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Background: International practice guidelines for high-stool-output (HSO) management in short bowel syndrome (SBS) are available, but data on implementation are lacking. This study describes the approach used to manage HSO in SBS patients across different global regions. Methods: This is an international multicenter study evaluating medical management of HSO in SBS patients using a questionnaire survey. Thirty-three intestinal-failure centers were invited to complete the survey as one multidisciplinary team. Results: Survey response rate was 91%. Dietary recommendations varied based on anatomy and geographic region. For patients without colon-in-continuity (CiC), clinical practices were generally consistent with ESPEN guidelines, including separation of fluid from solid food (90%), a high-sodium diet (90%), and a low-simple-sugar diet (75%). For CiC patients, practices less closely followed guidelines, such as a low-fat diet (35%) or a high-sodium diet (50%). First-line antimotility and antisecretory medications were loperamide and proton-pump inhibitors. Other therapeutic agents (e.g., pancreatic enzymes and bile acid binders) were utilized in real-world practices, and usage varied based on intestinal anatomy. Conclusion: Expert centers largely followed published HSO-management guidelines for SBS patients without CiC, but clinical practices deviated substantially for CiC patients. Determining the reasons for this discrepancy might inform future development of practice guidelines.

Supplemental material for research article "Real-World Management of High Stool Output in Patients with Short Bowel Syndrome: An International Multicenter Survey"

Questionnaire survey

Mucosal-associated invariant T (MAIT) cells are innate-like, unconventional T cells that are present in peripheral blood and mucosal surfaces. A clear understanding of how MAIT cells in the mucosae function and their role in host immunity is still lacking. Therefore, our aim was to investigate MAIT cell distribution and their characteristics in the gastrointestinal (GI) mucosal tissue based on Vα7.2+CD161hi identification. We showed that Vα7.2+CD161hi T cells are present in both intraepithelial layer and lamina propriae of the GI mucosa, but have different abundance at each GI site. Vα7.2+CD161hi T cells were most abundant in the duodenum, but had the lowest reactivity to MR1-5-OP-RU tetramers when compared with Vα7.2+CD161hi T cells at other GI tissue sites. Striking discrepancies between MR1-5-OP-RU tetramer reactive cells and Vα7.2+CD161hi T cells were observed along each GI tissue sites. Vα7.2+CD161hi TCR repertoire was most diverse in the ileum. Similar dominant profiles of TRBV usage were observed among peripheral blood, duodenum, ileum, and colon. Some TRBV chains were detected at certain intestinal sites and not elsewhere. The frequency of peripheral blood Vα7.2+CD161hi T cells correlated with mucosal Vα7.2+CD161hi T cells in lamina propriae ileum and lamina propriae colon. The frequency of peripheral blood Vα7.2+CD161hi T cells in Helicobacter pylori-infected individuals was significantly lower than uninfected individuals, but this was not observed with gastric Vα7.2+CD161hi T cells. This study illustrates the biology of Vα7.2+CD161hi T cells in the GI mucosa and provides a basis for understanding MAIT cells in the mucosa and MAIT-related GI diseases.

BACKGROUND: Current guidelines recommend that patients with chronic intestinal failure (CIF) should be managed by a multidisciplinary team (MDT). However, the characteristics of real-world IF centers and the patients they care for are lacking. The study aims to describe IF center characteristics as well as characteristics of patients with CIF across different global regions. METHODS: This is an international multicenter study of adult IF centers using a survey. The questionnaire survey included questions regarding program and patient characteristics. Thirty-three investigational centers were invited to participate. Each center was asked to answer the survey questions as one MDT. RESULTS: The survey center response rate was 91%. The median number of patients with CIF per center was 128 (range, 30-380). The most common disciplines reported were gastroenterologist (93%), dietitian (90%), nurse (83%), and advanced practitioner (nurse practitioner and physician assistant, 77%). There were centers that did not have a pharmacist, surgeon, psychologist, and social worker (30%, 37%, 60%, and 70%, respectively). The median full-time equivalents (FTEs) per 100 patients were 1.1 for nurses, 1 for dietitians, 1 for advanced practitioners, and 0.9 for gastroenterologists. Short bowel syndrome was the most common cause of CIF (50%) followed by intestinal dysmotility (20%). CONCLUSION: The majority of centers were managing around 100 patients with CIF. Despite the widespread use of the MDT, there are some variances in team characteristics. Gastroenterologists were the most common physicians supporting MDTs. In IF centers, one FTE of each core discipline was supported to manage 100 patients with CIF. ispartof: NUTRITION IN CLINICAL PRACTICE vol:38 issue:3 pages:657-663 ispartof: location:United States status: accepted

Mucosal-associated invariant T (MAIT) cells are innate-like, unconventional T cells that are present in peripheral blood and mucosal surfaces. A clear understanding of how MAIT cells in the mucosae function and their role in host immunity is still lacking. Therefore, our aim was to investigate MAIT cell distribution and their characteristics in the gastrointestinal (GI) mucosal tissue based on Vα7.2

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

Background Despite high risk of bacterial contamination, yet there are no studies that have evaluated the optimal hang time of blenderized and reconstituted powdered formulas at standard room temperature and high temperature. Aim To investigate the optimal hang time of both types of formulas at standard room temperature and high temperature. Methods Ten specimens of blenderized formula and 10 specimens of reconstituted powdered formula were prepared using aseptic techniques. Five specimens of each formula were administered at 25 °C and 32 °C. Simulated administration was done in an incubator. The samples were collected at 0, 2, 4, 6 h and aerobic culture was performed. Food and drug administration criteria were used to determine the unacceptable levels of bacterial contamination. Results Unacceptable contamination for blenderized formula began at 4 h at 25 °C and at 2 h at 32 °C. As for the reconstituted powdered formula, there was no bacterial growth in all specimens up to 6 h at both temperatures. Conclusion The optimal hang time to avoid significant bacterial contamination of the blenderized formula should be limited to 2 h at standard room temperature and be administered by bolus method at high temperature, while a reconstituted powdered formula may hang up to 6 h at both temperatures.

Acute pancreatitis (AP) is a common gastrointestinal disease and the leading cause of hospital admission and healthcare burden among gastrointestinal disorders in many countries. Patients can present with varying degrees of inflammation and disease severity, ranging from self-limiting mild AP to devastating and fatal severe AP. Many factors contribute to malnutrition in AP, especially abnormal metabolism and catabolism related to inflammation. The concept of “pancreatic rest” is not evidence-based. There is however, emerging evidence that supports the use of oral or enteral nutrition to improve nutrition status and to reduce local and systemic inflammation, complications, and death. In mild disease, patients are generally able to initiate solid oral diet and do not require specialized nutrition care such as enteral or parenteral nutrition. In contrast, nutrition interventions are imperative in moderately severe and severe AP. The current article aims to review the latest evidence and suggest practical nutrition interventions in patients with AP, including nutrition requirements, routes of nutrition treatment, types of formula, and the role of nutritional supplements, such as glutamine, probiotics, omega-3 fatty acids, and antioxidants.

Summary Background and aims Parenteral nutrition-associated liver disease (PNALD) is a common complication in patients receiving parenteral nutrition (PN). Few studies have investigated the incidence and risk factors of PNALD in adult patients receiving PN with newer generation intravenous lipid emulsions. The aim of this study was to investigate the incidence and risk factors of PNALD in hospitalized adult patients. Methods Patients expected to receive PN for more than 14 days and have normal liver tests at baseline during September 2016 to February 2017 were enrolled. All patients were followed until there were liver test abnormalities. Incidence, onset and characteristics of PNALD, calories intake, amount of fat and carbohydrate, types of fat, nutrition status, and incidence of infection were evaluated. Results Forty-four adults were recruited. The incidence of PNALD was 59.1% (22.7% steatosis, 34.1% cholestasis, and 2.3% mixed type). Median onset of PNALD was 12.5 days (range: 4–42) and the onset was not significantly different between each subtype. In multiple regression analysis, severe malnutrition and amount of carbohydrate were independent risk factors for PNALD with an odds ratio of 13.25 (95% CI: 1.37–128.24; p = 0.026) and 21.61 (95% CI: 1.81–258.56; p = 0.015), respectively. Conclusions PNALD was common in this group of patients. In contrast to previous studies, cholestasis was more common than steatosis, and the median onset was not different between each subtype. In severely malnourished patients, physicians need to exercise caution and monitor for PNALD intensively, and overfeeding of carbohydrate should be avoided to prevent PNALD from occurring.

To evaluate the effects of a Ready to Hang (RTH), pectin-containing enteral nutrition on gastrointestinal symptoms and nutrition status.An open-label, randomized, prospective controlled study. Thirty hospitalized patients with tube feeding for 9 days or more.A pectin-containing enteral formula (Hine E-Gel®) or a standard polymeric formula (Ensure®) was administered for 1 week. Administration methods: Administered via a nasogastric tube 4 times per day (every 6 hours), 30 minutes per administration.There was no significant difference in the frequency of diarrhea or the nutritional indicators. An additional survey was conducted of 50 nurses who were involved in the administration of the study products. Most respondents replied that the RTH, pectin-containing formula was easier to use and that the duties related to its administration were decreased.The pectin-containing formula was not detectably superior to the standard polymeric formula in terms of gastrointestinal symptoms. The use of RTH may simplify medical care and enable efficient management.

Background and aims: Acute illness might affect the swallowing function. However, there have been limited studies regarding dysphagia awareness in hospitalized patients, factors associated with dysphagia, and its outcomes. Methods: Consecutive patients in an internal medicine ward whom primary physicians prescribed oral diet were prospectively evaluated their swallowing problems by using a water swallow test (WST) and swallowing disturbance questionnaire (SDQ) within 48 hours after admission. Patients characteristics, nutritional status, readmission, and mortality rates were evaluated and compared between patients with and without impaired swallowing. Results: Among 131 enrolled patients (61 males, mean age 58±21 years), 20 patients (15.3%) had abnormal SDQ and 38 patients (29%) had abnormal WST. 19/20 patients with abnormal SDQ had abnormal WST while 19/38 patients with abnormal WST (50.0%) had abnormal SDQ. Patients with swallowing problems by either abnormal SDQ or WST were significantly older than those without (pConclusion: Dysphagia is an underrecognized problem in hospitalized patients. This problem was associated with underlying neurological diseases, malnutrition, the current diagnosis, and readmission due to pneumonia. Screening for dysphagia is recommended in hospitalized patients, particularly in patients at risk.

Malnutrition is associated with poor surgical outcomes, and therefore optimizing nutritional status preoperatively is very important. The purpose of this paper is to review the literature related to preoperative parenteral nutrition (PN) and to provide current evidence based guidance. A systemic online search of PubMed, Medline, and Cochrane Databases from January 1990 to February 2020 was done. Sixteen studies were included in this narrative review, including four meta-analyses and twelve clinical trials. The majority of studies have demonstrated benefits of preoperative PN on postoperative outcomes, including reduced postoperative complications (8/10 studies) and postoperative length of stay (3/4 studies). Preoperative PN is indicated in malnourished surgical patients who cannot achieve adequate nutrient intake by oral or enteral nutrition. It can be seen that most studies showing benefits of preoperative PN often included patients with upper gastrointestinal cancer and inflammatory bowel disease (10/12 studies), which gastrointestinal problems are commonly seen and enteral nutrition may be not feasible. When preoperative PN is indicated, adequate energy and protein should be provided, and patients should receive at least seven days of PN prior to surgery. The goal of preoperative PN is not weight regain, but rather repletion of energy, protein, micronutrients, and glycogen stores. Complications associated with preoperative PN are rarely seen in previous studies. In order to prevent and mitigate the potential complications such as refeeding syndrome, optimal monitoring and early management of micronutrient deficiencies is required.

No previous study has investigated the prevalence and risk factors for primary sarcopenia in outpatient setting. This study aims to evaluate the prevalence and factors associated with primary sarcopenia in outpatient elderly. Additionally, we compared the severity of sarcopenia based on the 2014 and 2019 Asian Working Group for Sarcopenia (AWGS) criteria. This cross-sectional study was performed in 330 subjects aged over 60 years in an outpatient setting. The muscle strength, muscle performance and muscle mass were assessed using the handheld dynamometer, 6-m gait speed, and bioelectrical impedance analysis, respectively. The prevalence of sarcopenia was 10% as per the 2014 and 2019 AWGS criteria. The development of sarcopenia was positively correlated with the age with an odds ratio (OR) of 6.87 [95% confidence interval (CI) 1.63–28.88] in the middle-old group (70–79 years), and 13.71 (95%CI 3.66–51.41; p = 0.009) in the very old group (≥ 80 years). Prefrailty and low physical activity were significantly associated with sarcopenia with an OR of 4.75 (95%CI 1.90—11.89) in prefrailty, 15.35 (95%CI 1.69–139.47) in the middle activity group, and 17.99 (95%CI 1.95–165.73) in the lowest activity group. In conclusion, primary sarcopenia was found in one-tenth of outpatient elderly. Age, prefrailty, and low activity were independent factors associated with sarcopenia.

The ketogenic diet (KD) has been shown to be effective in controlling super-refractory status epilepticus (SRSE) in adult. To the best of our knowledge, there has been no previous report of the MCT KD in adult with SRSE. A 19-year-old female was hospitalized due to SRSE from autoimmune encephalitis despite pulsed methylprednisolone, intravenous immunoglobulin, and eight antiepileptic drug treatments. The MCT KD treatment was initiated and rapid seizure control was observed within 6 days despite negative ketosis. We report the first successful treatment with MCT KD in a female adult with SRSE who was refractory to classic KD with severe hypertriglyceridemia, and reviewed all SE adults with KD treatment. Dramatic seizure control without positive ketosis might lead to a new focus on fatty acids instead, paving the way for further prospective study regarding the effects of the MCT KD in this fatal condition.

Short bowel syndrome (SBS) is a rare and life-threatening disease. Few studies have investigated risk factors for parenteral nutrition (PN)-dependence and death in SBS. Accordingly, the aim of this study was to investigate the risk factors for PN-dependence and long-term mortality in SBS.This retrospective study reviewed and evaluated children and adults who were diagnosed with SBS at King Chulalongkorn Memorial Hospital from October 2005 to January 2015. Age, causes of SBS, length of remnant bowel, type of anastomosis, types of nutrition support, SBS-associated complications, PN-dependence rate, duration of PN-dependence, mortality rate, and causes of death were evaluated.Twenty-two adults and 19 children were reviewed. The median follow-up time was 48 months. At the end of follow-up, PNdependence rate was 51.2%. The residual colon=50% group had a significantly lower PN-dependence rate, with a hazard ratio of 0.36 (95% CI: 0.14-0.93; p=0.03). The most frequent cause of death was infection, with the highest percentage of mortality occurring within the first 2 years after surgery. The mortality rate was 53.8% and the residual colon=50% group had a significantly lower mortality rate, with a hazard ratio of 0.36 (95% CI: 0.14- 0.88; p=0.03).PN-dependence and death occurred in about half of all patients. Residual colon=50% was significantly associated with lower death rate and PN-dependence. The crucial role of colon in continuity as a protective factor should be investigated further in prospective studies.

Background: Negative results of EUS-FNA for solid pancreatic lesions (SPL) can be false ones. Combination with strain ratio (SR) may ensure a correct benign diagnosis of SPL. Aims: We prospectively evaluated the sensitivity rate of EUS-FNA and EUS elastography using the strain ratio method for diagnosing SPL. Methods: Thirty-eight patients with SPL identified by CT or MRI between January 2013 and November 2013 were included in our prospective study. EUS diagnoses were made using SR by an endosonographer who was blinded to all clinical information. In SPL with adequate cellularity, the results of EUS-FNA were combined with strain ratio to diagnose SPL and the diagnostic value was calculated. Results: Benign SPL were diagnosed in nine patients with surgical or guided-biopsy pathology (n = 3) and benign cells from FNA with stable disease during the 12-month follow-up time (n = 6). Using the best cut-off strain ratio level at 3.17, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate of EUS elastography were 86.2%, 66.7%, 89.3%, 60%, and 81.6%, respectively. For the 28 patients who underwent EUS-FNA with results of adequate cellularity; EUS-FNA alone versus combination of results of cytology and SR provided sensitivity, specificity, PPV, NPV, and accuracy rate at 90% versus 95.2, 100% versus 71.4%, 100% versus 90.9%, 80% versus 83.3, and 92.9% versus 89.3%, respectively. Conclusions: In this prospective single-blinded study, the negative results of both EUS-FNA and SR were more reliable to exclude malignant SPL. The sensitivity of EUS elastography by SR was not superior to EUS-FNA. © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd

The involvement of the gallbladder in systemic lymphoma is extremely rare. We report a challenging case of systemic diffuse large B-cell lymphoma (DLBCL) that initially presented with septic shock from acalculous cholecystitis. After extensive investigation, DLBCL was found to be the underlying cause of gallbladder disease.

Critically ill patients with acute kidney injury (AKI) who receive renal replacement therapy (RRT) have very high mortality rate. During RRT, there are markedly loss of macro- and micronutrients which may cause malnutrition and result in impaired renal recovery and patient survival. We aimed to examine the predictive role of macro- and micronutrients on survival and renal outcomes in critically ill patients undergoing continuous RRT (CRRT). This prospective observational study enrolled critically ill patients requiring CRRT at Intensive Care Unit of King Chulalongkorn Memorial Hospital from November 2012 until November 2013. The serum, urine, and effluent fluid were serially collected on the first three days to calculate protein metabolism including dietary protein intake (DPI), nitrogen balance, and normalized protein catabolic rate (nPCR). Serum zinc, selenium, and copper were measured for micronutrients analysis on the first three days of CRRT. Survivor was defined as being alive on day 28 after initiation of CRRT.Dialysis status on day 28 was also determined. Of the 70 critically ill patients requiring CRRT, 27 patients (37.5%) survived on day 28. The DPI and serum albumin of survivors were significantly higher than non-survivors (0.8± 0.2 vs 0.5 ±0.3g/kg/day, p = 0.001, and 3.2±0.5 vs 2.9±0.5 g/dL, p = 0.03, respectively) while other markers were comparable. The DPI alone predicted patient survival with area under the curve (AUC) of 0.69. A combined clinical model predicted survival with AUC of 0.78. When adjusted for differences in albumin level, clinical severity score (APACHEII and SOFA score), and serum creatinine at initiation of CRRT, DPI still independently predicted survival (odds ratio 4.62, p = 0.009). The serum levels of micronutrients in both groups were comparable and unaltered following CRRT. Regarding renal outcome, patients in the dialysis independent group had higher serum albumin levels than the dialysis dependent group, p = 0.01. In conclusion, in critically ill patients requiring CRRT, DPI is a good predictor of patient survival while serum albumin is a good prognosticator of renal outcome.

Negative results of EUS-FNA for solid pancreatic lesions (SPL) can be false ones. Combination with strain ratio (SR) may ensure a correct benign diagnosis of SPL.We prospectively evaluated the sensitivity rate of EUS-FNA and EUS elastography using the strain ratio method for diagnosing SPL.Thirty-eight patients with SPL identified by CT or MRI between January 2013 and November 2013 were included in our prospective study. EUS diagnoses were made using SR by an endosonographer who was blinded to all clinical information. In SPL with adequate cellularity, the results of EUS-FNA were combined with strain ratio to diagnose SPL and the diagnostic value was calculated.Benign SPL were diagnosed in nine patients with surgical or guided-biopsy pathology (n = 3) and benign cells from FNA with stable disease during the 12-month follow-up time (n = 6). Using the best cut-off strain ratio level at 3.17, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate of EUS elastography were 86.2%, 66.7%, 89.3%, 60%, and 81.6%, respectively. For the 28 patients who underwent EUS-FNA with results of adequate cellularity; EUS-FNA alone versus combination of results of cytology and SR provided sensitivity, specificity, PPV, NPV, and accuracy rate at 90% versus 95.2, 100% versus 71.4%, 100% versus 90.9%, 80% versus 83.3, and 92.9% versus 89.3%, respectively.In this prospective single-blinded study, the negative results of both EUS-FNA and SR were more reliable to exclude malignant SPL. The sensitivity of EUS elastography by SR was not superior to EUS-FNA. © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

To the Editor: Marine bacteria of the family Shewanellaceae, genus Shewanella, are gram-negative, motile bacilli that grow aerobically or anaerobically and produce hydrogen sulfide (1). Organisms belonging to a Shewanella species were first isolated in 1931 by Derby and Hammer from dairy products and classified as Achromobacter putrefaciens (2). Members of Shewanella species usually are found in marine environments in warm climates or during summer in temperate climates (3). In humans, most Shewanella species infections occur in skin and soft tissues (4). One species (S. algae) and possibly a second (S. putrefaciens) have been isolated from human samples on multiple occasions (5). A third species, S. haliotis, was implicated in human infections during 2010 (6) and S. xiamenensis was reported as the fourth infectious species among humans during 2011 (7). S. haliotis is a novel bacterial species that was isolated from the gut microflora of abalones (Haliotis discus hannai) in 2007 (8). We report the second description, to our knowledge, of S. haliotis involved in human disease. In September 2012, a 52-year-old woman, living in Bangkok, Thailand, was hospitalized after experiencing drowsiness for 2 hours. She had a low-grade fever, chills, and swelling, erythema, and tenderness in her left leg. During the previous week, she had handled fresh seafood in a market and had eaten cooked mackerel. She denied having eaten uncooked food or wading into flooded areas or the sea. She had undergone orthotopic liver transplantation 6 months previously to excise hepatocellular carcinoma related to Child-Pugh class C hepatitis C cirrhosis; since that procedure, she had been under treatment with immunosupressive drugs. She also had diabetes, hypertension, and nephrotic syndrome. Physical examination revealed that in addition to above-named symptoms, multiple blisters were noted (Figure, panel A). Her oral temperature was 37.8°C, blood pressure 80/40 mm Hg, pulse was 110 bpm, and respiratory rate was 24 breaths/minute. A complete blood count showed a leukocyte count of 2,250 cells/μL (91.2% neutrophils). Despite adequate rehydration, monitored by central venous pressure, the patient required norepinephrine to stabilize her vital signs. The clinical diagnosis of her condition was septic shock with suspected necrotizing fasciitis. Figure Shewanella haliotis severe soft tissue infection of woman in Thailand, 2012. The patient sought treatment for painful erythematous swelling of the left leg. A) Arrow indicates affected area. B) Postsurgical fasciotomy wound with necrotic tissue. After tissue and blood samples were collected and submitted for microbiological analysis, shock resuscitation and an emergency fasciotomy (Figure, panel B) were performed, and antimicrobial drug treatment with meropenem and vancomycin was started. Surgeons did not confirm the suspected necrotizing fasciitis. Two sets of blood cultures and fluid culture sampled from the left leg identified S. algae by conventional biochemical methods. The MICs of antimicrobial drugs were determined by Etest (bioMerieux, Solna, Sweden). This strain was susceptible to ciprofloxacin (0.25 mg/L), piperacillin-tazobactam (1.0 mg/L), ceftriaxone (1.0 mg/L), and meropenem (0.38 mg/L). The patient had fever for the first 2 days of hospitalization. After 2 weeks of treatment, the antimicrobial drug was switched to oral ciprofloxacin; treatment was continued after dressing and debridement of the fasciotomy wound. The organism produced yellowish-brown mucoid colonies on sheep blood agar and chocolate agar after 18 hours of incubation at 35°C under CO2 atmosphere. MacConkey agar showed non–lactose-fermenting colonies that were oxidase-positive, motile, and produced hydrogen sulfide on triple sugar iron agar. Growth at 42oC with 6.5% NaCl suggested that this organism was S. algae. Because phylogenetically related Shewanella species may be misidentified by routine biochemical tests, the strain was confirmed by using 16S rRNA gene sequencing. Molecular characterization of 16S rRNA gene sequencing was performed by using PCR with Shewanella species consensus primers (Technical Appendix Table) and direct sequencing from PCR product ({"type":"entrez-nucleotide","attrs":{"text":"JX968803","term_id":"431982755","term_text":"JX968803"}}JX968803). Phylogenetic analysis of the 16S rRNA gene sequence showed clustering with S. haliotis ({"type":"entrez-nucleotide","attrs":{"text":"NR_044134","term_id":"343205730","term_text":"NR_044134"}}NR_044134T) and 99.9% similarity and 1 base difference (online Technical Appendix Figure). By using BLAST (http://blast.ncbi.nlm.nih.gov/Blast.cgi) analysis, {"type":"entrez-nucleotide","attrs":{"text":"JX968803","term_id":"431982755","term_text":"JX968803"}}JX968803 showed the closest match (99.9%; 1 base difference) with Alteromonadaceae bacterium PH39 ({"type":"entrez-nucleotide","attrs":{"text":"AF513471","term_id":"21667919","term_text":"AF513471"}}AF513471). The strain was confirmed as S. haliotis by using additional biochemical tests and API 20 NE System (bioMerieux, Durham, NC, USA). It was positive for ornithine decarboxylase, gelatinase, reduction of nitrates to nitrites, tolerance to 6% NaCl, and assimilation of caprate and malate, but negative for citrate utilization, arginine dihydrolase, lysine decarboxylase, urease, indole production, assimilation of mannose, glucose, arabinose, mannitol, maltose, adipate, and acidification of glucose. This strain was resistant to polymyxin B (300 µg/disc). More than 50 species of Shewanella have been reported. The route of Shewanella infection is associated with direct contact with the organism through seawater or ingestion of raw seafood (9). Japan reported 1 case of S. haliotis infection in an elderly patient in whom Vibrio vulnificus infection was initially suspected (6), and various clinical manifestations of S. algae infection have been reported (5). Community- and hospital-acquired infection with Shewanella species from contaminated medical devices have also been reported (10). S. haliotis and S. algae are closely related organisms; discriminating between them on the basis of biochemical tests is difficult. Molecular characterization of 16S rRNA gene sequencing can be used to differentiate the 2 species. In summary, this case suggests that immune-compromised persons in tropical climates could be susceptible to S. haliotis soft tissue infection in the absence of typical exposures. Technical Appendix: Specific Shewanella consensus primer sets for 16S rRNA gene sequencing and phylogenetic analysis. Click here to view.(162K, pdf)

To evaluate feasibility of the novel forward-viewing radial-array echoendoscope for staging of colon cancer beyond rectum as the first series.A retrospective study with prospectively entered database. From March 2012 to February 2013, a total of 21 patients (11 men) (mean age 64.2 years) with colon cancer beyond the rectum were recruited. The novel forward-viewing radial-array echoendoscope was used for ultrasonographic staging of colon cancer beyond rectum. Ultrasonographic T and N staging were recorded when surgical pathology was used as a gold standard.The mean time to reach the lesion and the mean time to complete the procedure were 3.5 and 7.1 min, respectively. The echoendoscope passed through the lesions in 13 patients (61.9%) and reached the cecum in 10 of 13 patients (76.9%). No adverse events were found. The lesions were located in the cecum (n = 2), ascending colon (n = 1), transverse colon (n = 2), descending colon (n = 2), and sigmoid colon (n = 14). The accuracy rate for T1 (n = 3), T2 (n = 4), T3 (n = 13) and T4 (n = 1) were 100%, 60.0%, 84.6% and 100%, respectively. The overall accuracy rates for the T and N staging of colon cancer were 81.0% and 52.4%, respectively. The accuracy rates among traversable lesions (n = 13) and obstructive lesions (n = 8) were 61.5% and 100%, respectively. Endoscopic ultrasound and computed tomography had overall accuracy rates of 81.0% and 68.4%, respectively.The echoendoscope is a feasible staging tool for colon cancer beyond rectum. However, accuracy of the echoendoscope needs to be verified by larger systematic studies.