In order to overcome these problems

In order to overcome these problems, we have developed an Internet-based e-learning system which is in English, and which is available anywhere in the world, and at any time of the day, so that clinicians worldwide can learn how to detect EGC (Yao, 2013). Recently, advanced imaging endoscopy techniques have become a topic for discussion in various academic meetings or publications (American Gastroenterological Association (AGA), 2008). Nevertheless, white-light endoscopy is still the most common practice throughout the world. This e-learning system is therefore dedicated to teaching diagnosis using white-light conventional endoscopy alone (Yao, 2012). We hypothesized that if endoscopists could acquire the detailed “knowledge, techniques and experience” essential for the early detection of gastric cancer through this e-learning system, then the detection rate of early-stage gastric cancer would increase throughout the world (Veitch et al., 2015). Accordingly, we investigated the feasibility of this e-learning system to improve the ability of endoscopic detection of EGC among endoscopists outside Japan.
Materials and Methods
Interventions
Results
Discussion
Funding
Author Contributions
Acknowledgements This trial was supported by the Central Research Institute of Fukuoka University (I) (111001) and JSPS Core-to-Core Program (B. Asia-Africa Science Platforms). We would like to express our sincere appreciation to Prof. Fatima Aparecida Ferreira Figueiredo (Head of the Digestive Endoscopy Department of the Copa D\'Or Hospital and Quinta D\'Or Hospital, Rio de Janeiro, Brazil) who participated as one of the team leaders of GEST and who made a substantial effort to bring this project to fruition before she rosmarinic acid passed away in 2014. We wish to thank Miss Katherine Miller (Royal English Language Centre, Fukuoka, Japan) for correcting the English used in this article.
Introduction There is compelling evidence demonstrating a gut-microbiome-brain connection linking the enteric microbiome to modulations in human health and behavior, as well as regulation of gut motility, nutrient absorption, immune system, and fat distribution (Cryan and Dinan, 2012, Backhed et al., 2005, Lee and Mazmanian, 2010). Further, the microbiome plays a role in several disorders including autism, anxiety, and depression (Cryan and Dinan, 2012, Bravo et al., 2011). Studies in mice elucidated a few of these roles: improved behavior (Hsiao et al., 2013), reduction in levels of hormones linked to stress (Desbonnet et al., 2010, Bravo et al., 2011), increased cognitive performance (Backhed et al., 2005), and modulation of brain control of emotion and sensation (Tillisch et al., 2013). These studies point out to the gut microbiota being a virtual endocrine organ, manipulating and producing hormones and neurotransmitters that influence the host\'s brain and behavior (Clarke et al., 2014). Key to unlocking the role of the gut microbiome is to understand the interactions with its environment. More than 90% of the body\'s monoamine serotonin is synthesized by gut enterochromaffin cells (Berger et al., 2009). However, the molecular mechanism that dictates the levels of serotonin produced and its metabolism is not fully elucidated. This is of utmost importance given that gut-derived serotonin is responsible for regulation of functions such as bone development, immune responses, gut motility, and platelet aggregation (Berger et al., 2009). Perhaps more interesting is the role that dysregulation of serotonin plays in the pathogenesis of certain intestinal diseases such as irritable bowel syndrome (IBS). IBS has been shown to have a microbial etiology (Knights et al., 2013, Jeffery et al., 2012) and as such, the link between the microbiome and serotonin is of interest. Two hypotheses have been formulated regarding the microbiome\'s contribution to serotonin levels in the host. The first relates to the fact that some species of bacteria, such as Escherichia coli and Streptococcus species, are capable of de novo serotonin synthesis (Lyte, 2013). The second hypothesis states that the microbiome influences the biosynthesis of serotonin by the host (Yano et al., 2015). Indigenous gut bacteria are able to regulate peripheral host serotonin biosynthesis by interactions with the intestinal enterochromaffin cells (Yano et al., 2015). Further, the microbiota plays a role in the regulation of central nervous system serotonergic neurotransmission profiles in a sex-dependent manner (Clarke et al., 2013). It has been also demonstrated that germ free mice synthesize lower levels of serotonin and its metabolites (Marcobal et al., 2013), indicating that the microbiome is an important factor for the synthesis of serotonin.