradication rates (intention to treat/per protocol) were 78.5/79.5% (2001, n=242), 71.2%/72.9% (2002, n=208), 67.8%/70.5% (2003, n=183), 75.6%/84.6% (2004, n=131), 56.4%/70.5% (2005, n=114), 70.5%/75.8% (2006, n=271), 67.4%/82.0% (2007, n=135), 64.0%/76.3% (2008, n=261), 60.5%/74.3% (2009, n=329), and 66.5%/78.8% (2010, n=370), respectively. Examination of eradication rates according to CAM dosage revealed an eradication rate of 65.6% (383/584) for CAM 400 mg daily, and 68.5% (1124/1642) for CAM 800 mg daily, with no significant difference seen between dosages.In recent years, eradication rates for first-line triple therapy have obviously decreased, but no noticeable decrease has occurred after 2001.

A retrospective cohort study was conducted in 55 symptomatic patients with amebic colitis that visited at St. Luke's International Hospital and Mie University Hospital from 1994 through 2013. To diagnose amebic colitis, 40 patients underwent total colonoscopy within 1 week after hospital visiting and before receiving any treatment. The percentage of characteristic endoscopic findings of amebic colitis including discrete ulcers or erosions with white or yellow exudates were 0% in terminal ileum, 93% in cecum, 28% in ascending, 25% in transverse, 15% in descending, 20% in sigmoid colon and 45% in rectum. The rectal lesions in 55% of patients with amebic colitis were nonspecific. The trophozoite identification rate by direct smear of intestinal tract washings performed during colonoscopy was 88%. The protozoan identification rate was 70% in biopsy specimens taken from the periphery of the characteristic discrete ulcers. Total colonoscopy should be considered for the diagnosis of amebic colitis.

Health care workers outside surgical suites in Asia use surgical-type face masks commonly. Prevention of upper respiratory infection is one reason given, although evidence of effectiveness is lacking.Health care workers in a tertiary care hospital in Japan were randomized into 2 groups: 1 that wore face masks and 1 that did not. They provided information about demographics, health habits, and quality of life. Participants recorded symptoms daily for 77 consecutive days, starting in January 2008. Presence of a cold was determined based on a previously validated measure of self-reported symptoms. The number of colds between groups was compared, as were risk factors for experiencing cold symptoms.Thirty-two health care workers completed the study, resulting in 2464 subject days. There were 2 colds during this time period, 1 in each group. Of the 8 symptoms recorded daily, subjects in the mask group were significantly more likely to experience headache during the study period (P.05). Subjects living with children were more likely to have high cold severity scores over the course of the study.Face mask use in health care workers has not been demonstrated to provide benefit in terms of cold symptoms or getting colds. A larger study is needed to definitively establish noninferiority of no mask use.