A Two Centre Observational Study of Simultaneous Pulse Oximetry and Arterial Oxygen Saturation Recordings in Intensive Care Unit Patients

The influence of variables that might affect the accuracy of pulse oximetry (SpO2) recordings in critically ill patients is not well established. We sought to describe the relationship between paired SpO2/SaO2 (oxygen saturation via arterial blood gas analysis) in adult intensive care unit (ICU) patients and to describe the diagnostic performance of SpO2 in detecting low SaO2 and PaO2. A paired SpO2/SaO2 measurement was obtained from 404 adults in ICU. Measurements were used to calculate bias, precision, and limits of agreement. Associations between bias and variables including vasopressor and inotrope use, capillary refill time, hand temperature, pulse pressure, body temperature, oximeter model, and skin colour were estimated. There was no overall statistically significant bias in paired SpO2/SaO2 measurements; observed limits of agreement were +/-4.4%. However, body temperature, oximeter model, and skin colour, were statistically significantly associated with the degree of bias. SpO2 <89% had a sensitivity of 3/7 (42.9%; 95% confidence intervals, CI, 9.9% to 81.6%) and a specificity of 344/384 (89.6%; 95% CI 86.1% to 92.5%) for detecting SaO2 <89%. The absence of statistically significant bias in paired SpO2/SaO2 in adult ICU patients provides support for the use of pulse oximetry to titrate oxygen therapy. However, SpO2 recordings alone should be used cautiously when SaO2 recordings of 4.4% higher or lower than the observed SpO2 would be of concern. A range of variables relevant to the critically ill had little or no effect on bias.

Comparison of electrochemiluminescence immunoassay and latex agglutination turbidimetric immunoassay for evaluation of everolimus blood concentrations in renal transplant patients

WHAT IS KNOWN AND OBJECTIVE

For analysis of blood concentrations of everolimus, many hospital laboratories use either latex agglutination turbidimetric immunoassay (LTIA) or electrochemiluminescence immunoassay (ECLIA). However, no studies have compared both immunoassay methods under the same conditions. Accordingly, in this study, we compared everolimus blood concentrations obtained by LTIA and ECLIA in renal transplant patients.

METHODS

Blood samples (n = 230) from 60 renal transplant patients (19 female and 41 male) were evaluated using both immunoassays. Subsequently, we switched the assay for detection of everolimus blood concentrations from LTIA to ECLIA as a clinical application. Three quality control (QC) samples for LTIA were analysed using ECLIA, and 3 QC samples for ECLIA were analysed using LTIA.

RESULTS

The Deming regression of ECLIA versus LTIA generated the following parameters: slope, 1.0067 and intercept, 1.7489 ng/mL, in the analysis of 230 samples. Bland-Altman analysis showed an average positive bias of 1.73 ng/mL between ECLIA and LTIA. When the clinical apparatus was switched from LTIA to ECLIA, the average everolimus blood concentration assayed by LTIA before switching was 3.57 ng/mL, whereas that by ECLIA after switching in the same patients taking the same daily dose (mean: 1.43 mg/day) was 5.85 ng/mL. The QCs assayed using LTIA were lower by an average of 67.3% (range: 55.8%-79.5%) for ECLIA, and in the same 230 samples from patients, the everolimus blood concentrations assayed by LTIA were lower by an average of 67.4% (range: 37.1%-114.5%) of ECLIA.

WHAT IS NEW AND CONCLUSION

Analysis of everolimus concentrations by immunoassays with high precision and accuracy is required to ensure long-term survival of transplant recipients. Although the concentrations of QCs and calibrators of everolimus in LTIA were previously corrected to 70% concentration because of cross-reactivity with everolimus metabolites, these adjustments may need to be reviewed.

The effect of bolus volume on laryngeal closure and UES opening in swallowing: Kinematic analysis using 320-row area detector CT study

This study investigated the effects of three different volumes of honey-thick liquid on the temporal characteristics of swallowing. Twenty-six healthy subjects (15 males, 11 females) underwent 320-row area detector CT scan while swallowing 3, 10 and 20 mL of honey-thick liquid barium. Three-dimensional images were created at 10 images/s. Kinematic events involving six structures (velopharynx, hyoid bone, epiglottis, laryngeal vestibule (LV), true vocal cords (TVC), upper esophageal sphincter (UES)) and timing of bolus movement were timed using frame by frame analysis. The overall sequence of events did not differ across three volumes; however, increasing bolus volume significantly changed the onset and termination of events. The bolus head reached to pharynx and esophagus earlier and the duration of bolus passing through UES was significantly longer in 10 and 20 mL compared to 3 mL (P < .05). Consequently, the onset of UES opening was significantly earlier with increased volume (P < .05). LV and TVC closure occurred later in 20 mL compared to 3 mL (P < .05). These changes in motion of pharynx and larynx appeared to promote swallow safety by preventing aspiration, suggesting that anatomical structure movements adapt in response to bolus volume. Our findings also suggest that the pharyngeal swallow behaviours may be modified by afferents in the oral cavity. The three-dimensional visualization and quantitative measurements provided by 320-ADCT provide essential benchmarks for understanding swallowing, both normal and abnormal.

Monitoring of methylergometrine in human breast milk by solid-phase extraction and high-performance liquid chromatography with fluorimetric detection

A high-performance liquid chromatographic assay has been developed for the detection and quantification of the conventional postnatal uterotonic drug, methylergometrine, in human breast milk using a C-18 reversed-phase column by isocratic elution. The analytical method consisted of sample clean-up by solid-phase extraction, and the fluorescence detection required only 8.5 min per sample for separation and quantitation. This assay gave intra- and inter-assay coefficients of variation of less than 7.9% and 7.7%, respectively, and the detection limit was approximately 50 pg/ml. This method was applied for drug level monitoring in the breast milk of patients given methylergometrine.

Long-term results of endovascular treatment for splenic artery aneurysms

AIM

The aim of this paper was to evaluate our single-center experience of the management of splenic artery aneurysm (SAA), with particular attention to the long-term results of endovascular treatment.

METHODS

Thirty-eight patients with the diagnosis of SAA at the Tokyo University Hospital during the past 23 years were retrospectively reviewed. Interventions were considered for patients with SAA>2 cm in diameter. Nine patients were treated by transcatheter embolization (TE), and 8 by open surgical repair (SR). Twenty-one patients were observed (OB). TE was performed with microcoils placed distal and proximal to the aneurysm in the afferent artery to isolate the aneurysm.

RESULTS

In the TE group, the primary technical success rate was 100%. No 30-day mortality or any catheter-related complication was observed. The median length of hospital stay after TE, excluding one patient who required further surgery, was shorter than that after SR (8 versus 16 days, P=0.001). During follow-up (median =45 months), no patient died and no recurrence of SAA was observed. In the SR group, all aneurysms were repaired successfully without any severe complication, and no aneurysm-related death occurred during follow-up (median =57 months). In the OB group, no aneurysm rupture or increase in aneurysm size was observed during follow-up (median =35 months).

CONCLUSION

TE provided good early and long-term results, comparable to those obtained with conventional SR. In addition, TE had several advantages associated with its minimal invasiveness. TE by the isolation technique could be the first-line strategy for all SAA requiring treatment.

A simple, sensitive high-performance liquid chromatography -ultraviolet method for the quantification of concentration and steady-state pharmacokinetics of itraconazole and hydroxyitraconazole

Background

A steady-state trough plasma itraconazole concentration greater than 500 ng/mL is a therapeutic target for itraconazole. A simple, rapid and sensitive high-performance liquid chromatography-based method was developed for quantitation of itraconazole and hydroxyitraconazole in human plasma.

Methods

Itraconazole and hydroxyitraconazole were separated using a mobile phase of 0.5% KH2PO4 (pH 6.0)-acetonitrile (30:70, v/v) on a CAPCELLPAK C18 MGII column at a flow rate of 0.5 mL/min and ultraviolet absorbance at 260 nm.

Results

The analysis required 200 μL of plasma and involved a rapid, simple solid-phase extraction with an Oasis HLB cartridge, which resulted in recoveries of 87–92% for itraconazole and 91–94% for hydroxyitraconazole. The lower limit of quantification for itraconazole and hydroxyitraconazole was 5 ng/mL each. Intra- and interday coefficients of variation for itraconazole and hydroxyitraconazole were less than 11.3% and 12.2%, respectively, and accuracies were within 11.7% and 4.5% over the linear range, respectively. Although the steady-state plasma concentrations of itraconazole and hydroxyitraconazole ranged from 506 to 2482 ng/mL and from 766 to 2444 ng/mL, respectively, after a two-day loading dose of 400 mg/day intravenous itraconazole followed by the administration of 200 mg/day itraconazole oral solution, calibration curves of itraconazole and hydroxyitraconazole showed positive linearity in a concentration range of 5–2500 and 50–2500 ng/mL, respectively.

Conclusions

Our results indicate that this method is applicable for the monitoring of plasma levels of itraconazole and hydroxyitraconazole in a clinical setting. Furthermore, the regimen presented here might also be effective in preventing infection, but further studies with large sample sizes are necessary to investigate this avenue.

Current status of the medical expenses for the treatment of arteriosclerosis obliterans in Japan

AIM

We aimed to determine the current status of the medical expenses for the treatment of arteriosclerosis obliterans (ASO) and evaluate the cost effectiveness of the medical practices employed in ASO treatment in Japan.

METHODS

We performed a prospective observational study using 140 ASO patients. The cost of the medical practices comprised the costs of outpatient treatment, pharmacological agents, and hospitalization. To compare the average monthly costs, the patients were divided into preintervention, postintervention, or conservative-therapy groups. To compare the total costs and effectiveness of each treatment, the patients who had first visited our division during the study period were classified into surgery, endovascular-revascularization (EVR), or conservative-therapy groups. The adverse reactions of the 4 most popular agents for ASO were investigated, and bleeding events were assessed specifically.

RESULTS

The average monthly costs for outpatient treatment and pharmacological agents were yen 168,002 in conservative cases, yen 149,871 in preoperation cases, and yen 128,527 in postoperation cases. The mean total costs were yen 5,407,950 in conservative cases, yen 7,375,290 in surgical cases, and yen 2,631,650 in EVR cases. The average change of the gauge in clinical status was 0.57 in conservative cases, 2.13 in surgical cases, and 2.25 in EVR cases. Warfarin induced more bleeding complications than the other agents.

CONCLUSION

The costs of pharmacological agents represented much of the medical costs in any treatment groups.

Intestinal CYP3A4 is not involved in the enantioselective disposition of lansoprazole

The contribution of (S)-lansoprazole to CYP3A4-catalysed sulfoxidation is greater than that of (R)-lansoprazole. The aim was to investigate the effect of grapefruit juice on the enantioselective disposition of lansoprazole among three CYP2C19 genotype groups. Eighteen healthy subjects, consisting of six each of homozygous extensive metabolizers (homEMs), heterozygous extensive metabolizers (hetEMs) and poor metabolizers (PMs), ingested a single oral dose of 60 mg racemic lansoprazole after taking either 200 ml grapefruit juice or water. There was no effect of grapefruit juice on the mean maximum plasma concentrations (C(max)) or the elimination half-life for each lansoprazole enantiomer in all three CYP2C19 genotype groups. Similarly, the pharmacokinetic parameters of lansoprazole sulfone remained unaltered by grapefruit juice in all three groups. The CYP3A4-mediated first-pass sulfoxidation of (R)- and (S)-lansoprazole were not influenced by grapefruit juice. In addition, stereoselectivity of the intestinal CYP3A4-catalysed sulfoxidation of (R)- and (S)-lansoprazole was not observed.

Comparison of enantioselective disposition of rabeprazole versus lansoprazole in renal-transplant recipients who are CYP2C19 extensive metabolizers

The purpose of this study was to investigate the comparative pharmacokinetics of rabeprazole and lansoprazole enantiomers in renal-transplant recipients on tacrolimus who were CYP2C19 extensive metabolizers. Sixteen Japanese patients were randomly assigned after renal transplantation to receive repeated doses of one of the following two regimens for 28 days; tacrolimus, mycophenolate mofetil and prednisolone together with either 20mg of racemic rabeprazole (n=8) or 30 mg of racemic lansoprazole (n=8). The mean Cmax and AUC0-24 of (R)-lansoprazole compared to (S)-lansoprazole in renal transplant recipients were 12-fold (954+/-522 vs. 167+/-137 ngml(-1), respectively) and 6.9-fold (4787+/-3454 vs. 451+/-354 nghml(-1), respectively) greater, and its elimination half-life was 2.1-fold (2.3+/-1.0 vs. 1.2+/-0.6h, respectively) longer. In contrast, although the elimination half-life of (R)-rabeprazole was significantly longer than that of the (S)-enantiomer (2.1+/-0.5 vs. 1.3+/-0.9h, respectively; P<0.05), there was no difference in Cmax between the (R)- and (S)-enantiomer (186+/-40 vs. 200+/-92 ngml(-1), respectively). In conclusion, in renal-transplant recipients who are CYP2C19 extensive metabolizers, there is less stereoselective difference in the pharmacokinetic disposition between the (R)- and (S)-enantiomers of rabeprazole than those of lansoprazole.

Influence of ABCB1 C3435T polymorphism on the pharmacokinetics of lansoprazole and gastroesophageal symptoms in Japanese renal transplant recipients classified as CYP2C19 extensive

OBJECTIVE

Lansoprazole and tacrolimus are substrates of ATP binding cassette (ABC) transporters such as P-glycoprotein (ABCBI/multidrug resistance 1) and cytochrome P450 (CYP). The purpose of this study was to investigate the implication of the ABCB1 C3435Tpolymorphism on the pharmacokinetics of (R)-lansoprazole, the major enantiomer, in CYP2C19 extensive metabolizers (EMs) and on gastroesophageal symptoms in renal transplant recipients receiving tacrolimus.

MATERIALS

24 recipients who were CYP2C19 EMs were studied.

METHODS

Oral administration of 30 mg lansoprazole was started 2 days before transplantation. On Day 2 before and Day 28 after transplantation, the plasma concentrations of (R)-lansoprazole and tacrolimus were measured.

RESULTS

Pretransplantation, there were no significant differences in the pharmacokinetic parameters of (R)-lansoprazole between the 3 ABCBI C3435T genotypes. However, after renal transplantation, the peak plasma concentration (Cma ) and area under the plasma concentration-time curve (AUCO-24) of (R)-lansoprazole in patients with the ABCB1 C3435T C allele significantly increased, but not in patients with the TT genotype. These pharmacokinetic variations in (R)-lansoprazole did not influence the AUC of tacrolimus. There were no significant differences in the frequency of gastroesophageal symptoms among the three ABCB] C3435Tgenotypes.

CONCLUSIONS

(R)-lansoprazole concentrations significantly increased in CYP2C19 extensive metabolizers with the ABCB1 C3435T C allele, but not TT genotype, after renal transplantation. However, the clinical relevance of this observation may be minor because these pharmacogenetic changes were not associated with the occurrence of gastroesophageal complications.

Impact of CYP3A5 and MDR1(ABCB1) C3435T polymorphisms on the pharmacokinetics of tacrolimus in renal transplant recipients

OBJECTIVE

The objective of this study was to assess the influence of CYP3A5 and MDR1 genetic polymorphisms on tacrolimus pharmacokinetics in Japanese renal transplant recipients.

METHOD

The pharmacokinetic parameters of tacrolimus were calculated in steady-state on day 28 after transplantation. Polymerase chain reaction-restriction fragment length polymorphism and direct sequence methods were used for CYP3A5 and MDR1 polymorphisms, respectively.

RESULTS

The dose-adjusted area under the concentration-time curve (AUC0-12) was significantly lower among CYP3A5*1 carriers than those bearing CYP3A5*3/*3. (0.570 +/- 0.105 vs 0.865 +/- 0.343 ng.h/mL per mg/kg, P = .00322). The daily tacrolimus dose per body weight was significantly higher in CYP3A5*1 carriers than those of CYP3A5*3/*3 carriers (0.271 +/- 0.110 vs 0.150 +/- 0.056 mg/kg, P = .00016). In this study, a distinction was made between carriers of CYP3A5*1/*1+*1/*3 and CYP3A5*3/*3 to investigate the influence of the MDR1 C3435T mutation on tacrolimus pharmacokinetics. The MDR1 C3435T polymorphisms did not affect any tacrolimus pharmacokinetic parameter in either group.

CONCLUSIONS

Renal transplant recipients who were CYP3A5*1 carriers required a higher dose of tacrolimus than CYP3A5*3/*3, indicating a significantly lower dose-adjusted AUC0-12 of tacrolimus. In contrast, MDR1 C3435T polymorphism was not an important factor in tacrolimus pharmacokinetics.

Biomagnification of 7Be, 234Th, and 228Ra in marine organisms near the northern Pacific coast of Japan

Enrichment of natural radionuclides of thorium, radium and beryllium in several kinds of marine organisms was investigated near the Pacific coast of Miyagi Pref., Japan. The radioactivity of 7Be, 210Pb, 234Th, 238U, 228Ra and 137Cs was measured using gamma spectrometry. High concentrations of 234Th were observed in ascidian livers (50-400 Bq/kg dry) and excrement (2000-2900 Bq/kg dry), although the parent 238U concentrations were less than 3 Bq/kg dry. Such extreme disequilibrium between 238U and 234Th activity was observed in other organisms (barnacles, mussels and brown algae). Relatively high concentrations of 228Ra were detected in ascidian livers and were observed to decrease according to its half-life (5.75 year), suggesting disequilibrium with its parent 232Th. High concentrations (about 1900-5000 Bq/kg dry) of 7Be were detected in ascidian liver. Possible mechanisms for the observed biomagnification and bioaccumulation of these radionuclides in the organisms analyzed were proposed.

Nomogram for individualizing supplementary iron doses during erythropoietin therapy in haemodialysis patients

AIMS

An adequate iron supplement is crucial not only for prompt erythropoiesis but also for the restoration of tissue iron reserves in haemodialysis patients receiving recombinant human erythropoietin (r-HuEPO). An attempt was made to establish a comprehensive nomogram that allows individualization of intravenous (i.v.) iron doses according to patients' body weights, the initial status of tissue iron reserves and desired increases in haemoglobin levels.

MATERIALS AND METHODS

Clinical and laboratory data retrieved from 95 haemodialysis patients who received r-HuEPO with or without iron supplements for at least 12 weeks were used to construct the nomogram. It was assumed that the administered iron was either incorporated into newly synthesized haemoglobin and tissue iron reserves or eliminated from the body at a constant rate. Tissue iron reserves of the patients were estimated by serum ferritin levels using van Wyck's equation (Kidney Int., 1989, 35, 712). The rate of iron loss in the patients was estimated by the data obtained from 15 of the above patients who exhibited stable haemoglobin levels but decreases in serum ferritin levels with no iron supplements. The validity of the equation was ascertained by comparing the measured serum ferritin levels at the end of r-HuEPO therapy and those predicted by the nomogram. The proposed nomogram was then validated prospectively in 24 haemodialysis patients to determine whether the nomogram-recommended iron doses would increase both haemoglobin and serum ferritin levels within 12 weeks.

RESULTS

The mean (+/-SD) iron loss of haemodialysis patients was calculated to be 10.5 +/- 7.4 mg/week. There was a significant correlation (r=0.77, P < 0.001) between the measured serum ferritin levels, an index of tissue iron reserves, at the end of r-HuEPO therapy and those predicted by the equations used for formulating the nomogram. The prospective study indicated that the nomogram-recommended supplementary iron doses attained haemoglobin and serum ferritin levels of > 95 g/L and >100 microg/L in 79 and 50% of the patients, respectively, within 12 weeks.

CONCLUSION

The present nomogram may be useful for individualizing supplementary i.v. iron doses for haemodialysis patients undergoing r-HuEPO therapy.

Efficacy of triple therapy with rabeprazole for Helicobacter pylori infection and CYP2C19 genetic polymorphism

BACKGROUND

Rabeprazole is a new, potent, proton pump inhibitor. The metabolism of rabeprazole is less dependent on CYP2C19 genetic polymorphism.

METHODS

A total of 102 Helicobacter pylori-positive patients with gastric ulcer were randomly allocated to three groups: rabeprazole 10 mg (RAC10), rabeprazole 20 mg (RAC20) or rabeprazole 40 mg (RAC40) plus amoxicillin 750 mg and clarithromycin 200 mg twice daily for 7 days. CYP2C19 genotype was determined by the polymerase chain reaction-restriction fragment length polymorphism method.

RESULTS

All-patients-treated-based eradication rates in patients treated with RAC10, RAC20 and RAC40 were 83%, 77% and 90%, respectively, and per protocol-based eradication rates were 83%, 80% and 90%, respectively. The eradication rates in the three groups were not significantly different. There was also no significant difference between the all-patients-treated-based eradication rate in CYP2C19 extensive metabolizers and that in poor metabolizers (86% vs. 77%). Adverse events were 12% in extensive metabolizers and 23% in poor metabolizers, and the difference in these incidence rates was also not statistically significant.

CONCLUSIONS

Triple therapy with 10 mg of rabeprazole combined with amoxicillin/clarithromycin is effective for Japanese patients with H. pylori infection, and the H. pylori eradication rate is not affected by CYP2C19 genetic polymorphism.

Molecular basis of ocular abnormalities associated with proximal renal tubular acidosis

Proximal renal tubular acidosis associated with ocular abnormalities such as band keratopathy, glaucoma, and cataracts is caused by mutations in the Na(+)-HCO(3)(-) cotransporter (NBC-1). However, the mechanism by which NBC-1 inactivation leads to such ocular abnormalities remains to be elucidated. By immunological analysis of human and rat eyes, we demonstrate that both kidney type (kNBC-1) and pancreatic type (pNBC-1) transporters are present in the corneal endothelium, trabecular meshwork, ciliary epithelium, and lens epithelium. In the human lens epithelial (HLE) cells, RT-PCR detected mRNAs of both kNBC-1 and pNBC-1. Although a Na(+)-HCO(3)-cotransport activity has not been detected in mammalian lens epithelia, cell pH (pH(i)) measurements revealed the presence of Cl(-)-independent, electrogenic Na(+)-HCO(3)-cotransport activity in HLE cells. In addition, up to 80% of amiloride-insensitive pH(i) recovery from acid load in the presence of HCO(3)(-)/CO(2) was inhibited by adenovirus-mediated transfer of a specific hammerhead ribozyme against NBC-1, consistent with a major role of NBC-1 in overall HCO(3)-transport by the lens epithelium. These results indicate that the normal transport activity of NBC-1 is indispensable not only for the maintenance of corneal and lenticular transparency but also for the regulation of aqueous humor outflow.

[Recent guidelines for the management of Helicobacter pylori infection]

The guidelines for the diagnosis and treatment of H. pylori infection have been developed in Europe, United States, Asia, and Japan. Each guideline is characteristic in recommended indication, diagnostic method, and eradication regimen, because it depends on different background of medical situation. Two guidelines were reported in 2000. One is Maastricht 2-2000 consensus report, another is the guideline of Japanese Society for Helicobacter Research. In this article, European and Japanese recent statement for the management of H. pylori infection were introduced to reveal the differences in indication, diagnosis, and treatment between both guidelines.

High-dose ecabet sodium improves the eradication rate of helicobacter pylori in dual therapy with lansoprazole and amoxicillin

AIM

The additive effect of ecabet sodium in combination with dual therapy on Helicobacter pylori eradication was evaluated.

METHODS

H. pylori-positive chronic gastritis patients were randomly assigned to one of the following three groups and medicated for 2 weeks. Group LA: dual therapy (lansoprazole 30 mg o.d. plus amoxicillin 750 mg b.d.). Group LA1E: dual therapy plus ecabet sodium (1 g b.d.). Group LA2E: dual therapy plus ecabet sodium (2 g b.d.). Patients were evaluated 4 weeks after the cessation of treatment by culture and 13C-urea breath test.

RESULTS

Seventy-one patients (mean age, 56.6 years; range, 26-79 years; 40 males, 31 females) were enrolled in this prospective, single-blind study, and 68 completed the protocol. The eradication rates per protocol patient were 43% in group LA, 62% in group LA1E, and 79% in group LA2E, and those on the intention-to-treat basis were 42% in group LA, 57% in group LA1E and 79% in group LA2E. The eradication rate in group LA2E was significantly higher than group LA (P=0.032 in per protocol, P=0.022 in intention-to-treat). Adverse effects were observed in 10 patients in this study. There were no severe adverse effects caused by ecabet sodium.

CONCLUSION

High-dose ecabet sodium increases eradication rates of H. pylori in dual therapy with lansoprazole and amoxicillin.

[Helicobacter pylori infection and eradication]

H. pylori infection is associated with various gastroduodenal diseases such as gastritis, peptic ulcer, gastric cancer, gastric MALT lymphoma. H. pylori infection is suggested that it plays a role as protective factor not promoting factor for reflux esophagitis and GERD. Epidemiological studies showed lower prevalence of H. pylori infection in reflux esophagitis and Barrett's esophagus comparing the control. Increased occurrence of reflux esophagitis after curing of H. pylori infection was reported. However, the relationship between H. pylori infection and reflux esophagitis has not been actually made clear. Also the mechanism of reflux esophagitis occurrence after H. pylori eradication is not obscure.

[Recent endoscopic treatment in gastroenterology]

Endoscopic diagnosis and treatment became to be necessary in gastroenterology for last two decades. Indication of endoscopic treatment is amazingly expanding because of developing new techniques and easy-to-use devices. Nowadays, the indication for endoscopic treatment includes the removal of foreign bodies in alimentary tract, the dilatation of stricture lesions by balloon or expandable metallic stent, the resection of polypoid and superficial tumors by polypectomy and EMR (endoscopic mucosal resection) techniques, the injection sclerotherapy and ligation method for gastroesophageal varices, the hemostasis of gastrointestinal hemorrhages by injection method or heat-burn method. In biliary and pancreatic area, there are some endoscopic treatments that are removal and destruction of stones in common bile duct, biliary and pancreatic drainage by tubing method. Our results of endoscopic resection for esophageal and gastric tumors are shown in this papers. In conclusion, complete resection that means histologically tumor negative of lateral and vertical margin of resected specimen is important to prevent recurrence of tumors after resection.

Non-Helicobacter pylori and non-NSAID peptic ulcer disease in the Japanese population

BACKGROUND

Helicobacter pylori and non-steroidal anti-inflammatory drugs (NSAIDs) are recognized as the major causes of peptic ulcer disease. The status of H. pylori infection in the background population may influence the incidence of H. pylori-negative peptic ulcer disease.

OBJECTIVE

To examine the incidence of H. pylori-negative peptic ulcer disease without intake of NSAIDs in Japan.

PATIENTS

A total of 398 patients who had no eradication therapy for H. pylori prior to this study, including 246 patients with gastric ulcer (GU) and 152 patients with duodenal ulcer (DU), were enrolled.

METHODS

H. pylori status was assessed by rapid urease tests, histological examinations (haematoxylin & eosin stain, Giemsa stain and/or immunostaining) and serum IgG antibody. Two biopsy specimens were taken from the antrum within 3 cm of the pyloric and two from the middle corpus of the stomach, along the greater curvature. Patients were asked a series of questions regarding risk factors, including the use of NSAIDs. The presence of gastritis, gastric atrophy and intestinal metaplasia was examined according to the updated Sydney system.

RESULTS

Of the 246 patients with GU, 12 patients (4.9%) were considered to be H. pylori-negative. Of the 152 patients with DU, two patients (1.3%) were considered to be H. pylori-negative. Hence, a total of 14 patients were found to be H. pylori-negative. Nine of them were taking NSAIDs. Consequently, the frequency of H. pylori-negative ulcer without intake of NSAIDs was 1.3%. There was no significant difference in the frequencies of H. pylori-negative patients between the GU and DU groups.

CONCLUSION

The incidence of H. pylori-negative peptic ulcer disease without intake of NSAIDs was very low in the Japanese population.

Pontine atrophy in spinocerebellar ataxia type 6

To investigate the clinical range of spinocerebellar ataxia type 6 (SCA6), we screened CAG repeat expansion in the voltage-dependent alpha 1A calcium channel gene (CACNL1A4) in 71 ataxic patients in 60 families; 54 patients in 43 families with hereditary ataxia and 17 sporadic patients. Thirteen patients with SCA6 were detected to have elongated CAG in CACNL1A4. Of these, 7 patients had been diagnosed as having hereditary cerebellar cortical atrophy, and 6 patients had been found to have sporadic occurrence. One patient showed distinct pontine atrophy with prominent horizontal or oblique gaze nystagmus which is an unusual feature in sporadic olivopontocerebellar atrophy. For the efficient screening of SCA6, we would propose testing CAG repeat expansion in CACNL1A4, in patients with one of two markers: (1) horizontal or oblique gaze nystagmus without other eye movement disorders, (2) pure cerebellar atrophy, even if occurrence is sporadic. We should note that the pontine atrophy could also be caused by CAG repeat expansion in CACNL1A4.

A prospective evaluation of new rapid urease tests before and after eradication treatment of Helicobacter pylori, in comparison with histology, culture and 13C-urea breath test

BACKGROUND

The rapid urease test is a simple and cost-effective method to detect Helicobacter pylori in biopsy specimens. The aim of this study was to evaluate the accuracy of two new rapid urease tests, Helicocheck and PyloriTek, before and after eradication.

METHODS

A total of 278 patients, including 115 patients who had not undergone eradication of H pylori and 163 patients after eradication treatment, were enrolled. Eight biopsy specimens were taken from both the antrum and the body of the stomach for histology, culture, and two rapid urease tests. Assessment of H pylori infection was determined by the combination of histology, culture, and (13)C-urea breath test.

RESULTS

Overall sensitivity, specificity, and positive and negative predictive values of the Helicocheck before eradication were 91.0%, 100%, 100%, and 62.5%; PyloriTek, 92.0%, 100%, 100%, and 65.2%. Those of Helicocheck after eradication were, respectively, 60. 5%, 99.2%, 95.8%, and 89.2%; PyloriTek, 60.5%, 99.2%, 95.8%, and 89. 2%. For the Helicocheck, determination of the infection status of H pylori by biopsies from the gastric body had a significantly higher sensitivity than antral biopsies. After eradication, the combination of 1 antral biopsy and 1 biopsy from the body was not effective enough to improve the overall sensitivity.

CONCLUSIONS

Helicocheck and PyloriTek have equally satisfactory overall sensitivity before eradication treatment. However, the sensitivity of these rapid urease tests was lower after eradication than before eradication.

Giant cauda equina schwannoma. A case report

STUDY DESIGN

Case report.

OBJECTIVES

To present a rare case of a giant schwannoma of the cauda equina.

SUMMARY OF BACKGROUND DATA

Giant spinal schwannoma of the cauda equina, which involves many nerve roots, is rare and there is usually no ossification in the schwannoma. It is unknown whether or not complete excision is preferable if the tumor is located in the lumbar lesion.

METHODS

A 57-year-old woman had a 10-year history of low back pain. Scalloping of the posterior surface of the vertebral bodies from L3 to the sacrum was found. Magnetic resonance imaging disclosed a giant cauda equina tumor with multiple cysts. Central ossification revealed by computed tomography and an unusual myelogram made the preoperative diagnosis difficult.

RESULTS

The patient underwent incomplete removal of the tumor, decompression of cysts, and spinal reconstruction. The tumor was proved to be a schwannoma. The postoperative course was uneventful and she has been almost free from low back pain for 3 years and 4 months.

CONCLUSIONS

Giant schwannoma in the lumbar spine region is usually excised incompletely, because complete removal had the risk of sacrificing many nerve roots. In spite of the incomplete removal of the tumor, the risk of recurrence is low.

Eradication of Helicobacter pylori using 30 mg or 60 mg lansoprazole combined with amoxicillin and metronidazole: one and two weeks of a new triple therapy

A new triple therapy using a proton pump inhibitor and two antibiotics shows high efficiency against Helicobacter pylori infection. The aim of this study was to determine the optimal dose and duration of lansoprazole (LA) administration in combination with amoxicillin (AMPC) and metronidazole (MNZ). A total of 91 patients were enrolled in this study. They were divided into four groups: group A, 2 weeks of 30mg LA once daily, 500mg AMPC tid, and 250mg MNZ tid; group B, 2 weeks of 30mg LA bid, 500mg AMPC tid, and 250mg MNZ tid; group C, 1 week of 30mg LA once daily, 500mg AMPC tid, and 250mg MNZ tid; group D, 1 week of 30mg LA bid, 500mg AMPC tid, and 250mg MNZ tid. H. pylori status was determined by the rapid urease test, culture, histology, and 13C-urea breath test before and at least 4 weeks after the end of therapy. The cure rates in a per-protocol analysis and the incidence of adverse events in the evaluated patients were, respectively, 89.5% and 21.1% in group A, 100% and 20.0% in group B, 96.8% and 12.9% in group C, and 92.3% and 26.9% in group D. Most of the adverse events were tolerated. All four regimens in this study showed the same cure rates, and they were effective and well tolerated. One week of triple therapy using once-daily administration of 30mg LA is a good alternative.

[Hereditary ataxias in Akita prefecture]

To provide a genetic survey of hereditary ataxia, we performed PCR screening of SCA1, SCA2, MJD1 (SCA 3), SCA6, DRPLA, with 71 patients in 61 families living in Akita prefecture (1,205,571 population in 1997) in Japan. Of 71 patients in 61 families, 18 MJD1, 14 SCA6, 5 DRPLA, 1 SCA1 and 1 SCA2 patients were detected. Eighty percent of autosomal dominant inherited spinocerebellar degeneration (AD-SCD) including 7 spoladic patients genetically diagnosed as AD-SCD was MJD1 (45.7%) and SCA6 (34.3%). These suggest the prevalence rate of hereditary ataxias in Akita prefecture; 1.5 and 1.2/100,000 of MJD1 and SCA6, respectively. Only one patient of SCA1 was detected, which was frequently reported in Hokkaido and Tohoku area in Japan.

Detection of cerebroside sulfotransferase mRNA in human gastric mucosa and adenocarcinoma

Sulfatide is a major acidic glycolipid in human gastric mucosa, and its sulfation is catalyzed by cerebroside sulfotransferase (CST). To investigate the expression of the CST gene in human gastric cancer, a reverse transcription PCR method was developed with the use of endoscopic bioptic specimens. By this method, we examined the CST mRNA expression in 11 cases of gastric cancer, and in all the cases we detected various levels of the expression both in cancer tissues and in uninvolved adjacent tissues. The present assay method was suggested to be useful in the detection of CST mRNA from a limited amount of bioptic samples.

Gait analysis following varus osteotomy of the femur for hip osteoarthritis

The purpose of this study was to evaluate differences in the gait patterns of healthy and osteoarthritic hips, and changes in these patterns after intertrochanteric varus osteotomy of the femur, in relation to the strength of the muscles around the hip joint. We measured the strength ratio of hip abductor muscles, temporal and distance factors, and pelvic movement, and carried out dynamic electromyography (EMG) in 24 women who underwent unilateral varus osteotomy of the femur for hip osteoarthritis (OA), 30 non-surgically-treated women with hip OA, and 54 healthy women. The stance phase time was shorter and the strength ratio of hip abductor muscles was lower in the operated patients than these values in the other two groups, changes in pelvic obliquity and tilt were smaller, and changes in the percent maximum voluntary contraction of the gluteus medius and tensor fascia latae muscles were greater than these values in the healthy subjects. This study showed the postoperative reappearance of the simulated conditions in the hip before varus osteotomy of the femur, providing evidence that the pelvis was horizontally maintained during walking due to the decreased stance phase time and increased performance of the hip abductor muscles achieved after this procedure.

Hybrid functional electrical stimulation for energy-efficient restoration of standing-up motion

OBJECTIVE

To find the most energy-efficient standing-up motion for quadriceps and to restore that motion in a person with complete paraplegia by using hybrid functional electrical stimulation.

DESIGN

Nonrandomized control trial.

SETTING

A referral center and institutional practice providing outpatient care.

PARTICIPANTS

Twenty-nine volunteer samples were used to collect normal data. One patient with complete paraplegia received treatment for the restoration of standing-up motion.

MAIN OUTCOME MEASUREMENTS

Joint angles and ground reaction forces were investigated during the standing-up motion with arms crossed in front of the chest with an ankle-foot orthosis set at various angles. The electromyogram (EMG) was performed during the standing-up motion with and without the orthosis. The energy costs of quadriceps during the standing-up motion were calculated using a mathematical model. Standing-up motion in a person with complete paraplegia was restored and then analyzed by measuring the vertical ground reaction force and the hip and knee angles.

RESULTS

Quadriceps energy cost was lowest (p < .05) in subjects wearing the ankle-foot orthosis set at neutral with a flat sole line. In the integrated EMG the peak value of rectus femoris contraction was larger with the orthosis than without it (p < .05). A patient with complete paraplegia was able to stand up smoothly from a wheelchair based on stimulation patterns obtained from healthy subjects.

CONCLUSIONS

Energy-efficient standing-up motion in a patient with complete paraplegia was restored when the patient used an ankle-foot orthosis set at neutral with a flat sole line.

Ten minute 13C-urea breath test for the diagnosis of Helicobacter pylori infection

We investigated the utility of a 10-min 13C-urea breath test (13C-UBT) using 100mg of 13C-urea; this is a simple and rapid method for the detection of Helicobacter pylori infection. One hundred and fifty-one patients in whom the identification of H. pylori was established by rapid urease test, culture, and histology of six biopsy specimens underwent 254 13C-UBT examinations before and/or after eradication treatment. In the 133 patients who did not receive eradication treatment, the calculated sensitivity of the 10-min 13C-UBT was 99.4% and specificity 100% when the cut-off point was set at 3.5/1000, using a mass spectrometer. In the 121 patients who received eradication treatment, this cut-off point gave a sensitivity of 86.7%, a specificity of 99.1%, and a positive predictive value of 92.9%, with a negative predictive value of 98.1%. There were no significant differences between the diagnosis of H. pylori infection at 1 month and more than 3 months after the endpoint of eradication treatment. The 10-min 13C-UBT is suitable for the diagnosis of H. pylori infection before and after eradication treatment.

Effects of rebamipide in combination with lansoprazole and amoxicillin on Helicobacter pylori-infected gastric ulcer patients

The aim of this study was to compare the additive effect of rebamipide with that of teprenone in combination with dual therapy on H. pylori eradication. A total of 102 H. pylori-positive gastric ulcer patients were assigned at random to two groups; in addition to dual therapy (amoxicillin 500 mg thrice daily and lansoprazole 30 mg every morning for two weeks), one group received rebamipide 100 mg thrice daily for eight weeks, while the other group received teprenone 50 mg thrice daily for eight weeks. H. pylori diagnosis after treatment was made by [13C]UBT. The ulcer healing rate was 85.7% in the rebamipide group and 79.5% in the teprenone group (P = NS). The eradication rate was 68.4% (95% CI = 54-83%) in the rebamipide group and 47.7% (95% CI = 32-61%) in the teprenone group (P = 0.043) by per-protocol analysis. These findings suggest that the efficacy of dual therapy may be increased by the administration of rebamipide.

Electrophysiologic evaluation of denervated muscles in incomplete paraplegia using macro electromyography

OBJECTIVE

To evaluate denervated muscles in persons with incomplete paraplegia due to thoracolumbar spinal injury (TLSI) using macro electromyography in determining indications for functional electrical stimulation (FES).

DESIGN

A randomized clinical trial and a criterion standard.

SETTING

A department of orthopedic surgery in a university hospital.

PATIENTS AND OTHER PARTICIPANTS

Eighteen patients with incomplete paraplegia, including 11 with TSLI, and 50 healthy adults.

INTERVENTION

Area and amplitude of macro motor unit potential (macro MUP) were measured at the tibialis anterior, the vastus lateralis, and the vastus medialis. The normal limits of macro MUP parameters were defined based on values from healthy subjects. Abnormal denervated muscles were detected by macro EMG and conventional EMG in paralytic patients. The correlation between macro MUP parameter values and muscle forces of the tibialis anterior and quadriceps femoris induced by electrical stimulation was analyzed.

MAIN OUTCOME MEASURES

The number of abnormal muscles, parameter values, and muscle force induced by electrical stimulation.

RESULTS

Abnormal muscles were found only in the TLSI patients and 13 abnormal muscles were detected by macro EMG only. The abnormal muscles defined by macro EMG showed insufficient contraction induced by electrical stimulation. The increase of parameter value negatively correlated with the muscle force (tibialis anterior area r=-.797, amplitude r=-.866; quadriceps area r=-.866, amplitude r=-.893; p < .001).

CONCLUSIONS

These results suggest that macro EMG is useful in detecting denervated muscles, in determining indications for FES, and in predicting FES effects before implantation of electrodes.