[The laparoscopic treatment of esophageal achalasia. Our experience]

BACKGROUND

Laparoscopic Heller myotomy combined with a Dor fundoplication is considered the procedure of choice to treat esophageal achalasia. The aim of this study is to report a personal experience and to analyse the controversial aspect of this procedure.

METHODS

From January 1997 to March 1998 six patients with esophageal achalasia were treated by Heller laparoscopic myotomy with anterior fundoplication.

RESULTS

There was one intraoperative perforation of esophageal mucosa, sutured laparoscopically with non postoperative sequelae. There were no surgical mortality and no postoperative morbidity. Complete relief of dysphagia in five of six patients, the good clinical and instrumental results and the satisfaction of these patients, lead to a prudent optimism.

CONCLUSIONS

Personal initial experience, although the little number of patients and the short follow-up, confirms that laparoscopic cardiomyotomy is a safe and effective procedure for the treatment of esophageal achalasia.

A spatio-temporal comparison of semantic and episodic cued recall and recognition using event-related brain potentials

The event-related brain potential (ERP) was used to spatially and temporally map the brain areas active as a function of type of recall (semantic vs. episodic) and episodic retrieval mode (recall vs. recognition) while difficulty of episodic recall was manipulated. ERPs were recorded from 32 scalp sites in 12 subjects, along with behavioral accuracy and recall speed. The results revealed that different but overlapping patterns of ERP activity were elicited during semantic and episodic recall. Recall of both types of information was characterized by ERP activity over left inferior frontal, central, bilateral temporal and posterior inferior brain areas. Compared to semantic recall, episodic recall elicited more activity over the frontal poles and right frontal scalp. Different but overlapping patterns of ERP activity were also found as a function of episodic retrieval mode. While episodic recall and recognition showed similar activity over the frontal poles and central scalp, there was no left inferior frontal activity elicited during recognition and no large, topographically widespread, late positive component (LPC) elicited when the same words were recalled. Manipulation of episodic recall difficulty and analysis of trials when recall failed indicated that these task (i.e., episodic vs. semantic) and retrieval mode (recall vs. recognition) differences in ERP activity were not likely to be due to differences in task difficulty. The results are discussed in terms of processes that the ERP activity may reflect and their similarity to results of PET studies of semantic and episodic retrieval.

A spatio-temporal analysis of recognition-related event-related brain potentials

Words correctly recognized as previously studied (i.e. old) elicit greater amounts of positive event-related brain potential (ERP) activity over posterior scalp between 400 and 800 ms than do previously unstudied (i.e. new) words. While investigators have reported that this old/new effect consists of more than one subcomponent, the spatio-temporal parameters of these possible subcomponents, as well as any other patterns of brain activity associated with recognition, remain incompletely specified. Thus, ERPs were recorded from 32 scalp sites while 13 subjects performed four repetitions of a study-test recognition paradigm. The subjects' task was to decide whether each word was old or new and press the appropriate button as quickly as possible. The timing and topography of the ERPs elicited by old and new words was assessed with topographic profile comparisons on the areas with a variety of temporal windows, and visualized with potential and CSD maps. The results revealed that seven patterns of ERP activity, dissociable on the basis of their topography, timing and response to experimental variables, were elicited between 300 and 2000 ms. Three of these appeared as subcomponents of the old/new effect (maximal over left medial frontal, left parietal-occipital and right central-frontal scalp), another was related to decision confidence and/or memory trace strength (maximal over left central scalp) and three others appeared to be related to more general aspects of recognition (maximal over the frontal poles, midline frontal scalp and right frontal scalp). Taken together, the seven distinct patterns of neural generator activity described here support the hypothesis that retrieval of information from episodic memory depends on a collection of different processes that occur in a temporally and spatially distributed neural circuit.

[Laparoscopic incidental diagnosis: treatment during laparoscopic surgery]

BACKGROUND

The authors consider the importance of laparoscopic exploration of the abdominal cavity for the diagnosis of mistaken preoperative pathologies, during laparoscopic surgery.

RESULTS

In our series the incidental diagnosis is 5.3%.

CONCLUSIONS

The additional treatment diagnosis is realized when there is no great surgical engagement or when there are risks for the patient's life (i.e.: hemorrhagic ovarian cyst). In case of incidental neoplasia diagnosis it would been more appropriate to do a biopsy only, for typing. The realization of demanding or non-programmed surgical operations must be consequent on written consent.

QTc and not QTc dispersion behavior affects the occurrence of ventricular extrasystole during exercise in infarcted patients

Both a long QTc and a large QTc dispersion (QTcd) can predispose infarcted patients to ventricular arrhythmias. The former simply reflects a general prolongation of ventricular recovery time, whereas QTcd is useful for revealing regional inhomogeneities of ventricular repolarization. The aim of our study was to evaluate QTc and QTcd behavior during exercise in 50 patients (all men) with previous myocardial infarction, and its possible correlation with the occurrence of exercise-induced premature ventricular complexes (EIPVC). Our patients underwent ergometric stress test with a load increase of 25 W, every 2 min, until the maximal age-related heart rate or symptoms were obtained, followed by a 10-min recovery phase. QTc and QTcd measurement was performed at rest (BS) and during exercise at two progressively increasing heart rate steps: 100-115 beats/min (T1) and 116-130 beats/ min (T2). The patients were divided into two groups according to the absence (group A; n = 22) or presence (group B; n = 28) of EIPVC. In terms of QTcd, no significant difference was found between the two groups at BS, T1, and T2. As for the mean QTc (QTcm), it was significantly longer in group B at BS (416 +/- 22 ms versus 395 +/- 19 ms; P = 0.001) and at T1 (431 +/- 24 ms versus 410 +/- 8 ms; P = 0.0001). When group B was further differentiated into two subgroups-Bx and Bz-according to the severity of EIPVC, we noted that patients with the most severe arrhythmic response (group Bz; n = 12) showed a persisting, significantly longer QTcm than group A (BS, 426 +/- 28 ms versus 395 +/- 19 ms; P < 0.05; T1, 445 +/- 24 ms versus 410 +/- 8 ms; P < 0.05; T2, 427 +/- 17 ms versus 412 +/- 14 ms; P < 0.05), and group Bx (n = 16) (BS, 426 +/- 28 ms versus 409 +/- 15 ms; P < 0.05; T1, 445 +/- 24 ms versus 420 +/- 19 ms; P < 0.05; T2, 427 +/- 17 ms versus 410 +/- 17 ms; P < 0.05). Group Bx showed a significantly longer QTcm than group A only at BS (409 +/- 15 ms versus 395 +/- 19 ms; P < 0.05). No significant difference in QTcd was found between the three groups at BS, T1, and T2. We also noted that the relationship between QTcm and QTcd was modified by the exercise, changing from a trend of direct relation at BS, towards an inverse one during effort, which reached significance at T2 (r = -0.319; P = 0.037). Based on our data, EIPVC occurrence seems to be more affected by the total duration rather than by regional inhomogeneities of the ventricular recovery time. In those patients with the most severe arrhythmic response, the autonomic modifications generated by the exercise succeed in attenuating only the regional inhomogeneities, but do not eliminate the differences in total duration of the repolarization period.

Ionic mechanisms of ischemia-related ventricular arrhythmias

The aim of this review is the utmost simplification of the cellular electrophysiologic background of ischemia-related arrhythmias. In the acute and subacute phase of myocardial infarction, arrhythmias can be caused by an abnormal impulse generation, abnormal automaticity or triggered activity caused by early or delayed afterdepolarizations (EAD and DAD), or by abnormalities of impulse conduction (i.e., reentry). This paper addresses therapeutic intervention aimed at preventing the depolarization of "pathologic" slow fibers, counteracting the inward calcium (Ca) influx that takes place through the L-type channels (Ca antagonists), or hyperpolarizing the diastolic membrane action potential, increasing potassium (K) efflux (K-channel openers) in arrhythmias generated by an abnormal automaticity (ectopic tachycardias or accelerated idioventricular rhythms). If the cause enhanced impulse generation is related to triggered activity, and since both EAD and DAD are dependent on calcium currents that can appear during a delayed repolarization, the therapeutic options are to shorten the repolarization phase through K-channel openers or Ca antagonists, or to suppress the inward currents directly responsible for the afterdepolarization with Ca blockers. Magnesium seems to represent a reasonable choice, as it is able to shorten the action potential duration and to function as a Ca antagonist. Abnormalities of impulse conduction (re-entry) account for the remainder of arrhythmias that occur in the acute and subacute phase of ischemia and for most dysrhythmias that develop during the chronic phase. Reentrant circuits due to ischemia are usually Na channel-dependent. Drug choice will depend on the length of the excitable gap: in case of a short gap (ventricular fibrillation, polymorphic ventricular tachycardia, etc.), the refractory period has been identified as the most vulnerable parameter, and therefore a correct therapeutic approach will be based on drugs able to prolong the effective refractory period (K-channel blockers, such as class III antiarrhythmic drugs); on the other hand, for those arrhythmias characterized by a long excitable gap (most of the monomorphic ventricular tachycardias), the most appropriate therapeutic intervention consists of depressing ventricular excit-ability and conduction by use of sodium-channel blockers such as mexiletine and lidocaine. Compared with other class I antiarrhythmic agents, these drugs minimally affect refractoriness and exhibit a use-dependent effect and a voltage dependent action (i.e., more pronounced on the ischemic tissue because of its partial depolarization).

Correlation between late potentials duration and QTc dispersion: Is there a causal relationship?

QTc interval dispersion (QTcd) analysis (difference between maximum and minimum QTc calculated from at least five of the standard 12 ECG leads) and signal-averaged electrocardiograms were performed on 23 patients referred to our coronary care unit because of acute myocardial infarction. Late potentials were considered positive if all three of the following criteria were satisfied: (1) total QRS duration (QRSd) > 114 ms; (2) duration of QRS under 40 muV (LAS 40) > 38 ms; (3) root mean square voltage of the last 40 ms of QRS (RMS 40) < 25 muV. Patients were divided into two groups according to the presence (group A, 9 patients) or absence of late potentials (group B, 14 patients). Group A patients showed a significantly higher QTcd (0.0652 +/- 0.0177 s vs. 0.0448 +/- 0.0201 s; P = 0.021) and a significantly longer mean QTcm (0.43117 +/- 0.01817 s vs. 0.40472 +/- 0.03013 s; P = 0.028) than group B patients. Among the three different parameters used to define the presence of late potentials, QTcd was significantly related to LAS 40 (r = 0.418, P = 0.047) and mean QT cm to QRSd (r = 0.497; P = 0.016). We also found a significant correlation between QTcd and mean QTcm (r = 0.426; P = 0.043). In conclusion, our data suggest that (1) the presence of late potentials is associated with a greater dishomogeneity of ventricular recovery time; (2) the longer the duration of late potentials, expressed by LAS 40, the greater the QTcd, suggesting that the dispersion of repolarization could be attributed to slowly conducting areas from which late potentials arise; (3) mean QTcm is not useful to identify these areas because it is more affected by total rather than by terminal QRS duration; (4) regional discrepancies of ventricular recovery time are connected with general repolarization duration.

[Sex hormones, glycolipid metabolism, and atherogenesis]

The prevalence of coronary artery disease is lower in women than in men. Ovarian estrogen is believed to decrease the risk of coronary heart disease. Today, there is an increasing demand for estrogen replacement not only for amelioration of menopausal subjective symptoms but also for the prophylactic action of estrogen against osteoporosis in postmenopausal women. Is generally agreed that estrogen replacement therapy reduces cardiovascular morbidity and mortality in postmenopausal women. Estrogen replacement therapy may protect against coronary heart disease by altering plasma lipoprotein concentrations, by increasing HDL cholesterol and decreasing LDL cholesterol, and thereby inhibiting progression of coronary artery atherosclerosis. Oral contraceptive can induce deterioration in glucose tolerance that has consistently been associated with insulin excess and insulin resistance. This situation can increase the coronary heart disease risk. New findings suggest that there may be independent cardioprotective effects of estrogen, such a direct inhibitory influence on thrombosis, vasospasm or atherogenesis, inhibiting atherosclerotic plaque formation in arterial walls.

[Estrogens, left ventricular function and coronary circulation: what are the possibilities of therapeutic use?]

Low-dose estrogen replacement therapy should be recommended to post-menopausal women, especially if they suffer from circulatory disorders, because it significantly reduces cardiovascular risk. Low-dose estrogens favourably affects lipid profile, without causing a significant increase of thrombotic risk: atherosclerosis is therefore prevented. Estrogen can augment coronary flow by the relaxation of vascular smooth-muscular cells. Finally, estrogen can improve left ventricle systolic and diastolic function, delaying the physiological aging process.

[Structural analysis of the gene for the beta chain of the antigen-specific receptor of mammalian T-lymphocytes]

The antigen specific receptor of T cells (TCR) is composed of alpha and beta chains and is normally present on the T cell surface complexed with the components which make up T3. In the case of beta chain, multiple somatic DNA rearrangements bring together V beta (variable), D beta (diversity) and J beta (joining) gene segments before a mature messenger RNA can be transcribed. So far beta chain genes have been extensively studied in the human and in the mouse system and we have very little information on other mammals. Our aims were to obtain information that may provide a structural basis for understanding developmental as well as evolutionary aspects of the TCR gene system in mammals. In this study we compare the hybridization pattern between a human cDNA probe coding for the beta chain constant region and restricted genomic DNA extracted from lymphocytes deriving from human as well as from rat and lamb. The comparison of the hybridization data represent a first piece of information about the variation of the structure of the TCR beta chain genes in mammals.