Propofol é amplamente utilizado para sedação consciente durante a colangiopancreatografia endoscópica retrógrada (CPER) e a dexmedetomidina tem potenciais propriedades sedativas de eficácia equivalente. O objetivo deste estudo foi examinar a hipótese de que dexmedetomidina é tão eficaz quanto propofol combinado com fentanil para promover sedação consciente durante a CPER. Trata-se de um ensaio clínico, randomizado, cego, double-dummy, que abrangeu 26 pacientes adultos, estado físico I-III de acordo com a Sociedade Americana de Anestesiologia. Os pacientes foram randomizados para receber propofol (n = 14) (concentração plasmática alvo de 2 a 4 μg. ml-1) associado a fentanil (1 μg. kg-1) ou dexmedetomidina (n = 12) (1 μg.kg-1 por 10 minutos), seguida de infusão de 0,2 a 0,5 μg.kg-1.min. Sedativos adicionais foram utilizados se não fosse alcançada sedação adequada com a dose máxima permitida. Os desfechos primários foram o nível de sedação mensurado através da Escala Richmond de Agitação-Sedação e a necessidade de sedativos adicionais. Os desfechos secundários foram as variações hemodinâmicas e respiratórias aferidas pela freqüência cardíaca, pressão arterial, saturação de oxigênio, pressão parcial exalada de dióxido de carbono e freqüência respiratória. Quanto à sedação, o risco relativo (RR) foi de 2,71 (IC 95%, 1,31 a 5,61) e o número de pacientes que foi necessário tratar (NNT) foi de 1,85 (IC95%, 1,19 a 4,21) para observar um paciente adicional apenas sonolento, 15 minutos após o início da sedação no grupo dexmedetomidina. Também o RR foi de 9,42 (IC95%, 1,41 a 62,80), e o NNT, de 1,42 (IC 95%, 1,0 a 2,29) para requerer analgesia adicional. Entretanto, no pós-operatório, o grupo dexmedetomidina apresentou maior redução na pressão arterial e na freqüência cardíaca e sobretudo, maior nível de sedação. Dexmedetomidina isolada não foi tão eficaz quanto propofol combinado a fentanil para promover sedação consciente durante a CPER. Além disso, foi associada com maior instabilidade hemodinâmica e tempo de recuperação prolongado. / Propofol is a wildly used therapeutic for conscious sedation during endoscopic retrograde cholangiopancreatography (ERCP), and dexmedetomidine has sedative properties of equivalent efficacy. The aim of this study was to examine the hypothesis that dexmedetomidine is as effective as propofol combined with fentanyl for providing conscious sedation during ERCP. A randomized clinical trial, blind and double-dummy, was conducted where twenty-six adults with physical status I-III according to the American Society of Anesthesiology were studied. Patients were randomized to receive propofol (n= 14) (target plasma concentration ranged from 2 to 4 μg/ mL) combined with fentanyl (1 μg/kg) or dexmedetomidine (n=12) (1 μg/kg over 10 min), followed by 0.2 to 0.5 μg/kg/min. Additional sedatives were used if adequate sedation was not achieved at the maximum dose allowed. The main outcomes were sedation level that was assessed by the Richmond Agitation-Sedation Scale and the demand for additional sedatives. The secondary outcomes were the effects on hemodynamic and respiratory parameters, which included heart rate, blood pressure, oxygen saturation, partial pressure of exhaled carbon dioxide and respiratory rate. In sedation, the relative risk (RR) was 2.71 (95% CI, 1.31 to 5.61) and number of patients needed to treat (NNT) was 1.85 (95% CI, 1.19 to 4.21) to observe one additional patient only drowsiness 15 minutes after beginning of sedation in the dexmedetomidine group. Also, the RR was 9.42 (95% CI, 1.41 to 62.80) and NNT 1.42 (95% CI, 1.0 to 2.29) to require additional analgesic. However, in the postoperative period, the dexmedetomidine group had a greater reduction in blood pressure and heart rate, and especially greater sedation level. Dexmedetomidine alone was not as effective as propofol combined with fentanyl for providing conscious sedation during ERCP. Furthermore, it was associated with more hemodynamic instability and prolonged recovery.

Abstract The purpose of this study was to explore the development and course of social phobia by analysing qualitatively all the textual material obtained about the persons with treatment-resistant social phobia who, during the years 1995-2000, underwent a surgical procedure called endoscopic sympathetic block (ESB) to alleviate their phobic symptoms. In the other part of this study, the effect of this surgical procedure on social phobia was assessed quantitatively. The qualitative part of the study was based on the phenomenologic-existential philosophy and the principles of grounded theory. The qualitative analysis revealed four kinds of parenthood in the families of socially phobic persons: a violent, alcoholic type, a dominant type with high demands, a negligent type and a good enough type. A "vicious circle of social phobia" was formulated as a substantial category. The quantitative part of the study was an open, prospective follow-up study, where 169 patients operated on for social phobia during the years 1995–2000 were followed up for 5 years, and the changes in their symptoms were estimated using a modified version of Davidson's brief social phobia scale and the Liebowitz quality of life scale. The quantitative and qualitative parts of the study were linked together by investigating each person's family background with a semi-structured interview. According to variation analysis of the results, all symptoms of social phobia seemed to be alleviated highly significantly by ESB, and the results remained similar throughout the follow-up. Reflex sweating of the trunk was the only significant side effect. Overall satisfaction with the operation was estimated to be 3.5 on a five-point scale, representing the description "some help of the operation". Thus, ESB can be regarded as an additional treatment method for social phobia if traditional treatment with medication and psychotherapy has not provided any help for the patient.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13363号 / 論医博第2205号 / 新制||医||1045(附属図書館) / (主査)教授 妹尾 浩, 教授 今中 雄一, 教授 川上 浩司 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Percutaneous endoscopic placement of feeding gastrostomies (PEG) was pioneered by Gauderer et. al, in 1980. Since then, it has become the preferred method of providing enteral nutritional support in children and adults because of advantages in morbidity and cost. Pneumonia is a known sequel of this procedure, occurring at different rates, depending on the length of follow-up. Some series have shown an incidence of 10% at 30 days and others 56% at 11 months. It does not appear that PEG feeding offers an advantage over the more traditional naso-enteric tube feeding methods in this respect. To study the prevalence of gastroesophageal reflux (GER) in PEG-fed patients, we quantitated GER by 24-hour intraesophageal pH monitoring in a group of patients who developed post-PEG pneumonia and compared it with a control group. Our study demonstrates an increased prevalence of GER in the pneumonia group compared with the control group. However, the exact contribution of this observed increased GER to the development of pneumonia needs to be determined.

BACKGROUND. The cytologic differentiation between neoplastic and reactive/reparative processes in the endoscopic ultrasound-guided fine-needle aspirations (EUS-FNA) of the pancreas can be difficult. Malignant transformation of the pancreatic ductal epithelium changes the expression of apomucins. The goal of the current study was to determine an optimal immunohistochemical panel of mucin (MUC) antibodies that would allow the cytomorphologic distinction of pancreatic ductal adenocarcinoma and its differentiation from reactive/reparative processes and inadvertently sampled gastric and duodenal mucosa. METHODS. Pancreatic EUS-FNA specimens performed on 351 patients were reviewed. Expression profiles of MUC1, 2, 5AC, and 6 were examined on 56 cell block sections and 26 follow-up pancreatectomy specimens. RESULTS. MUC1 and 6 expression was found in nonneoplastic pancreatic samples, whereas there was an absence of expression of MUC2 and 5AC. MUC2 was detected in mucosal goblets cells of the duodenum, MUC6 in Brunner glands, and MUC5AC in gastric foveolar cells. MUC5AC expression in differentiating ductal adenocarcinomas from benign conditions demonstrated better operating characteristics than either MUC1 or MUC6. The apomucin expression pattern both in cytology and follow-up surgical pathology specimens was similar. In surgical pathology specimens, the panel of 3 antibodies, MUC1+/MUC2-/MUC5AC+, was noted in 15 of 17 ductal carcinomas (88.2%). In nonneoplastic pancreatic tissue, the expression panel MUC1+/MUC2-/MUC5AC- was observed in 14 of 17 (82.4%) cases. In cytology specimens, the combination of MUC1+/MUC2-/MUC5AC+ was noted in 21 of 30 ductal carcinoma cases (70.0%), 3 of 6 atypical cases (50%), and 1 of 1 suspicious for malignancy cases (100%). The combination MUC1+/MUC2-/MUC5AC+ was not observed in any of the negative for malignancy or reactive cases (0 of 6). CONCLUSIONS. The most optimal panel for the diagnosis of ductal adenocarcinoma in both the EUS-FNA specimens is a panel including MUC1/MUC2/MUC5AC, whereas a panel of all 4 antibodies (MUC1, 2, 5AC, and 6) will in addition aid in differentiating inadvertently sampled normal/reactive duodenal and gastric epithelium from neoplastic pancreatic tissue.

Background/Aims: Peripancreatic fluid collections (PFCs) result from acute or chronic pancreatic inflammation that suffers a rupture of its ducts. Currently, there exists three options for drainage or debridement of pancreatic pseudocysts and walled-off necrosis (WON). The traditional procedure is drainage by placing double pigtail plastic stents (DPPS); lumen-apposing metal stent (LAMS) has a biflanged design with a wide lumen that avoids occlusion with necrotic tissue, which is more common with DPPS and reduces the possibility of migration. We performed a systematic review and meta-analyses head-to-head, including only studies that compare the two main techniques to drainage of PFCs: LAMS vs DPPS. Methods: We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. This meta-analysis considers studies published from 2014 to 2020, including only studies that compare the two main techniques to drainage of PFCs: LAMS vs DPPS. Results: Thirteen studies were included in the meta-analyses. Only one of all studies was a randomized controlled trial. These studies comprise 1584 patients; 68.2% were male, and 31.8% were female. Six hundred sixty-three patients (41.9%) were treated with LAMS, and 921 (58.1%) were treated with DPPS. Six studies included only WON in their analysis, two included only pancreatic pseudocysts, and five studies included both pancreatic pseudocysts and WON. The technical success was similar in patients treated with LAMS and DPPS (97.6% vs 97.5%, respectively, P =.986, RR = 1.00 [95% CI 0.93-1.08]). The clinical success was similar in both groups (LAMS: 90.1% vs DPPS: 84.2%, P =.139, RR = 1.063 [95% CI 0.98-1.15]). Patients treated with LAMS had a lower complication rate than the DPPS groups, with a significant statistical difference (LAMS: 16.0% vs DPPS: 20.2%, P =.009, RR = 0.746 [95% CI 0.60-0.93]). Bleeding was the most common complication in the LAMS group (33 patients, [5.0%]), whereas infection was the most common complication in the DPPS group (56 patients, [6.1%]). The LAMS migration rate was lower than in the DPPS (0.9% vs 2.2%, respectively, P =.05). The mortality rate was similar in both groups, 0.6% in the LAMS group (four patients) and 0.4% in the DPPS group (four patients; P =.640). Conclusion: The PFCs drainage is an indication when persistent symptoms or PFCs-related complications exist. EUS guided drainage with LAMS has similar technical and clinical success to DPPS drainage for the management of PFCs. The technical and clinical success rates are high in both groups. However, LAMS drainage has a lower adverse events rate than DPPS drainage. More randomized controlled trials are needed to confirm the real advantage of LAMS drainage over DPPS drainage. / Revisión por pares

BACKGROUND: Delayed symptomatic hyponatremia (DSH) is among the most common reasons for readmission following transsphenoidal surgery. Patients can present with a large range of symptoms, requiring immediate attention and prolonging hospital stay. In rare and severe cases, DSH can result in death. While various risk factors for DSH have been investigated, there is still a need for better understanding in order to identify patients who are at risk. Clinicians can then take preventative measures to improve patient outcomes. A systematic review was performed to determine both predictors and rates of DSH after both endoscopic (eTSS) and microscopic transsphenoidal surgery (mTSS). METHODS: We conducted a systematic search through databases MEDLINE/PUBMED, MEBASE, and The Cochrane Library. Included studies were selected with the following criteria: (i) case series with at least 10 cases reported, (ii) adult patients who underwent eTSS or mTSS for pituitary adenomas, and (iii) reported occurrence of DSH (hyponatremia defined as blood sodium level <135 mEq/L) three days post-operatively. Data were analyzed using CMA V.3 Statistical Software (2014). RESULTS: We identified 10 case series that satisfied the inclusion criteria consisting of 2,947 patients with pituitary adenomas. The following were investigated as potential predictors of DSH: age, CSF leak, gender, and tumor size. Rates of DSH were found to be between 4 and 12 percent for both mTSS and eTSS. CONCLUSIONS: Age, gender, tumor size, rate of blood sodium level decline between post-operative day (POD) 4 and 7, and Cushing’s disease are potential predictors of DSH. A better understanding of these predictors can help clinicians identify patients at risk for DSH so preventative measures can be taken to reduce the deleterious effects of hyponatremia after transsphenoidal surgery.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18131号 / 医博第3851号 / 新制||医||1001(附属図書館) / 30989 / 京都大学大学院医学研究科医学専攻 / (主査)教授 千葉 勉, 教授 坂井 義治, 教授 羽賀 博典 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13029号 / 論医博第2111号 / 新制||医||1016(附属図書館) / 32987 / (主査)教授 大森 孝一, 教授 別所 和久, 教授 坂井 義治 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21667号 / 医博第4473号 / 新制||医||1035(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 小柳 義夫, 教授 中川 一路, 教授 長船 健二 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM