Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia.

The authors treated 17 patients with achalasia by a thoracoscopic (15 patients) or laparoscopic (2 patients) Heller myotomy. All patients had dysphagia and an upper gastrointestinal series demonstrating a dilated esophagus with a bird-beak deformity at the cardia. Manometry showed a mean lower esophageal sphincter (LES) pressure of 32 +/- 4 mmHg, incomplete sphincter relaxation on swallowing, and no primary esophageal peristalsis. After operation, mean LES pressure was 10 +/- 2 mmHg. Fifteen patients were fed on the second postoperative day. The average hospital stay was 3 days, and there were no deaths or major complications. In three early patients, the myotomy was not carried far enough onto the stomach, and dysphagia persisted until a second myotomy was performed (laparoscopically in two patients). The authors found that having an endoscope in the esophagus during the operation facilitated exposure and was vital to determine the appropriate length of the myotomy. With regard to dysphagia, final results were excellent in 12 patients (70%), good in two patients (12%), fair in two patients (12%), and poor in one patient (6%). Heller myotomy can be safely and reliably performed with minimally invasive techniques. Dysphagia is relieved, postoperative pain is minimal, hospital stay is short, and the patient can return quickly to normal activity.     

Microstructure of the non-rapid eye movement sleep electroencephalogram in patients with newly diagnosed Parkinson's disease: effects of dopaminergic treatment.

We investigated non-rapid eye movement (non-REM) sleep in patients with newly diagnosed Parkinson's disease (PD) who had never previously received dopaminergic medication. There were no significant differences in the conventional sleep parameters between de novo patients with PD and a healthy control group, but the length of stage 1 sleep and the number of awakenings increased significantly upon administration of dopaminergic drugs. Analyzing the quantitative electroencephalogram (EEG), we observed a significant reduction in the low-delta frequency range and a nonsignificant increase in the sigma frequency range in de novo patients with PD. The dopaminergic medication also nonsignificantly reduced the low-delta and sigma frequencies, the latter to the level of the controls. Possible mechanisms that may account for the observed differences are discussed. It is suggested that Parkinson's disease as well as the application of dopaminergic drugs exerts a desynchronizing effect on the sleep EEG that is reflected in a disruption of sleep continuity.     

Zur Polypeptidketten-Struktur von Immunglobulinen

Zusammenfassung Individuelle normale IgG wurden isoelektrisch in eine Vielzahl von Komponenten getrennt, deren IP zwischen pH 5,5 und 9,5 lagen. Im Gegensatz dazu focussierten individuelle Myelom IgG einheitlich. Die isoelektrischen Punkte dieser Paraproteine unterschieden sich untereinander stark, verteilten sich alle zusammen jedoch ebenfalls über den pH-Bereich 5–9. Dieser Befund entspricht der Auffassung, daß diese Paraproteine normale Immunglobuline repräsentieren.Ähnliche Ergebnisse hatte die Fraktionierung der L- und H-Polypeptidketten. Während normale L- und H-Ketten eine ausgeprägte Heterogenität aufwiesen, waren die IgG-L- und H-Ketten von Myelomproteinen einheitlich. Mittels gleichzeitiger Anwendung der PAA-Elektrophorese, quantitativen Aminosäurenanalyse, Endgruppenbestimmung und anderer protein-chemischer Methoden konnte gezeigt werden, daß im Falle der L-Ketten sowohl die Aminosäureverteilung als auch die Konfiguration das unterschiedliche isoelektrische Verhalten bedingt. Die Anwendung der isoelektrischen Analyse für den Nachweis von Rekombinatbildungen aus L- und H-Ketten wurde gezeigt.

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Summary Myeloma IgG and its light and heavy polypeptide chains were subjected to isoelectric focusing in a vertical column containing a combined pH and density gradient. The results have been compared to those obtained by isoelectric separation of normal individual IgG and its polypeptide chains. In carrier ampholytes of two pH steps each individual myeloma globulin was focused in only one fraction, but the isoelectric points of all myeloma globulins were distributed between pH 5 and pH 9. In contrast to these results each normal individual IgG was electrofocused in a multiplicity of isoelectric fractions exhibiting the same pH range from pH 5 to pH 9. Similar results were obtained by the analysis of light and heavy polypeptide chains. A remarkable degree of heterogeneity could be demonstrated in normal and a homogenous isoelectric pattern in myeloma IgG polypepide chains. By polyacrylamide-gel-electrophoresis it could be demonstrated that a direct proportionality of isoelectric point and electrophoretic mobility in polyacrylamide-gel did'nt exist. By the quantitative aminoacid determination, endgroup analysis and other physico-chemical methods it could be shown, that differences in the isoelectric point of L-chains are not exclusively caused by differences in the amino acid composition. The use of isoelectric focusing for the analysis of L- and H-chains recombination has been demonstrated.

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Wir danken der Deutschen Forschungsgemeinschaft für ihre Unterstützung.     

Gender differences in chronic disease risk behaviors through the transition out of high school.

BACKGROUND: Major life transitions (e.g., graduation from high school) are times when many changes occur in a person's social and physical environment. Men and women likely experience aspects of these changes differently. As a result, health-related behaviors likely change at these times with possible differences in these changes by gender. METHODS: Gender differences in the performance of chronic disease risk-related behaviors (fruit, juice, and vegetable intake; physical activity; tobacco and alcohol use; and sexual practices) through the transition out of high school (HS) were assessed in a secondary analysis of a nationally representative sample from the 1992 National Health Interview Survey-Youth Risk Behavior Survey. The survey was completed by 5881 young people aged 14 to 21 years. Regression discontinuity analysis with piecewise regression was performed. RESULTS: Statistically significant gender by transition effects were obtained for exercise/physical activity (decreases at the transition point for males), snuff use (decrease for females in HS), binge drinking and number of days drinking alcohol (increases for males at the transition point), and use of alcohol or drugs before sexual intercourse (decrease for females post HS). Fruit intake decreased for males and females and daily and heavy cigarette smoking increased during the HS years. Effect sizes were small but promising, given that the data set was not designed to test this hypothesis. CONCLUSION: These data offer evidence of differences by gender in chronic disease risk behaviors through the HS transition. Longitudinal studies are needed to assess the true nature of these differences, the tracking of these risk behaviors and their personal, social, and environmental determinants, including gender-specific determinants, that may explain these changes and inform future intervention development.     

Restless legs syndrome and its treatment by dopamine agonists

The restless legs syndrome (RLS) characteristically presents with an irresistible urge to move that is most often accompanied by creeping sensations deep in the limbs. Occasionally the upper limbs can also be affected. RLS symptoms occur at rest and are typically more intense at night and at bedtime. Some patients complain about involuntary leg movements, so-called periodic limb movements (PLM), while at rest or PLM have been observed by the bed partner. Often, patients have to get out of bed several times at night, to relieve themselves of their disagreeable sensations.The prevalence of RLS is estimated to be about 5%. Up to now only three classes of drugs have been systematically evaluated for treatment of RLS: benzodiazepines, opioids and dopaminergic agents.The most consistent results have been obtained with dopaminergic drugs. Several studies have shown that L-dopa given with a peripheral decarboxylase inhibitor at a 10:4 ratio is effective in treating RLS. Controlled studies using polysomnographic recordings in a double-blind design showed that L-dopa administered at night produces a significant reduction of RLS occurring at bedtime and of PLM, which are often associated with nocturnal arousals. In most cases, L-dopa 100mg, in conjunction with the decarboxylase inhibitor carbidopa or benserazide 25mg, suppresses RLS although a rebound of PLM may be observed in the last part of the night. The two major adverse effects frequently seen in patients treated with L-dopa are:Augmentation is one of the limiting factors of L-dopa therapy; thus, alternative treatment options are of major interest. In several open treatment trials performed with pergolide, patients reported a marked improvement of RLS symptoms including sleep problems. Mild symptoms of augmentation under pergolide treatment have been reported from single patients. In another 6-month open label trial, pergolide proved to be effective in patients who developed augmentation under L-dopa by relieving daytime symptoms after switching to pergolide.Most recently, the results of these open label trials have been replicated in a randomized, placebo-controlled, double-blind multicenter trial. Treatment with a single evening dose of 0.25-0.75mg pergolide resulted in a significant improvement of almost all subjective and objective parameters. Under pergolide, patients rated their RLS symptoms and sleep disturbances much less severe and polysomnographic recordings also revealed a significant improvement of all important sleep parameters. To prevent peripheral side-effects such as nausea or orthostatic hypotension, pergolide should be slowly up-titrated or domperidone should be added. Under these conditions, no major side-effects have been observed in treatment trials with pergolide in dosages up to 1.25mg.Pergolide with a half-life of 12-16h thus appears to be an appropriate drug in the therapy of RLS especially in those patients who developed augmentation under L-dopa therapy. Owing to the remarkable therapeutic effect of pergolide on RLS symptom control, other dopamine agonists are presently being tested for the treatment of RLS.