Double-balloon endoscopy versus magnet-imaging enhanced colonoscopy for difficult colonoscopies, a randomized study.

BACKGROUND AND STUDY AIMS: Studies have estimated that failure of cecal intubation occurs with conventional colonoscopy in up to 10 % of cases. Double-balloon endoscopy (DBE) systems, magnetic endoscope imaging (MEI), and transparent cap have been shown to improve success rates for colonoscopy. This study evaluated the utility of DBE for complete examination of the colon compared with MEI plus cap (MEI-Cap) after incomplete or technically difficult colonoscopy in a randomized comparative manner. PATIENTS AND METHODS: A total of 94 patients with incomplete or technically difficult colonoscopy were randomly assigned to receive either DBE (n = 47) or colonoscopy with MEI-Cap (n = 47). The primary end point was cecal intubation rate within 30 minutes. Secondary end points included intubation time, pain score using a visual analog scale, abdominal pressure attempts, doses of sedative medication, and changes in patient position during colonoscopy. RESULTS: Patient characteristics were comparable in both groups. Cecal intubation rate within 30 minutes was significantly higher for DBE (45 /47, 95.7 %) than for MEI-Cap (34 /47, 72.3 %) (P = 0.0049). Mean time to reach the cecum was significantly lower in the DBE group (13.0 ±â€Š5.3 minutes) than in the MEI-Cap group (16.4 ±â€Š4.8 minutes; P = 0.0003). No complications were encountered in either group.   CONCLUSION: DBE is more useful for complete examination of the colon than MEI-Cap in patients with incomplete or technically difficult colonoscopy.

Propofol activates vanilloid receptor channels expressed in human embryonic kidney 293 cells.

Propofol (2,6-diisopropylphenol) is an intravenous anesthetic agent structurally unrelated to any other intravenous anesthetics. We examined the effect of propofol on a rat vanilloid receptor that was expressed in the human embryonic kidney (HEK) 293 cells by using calcium imaging method. Propofol caused a concentration-dependent increase in [Ca(2+)](i) in the HEK293 cells with the receptor. These responses were inhibited by removing extracellular calcium ions. The propofol-evoked increase in [Ca(2+)](i) in the HEK293 cells with the receptor was partially inhibited by capsazepine, a competitive antagonist of capsaicin. We conclude that propofol acts as an agonist for the receptor.

Scapulohumeral reflex (Shimizu). Its clinical significance and testing maneuver.

Searching for a muscle stretch reflex that is innervated by the high cervical cord, the authors discovered the scapulohumeral reflex (Shimizu)--SHR (Shimizu). The testing maneuver, localization of the reflex center, its clinical significance, and the designation of the SHR (Shimizu) are dealt with in this report. The SHR is elicited by tapping the tip of the spine of the scapula and acromion in a caudal direction. The SHR is classified as hyperactive only when an elevation of the scapula or an abduction of the humerus have been clearly defined after tapping at these points. Two hundred twenty-five patients with cervical spine disorders, 90 normal individuals, and 17 patients with cerebrovascular strokes were examined. The incidence of hyperactive SHR was highest among several neurologic abnormalities in spastic cases with craniovertebral or high cervical lesions, and all cases with hyperactive SHR in the cervical spine disorder group exhibited neural compressive factors at the high cervical region. The major muscles participating in the SHR are considered to be the upper portion of the trapezius, the levator scapulae, and the deltoid. According to the anatomic level of compressive factors and the postoperative course of the activity in hyperactive SHR cases, the reflex center of the SHR is clinically presumed to be located between the posterior arch of C1 and the caudal edge of the C3 body. Hyperactive SHR provides useful information about dysfunctions of the upper motor neurons cranial to the C3 vertebral body level.

Characteristics of the isokinetic performance of patients with injured cruciate ligaments.

The torques of the quadriceps muscle in patients with cruciate ligament injuries were evaluated under isokinetic contraction. There were 30 patients with anterior cruciate ligament injuries, 19 with posterior cruciate ligament injuries, and 30 controls. The torques of concentric and eccentric contractions in anterior cruciate ligament-injured knees showed a significant difference from those in the uninjured sides at extension angles of less than 45 degrees, yet the values of the peak torques for concentric and eccentric contractions were the same as those for the uninjured sides. The torques of concentric and eccentric contractions in posterior cruciate ligament-injured knees showed a significant difference from the uninjured sides at flexion angles of more than 36 degrees. The peak torques for concentric and eccentric contraction also showed a significant difference from the uninjured sides. The concentric and eccentric peak torque angles of the injured knees were similar to those of the uninjured sides in all subjects. The ratios of eccentric to concentric peak torque of the contralateral knees in the anterior cruciate ligament-injured groups did not show a significant difference from those of the controls. The evaluation of the biomechanical change in these categories is of great advantage in determining proper methods of treatment and rehabilitation.

The influence of osteoporosis on varus osteoarthritis of the knee.

We studied 37 patients with varus osteoarthritis of the knee to determine the influence of the bone mineral density (BMD) on the varus deformity. There were 15 men (21 knees) and 22 women (38 knees). The mean age of the men was 69 years and of the women 68 years. BMD was measured in the L1-L4 spinal region using dual X-ray absorptiometry. In the women a low level of BMD was associated with varus deformity originating at the proximal tibia, but a high level was predominantly linked with deformity originating in the joint space. Similar findings were obtained in the men. Our results suggest that a low BMD predisposes to trabecular microfractures and consequently increased stress on the articular cartilage. A low BMD does not preclude osteoarthritic change in the knee.

Varus inclination of the distal femur and high tibial osteotomy.

We have analysed retrospectively the relationship between the axial parameters of alignment of the lower limb and the recurrence of varus deformity after high tibial osteotomy. We studied 29 patients (37 knees) with a mean age at surgery of 66 years. The mean follow-up was for 7.4 years (5 to 10.5). Recurrence of varus deformity was defined as an increase in the femorotibial angle of 3 degrees or more, compared with that obtained six months after the operation. There were four patients (four knees) with recurrence of varus deformity. They had a greater varus inclination of the distal femur than those without varus recurrence. An association between varus inclination of the distal femur and horizontal obliquity of the joint surface was observed. Excessive obliquity prevents the shift of weight-bearing to the lateral compartment, and may cause a recurrence of varus deformity after high tibial osteotomy.

[Preliminary survey of illegal drug misuse among Japanese high school students].

For several years, amphetamine misuse by high school students has been increasing in Japan. The Japanese National Police Agency announced that the third widespread use of amphetamines has started, especially among adolescents. However, there are few data on misuse of amphetamines or other substance abuse among high school students except for solvent inhalation. This is a preliminary survey report concerning substance abuse and substance-related problems among high school students. We surveyed 3393 high school students from 8 high schools in Kanagawa Prefecture and Kyushu Area on drinking and smoking status, and experience of illegal substance use. The results showed that 5.1% of the high school students had experiences of solvents inhalation, 1.1% of marijuana use, and 0.8% of amphetamine use. Around these illegal drug misusers, there were many reserves, such as students who experienced temptation to use solvents (13.6%), marijuana (2.4%), and amphetamines (2.5%), and those who responded that they wanted to use solvents (3.7%), marijuana (3.5%), and amphetamines (2.4%) if they were tempted. The prevalence of illegal drug misusers and reserves was not significantly different between male and female students, and they were concentrated among problem drinkers by the QF Scale and among current smokers. Prevalence of illegal drug misuse among Japanese high school students can not be estimated from the results of the survey because the subjects were limited to two areas and a small number of schools.

Clinical application of biofeedback treatment with a microvibration transducer.

This article demonstrates one clinical application of biofeedback treatment with a microvibration (MV) transducer to relieve functional tremors. A MV transducer, a kind of accelerometer, was originally developed to detect invisible tremors from the body surface but this equipment is also utilized to detect visible tremors to convert them to auditory signals. Our method uses almost the same procedure as electromyographic biofeedback treatment. The threshold level for production of auditory signals should be determined as high as possible between the superimposed amplitudes of essential MV and tremor components. As the sessions progress, the predeterminate threshold level should be gradually lowered to almost the same amplitude as MV itself. In determining the threshold, it is more appropriate to utilize records of the frequency band in which the tremor components are described more clearly, in order to remove noises or MV waves of different frequency ranges. Because of the high sensitivity of this accelerometer, such "tremor feedback" treatment can be recommended only if the tremor is present while the patient is resting or remains still.

Application of a screening test for depression in the Health Counselling Center.

This paper outlines the process of development and the clinical usefulness of a screening test for depression. First we developed a draft questionnaire consisting of 13 items, each of which had three answers--(1) often, (2) sometimes, (3) none--, with reference to certain kinds of rating scales. After each answer was quantified by the sigma method, each item was statistically analyzed among 75 depressive patients and 250 almost healthy subjects visiting the AMHTS (Automated Multiphasic Health Testing and Services) center. Then 12 items effective for discriminating between the two groups were computed by discriminant analysis to produce depression scores which varied from 0 to almost 100 in proportion to the severity of depression. This questionnaire was applied to all consultees visiting the AMHTS, and revealed that almost 1% of them showed higher scores than the threshold score. Psychiatric interviews with the subjects suspected of depression indicated that all of them were in the transient maladapted state although only ten out of 16 were referred to a psychiatric outpatient clinic for further examination and treatment. The validity of this questionnaire was also confirmed by the fact that 86% of 50 additional depressive patients showed higher scores than the threshold score.

Intraoperative EEG monitoring: (I). Parametric representation of processed EEG during anesthesia.

One of the most common techniques of EEG monitoring during operations is to produce a three dimensional image by displaying the frequency distributions with respect to time as in compressed spectral array (CSA) and density-modulated spectral array (DSA). In order to characterize these images by numerical parameters, we defined two parameters; the percent spectral edge frequency as the frequency at which the one-sided-power sum reaches the designated percentage of the total; and the mean frequency as the power-weighted mean within the interval that includes a dominant spectrum in the frequency distribution. These parameters were superimposed on displays to characterize EEG changes, and they proved to be a very powerful tool to quantitate variations in data among anesthetic techniques and thus efficiently control the depth and duration of anesthesia. We report a number of actual cases.

Intraoperative EEG monitoring: (II). Similarity analysis using density-modulated t array.

A method of showing the similarity, in other words, defining the difference between a pair of EEG patterns has been developed. By using the student t test on the power spectra at the appropriate frequency intervals, the t values obtained can be used as an indicator of the difference between the spectral patterns with respect to the frequency intervals. This so-called t-profile can be computed on real time basis and the result superimposed in different colors using the apparatus described previously to produce a 3-dimensional picture. We call this picture a density-modulated t array or DTA. Along with CSA and DSA (compressed/density-modulated spectral arrays), it proved to be a very powerful tool in intraoperative EEG monitoring.

Changes in biochemical parameters after anterior cruciate ligament injury.

We studied the biochemical characteristics of human knees with deficient anterior cruciate ligaments (ACL) and analysed their relationship to the time after ligamentous injury. Thirty-two patients with isolated ACL-injured knees and six healthy volunteers were enrolled. Synovial fluid samples were centrifuged after aspiration during arthroscopic examination, and aliquots of supernatant were frozen and stored at -80 degrees C. The samples were analysed for interleukin (IL)-1beta, tumour necrosis factor (TNF)-alpha, IL-6, matrix metalloproteinase (MMP)-3, and tissue inhibitor of metalloproteinase (TIMP)-1 using commercially available sandwich enzyme-linked immunosorbent assay. In fluid from ACL-injured knees, the average concentrations of IL-6, MMP-3 and TIMP-1 were highly elevated in comparison with normal controls. There was a statistically significant correlation between the concentrations of MMP-3 and IL-6. The IL-6 and TIMP-1 concentrations were interrelated. The concentration of MMP-3 remained high, independent of the duration since the injury, whereas the TIMP-1 and IL-6 levels decreased. The results suggest that the timing of the treatment of an ACL-injured knee might be of importance.

Meniscal repair using a flap of synovium. An experimental study in the dog.

The healing process of longitudinal lesions in the avascular region of the meniscus was investigated in 42 menisci from 21 dogs. A longitudinal incision was made in the avascular portion of the medial menisci of 21 dogs. In one knee, a flap of synovium was sutured into the wound, and in the other, the wound was sutured as a control. Animals were killed after 1 to 12 weeks, and the menisci were removed and examined by gross inspection, light microscopy, and microangiography. In the control knees, no healing had occurred. In 19 of 21 knees in which a synovial pedicle was used, the suture site did not open at any of the postoperative weeks. The longitudinal lesion was repaired with fibrovascular tissue at 6 weeks, and the vessels over the femoral surface of the menisci and an inner portion of the menisci had reached the suture site. The healing of meniscal lesion occurred due to the use of the vascularized synovial pedicle flap and the neovascularization from the parameniscal area.

Dissolution of solid dosage form. II. Equations for the dissolution of nondisintegrating tablet under the sink condition.

An equation for dissolution from the whole surface of a nondisintegrating single component tablet under the sink condition was derived. Also, equations for several dissolution manners of the tablet under the sink condition were derived in the postulation of the dominant dissolution rate constant which determines the dissolution manner. The applicability or validity of these equations were examined by the dissolution measurements with nondisintegrating single component tablets. About one-tenth the amount of the amount needed to saturate the solution was used to prepare a tablet, and dissolution measurements were carried out with the tablet whose flat or side surface was masked with an adhesive tape in accordance with the conditions for derivation of equations. Among the derived equations, dissolution from the whole surface of a tablet was expressed by a form similar to the cube root law equation for particles. Hence, a single component tablet compressed by the use of a suitable amount was thought to behave like a single crystal. Also, equations derived for several dissolution manners were thought to be applicable for the dissolution of a nonspherical particle and crystal concerning the crystal's habit and its dissolution property, and the extended applicability was examined by converting the crystal into a simplified or idealized form, i.e., rectangle or plate.

Axial parameters affecting lower limb alignment after high tibial osteotomy.

Lower limb alignment of 46 knees treated with high tibial osteotomy was studied to find a method for determining the precise correction angle. The femorotibial angle was divided into several axial alignment parameters. Before the operations, the femorotibial angle correlated with the tilting angle of the femoral shaft toward the horizontal (femoral shaft-horizontal angle) and that of the tibial shaft toward the horizontal (tibial shaft-horizontal angle). After the operations, the femorotibial angle correlated with the tibial shaft-horizontal angle, but not with the femoral shaft-horizontal angle. The postoperative femoral shaft-horizontal angle tends to be constant regardless of the degree of valgus. In preoperative varus knees, the varus deformity increases the degree of shift of the femoral and tibial shaft toward the varus direction. In postoperative valgus knees, the more valgus the knee the more the tibial shaft shifted toward the valgus direction, which was not true for the femoral shaft. The femorotibial angle was influenced more by the tibial axial alignment in the postoperative valgus knee. The slope of the distal femoral articular surface influenced the tilt of tibial articular surface toward the horizontal which, in turn, influenced the tibial shaft-horizontal angle. The authors recommend relying on the tibial axial alignment parameter to determine the amount of correction. The slope of the distal femoral articular surface should be considered in preoperative planning.

Free synovium promotes meniscal healing. Synovium, muscle and synthetic mesh compared in dogs.

We studied the effect of free synovium on the healing of tears in the avascular portion of the menisci in dogs. A longitudinal incision was made in the medial meniscus. In 35 dogs, a free graft of synovium was inserted into the tear and sutured. In 10 dogs, a free graft of quadriceps muscle was used. In 10 dogs, a Dacron mesh was inserted. In the contralateral knee, the tear was sutured without implantation as a control. 2, 4, 6, 8, and 12 weeks after the operation, the menisci were dissected. 11 of the 35 with free synovium were healed. The menisci with muscle grafts, those with Dacron mesh and those in the control group did not heal. Histology showed that tears were repaired with fibrous tissue. Microangiography showed that capillaries grew from the periphery, but they did not reach the tear.

Separated ossicles of the lateral malleolus.

Sixty ankles of 59 patients with symptomatic ossicles of the lateral malleolus were studied. All patients underwent clinical and radiographic examinations. Stress arthrography was performed on 58, arthroscopy on 48, operative treatment on 52, and histologic examination on 23. The ossicles were classified into 3 sizes (small, medium, and large) and 2 levels (A and B) by location. The relationship between the ossicle and fibular tip was classified into 3 grades according to arthrography results (Grade 1, little inflow [< 1 mm] of the contrast medium; Grade 2, an apparent space [1-2 mm]; Grade 3, a large gap [> 2 mm]) and to operative and arthroscopic findings (Type A, a fibrous union; Type B, a partial continuity; Type C, a lax thin scar tissue; Type D, no continuity). There were significant differences in talar tilt angles on stress radiography between the 3 grades. Chronic symptoms had a tendency to increase from Grade 1 to Grade 3 and from Type A to Type C or D, with instability occurring more than pain. The size and level did not correlate with instability. Acute or chronic inversion forces may act on the connection between the ossicle and fibular tip, and damage to this structure may cause symptoms.

The natural history of untreated anterior cruciate tears in recreational athletes.

A followup study was performed to elucidate the natural course of acutely torn anterior cruciate ligaments in recreational athletes. Fifty-six consecutive patients had arthroscopy within 2 weeks of their initial injuries; however, no surgery was done on the torn anterior cruciate ligament. Twenty anterior cruciate ligament and medial collateral ligament combined ruptures occurred. Patient ages ranged from 14 to 50 years old (mean, 28.9 years). Followup periods ranged from 2 to 10 years (mean, 5 years 6 months). Through examination with the KT-1000 arthrometer, side-to-side differences of anterior translation of the tibia of > or = 3 mm in 72% patients at reexamination were seen. Eight of 46 patients had mild osteoarthritic changes of Grade 1 visible on radiographs, but only 1 patient reported knee trouble. Nine patients had repeat injuries, 3 of whom had late reconstructions and 4 late meniscectomies. Functional scores averaged 95 +/- 6.5 points. Activity scores averaged 4.8 +/- 1.6 points. Operative management for the medial structure did not improve the stability better than nonoperative management. Anterior translation and functional scores of patients with medial meniscectomies showed significant differences from those of other patients. Anterior cruciate ligament reconstruction for recreational athletes should be considered when the patients have reparable meniscal tears, and meniscal repairs should be performed simultaneously.