A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions

BACKGROUND & AIMS: Wireless capsule endoscopy is a new, painless method of imaging the entire small bowel. It has not been compared with push enteroscopy. We compared the sensitivity, specificity, and safety of capsule and push enteroscopy in detecting small-bowel lesions. METHODS: Nine to 13 radiopaque, colored beads (3-6 mm diameter) were sewn in random order inside 9 canine small bowels, half within the first meter, and confirmed on x-ray. After recovery, the number, order, and color of beads were assessed in 23 capsule enteroscopies and 9 push enteroscopies in a random order. The surgeons, push enteroscopists, capsule video interpreters, and pathologist were blinded to the others' findings. RESULTS: The capsules identified more beads than push enteroscopy (median, 6 [range, 2-9] vs. 3 [range, 2-6 beads]; P < 0.001). The sensitivity of the capsule was 64% compared with 37% for push enteroscopy. The specificity was 92% for capsule enteroscopy and 97% for push enteroscopy. The capsules identified significantly more beads beyond the reach of the push enteroscope (median, 4 [range, 2-7] vs. 0; P < 0.0001). Hair, ingested plastic, ulceration, submucosal swelling, and worms were clearly identified by the capsule. The capsules passed safely through the animals with no significant histologic findings. CONCLUSIONS: Wireless capsule endoscopy detected more abnormalities in the small bowel than push enteroscopy.     

Culture supernatants of a stimulated T-cell line have helper activity that acts synergistically with interleukin 2 in the response of B cells to antigen.

Culture supernatants of an antigen-stimulated long-term alloreactive T cell line, C.C3.11.75, contain a T-cell-replacing factor (TRF) activity for the B-cell response to antigen. These same supernatants show little activity in the T-cell growth assay or the costimulator assay. TRF activity was assayed by using spleen cells that were rigorously depleted of both T cells and macrophages. In this assay preparations containing interleukin 2 and supernatants from stimulated C.C3.11.75 cells are relatively inactive if added alone but show marked synergy when added together. We conclude that the C.C3.11.75 TRF activity is not due to interleukin 1 or to interleukin 2 but to a third factor provisionally designated as (DL)TRF. This activity may be equivalent to the (late-acting) TRF described by Schimpl and Wecker. Evidence is presented suggesting that the helper activity (DL)TRF is a product of the T-cell line.     

Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: Results of a pilot study

BACKGROUND: A video capsule has been developed to acquire photographic images of the small intestine during normal peristaltic motion. METHODS: Patients between 21 and 80 years of age referred for enteroscopy because of obscure GI bleeding were offered entry into a trial in which they would undergo both capsule endoscopy and subsequent push enteroscopy. Results of capsule examinations were compared with push enteroscopy findings. Capsule endoscopy was performed with the Given M2A video capsule system. RESULTS: Twenty-one patients (12 women, 9 men, average age 61 years) were enrolled, all of whom completed the study. A bleeding site was found in 11 of 20 patients during capsule endoscopy. No additional intestinal diagnoses were made by enteroscopy. The yield of push enteroscopy in the evaluation of obscure bleeding was 30% (6/20), the yield of capsule endoscopy 55% (11/20). This difference did not reach statistical significance (p = 0.0625). Capsule endoscopy found a distal source of bleeding in 5 of 14 patients who had normal push enteroscopic examinations. Patients preferred capsule endoscopy to enteroscopy. CONCLUSIONS: This pilot study demonstrates that capsule endoscopy provides excellent visualization of the small intestine, is well tolerated by patients, and is safe. Capsule endoscopy identified small intestinal bleeding sites beyond the range of push enteroscopy.     

Erythroid Fc-IgG and complement receptor expression: a study of normoblastic and megaloblastic human bone marrows

Using a standardized rosetting technique with IgG-coated ox erythrocytes, avid IgG (Fc) receptors were demonstrated on red cell precursors. The proportion of receptor-positive cells in normal marrows was highest in early precursors and appeared to be lost with maturation. In megaloblastosis, the absolute percentage of early precursors increase, but there is an even greater increase in the proportion of receptor-positive cells. It is proposed that this reflects the degree of maturation arrest. The specificity of the receptor was confirmed by inhibition studies with aggregated human IgG. In contrast, the expression of the C3b "immune adherence" receptor, assessed by IgM-C3b-coated ox erythrocytes, was seen to increase with erythroid maturation. Early megaloblasts, especially in severe megaloblastosis, showed a marked decrease in C3b receptor activity, again in proportion to the level of maturation arrest. The significance and possible function of these receptors is discussed.     

Delayed postoperative cardiac tamponade mimicking severe tricuspid valve stenosis

A patient developed acute, severe hemodynamic deterioration five days after an aortic valve replacement. Cardiac catheterization revealed a markedly elevated right atrial pressure but a normal right ventricular end-diastolic pressure. Angiography revealed an extrinsic mass causing compression of the right atrium and the tricuspid anulus. A large clot overlying the right atrium and ventricle was found at emergency surgery. Postoperative cardiac tamponade may result in an atypical hemodynamic presentation when there is selective compression of one chamber or of a valve anulus.     

Direct in vivo gene transfer into the coronary and peripheral vasculatures of the intact dog

Gene therapy approaches have been suggested for the treatment of cardiovascular disease. Recently, direct transfer of the gene encoding beta-galactosidase into peripheral arteries of the pig has been demonstrated. To determine whether this approach is applicable to other arterial beds and to other species, we first evaluated the use of beta-galactosidase as a marker protein in the canine model. We demonstrate that variable but substantial endogenous beta-galactosidase-like activity is induced by manipulation of canine peripheral arteries, which precludes the use of this marker protein in evaluating the efficiency of gene transfer in this model. A marker gene encoding firefly luciferase was then evaluated, and background luciferase activity was found to be low in the dog even after arterial manipulation. Using the luciferase gene, we then demonstrated lipid-mediated gene transfer directly into both coronary and peripheral arteries of the intact dog. These results indicate the feasibility of in vivo gene transfer into coronary arteries and demonstrate the use of the luciferase marker protein in quantifying recombinant protein expression following gene transfer in canine models. This simple and effective method for direct in vivo gene transfer into coronary and peripheral arteries may be applicable to the localized production of therapeutically important proteins for the treatment of cardiovascular diseases.     

Immunophenotypic characteristics of cerebrospinal fluid cells in children with acute lymphoblastic leukemia at diagnosis

The presence of meningeal involvement in children with acute lymphoblastic leukemia (ALL) may have important prognostic and therapeutic implications. Conventional methods of diagnosing central nervous system (CNS) leukemia rely on the interpretation of cerebrospinal fluid (CSF) cell morphology, which may produce ambiguous results in the presence of minimal leukemic involvement. A methodology has been developed for immunophenotyping small numbers of CSF cells while preserving cell morphology. CSF samples from 33 children with CD10 (common ALL antigen [CALLA]) positive ALL were examined at initial presentation using both conventional morphology and this combined immunohistopathologic technique. Six (18%) of the samples contained lymphoblasts or cells considered morphologically suspicious for leukemic involvement. Nine additional samples (27% of the total) had normal CSF morphology, but contained increased numbers of CALLA positive cells. Twelve of the 33 samples were also examined for the simultaneous presence of nuclear terminal deoxynucleotidyl transferase (TdT) and demonstrated increased numbers of cells positive for both TdT and CD10. These data suggest that a large proportion of children with ALL may have abnormalities of CSF cells at initial diagnosis consistent with the presence of occult leukemic involvement.     

Early clinical experience with a new flexible endoscopic suturing method for natural orifice transluminal endoscopic surgery and intraluminal endosurgery (with videos)

BACKGROUND: To perform advanced endoscopic treatments, one has to be able to close defects and perforations. Many devices have been constructed to perform endoscopic suturing, but all are rather complicated, expensive, and difficult to use. OBJECTIVE: To develop and use a new simple stitching technique at intraluminal flexible endoscopy. DESIGN: A flexible 19-gauge needle, loaded with a metal tag attached to a 3-0 polypropylene thread is passed down the working channel of a conventional endoscope. Two tags are placed into the stomach or the intestinal wall, 1 on each side of the defect. The threads are then locked together and cut. Precise stitch positioning is possible. Multiple stitches can be placed quickly, without removal of the endoscope. SETTING: Surgical department at Sahlgrenska University Hospital in G?teborg, Sweden. PATIENTS: Three patients in whom other conventional treatments had failed. INTERVENTIONS: Initially, survival studies in pigs were performed, and full-thickness resections, pyloroplasty, and gastrojejunostomies could be completed. The technique was subsequently used in patients when surgery was not feasible and when other endoscopic interventions had failed. MAIN OUTCOME MEASUREMENTS: Clinical evaluation; successful sealing of defects, leaks, or a bleeding vessel. RESULTS: We present 3 human cases and describe endoluminal closure of a perforated duodenal ulcer, a leaking gastroenteroanastomosis after gastroplasty, and successful treatment of upper-GI bleeding by oversewing a bleeding vessel. CONCLUSIONS: This stitching technique is easy to use and makes endoscopic suturing possible for closure of perforations and tissue approximation almost anywhere in the GI tract that can be reached by a flexible endoscope.     

Histological changes following Nd YAG laser photocoagulation of canine gastric mucosa.

Tissue changes produced in the dog stomach by exposure to a Nd YAG laser varied from mild mucosal oedema to cell vaporisation. Intermediate degrees of damage caused a marked inflammatory response leading to extensive fibrosis in the submucosa and muscularis propria. The true extent of tissue damage was not apparent immediately, and treated mucosa that initially appeared intact sometimes sloughed several days later to leave an ulcer. The extent of damage and the rate of healing depended on the amount of laser energy used. With pulses at optimum laser power (75 w) and exposure time (0.4 sec), however, haemostasis was achieved in induced ulcers with total energy concentrations that did not produce full thickness tissue damage nor alter the healing rate from that observed in untreated ulcers. Thermal contraction was the primary haemostatic mechanism, thrombosis only occurring as a secondary effect.     

Hepatic concentrations of proenkephalin-derived opioids are increased in a rat model of cholestasis

Abstract: The liver of adult rats with cholestasis secondary to bile duct resection has been shown to express the proenkephalin gene and, by immunohistochemical stains, to contain met-enkephalin. To further study hepatic opioids in cholestasis, concentrations of proenkephalin-derived endogenous opioids were measured in a rat model of cholestasis by the use of radioimmunoassays. The specificity of the immunoreactivity detected by the assays was confirmed by high performance liquid chromatography (HPLC). In adult male rats with cholestasis due to BDR, the concentrations of three proenkephalin-derived opioid peptides were increased. Specifically, the mean hepatic concentrations of met-enkephalin, Met-Enk-Arg⁶-Phe⁷ and leu-enkephalin were 2.5 (p<0.005), 2.1 (p<0.005) and 2.5 (p<0.01) fold higher than the corresponding mean for controls. These findings provide further independent evidence that opioid peptides accumulate in the liver in a model of cholestasis and are consistent with de novo synthesis of opioid peptides occurring in the cholestatic liver. This phenomenon may have relevance to the altered function of the opioid system in cholestasis and to the role of the liver as a neuroendocrine organ.