A cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus, which occur together more often than by chance alone, have become known as the metabolic syndrome. The risk factors include raised blood pressure, dyslipidemia (raised triglycerides and lowered high-density lipoprotein cholesterol), raised fasting glucose, and central obesity. Various diagnostic criteria have been proposed by different organizations over the past decade. Most recently, these have come from the International Diabetes Federation and the American Heart Association/National Heart, Lung, and Blood Institute. The main difference concerns the measure for central obesity, with this being an obligatory component in the International Diabetes Federation definition, lower than in the American Heart Association/National Heart, Lung, and Blood Institute criteria, and ethnic specific. The present article represents the outcome of a meeting between several major organizations in an attempt to unify criteria. It was agreed that there should not be an obligatory component, but that waist measurement would continue to be a useful preliminary screening tool. Three abnormal findings out of 5 would qualify a person for the metabolic syndrome. A single set of cut points would be used for all components except waist circumference, for which further work is required. In the interim, national or regional cut points for waist circumference can be used.

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Harmonizing the Metabolic Syndrome A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity

DNA microarrays can be used to identify gene expression changes characteristic of human disease. This is challenging, however, when relevant differences are subtle at the level of individual genes. We introduce an analytical strategy, Gene Set Enrichment Analysis, designed to detect modest but coordinate changes in the expression of groups of functionally related genes. Using this approach, we identify a set of genes involved in oxidative phosphorylation whose expression is coordinately decreased in human diabetic muscle. Expression of these genes is high at sites of insulin-mediated glucose disposal, activated by PGC-1α and correlated with total-body aerobic capacity. Our results associate this gene set with clinically important variation in human metabolism and illustrate the value of pathway relationships in the analysis of genomic profiling experiments.

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PGC-1alpha-responsive genes involved in oxidative phosphorylation are coordinately downregulated in human diabetes

The metabolic syndrome

Adipose tissue is a complex, essential, and highly active metabolic and endocrine organ. Besides adipocytes, adipose tissue contains connective tissue matrix, nerve tissue, stromovascular cells, and immune cells. Together these components function as an integrated unit. Adipose tissue not only responds to afferent signals from traditional hormone systems and the central nervous system but also expresses and secretes factors with important endocrine functions. These factors include leptin, other cytokines, adiponectin, complement components, plasminogen activator inhibitor-1, proteins of the renin-angiotensin system, and resistin. Adipose tissue is also a major site for metabolism of sex steroids and glucocorticoids. The important endocrine function of adipose tissue is emphasized by the adverse metabolic consequences of both adipose tissue excess and deficiency. A better understanding of the endocrine function of adipose tissue will likely lead to more rational therapy for these increasingly prevalent disorders. This review presents an overview of the endocrine functions of adipose tissue.

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Adipose Tissue as an Endocrine Organ

The epidemic of type 2 diabetes and impaired glucose tolerance is one of the main causes of morbidity and mortality worldwide. In both disorders, tissues such as muscle, fat and liver become less responsive or resistant to insulin. This state is also linked to other common health problems, such as obesity, polycystic ovarian disease, hyperlipidaemia, hypertension and atherosclerosis. The pathophysiology of insulin resistance involves a complex network of signalling pathways, activated by the insulin receptor, which regulates intermediary metabolism and its organization in cells. But recent studies have shown that numerous other hormones and signalling events attenuate insulin action, and are important in type 2 diabetes.

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Insulin signalling and the regulation of glucose and lipid metabolism

Background/aims The Japan Gastroenterological Endoscopy Society (JGES) has published guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. These guidelines classify endoscopic ultrasound-guided biliary drainage (EUS-BD) as a high-risk procedure. Nevertheless, the bleeding risk of EUS-BD in patients undergoing antithrombotic therapy is uncertain. Therefore, this study aimed to assess the bleeding risk in patients undergoing antithrombotic therapy. Methods This single-center retrospective study included 220 consecutive patients who underwent EUS-BD between January 2013 and December 2018. We managed the withdrawal and continuation of antithrombotic agents according to the JGES guidelines. We compared the bleeding event rates among patients who received and those who did not receive antithrombotic agents. Results A total of 18 patients (8.1%) received antithrombotic agents and 202 patients (91.8%) did not. Three patients experienced bleeding events, with an overall bleeding event rate of 1.3% (3/220): one patient was in the antithrombotic group (5.5%) and two patients were in the non-antithrombotic group (0.9%) (p=0.10). All cases were moderate. The sole thromboembolic event (0.4%) was a cerebral infarction in a patient in the non-antithrombotic group. Conclusions The rate of EUS-BD-related bleeding events was low. Even in patients receiving antithrombotic therapy, the bleeding event rates were not significantly different from those in patients not receiving antithrombotic therapy.

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Outcomes of Endoscopic Ultrasound-Guided Biliary Drainage in Patients Undergoing Antithrombotic Therapy

Background/aims This study evaluated the efficacy and safety of transnasal endoscopy (TNE) with flexible spectral imaging color enhancement (FICE) for detection of superficial cancer in the pharyngeal and esophageal regions for high-risk populations. Methodology Patients who previously had head and neck or esophageal squamous cell carcinoma were enrolled. Screening was conducted using TNE with conventional white-light endoscopy (WLE) followed by FICE chromoendoscopy. For observation of the pharyngeal region, the Valsalva maneuver was employed. Results 99 patients were eligible. Six esophageal cancers were detected in four patients (4.0%). The sensitivity, specificity, and accuracy for the detection of cancer were 25.0% (95% CI, 3.4- 71.0), 97.8% (95% CI, 92.1-99.8), and 94.9 % (95% CI, 88.4-98.1), respectively for WLE; 100% (95% CI, 45.4%- 100%), 96.8% (95% CI, 90.7%-99.3%), and 96.9% (95% CI, 89.3%-99.1%), respectively for FICE chromoendoscopy. Pain in the nose and nasal hemorrhage were observed in 3 (3.0%) and 2 patients (2.0%), respectively. Following the Valsalva maneuver, endoscopic scores significantly increased from a mean of 1.1 (0.8-1.4) to 2.0 (1.3-2.6) (p Conclusions TNE with the Valsalva maneuver is a promising screening method for the pharyngeal and esophageal regions. TNE with FICE chromoendoscopy for detecting pharyngeal and esophageal cancer was more sensitive than WLE.

Prospective evaluation of a transnasal endoscopy utilizing flexible spectral imaging color enhancement (FICE) with the Valsalva maneuver for detecting pharyngeal and esophageal cancer.

A patient who developed Hodgkin's disease after an 11-year remission of marginal zone B-cell (MZB) lymphoma (low grade B-cell lymphoma of mucosa-associated lymphoid tissue type) is presented. Except for L26/CD20 expression by Reed-Sternberg cells, morphologic, immunophenotypic, and genotypic findings were compatible with the diagnosis of Hodgkin's disease. The relationship between Hodgkin's disease and the preceding MZB lymphoma in this patient is discussed.

Hodgkin's disease following extranodal marginal zone B-cell lymphoma in remission.

Endoscopic ultrasoundpancreatic duct drainage (EUSPD) is an effective treatment for obstructive pancreatitis.1 However, it is a difficult and dangerous procedure even for experts in the stenosis after pancreatojejunostomy.2 EUSPD is a challenging procedure that must be successful to avoid serious complications. MPD puncture is sometimes difficult because of the hard pancreas. A 22G needle with a 0.018inch wire is one of the ways for easier access in the difficult condition.3 However, a 0.018inch guidewire is comparatively soft for the complicated procedure. If the wire is not coiled enough, mechanical dilation is unsuccessful. In this situation, exchanging the wire for a bigger size and cautery dilator are rescue methods for success.4 But guidewire change itself is usually difficult in this condition. To overcome these problems, we applied a special dedicated dilator for EUSPD, as shown in Figure 1A,B. This dilator looks like a drill named Tornus ES (Tornus ES, Asahi Intec). We can dilate the truck very easily by a clockwise rotation of the Tornus ES, as shown in the Video S1. EUSPD was performed for abdominal pain caused by anastomotic stenosis of pancreatojejunostomy. At first, pancreatic duct is visualized under the Linear EUS (GFUCT260, OLYMPUS) and then punctured using a 22gauge needle (Expect Slimline [SL] – Boston Scientific) preloaded with the 0.018inch wire

Utility of a novel drill dilator for easier EUS‐guided pancreatic duct drainage

PURPOSE:To obtain a neutral density filter which has substantially no reflection at a preset wavelength and has stable characteristics by providing a transparent dielectric film in contact with the surface of a metallic film and providing a thin metallic film to the side opposite from the metallic film in contact with the surface of this transparent dielectric film. CONSTITUTION:A glass substrate 17 and a chromium metallic film 14 have the same constitution as the constitution of a neutral density filter formed by using metallic films. A thin chromium metallic film 12 and a magnesium fluoride (MgF2) film 13 which is a transparent dielectric material constitute an antireflection film. The light entering from the direction of air 11 passes the antireflection film consisting of the thin chromium metallic film 12 and the magnesium fluoride (MgF2) film 13 and is absorbed and reflected by the chromium metallic film 14, by which the light is attenuated. This light is successively transmitted through the glass substrate 17. The light reflected by the chromium metallic film 14 is annihilated by the interference in the two-layered antireflection film consisting of the thin chromium metallic film 12 and the magnesium fluoride (MgF2) film 13. The neutral-density filter having the stable characteristics is thereby obtd.

Kazuo Hara

Papers

Outcomes of Endoscopic Ultrasound-Guided Biliary Drainage in Patients Undergoing Antithrombotic Therapy

Prospective evaluation of a transnasal endoscopy utilizing flexible spectral imaging color enhancement (FICE) with the Valsalva maneuver for detecting pharyngeal and esophageal cancer.

Hodgkin's disease following extranodal marginal zone B-cell lymphoma in remission.

Utility of a novel drill dilator for easier EUS‐guided pancreatic duct drainage

Neutral density filter