Therapeutic Research

腹腔鏡下胃瘻造設術の上部消化管motilityへの影響について後方視的に検討した。対象は経口摂取困難の重度障害児16例（1 ～ 17歳）であった。対象を術前の酸逆流時間率（reflux index：RI）でGroupⅠ（RI＜10.0％，n＝9）とGroupⅡ（RI≧10.0％，n＝7）に分け，24時間食道インピーダンスpH検査と13C呼気胃排出検査結果を術前後で比較検討した。術後にGroupⅠでは酸逆流回数が増加したが，GroupⅡではRIと酸クリアランス時間が低下した。胃排出能は全体ではT1/2とgastric emptying coefficien（t GEC）が改善し，GroupⅡではGECは改善し，T1/2 は改善する傾向を示した。胃食道逆流（gastroesophagealreflux：GER）が高度なGroupⅡの症例では腹腔鏡下胃瘻造設術によって酸逆流と胃排出遅延が改善される可能性が示唆された。

われわれが開発したcardiac –type mucosaが発生するラット胃・十二指腸液逆流モデルでは，手術後50 週において膵上皮化生が必発している。ヒトの症例では，膵上皮化生は食道胃接合部付近にみられることが多く，外分泌の膵腺房細胞のみで構成されている。その発生機序については，先天的なものであるとの報告がある一方でBarrett 食道の発生と関連しているとの報告もあり，いまだ明らかにされていない。本研究結果は，膵上皮化生が後天的に発生する可能性を示唆するとともに，食道胃接合部の生検組織や内視鏡的粘膜切除標本などで膵上皮化生が確認できた場合には，胃や食道内に十二指腸液の逆流が起こっている可能性があることを示唆するものである。

目的：循環器医による高齢者高血圧薬物療法の現状を明らかにする。方法：札幌医科大学第二内科およびその関連施設の循環器医を対象に，外来受診の高血圧連続20 症例についてケースカード調査を行い，非高齢者，前期高齢者，後期高齢者の3 群に分けて対比した。結果：3,186 例が解析対象となり，そのうち非高齢者は1,064例，前期高齢者は1,018例，後期高齢者は1,104例であった。高齢になるに従ってCa拮抗薬（CCB）の処方率は68.2％，73.0％，75.5％と漸増し，アンジオテンシン受容体拮抗薬（ARB）はおのおの67.8％，64.2％，61.8％とむしろ低下し，後期高齢者ではアンジオテンシン変換酵素（ACE）阻害薬を加えたレニン– アンジオテンシン（RA）系抑制薬で検討しても，CCBの処方率を下回った。また，利尿薬の使用率はCCBと同様に高齢になるにつれて増大し，後期高齢者では30％を上回った。平均薬剤使用数は高齢になるにつれて，1.96剤，2.00剤，2.12 剤と漸増し，主治医判定による血圧コントロール良好例は60.8％，60.3％，62.5％と後期高齢者で増加した。まとめ：高齢者では，RA系抑制薬よりはCCBが優先して使用されていた。利尿薬は，各種の代謝に対する影響を考慮しても良好な降圧の観点からは高齢者ではむしろ積極的に使用された結果，平均処方数が多くなり，これらのことが非高齢者と変わらぬ良好な血圧コントロールに寄与していると推察された。

Post –marketing surveillance was conducted to evaluate the safety and effectiveness of long term use of Adoair® 250 Diskus®(salmeterol xinafoate/fluticasone propionate combination dry –powder inhaler [SFC]) in patients with chronic obstructive pulmonary disease(COPD) in clinical practice. This was a non –interventional, observational study and COPD patients who were naïve to SFC were enrolled and observed for 1 year. Safety was assessed based on adverse events, and effectiveness on the physician’s overall assessment, the rate of COPD exacerbations(hospitalization, emergency outpatient visits, unscheduled outpatient visits, and use of antibiotics or oral corticosteroids), lung function(forced expiratory volume in one second [FEV1], forced vital capacity [FVC]) and quality of life(QOL) assessment. Among 1,801 patients in the safety analysis set, the incidence of adverse drug reactions (ADRs) was 14.0%. Most frequently reported ADRs included bacterial pneumonia, dysphonia, bronchitis, pneumonia, oral candidiasis, and oropharyngeal pain. Among 1,628 patients in the effectiveness analysis set, the rate of effectiveness was 72.6% in overall assessment. Decreased rate of COPD exacerbations, improvements in lung function and QOL were observed compared to before SFC treatment. SFC treatment did not cause a significant difference in the incidence of pneumonia as an adverse event; confirmed pneumonia was found in 121 patients(6.8%) after SFC treatment and in 114 patients(6.4%) during 1 year before the start of treatment. Analysis of predictors of the risk of pneumonia revealed higher odds ratios in patients with low body mass index(BMI) and those who had COPD exacerbations during 1 year before the start of treatment. Risk factors for severe exacerbations(COPD exacerbations resulting in hospitalization) were consistent with those of pneumonia. The safety and effectiveness of long term use of SFC were confirmed in patients with COPD in Japanese clinical practice.

Objectives:To elucidate the efficacy of pramipexole extended –release(PPX–ER) formulation for the treatment of Parkinson’s disease(PD) in clinical practice, we investigated PD patients who received regular outpatient treatment with PPX –ER at our department. Methods:Fifty –five patients in whom pramipexole immediate –release(PPX–IR) had been switched to PPX –ER(switch patients) and 37 patients who had been newly administered PPX–ER(newly –administered patients) at our department between July 2011 and May 2013 were included in the study. We retrospectively investigated the clinical characteristics and the efficacy and safety of treatment with PPX –ER based on patients’ medical records. Results:Baseline characteristics of switch patients were as follows: age, 68.7 ±8.3 years; female, 60.0%; duration of PD, 10.4 ±5.8 years; Hoehn & Yahr stage, 3.0 ±0.7; and the presence of wearing –off phenomenon, 58.2%. Improvement was observed in 21 out of 53 patients who were evaluated efficacy(39.6%). Side effects occurred in 20.0% of patients (11/55 patients), and 90.9% of patients(50/55 patients) continued PPX–ER throughout the study. In the newly –administered patients, baseline characteristics were as follows:age, 67.7 ±8.9 years; female, 56.8%, duration of PD, 6.6 ±5.4 years, Hoehn & Yahr stage, 2.4 ±0.8; and the presence of wearing –off phenomenon, 32.4%. Sixteen out of 31 patients who were evaluated efficacy showed an improvement (51.6%). 10.8% of patients(4/37 patients) reported side effects, and 94.6% of patients(35/37 patients) continued PPX –ER.Conclusions:Switching from PPX–IR to PPX–ER and newly administration of PPX–ER in PD patients are effective and well tolerated in clinical practice.

The author attempted for the first time a new sclerotherapy using microfiber threadafter soaked in 2 mL of 3% polidocanol solution placed inside the great saphenous vein. This study reports the first trial of 16 cases of great saphenous varicose vein treatment using microfiber of 2 mm in diameter. Before surgery, a small stainless steel tube tip of 20 mm in length must be attached to one side of a microfiber of 120 cm in length using a crimper at laboratory. Operative procedure begins with exposure of the great saphenous vein at the ankle with small skin incision and insertion of a conventional guide wire toward the groin. After the inserted guide wire came out from the great saphenous vein at the groin, distal end of the guide wire was cutted off with a sterile commercially available nipper. And polidocanol dipped microfiber with attached stainless tube tip was fixed firmly to the excised stump of the guide wire with the aid of the same nipper. Then it was pulled inside the great saphenous vein and was placed in it in situ. After about 20 hours, intravascular placed microfiber thread was pulled out and all patients had discharged. One week after surgery, total occlusion of the great saphenous vein was confirmed by a Doppler Duplex in all cases. No complications were observed. Day surgery under local anesthesia could be successfully performed in all cases.