Respiratory failure and intraoperative oxygenation following oesophagectomy

Respiratory complications are a major cause of morbidity andmortality following oesophagectomy.¹ We hypothesized that patientswho develop postoperative respiratory failure would have anunstable intraoperative course. Two stage oesophagectomy requiresa period of one lung ventilation (OLV) and one measure of intraoperativeinstability is desaturation during OLV. We therefore studiedthe relationship between Sa_O2 during OLV and postoperative course.Previous work has focused on preoperative factors associatedwith postoperative complications.² There is little informationon intraoperative factors that may influence outcome. We performed a retrospective analysis of all elective oesophagectomiesperformed between January 1998 and August 1999. Seventy-sevenpatients had a 2-stage sub-total oesophagectomy requiring OLV.Oxygen saturation recorded on the anaesthetic chart during OLVwas plotted on a fixed linear scale of 0–100% againsttime for each patient. The area above the curve was calculated,as a measure of intraoperative oxygenation during OLV. Thiswas standardized by dividing the area by the OLV duration, thusobtaining the Area Per Unit Time (APUT). The postoperative courseof each patient was recorded including outcome, total durationof ITU stay and the worst Pa_O2/F_O2 ratioattained. ARDS was defined using the American-European ConsensusConference on ARDS criteria. Twenty-one patients had a prolongedITU stay (>48 h) and all had a persistent Pa_O2/F_O2<27. Thirteen patients (17% of the total) fulfilled the ConsensusConference criteria for ARDS and seven of these died in hospital. Total OLV time was not significantly different between the groupsbut patients who developed ARDS had significantly greater intraoperativehypoxaemia as measured by the APUT (Table 17). We conclude thatintraoperative hypoxaemia is associated with respiratory failurefollowing oesophagectomy.     

Difficulties in diagnosing intrinsic spinal cord tumours.

Thirteen children with intrinsic spinal cord tumours were seen between 1984 and 1995. In only one was this the presumptive diagnosis at referral, despite a high incidence of characteristic features. Eight had presented to their local paediatrician, four to local orthopaedic teams, and one to a general surgeon. Eleven had back pain. Eleven had either spinal curvature or change in gait. The interval between onset of symptoms and diagnosis ranged from one week to six years, with a mean of 17.5 months. In nine children symptoms had been present for four or more months. In nine, unrewarding investigations had been carried out. This paper highlights typical presenting features of these tumours and how earlier diagnosis can be achieved.     

Pharmacologic responses of cells of a neuroblastoma x glioma hybrid clone and modulation of synapses between hybrid cells and mouse myotubes

Cells of the hybrid clone NG108-15 responded to 5-hydroxytryptamine (5-HT), dopamine or acetylcholine with graded depolarizations involving membrane conductance increases. Responses desensitized during continuous application of the neurotransmitters, and responses to 5-HT and dopamine cross-desensitized: a desensitizing application of one neurotransmitter also desensitized the hybrd cell to the other neurotransmitter. 5-HT and acetylcholine did not cross-desensitize. The hybrid cell 5-HT response was not attenuated by D-LSD, and was blocked by 10(-5) M morphine, although not via binding to naloxone-sensitive opiate receptors. 5-HT or the prostaglandin PGF2alpha caused the release of acetylcholine at the synapses of hybrid cells with mouse myotubes. Application of 5-HT or PGF2alpha also facilitated the synaptic release elicited by hybrid cell action potentials. Following treatment with the antimitotic agent cytosine arabinoside, co-cultures of hybrid cells and mouse myotubes exhibited plentiful synaptic connections only if maintained in medium containing 1 mM dibutyryl cAMP (dBcAMP). After X-irradiation, co-cultures were synaptically active even in the absence of dBcAMP. Thus, methods have been found to regulate both the short-term and long-term synaptic activity of NG108-15 hybrid cells.     

The role of gluten, milk, and other dietary proteins in chronic or intermittent dyspepsia

In twenty-seven patients with chronic or intermittent dyspepsia raised levels of the gamma-M-globulin and of the α₁- and of the α₂-globulin were encountered. Malabsorption, present in about three-quarters of the cases, was usually mild. Various degrees of villous abnormalities were seen but no flat mucosa. Eight patients also had dermatitis. During dietary treatment with the elimination of gluten, milk, or other food elements the dyspepsia and the malabsorption subsided in all but two, and the dermatitis in all but one. In nearly all the investigated cases the raised levels of the gamma-M-globulin and of the α₁- and of the α₂-globulin decreased. During challenge feeding with the offending food the dyspepsia and the dermatitis reappeared. Also the faecal fat excretion increased again, and a rise was noticed in the α₁- and in the α₂-globulins and in the gamma-M-globulins. The findings suggest that gluten, milk and other dietary proteins may play a role in some chronic dyspepsias by exerting an antigenic stimulus on the small intestinal mucosa, and thus inducing a state of hypersensitivity towards these foods. The clinical and laboratory findings favour the view that the condition is different from coeliac disease