Anesthetic considerations for patients with esophageal achalasia undergoing peroral endoscopic myotomy: a retrospective case series review

Purpose

Peroral endoscopic myotomy (POEM) is a novel technique for treating esophageal achalasia. During POEM, carbon dioxide (CO₂) is insufflated to aid surgical dissection, but it may inadvertently track into surrounding tissues, causing systemic CO₂ uptake and tension capnoperitoneum. This in turn may affect cardiorespiratory function. This study quantified these cardiorespiratory effects and treatment by hyperventilation and percutaneous abdominal needle decompression (PND).

Methods

One hundred and seventy-three consecutive patients who underwent POEM were included in this four-year retrospective study. Procedure-related changes in peak inspiratory pressure (p_max), end-tidal CO₂ levels (etCO₂), minute ventilation (MV), mean arterial pressure (MAP), and heart rate (HR) were analyzed. We also quantified the impact of PND on these cardiorespiratory parameters.

Results

During the endoscopic procedure, cardiorespiratory parameters increased from baseline: p_max 15.1 (4.5) vs 19.8 (4.7) cm H₂O; etCO₂ 4.5 (0.4) vs 5.5 (0.9) kPa [34.0 (2.9) vs 41.6 (6.9) mmHg]; MAP 73.9 (9.7) vs 99.3 (15.2) mmHg; HR 67.6 (12.4) vs 85.3 (16.4) min^?1 (P < 0.001 for each). Hyperventilation [MV 5.9 (1.2) vs 9.0 (1.8) L·min^?1, P < 0.001] was applied to counteract iatrogenic hypercapnia. Individuals with tension capnoperitoneum treated with PND (n = 55) had higher peak p_max values [22.8 (5.7) vs 18.4 (3.3) cm H₂O, P < 0.001] than patients who did not require PND. After PND, p_max [22.8 (5.7) vs 19.9 (4.3) cm H₂O, P = 0.045] and MAP [98.2 (16.3) vs 88.6 (11.8) mmHg, P = 0.013] decreased. Adverse events included pneumothorax (n = 1), transient myocardial ischemia (n = 1), and subcutaneous emphysema (n = 49). The latter precluded immediate extubation in eight cases. Postanesthesia care unit (PACU) stay was longer in individuals with subcutaneous emphysema than in those without [74.9 min (34.5) vs 61.5 (26.8 min), P = 0.007].

Conclusion

Carbon dioxide insufflation during POEM produces systemic CO₂ uptake and increased intra-abdominal pressure. Changes in cardiorespiratory parameters include increased p_max, etCO₂, MAP, and HR. Hyperventilation and PND help mitigate some of these changes. Subcutaneous emphysema is common and may delay extubation and prolong PACU stay.

     

Peripartum changes in partnership quality among women with and without anxiety and depressive disorders prior to pregnancy: a prospective-longitudinal study

The purpose of this study is to prospectively examine peripartum changes in partnership characteristics among women with and without anxiety and depressive disorders prior to pregnancy. In the prospective-longitudinal Maternal Anxiety in Relation to Infant Development (MARI) study, n?=?306 expectant mothers completed up to seven waves of assessment from early pregnancy until 16 months postpartum. Lifetime anxiety and depressive disorders according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) were evaluated at baseline using the Composite International Diagnostic Interview for Women (CIDI-V, Martini et al. 2009). Partnership characteristics were assessed during pregnancy as well as 4 and 16 months postpartum using the Partnership Questionnaire (Hahlweg 1996). Linear regressions were applied to test associations between diagnostic status prior to pregnancy and peripartum partnership characteristics. Compared to women without anxiety and depressive disorders prior to pregnancy, women with comorbid anxiety and depressive disorders reported less tenderness during pregnancy, less postpartum tenderness, satisfaction, and overall partnership quality as well as a lower decrease in communication from pre- to postpartum. Women with pure depressive disorders and comorbid anxiety and depressive disorders prior to pregnancy indicated a higher increase in quarreling from pre- to postpartum. Findings suggest that women with depressive (and comorbid anxiety) disorders prior to pregnancy are at elevated risk for an unfavorable peripartum partnership development and might thus profit from targeted family interventions during this period.     

Nachweis von Adenovirus-Partikeln beim Pferd

Ohne Zusammenfassung

---

Isolation of adenovirus particles from horse

     

Measurement of free human leukocyte elastase and human leukocyte elastase/alpha 1 proteinase inhibitor complexes by an enzyme-linked immunosorbent assay

We report on an ELISA procedure for the quantitative analysis of total human leukocyte (PMN)-elastase, i.e., the simultaneous determination of (i) free (non-complexed) PMN-elastase and of (ii) PMN-elastase that is complexed to alpha 1 proteinase inhibitor. Simultaneous detection of both forms of PMN-elastase was achieved using a monoclonal antibody that recognizes a PMN-elastase-specific epitope present on both the uncomplexed and the complexed form of the enzyme. The test system described is reliable, easy to perform and permits the determination of total PMN-elastase in complex biological fluids such as plasma or seminal fluid. It is to be expected that this test system will be useful for investigations of human PMN-elastase in biological specimens obtained from both normal and pathological conditions.     

The glycosphingolipid globoside as a serological marker on cytolytic T lymphocyte precursors and alloantigen-responsive proliferating T lymphocytes in murine spleen

Biochemical analyses of murine lymphocytes have shown that the glycosphingolipid globoside (Glo) is present exclusively on alloantigen-stimulated murine T lymphocytes (Gruner, K. R., Van Eijk, R. V. W. and Mühlradt, P. F., Biochemistry 1981. 20: 4518). An anti-Glo antibody has now been raised in rabbits immunized with purified antigen. Most activity was recovered in the IgM fraction. The specificity of the antibody was ascertained in an enzyme-linked immunosorbent assay with purified glycosphingolipids bound to the solid phase. In antibody-dependent complement lysis experiments the anti-Glo eliminated about 20% of nylon wool-nonadherent splenic T cells of CBA/J mice. To determine the functional identity of these Glo+ cells, the effects of Glo+ cell elimination on mitogen stimulation with concanavalin A and lipopolysaccharide, as well as the effects on the mixed lymphocyte culture (MLC) reaction and cell-mediated lympholysis with mitomycin-treated DBA/2 splenocytes as stimulator cells were studied. Whereas lipopolysaccharide stimulation was not affected by elimination of Glo+ cells, there was a slight inhibitory effect on the concanavalin A stimulation, and a severe inhibition of the MLC reaction and the generation of H-2d-specific cytolytic T lymphocytes. Addition of interleukin 2 increased the MLC reaction, but interleukin 2-saturated cultures were also severely inhibited by anti-Glo and complement treatment. Combined treatment with anti-Glo and anti-Lyt-1 or anti-Lyt-2 antibodies, and determination of cytolytic T lymphocyte precursor frequencies in limiting dilution cultures after Glo+ cell elimination showed that a large proportion of T cells proliferating in a primary MLC are Lyt-1+,2+,3+Glo+, whereas in secondary MLC they are Lyt-1+,2-,3-,Glo+. Fifty % of the cytolytic T lymphocyte precursors in primary as well as secondary MLC are Glo+. The Glo marker is lost upon differentiation to cytolytic T lymphocyte effector cells. It is discussed herein that Glo is a marker for alloantigen-stimulated precursor T lymphocytes of both helper and cytolytic T cells.     

Delineation of distinct tumour profiles in mantle cell lymphoma by detailed cytogenetic, interphase genetic and morphological analysis

Mantle cell lymphoma (MCL) is an aggressive lymphoid tumour characterized by the translocation t(11;14)(q13;q32) and a poor clinical outcome (median survival: 3–4 years). Recent studies revealed that increased proliferation of the tumour cells and certain chromosomal aberrations, such as deletions of 17p13 and 9p21 represent major adverse biological markers in this disease, although the molecular targets of chromosomal imbalances in MCL have not been identified for the large majority of loci affected. To correlate histomorphological and proliferation features of MCL with genetic findings, we investigated 223 MCL by fluorescence in situ hybridization (FISH) ( n  = 157) and/or classical cytogenetic banding analysis ( n  = 129). FISH analysis turned out to be distinctly more sensitive in the delineation of aberrations. Complex karyotypic alterations were associated with higher proliferation indices and inferior prognosis. A comprehensive analysis of biological features including genetic alterations in MCL by hierarchical clustering resulted in the delineation of four tumour subgroups differing with respect to their genetic constitution and suggesting different transformation or progression pathways. Moreover, in one of the groups identified, a more indolent clinical behaviour was associated with few secondary aberrations and fewer known high-risk chromosomal aberrations, which points to the importance of the quality of karyotypic evolution in MCL tumours.     

Sensitivity of Neisseria gonorrhoeae to penicillin in West Germany.

The sensitivity of gonococci to penicillin in Germany has largely decreased in the last 22 years. No significant decrease has occurred, however, in the last three years, but the results show that a slight tendency to decrease may be persisting.     

Effect of a corticosteroid additive on the result of local therapy of bacterial superinfection in tinea pedis intertriginosa]

Sixty cases of tinea pedum intertriginosa were topically treated in a double-blind trial. In 34 cases a cream was used, which contained 5-chloro-8-hydroxyquinoline, gentamycin and fluprednyliden-21-acetate. In 26 cases a cream was used, which contained 5-chloro-8-hydroxyquinoline and gentamycin alone. Treatment was continued over three weeks. In weekly intervalls mycological, bacteriological and clinical controls were performed, which showed that the steroid-component had no disadvantageous effect on the course of infection. In contrast the steroid containing preparation proved to be slightly superior.     

Human sperm penetration in different media

Sperm penetration into bovine cervical mucus and hen egg white using capillary tube penetration was investigated to verify the suitability of the capillary tube penetration test with hen egg white as a test of human sperm function. Semen samples from 50 consecutive patients were used for penetration tests and spermatozoa of a further 10 semen samples were penetrated into bovine cervical mucus and hen egg white for special motility assessment by computer-assisted motility analysis. Penetration tests revealed the well-known different ability of spermatozoa to penetrate into cervical mucus and a different penetration of spermatozoa into egg white for two nearly equal groups (n = 24 and n = 26, respectively). One group showed penetration comparable with cervical mucus and one group a very fast penetration up to the limit of the scale of measurement. Motility assessment of spermatozoa that penetrated into cervical mucus and egg white revealed significant differences in straight-line velocity, linearity and lateral head displacement. The number of spermatozoa selected actively during the penetration procedure was significantly higher in cervical mucus than in hen egg white. Spermatozoa selected by bovine cervical mucus and hen egg white exhibited a different motility pattern. There was significantly better linearity and less lateral head displacement in egg white than in cervical mucus. Sperm penetration into hen egg white appeared to be influenced by different sources of egg white.     

Cardiac index assessment using bioreactance in patients undergoing cytoreductive surgery in ovarian carcinoma

This clinical study compared the cardiac index (CI) assessed by the totally non-invasive method of bioreactance (CI_BR) (NICOM?, Cheetah Medical, Vancouver, USA) to transpulmonary thermodilution (CI_TD) during cytoreductive surgery in ovarian carcinoma. The hypothesis was that CI could be assessed by bioreactance in an accurate and precise manner including accurate trending ability when compared to transpulmonary thermodilution. In 15 patients CI_BR and CI_TD were assessed after induction of anesthesia, after opening of the peritoneum, hourly during the operative procedure, and 30 min after extubation. Trending ability was assessed between the described timepoints. In total 84 points of measurement were analyzed. Concordance correlation coefficient for repeated measures correlating the CI_BR and CI_TD was 0.32. Bias was 0.26 l/min/m² (limits of agreement ?1.39 and 1.92 l/min/m²). The percentage error was 50.7 %. Trending ability quantified by the mean of angles θ which are made by the ΔCI vector and the line of identity (y = x) showed a value for CI_BR of θ = 23.4°. CI assessment by bioreactance showed acceptable accuracy and trending ability. However, its precision was poor. Therefore, CI measurement can not be solely based on bioreactance in patients undergoing cytoreductive surgery in ovarian carcinoma.