Double balloon endoscopy in two hundred fifty cases for the diagnosis and treatment of small intestinal disorders.

Double balloon endoscopy is based on a new insertion mode in which two balloons at the distal ends of both an endoscope and an overtube are operated in combination. We have performed 419 enteroscopic examinations in 250 patients using the Fujinon double balloon endoscopy system between September 2000 and October 2005. Total enteroscopy was successfully achieved by the combination of both oral and anal approaches in 55 out of 71 cases in whom total enteroscopy was intended. Of 250 patients, ulcerative and/or erosive lesions were found in 49 cases and tumors/polyps were found in 49 cases. We also found 26 cases of vascular lesion, including angiodysplasia. Endoscopic treatments, including hemostasis using either clipping devices or electro coagulation, polypectomy, endoscopic mucosal resection, balloon dilation, and stent placement was successfully carried out. Double balloon enteroscopy is both feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders.

Endoscopic submucosal dissection using sodium hyaluronate, a new technique for en bloc resection of a large superficial tumor in the colon.

En bloc resection of superficial tumors in the colon is challenging but beneficial for the precise diagnosis and treatment. We have been using a novel technique of endoscopic submucosal dissection with a viscous substance, sodium hyaluronate, and a needle knife in combination with a small-caliber-tip transparent hood and succeeded in the endoscopic en bloc resection of large superficial tumors in the colon. We endoscopically treated superficial tumors larger than 20mm in diameter of the colon in 166 patients between June 1998 and March 2005. All the lesions were successfully resected endoscopically and en bloc resection was achieved in 77% of them. Even large superficial tumors in the colon can be resected in one piece by using this technique.

Comparison of hemostatic effects by route of H2 receptor antagonist administration following endoscopic mucosal resection in patients with neoplastic gastric lesions.

BACKGROUND: To date, there has not been an in-depth investigation to identify differences in the effects of bleeding prevention among different routes of administration of H2 receptor antagonists to treat gastric ulcers following endoscopic mucosal resection (EMR). AIM: To prospectively compare the frequency of bleeding following EMR between patients treated with intravenous (IV) famotidine and those with oral famotidine. METHODS: Fifty-three patients with neoplastic gastric lesions (33 carcinoma and 20 adenoma) treated by EMR were included. Subjects underwent EMR with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate (EMRSH), followed by IV or oral (PO) administration of famotidine at a dosage of 40 mg/day for 2 days. Patients with odd ID numbers were assigned to IV therapy (30 cases) while even numbers were given PO therapy (23 cases). Frequencies and endoscopic findings of bleeding during the first 2 days after EMR were examined. RESULTS: Frequency of bleeding within 2 days after EMR was 3 and 4% in IV and PO patients, respectively, showing no significant difference. No significant difference was seen in the endoscopic findings of bleeding and therapy, either, with respective IV and PO findings at 23 and 26%. CONCLUSIONS: No significant difference was observed in frequency of bleeding within 2 days after gastric EMR between IV and oral administrations of famotidine.

A case of inflammatory fibroid polyp causing small-bowel intussusception in which retrograde double-balloon enteroscopy was useful for the preoperative diagnosis.

We showed a newly developed method, retrograde double-balloon enteroscopy, to be useful for preoperative diagnosis in a case of inflammatory fibroid polyp accompanied by small-bowel intussusception. A 64-year-old woman was admitted to our hospital with small-bowel intussusception. Results of radiographic and ultrasonographic examination were suggestive of a small-bowel mass. Retrograde double-balloon enteroscopy was performed in an attempt to make a preoperative diagnosis. Endoscopic observation, in combination with histological findings derived from endoscopic biopsy, was suggestive of an inflammatory fibroid polyp. The patient then underwent laparotomy with minimal incision, which revealed a polypoid mass leading to a jejunojejunal intussusception, without bowel necrosis, and a partial small-bowel resection was performed. The pathological diagnosis was an inflammatory fibroid polyp.

Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood.

En-bloc resection is desirable for accurate histopathological assessment of tissue specimens obtained using endoscopic mucosal resection (EMR). A new EMR method using sodium hyaluronate and a small-caliber-tip transparent hood has been developed. This is a peeling-off method using a needle-knife for mucosal and submucosal incisions. Long-lasting submucosal thickening resulting from an injection of sodium hyaluronate, and good visualization of the submucosal tissue with the aid of a small-caliber-tip transparent hood, make the cutting procedures easy and safe. A large superficial gastric cancer and a large villous tumor of the sigmoid colon were endoscopically resected using this method. En-bloc endoscopic resection was successful in both patients. The gastric lesion was an well-differentiated intramucosal adenocarcinoma, completely resected in a specimen measuring 97 x 50 mm. The colonic lesion was an intramucosal well-differentiated adenocarcinoma in adenoma, completely resected in a specimen measuring 70 x 55 mm in diameter. No significant complications were noted in either patient. The new method of EMR using sodium hyaluronate and the small-caliber-tip transparent hood is a promising method for endoscopic en-bloc resection of large superficial neoplastic lesions, both in the stomach and the colon.

Medical evaluation of persons with mental retardation referred for psychiatric assessment.

Many people with developmental disabilities and "challenging behaviors" present to primary care physicians, internists, or general psychiatrists for assessment and treatment. These clinicians seek to provide the comprehensive biopsychosocial assessment necessary for successful treatment, but may encounter interference from funding agencies. Epidemiologic data on medical comorbidity in persons with developmental disabilities with a primarily "behavioral" presentation may assist in facilitating these assessments. A total of 1135 people with mental retardation referred for mental health assessment were medically evaluated according to a two-step protocol which included a screening evaluation of all persons and expanded testing, depending on clinical status. The workup was considered complete when the person with either improving clinically or had a specific terminal diagnosis and was as comfortable as possible. Medical comorbidity was about double that of people referred for mental health assessment who do not have mental retardation. Common conditions presented in unusual ways, and less frequent conditions presented more often. The cost of the medical assessments was promptly recovered in a variety of savings to systems. Comprehensive medical assessment discloses increased medical comorbidity in persons with mental retardation referred for psychiatric evaluation. Comprehensive treatment based on the assessment findings appears to be associated with better clinical outcomes and cost savings to systems.

Clinically safe dosage of felypressin for patients with essential hypertension.

Hemodynamic changes were evaluated in patients with essential hypertension when felypressin of various concentrations was administered. The parameters studied were systolic pressure, diastolic pressure, heart rate, left ventricular systolic phase, and endocardial viability ratio. Results showed that blood pressure tended to increase, and the value of 1/pre-ejection period2 (PEP2) tended to decrease, upon administration of 3 ml of 2% propitocaine containing 0.06 international units/ml (IU/ml) of felypressin. Significant increase of blood pressure and decrease in 1/PEP2 was noted upon administration of 3 ml of anesthetic solution containing 0.13 IU/ml of felypressin. No ischemic change of the myocardium was detected even with the highest felypressin concentration (3 ml of 2% propitocaine containing 0.25 IU/ml of felypressin). These results suggest that the clinically safe dosage of felypressin for patients with essential hypertension is approximately 0.18 IU. This amount is equivalent to 6 ml of 3% propitocaine with 0.03 IU/ml of felypressin, which is a commercially available local anesthetic for dental use. It seems that the decrease in 1/PEP2 that occurred during blood pressure increase was due to the increase in afterload caused by contraction of the arterioles. Although in the present study no ischemic change was noted, special care should be taken to prevent myocardial ischemia in patients with severe hypertension.

[Percutaneous absorption of drug from alpha-olefin oligomer gel bases].

The percutaneous absorption of drug from the alpha-olefin oligomer (alpha-OL) gel base prepared by using palmitate of dextrin (Rheopearl KL) as a gelling agent was investigated by using the abdominal skin of rats in vivo. The 20, 30, 40 and 50 alpha-OLs with average molecular weights of 288, 380, 440 and 535, respectively were used in this study. The flurbiprofen (FP) was selected as a model drug. The percutaneous absorption of FP from the alpha-OL gel base was observed to be influenced by the molecular weight of alpha-OL. The percutaneous absorption profiles of FP from 40 and 50 alpha-OLs gel bases were almost the same. On the other hand, the absorption of FP from 30 alpha-OL gel base was significantly higher than those of 40 and 50 alpha-OLs gel bases. Furthermore, the percutaneous absorption of FP from 20 alpha-OL gel base was observed to be the highest in the test gel bases. In order to establish the reason for the differences in the percutaneous absorption of FP from 20, 30, 40 and 50 alpha-OLs gel bases, the apparent partition ratios of FP between water and four different alpha-OLs were determined as a parameter of the affinity of FP for the vehicle. Consequently, it has become apparent that the partition ratio exerts an influence on the percutaneous absorption of FP from the alpha-OL gel bases.

Assay of glycosidase by lectin affinity high-performance liquid chromatography.

Human transferrin was incubated with sialidase and beta-galactosidase and then examined by lectin affinity high-performance liquid chromatography (HPLC). The elution patterns were changed according to the period of incubation and the amount of enzyme. This method of studying lectin affinity HPLC using human transferrin as a substrate makes possible the rapid and important detection of glycosidase activity.

The influence of renal sympathetic nerves on renal hemodynamic and renin responses during hypercapnia in dogs.

Studies were conducted in anesthetized dogs to examine the influence of the renal sympathetic nerves on renal hemodynamic and renin responses during controlled hypercapnia. The dogs were subjected to unilateral denervation and tested for their responses to hypercapnia induced by inhalation of 15% CO2 in air. Simultaneous measurements of the responses from both the denervated and innervated kidneys allowed an assessment of the influence of the renal nerves on the responses during acute hypercapnia. The data indicate that reductions in renal blood flow and glomerular filtration rate and increases in renin of the renal vein during respiratory acidosis are dependent, in part, on the presence of intact renal nerves. Other factors, however, are probably also present.

Intestinal absorption of several beta-lactam antibiotics. V. Effect of amino beta-lactam analogues and dipeptides on the absorption of amino beta-lactam antibiotics.

The absorption mechanism of amino beta-lactam antibiotics was investigated by using the whole small intestine of a rat. Mutual inhibition among amino beta-lactam analogues and the effects of dipeptides were studied. The influences of glycylglycine on the absorption of cephradine at the four different parts of intestine were also studied. Similarly to the case of cephalexin and cephradine, the absorption of amoxicillin was significantly inhibited by cyclacillin, cephradine, and cephalexin, but the absorption of ampicillin was not reduced by all tested antibiotics. In the experiments using dipeptides (6.0 mM), the absorption of cyclacillin was reduced significantly by glycylglycine, not by L-carnosine. And cephalexin absorption was influenced by L-carnosine (6.0, 10 mM), not by glycylglycine (6 mM). On the contrary, the absorption of cephradine was not reduced at all by these dipeptides. And from the experiment using the four different parts of intestine, it was shown that the transport interaction of glycylglycine with cephradine was observed in only one segment (the upper part of jejunum). These result suggest that the carrier-mediated transport system correlated to dipeptides participates only to a small degree in the common absorption mechanisms of these amino beta-lactam antibiotics.

[The changes on plasma aldosterone concentration during acute respiratory acidosis in dogs. The relationship to renin-angiotensin system and electrolyte metabolism (author's transl)].

It is well known that the alternations on humoral homeostasis such as a decrease of pH, an elevation of PaCO2 and changes of electrolytes have been detected during respiratory acidosis. The author is of the opinion that the renin-angiotensin-aldosterone system might be related to these changes during respiratory acidosis. Recently, Fujii and Morita have reported that an increase in plasma renin activity appeared during acute respiratory acidosis. These reports prompted me to question whether the renin-angiotensin-aldosterone system was related to the pathophysiological evidence concerning the respiratory acidosis. It is generally accepted that plasma aldosterone concentration is controlled by (1) the renin-angiotensin system, (2) ACTH and (3) serum potassium. Therefore, the purpose of this experiment was to investigate the roles of the renin-angiotensin system and electrolyte metabolism on plasma aldosterone concentration during acute respiratory acidosis. I initiated acute respiratory acidosis with 10% CO2 inhalation in healthy mongrel dogs, and then plasma aldosterone concentration, plasma renin activity, electrolytes and cardiorenal hemodynamics were measured. The results were as follows: 1. The increase of plasma aldosterone concentration was delayed and blurred, in contrast with a significant increase of plasma renin activity, during the acute respiratory acidosis, due to delayed time course of angiotensin II stimulation and also the expected changes in the concentration of angiotensin II receptors on the zona glomerulosa in the adrenal cortex. 2. There was a possibility that the increase in the reabsorption of sodium and water in the proximal tubules, and the increase of ADH secretion during the acute respiratory acidosis, could be related to a decrease in excreted sodium and potassium as well as urine volume. These results suggest that the changes of plasma aldosterone concentration may be affected partially by renin-angiotensin system but not by serum potassium, and plasma aldosterone should be a minimal determinant on the electrolyte metabolism during respiratory acidosis with 10% CO2 inhalation.

Phagocytic function in Down syndrome--II. Bactericidal activity and phagocytosis.

Bactericidal capacity was investigated to delineate the impairment of phagocytic function. Fourteen individuals with Down syndrome and fifteen matched institutionalised controls were studied. A non-matched comparison normal group was also evaluated, representing a non-institutionalised young adult population. Neutrophil bactericidal capacity was impaired in institutionalised subjects, the defect being most apparent in Down syndrome. Monocyte bactericidal capacity was identical in institutionalised and non-institutionalised subjects. Humoral functions revealed no differences. Neutrophil phagocytosis was diminished in institutionalised individuals, Down syndrome subjects being the least effective. Monocytes had normal phagocytosis, but opsonisation was defective in both the Down syndrome and matched institutionalised groups. Neutrophils were more efficient at phagocytosis than monocytes. No physiologically significant differences were noted in neutrophil or monocyte intracellular killing.