Satisfaction with bispectral index monitoring of propofol-mediated sedation during endoscopic submucosal dissection: a prospective, randomized study.

BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is one of the most complex and lengthy endoscopic procedures, so deep sedation during ESD is indispensable. Our study aims were to determine whether bispectral index (BIS) monitoring is useful in titrating and reducing the dose of the sedative propofol during ESD, and to measure the satisfaction of patients and endoscopists involved in this complex and lengthy endoscopic therapy. PATIENTS AND METHODS: We performed a prospective, randomized clinical trial from July 2006 to February 2008. A total of 156 patients, with gastric neoplasm to be treated using ESD, were randomized to two groups. The BIS group (n = 78) was monitored for propofol sedation using BIS, and the no-BIS group (n = 78) was monitored by standard methods only. The two groups were compared by evaluating the doses of propofol administered to patients and the satisfaction scores (scale of 0 - 10) of patients and endoscopists. RESULTS: Although there were no significant differences between the two groups in the mean dose of propofol used (BIS group vs. no-BIS group, 5.32 mg/kg/hour vs. 4.85 mg/kg/hour; P = 0.10), the satisfaction scores of the patients (9.15 vs. 7.94; P < 0.01) and endoscopists (8.53 vs. 6.42; P < 0.001) were significantly higher with BIS monitoring. CONCLUSIONS: Monitoring with BIS during the ESD procedure did not lead to a reduction in the dose of propofol required, but did lead to higher satisfaction scores from the patients and endoscopists. A complicated and prolonged endoscopic treatment such as ESD can be carried out with optimal safety, control, and comfort by using BIS to monitor propofol sedation.

Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success.

BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is a new method for the curative treatment of early gastrointestinal neoplasms, which was developed in order to increase the en bloc and R0 resection rate, especially for lesions larger than 20 mm in diameter. Drawbacks of ESD include the fact that it is technically a substantially more difficult procedure and that it is associated with a higher perforation rate. A retrospective study was therefore carried out to analyze cases in relation to the procedure time and resection success, and these factors were correlated with the characteristics of the lesions. PATIENTS AND METHODS: From January 2002 to November 2005, 196 lesions in 185 patients with early gastric cancer were treated using ESD in our hospital. The rates of curative en bloc resection, the incidence of perforation, and the procedure times were analyzed in relation to lesion size (small, 20 mm or less in diameter; large, over 20 mm), location (upper, middle, or lower third of the stomach) and the presence or absence of ulceration. RESULTS: The rate of curative en bloc resection was 84 % (93 % of the lesions overall were resected in one piece), with a perforation rate of 6.1 % (all perforations were managed endoscopically) and a mean procedure time of 68 min. The rate of curative en bloc resection differed significantly depending on the location of the lesion (upper vs. middle vs. lower, 74 % vs. 77 % vs. 91 %; P < 0.05), as well as on the size of the lesion (> 20 mm vs. 20 mm or less, 59 % vs. 89 %; P < 0.0001). There were also significant differences in the mean procedure times in relation to the location of the lesion (upper vs. middle vs. lower, 105 min vs. 81 min vs. 45 min; P < 0.0001) and the size of the lesion (> 20 mm vs. 20 mm or less, 124 min vs. 55 min; P < 0.0001), as well as the presence of ulceration (positive vs. negative, 97 min vs. 65 min; P < 0.05). With regard to perforation rates, significant differences were also observed in relation to the location of the lesion (upper vs. middle vs. lower, 22.6 % vs. 2.8 % vs. 3.2 %; P < 0.0005) and size of the lesion (> 20 mm vs. 20 mm or less, 16.2 % vs. 3.8 %; P < 0.005). No local recurrences of curatively resected lesions (n = 119) were observed after a follow-up period of 1 year. CONCLUSIONS: The difficulty of ESD depends on the location and size of the lesion, as well as on the presence of ulceration. We would recommend that trainees should begin by carrying out ESD on lesions with a diameter of less than 20 mm without ulceration that are located in the lower third of the stomach.

A proton-pump inhibitor, rabeprazole, improves ventilatory function in patients with asthma associated with gastroesophageal reflux.

BACKGROUND: Treatment of gastroesophageal reflux (GER) with proton-pump inhibitors (PPI) improves symptoms of asthma in some patients. However, the effects of a PPI on ventilatory function are still controversial. In this study, we measured ventilatory function in asthma patients treated with a PPI in order to identify those in whom a therapeutic effect on asthma can be expected from the acid suppression. METHODS: From a cohort of 114 consecutive patients with bronchial asthma, 53 patients agreed to participate in the study and were treated with rabeprazole 20mg daily for 8 weeks during an asymptomatic, stable period with no exacerbations of their asthma. Of the 53 patients, 22 were diagnosed as GER on the basis of the QUEST questionnaire and endoscopic examination. The patients were monitored for improvement in ventilatory function. RESULTS: Four patients dropped out because of adverse drug reactions. All the patients with GER noted an improvement in reflux symptoms with PPI treatment. An improvement of more than 20% in peak expiratory flow (PEF) was observed in 8 of 21 GER patients but in none of the non-GER patients. Factors predictive of improvement in PEF with rabeprazole therapy were the QUEST score (odds ratio: 1.47, 95% CI: 1.06-2.04, P = 0.022) and steroid-dependency of asthma (odds ratio: 0.01, 95% CI: 0.001-0.31, P = 0.008). CONCLUSIONS: Treatment with rabeprazole is expected to ameliorate asthma in non-steroid-dependent patients who have symptomatic GER defined by the QUEST score.

XAFS study on metal endohedral fullerenes.

Structure of metal endohedral fullerenes is studied by XAFS and XANES. The Sc-Sc distance of 2.23(1) A determined from Sc K-edge XAFS supports the formation of a triangular Sc3 cluster in Sc3@C82 as is found by MEM analysis for the X-ray diffraction. Gd L(III)-edge XAFS of Gd@C82 shows that the first and the second neigboring Gd-C distances are 2.51(2) and 2.85(4) A, respectively. The La-La distance of La2@C80 has been determined to be 3.90(1) A at 40 K. This value does not change when increasing temperature [3.90(2) A at 240 K]. The position and the valenece of the Eu atom in Eu@C60 are also discussed based on Eu L(III)-edge XAFS and XANES.

XAFS study on a pressure-induced superconductor Cs3C60 under high pressure.

Cs K-edge XAFS of Cs3C60 which is a pressure-induced superconductor were measured at 21 and 34 kbar by using a diamond anvil cell (DAC) in order to obtain the structural information under high pressure, and to clarify the origin of the pressure-induced superconductivity. The distances and the mean square displacements between the Cs and C atoms are consistent with those determined by X-ray powder diffraction. Consequently, the high-pressure XAFS can give the reliable structural-information on a fullerene superconductor under high pressure. We also show the procedure of the analysis of high-pressure XAFS with DAC in detail.

ATP release and contraction mediated by different P2-receptor subtypes in guinea-pig ileal smooth muscle.

1. The present study was addressed to clarify the subtypes of P2-purinoceptor involved in ATP release and contraction evoked by alpha, beta-methylene ATP (alpha, beta-mATP) and other P2-agonists in guinea-pig ileum. 2. alpha, beta-mATP 100 microM produced a transient and steep contraction followed by ATP release from tissue segments. These maximum responses appeared with different time-courses and their ED50 values were 5 and 25 microM, respectively. The maximum release of ATP by alpha, beta-mATP was markedly reduced by 250 microM suramin, 30 microM pyridoxal-phosphate-6-azophenyl-2',5'-disulphonic acid (PPADS) and 30 microM reactive blue 2 (RB-2), P2-receptor antagonists. However, the contractile response was inhibited by suramin, tetrodotoxin and atropine, but not by PPADS and RB-2. 3. Although the contraction caused by alpha, beta-mATP was strongly diminished by Ca(2+)-removal and nifedipine, and also by tetrodotoxin and atropine at 0.3 microM, the release of ATP was virtually unaffected by these procedures. 4. UTP, beta, gamma-methylene ATP (beta, gamma-mATP) and ADP at 100 microM elicited a moderate release of ATP. The release caused by UTP was virtually unaffected by RB-2. However, these P2-agonists failed to elicit a contraction of the segment. 5. The potency order of all the agonists tested for the release of ATP was alpha, beta-mATP > UTP > beta, gamma-mATP > ADP. 6. In superfusion experiments with cultured smooth muscle cells from the ileum, alpha, beta-mATP (100 microM) enhanced the release of ATP 5 fold above the basal value. This evoked release was inhibited by RB-2. 7. These findings suggest that ATP release and contraction induced by P2-agonists such as alpha, beta-mATP in the guinea-pig ileum result mainly from stimulation of different P2-purinoceptors. P2Y-like purinoceptors on the smooth muscles and, probably, P2X-purinoceptors on cholinergic nerve terminals, respectively. However, the ATP release may also be mediated, in part, by P2U-receptors, because UTP caused RB-2-insensitive ATP release.

Endoscopical segmental piecemeal tumorectomy for nodular elevation of colorectal tumor: applicability and patient's quality of life.

Endoscopical segmental piecemeal tumorectomy (ESPT) for nodular elevation of colorectal tumor is advantageous in terms of minimizing both surgical invasion and postoperative burden to the patients. Nodular elevation of colorectal tumors is said to occur when the body of the tumor is adenomatous and the surface of the focal cancer grows more horizontally into the lumen than vertically. We report here four cases of nodular elevation of colorectal tumors which were each treated by different surgical procedures.

[A case of splenial astrocytoma with various neuropsychological symptoms].

A case with splenial astrocytoma that showed various neuropsychological symptoms after disappearance of tumor due to chemo- and radiation therapies. A 40-year-old right-handed truck driver visited the Neurosurgical Clinic with complaints of memory disturbance and loosing his way during truck driving. Under diagnosis of protoplasmic astrocytoma chemotherapy and radiation treatments were carried out. These treatments were satisfactorily effective, but the patient showed marked memory deficits and personality change. He was hospitalized, therefore, into the Neuropsychiatric Clinic 20 months after the above mentioned treatments. Aside personality changes such as lack of inhibition and shameless acts, the patient showed interhemispheric disconnection symptoms (dyslexia in the left visual hemifield), memory deficits, and visual perceptual disturbances. His memory deficits consisted of anterograde and retrograde amnesia and disorientation of time and place, indicating that he had typical amnesic syndrome. In other words he had so-called retrosplenial amnesia. His visual perceptual deficits were impaired performance on many tasks already described as tests of visual perception.

Hepatitis C virus antibody titration in patients with chronic hepatitis C, before and after interferon treatment.

We measured hepatitis C virus antibody titers in 13 patients with chronic hepatitis C to determine whether titration of hepatitis C virus antibody was useful or not, to predict and evaluate the efficacy of interferon (IFN) treatment. During administration of IFN, hepatitis C virus titers declined in all patients. Antibody titers performed before treatment as well as just at the end of treatment did not correlate with change of the alanine aminotransferase levels during administration of IFN. Antibody titers declined continuously after treatment in 5 patients with normal alanine amino-transferase levels for over 6 months after discontinuation of IFN. Antibody titers rose again in 6 patients whose alanine aminotransferase levels fluctuated after treatment. An exceptional pattern of change occurred in 2 patients whose antibody titers declined continuously although their alanine aminotransferase levels fluctuated after treatment. Repeated titration of hepatitis C virus antibody appears to be useful for evaluating the long-term efficacy of IFN treatment.

Hepatitis type C virus infection in patients with type B chronic liver disease.

Anti-c100-3 (Ortho) was determined in the sera of 152 patients with HBs antigen-positive chronic liver diseases to assess coinfection of hepatitis B virus (HBV) and hepatitis C virus (HCV). Eleven patients (7.2%) were positive for anti-c100-3. Anti-CP-9 (Okamoto) and HCV-RNA (RT-PCR) were also examined in these 11 patients. Anti-CP-9 was detected in 7 patients and HCV-RNA was detected in all 11 patients. Four of the 11 anti-c100-3-positive patients were positive for HBe antigen (HBeAg) and others were negative. In 8 of the 11 patients, HCV was suspected to be superinfected by blood transfusion. In HBeAg-positive patients, serum glutamic pyruvic transaminase (SGPT) was elevated in relation to active replication of HBV shown by DNA-polymerase activity. The histological findings showed chronic active hepatitis, with or without cirrhosis. On the other hand, in HBeAg-negative patients, SGPT fluctuated without evidence of active replication of HBV. Active inflammation in the liver was observed in 3 of 5 HBeAg-negative patients by liver biopsy. These findings suggest that HBV might play an important role in chronic active inflammation in HBeAg-positive patients coinfected with HCV, and that HCV might be responsible for continuous inflammation in HBeAg-negative patients coinfected with HCV.

Four cases with intrafamilial clustering of hepatitis C virus infection.

Four hepatitis C patients with intrafamilial clustering of hepatitis C virus (HCV) infection are reported. Antibodies to C100-3 antigen, capsid protein of HCV and GOR epitope were tested to detect histories of HCV infection. Transmission of HCV from mother to children, from father to children, and from wife to husband was implicated. Of all family members studied, three were positive for all antibodies, one for only antibody to capsid protein, two for antibodies to capsid protein and GOR epitope but negative for antibody to C100-3 antigen and one vice versa.

Immunoelectron microscopic observation of intrahepatic HBeAg in patients with chronic hepatitis B.

Immune light and electron microscopic studies using monoclonal antibodies have been applied to localize HBeAg in liver biopsy specimens of 19 patients with chronic hepatitis B. Under the light microscope, HBeAg was demonstrated in nuclei, cytoplasm and on the cell surface of hepatocytes. The number of HBeAg-positive hepatocytes correlated well with the serum levels of HBeAg (enzyme immunoassay) and DNA-polymerase. Of 11 patients in whom high numbers of HBeAg-positive hepatocytes were found at the light microscopic level, HBeAg was also studied in hepatocytes at the electron microscopic level. The HBeAg in nuclei was either found as aggregates or dispersed diffusely. In the aggregates of HBeAg, the 27-nm core particles were frequently found. In addition, the antigen was found in the cytosol of some hepatocytes as amorphous mass and in some hepatocytes in the cisternae of perinuclear space, endoplasmic reticulum and Golgi saccules. Occasionally the antigen was found on the membranes of the cell organelles and on the plasma membranes that faced the intercellular and the Disse spaces. These findings suggest that cytoplasmic HBeAg in hepatocytes may be ultrastructurally classified into two different patterns by its distribution, mainly in endoplasmic reticulum or in cytosol. The ratio varied between hepatocytes with these two types of patterns. The titer of serum HBeAg tended to be higher when the corresponding liver biopsy specimens contained more hepatocytes with HBeAg in endoplasmic reticulum than those with HBeAg in the cytosol.

Cellular immune response in liver of patients with chronic hepatitis B. Electron microscopic observation of lymphocyte subsets by the immunoperoxidase method using monoclonal antibodies.

The morphological association between lymphocytes and hepatocytes was studied at the light and electron microscopic levels by the peroxidase-labeled antibody method using mouse monoclonal antibodies against Leu-1, Leu-2a, Leu-3a, Leu-7 and Leu-10 antigens in liver biopsy specimens from patients with chronic hepatitis B. Leu-1 + cells (T cells), especially Leu-2a + cells (cytotoxic/suppressor T cells), infiltrated mostly in periportal areas with piecemeal necrosis and in parenchymal areas with focal necrosis. By double staining techniques, Leu-2a + cells were often seen in contact with hepatocytes containing membranous hepatitis B surface and/or core antigens in patients with chronic active hepatitis. At the ultrastructural level, Leu-2a + cells frequently occupied the sinusoid and also migrated into both the space of Disse and between hepatocytes. Furthermore, they often showed intimate surface-contact with hepatocytes having hepatitis B surface and/or core antigens, and, occasionally, injured hepatocytes were surrounded by several Leu-2a + cells. In contrast, Leu-3a + cells, Leu-7 + cells and Leu-10 + cells sometimes appeared in the sinusoid, but seldom in the space of Disse and between hepatocytes. These findings suggest that cytotoxic T lymphocytes may be associated with the necrosis of hepatocytes in chronic hepatitis B.