Effects of high-intensity exercise training on physical fitness, quality of life and treatment outcomes after oesophagectomy for cancer of the gastro-oesophageal junction: PRESET pilot study

Background

Treatment for cancer of the gastro‐oesophageal junction (GOJ) can result in considerable and persistent impairment of physical fitness and health‐related quality of life (HRQoL). This controlled follow‐up study investigated the feasibility and safety of postoperative exercise training.

Methods

Patients with stage I–III GOJ cancer were allocated to 12 weeks of postoperative concurrent aerobic and resistance training (exercise group) or usual care (control group). Changes in cardiorespiratory fitness, muscle strength and HRQoL were evaluated. Adherence to adjuvant chemotherapy, hospitalizations and 1‐year overall survival were recorded to assess safety.

Results

Some 49 patients were studied. The exercise group attended a mean of 69 per cent of all prescribed sessions. After exercise, muscle strength and cardiorespiratory fitness were increased and returned to pretreatment levels. At 1‐year follow‐up, the exercise group had improved HRQoL (+13·5 points, 95 per cent c.i. 2·2 to 24·9), with no change in the control group (+3·7 points, −5·9 to 13·4), but there was no difference between the groups at this time point (+9·8 points, −5·1 to 24·8). Exercise was safe, with no differences in patients receiving adjuvant chemotherapy (14 of 16 versus 16 of 19; relative risk (RR) 1·04, 95 per cent c.i. 0·74 to 1·44), relative dose intensity of adjuvant chemotherapy (mean 57 versus 63 per cent; P = 0·479), hospitalization (7 of 19 versus 6 of 23; RR 1·41, 0·57 to 3·49) or 1‐year overall survival (80 versus 79 per cent; P = 0·839) for exercise and usual care respectively.

Conclusion

Exercise in the postoperative period is safe and may have the potential to improve physical fitness in patients with GOJ cancer. No differences in prognostic endpoints or HRQoL were observed. Registration number: NCT02722785 ( https://www.clinicaltrials.gov).

Quantifying Anterior Chest Wall Deformity in Adolescent Idiopathic Scoliosis: Correlation With Other Deformity Measures and Effects of Anterior Thoracoscopic Scoliosis Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study investigated how anterior chest wall deformity is affected by thoracoscopic anterior scoliosis fusion (TASF) surgery in adolescent idiopathic scoliosis patients. We aimed to determine correlations pre- and postoperatively with other clinical and radiological scoliosis measures.

BACKGROUND DATA

Scoliosis surgery aims to halt progression of the deformity, and to reduce its severity. Currently, deformity correction is clinically measured in terms of Cobb angle and rib hump (RH); however, a significant cosmetic concern for patients is anterior chest wall deformity.

METHODS

Pre- and postoperative CT scans of 28 female, Lenke type 1 patients with a mean preoperative Cobb angle of 50.2° ± 7.1° were retrieved from the Research Group's surgical database. Using ImageJ, 3D reconstructions of the thorax were created. Two observers measured the anterior chest wall deformity as a chest wall angle (CWA) and posterior deformity as a posterior apical deformity angle (PDA). We investigated pre- to postoperative changes in CWA, PDA, RH, and Cobb angle as well as their interrelationship.

RESULTS

All deformity parameters (Cobb angle, RH, CWA, and PDA) showed statistically significant improvement post TASF. Correlation was found between RH and Cobb angle pre- and postoperatively, Cobb angle and CWA preoperatively and between postoperative change in Cobb angle and CWA. No relationship was found between CWA and RH or PDA.

CONCLUSIONS

Anterior chest wall deformity is independent from the posterior chest wall measures RH and PDA, indicating that the anterior chest wall deformity is not reflected in the posterior rib cage. The correlation between Cobb angle and CWA indicates that the deformity in the spine and the deformity in the ribs are related, and shows that the anterior chest wall deformity is improved post thoracoscopic anterior scoliosis fusion surgery as the lateral deviation of the spine is corrected.

LEVEL OF EVIDENCE

Level III.

P3-13-03: Long-Term Symptoms after Radiotherapy of Supraclavicular Lymph Nodes in Breast Cancer Patients

Background and Purpose: Irradiation of the supraclavicular lymph nodes has historically been shown to increase the risk of brachial plexopathy with neurological problems in the upper limb. The purpose of this study was to compare long-term symptoms after modern radiotherapy (based on 3D dose planning) in breast cancer patients with or without irradiation of the supraclavicular lymph nodes.

Material and Methods: We collected information from 814 recurrence free women consecutively treated with adjuvant radiotherapy for breast cancer at the Sahlgrenska University Hospital in Gothenburg, Sweden, 1999 to 2004. The women had breast conserving surgery or mastectomy with axillary dissection or sentinel node biopsy. The breast area was irradiated to 50 Gy in 2.0 Gy fractions. Women with more than three lymph node metastases had regional radiotherapy to the supraclavicular lymph nodes delivered in 2.0 Gy fractions up to 50 Gy. Systemic treatments were given according to regional guidelines. In this study the women were classified into three groups depending on if they had axillary dissection and regional radiotherapy. The first group had both axillary dissection and regional radiotherapy, the second group had axillary dissection without regional radiotherapy, and the third group had sentinel node biopsy (i.e. no axillary dissection) without regional radiotherapy. Three to eight years after radiotherapy, the women received a questionnaire asking about paresthesia, pain and strength in the upper limb.

Results: Among women with axillary dissection and regional radiotherapy 38/192 (19.8%) reported paresthesia in the hand compared to 68/505 (13.5%) among women with axillary dissection without regional radiotherapy; relative risk (RR) 1.47; 95% confidence interval (95% CI) 1.02 - 2.11, and compared to 9/112 (8.0%) among women with sentinel node biopsy without regional radiotherapy; RR 2.46 (95% CI 1.24−4.90). Type of breast surgery, number of examined axillary lymph nodes, and chemotherapy had no impact on the occurrence of paresthesia. Age was an effect modifier among the women with axillary dissection and regional radiotherapy; up to 49 years of age 26.8% reported paresthesia (RR 2.45; 95% CI 1.05−5.73), between 50 and 59 years of age 19.7% reported paresthesia (RR 1.81; 95% CI 0.73−4.44), and above 59 years of age 10.9% reported paresthesia (RR 1.00 Reference). We found no statistically significant differences between the groups regarding pain or decreased strength.

Conclusions: Radiotherapy to the supraclavicular lymph nodes increases the occurrence of paresthesia in the hand. The effect was mainly seen among younger women. Dose/volume-response analysis regarding paresthesia will be presented at the meeting.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-13-03.

A UV resonance Raman (UVRR) spectroscopic study on the extractable compounds of Scots pine (Pinus sylvestris) wood. Part I: lipophilic compounds

The wood resin in Scots pine (Pinus sylvestris) stemwood and branch wood were studied using UV resonance Raman (UVRR) spectroscopy. UVRR spectra of the sapwood and heartwood hexane extracts, solid wood samples and model compounds (six resin acids, three fatty acids, a fatty acid ester, sitosterol and sitosterol acetate) were collected using excitation wavelengths of 229, 244 and 257 nm. In addition, visible Raman spectra of the fatty and resin acids were recorded. Resin compositions of heartwood and sapwood hexane extracts were determined using gas chromatography. Raman signals of both conjugated and isolated double bonds of all the model compounds were resonance enhanced by UV excitation. The oleophilic structures showed strong bands in the region of 1660-1630 cm(-1). Distinct structures were enhanced depending on the excitation wavelength. The UVRR spectra of the hexane extracts showed characteristic bands for resin and fatty acids. It was possible to identify certain resin acids from the spectra. UV Raman spectra collected from the solid wood samples containing wood resin showed a band at approximately 1650 cm(-1) due to unsaturated resin components. The Raman signals from extractives in the resin rich branch wood sample gave even more strongly enhanced signals than the aromatic lignin.

Determination of urinary thymidine glycol using affinity chromatography, HPLC and post-column reaction detection: a biomarker of oxidative DNA damage upon kidney transplantation

Reactive oxygen species are generated during ischaemia-reperfusion of tissue. Oxidation of thymidine by hydroxyl radicals (HO) leads to the formation of 5,6-dihydroxy-5,6-dihydrothymidine (thymidine glycol). Thymidine glycol is excreted in urine and can be used as biomarker of oxidative DNA damage. Time dependent changes in urinary excretion rates of thymidine glycol were determined in six patients after kidney transplantation and in six healthy controls. A new analytical method was developed involving affinity chromatography and subsequent reverse-phase high-performance liquid chromatography (RP-HPLC) with a post-column chemical reaction detector and endpoint fluorescence detection. The detection limit of this fluorimetric assay was 1.6 ng thymidine glycol per ml urine, which corresponds to about half of the physiological excretion level in healthy control persons. After kidney transplantation the urinary excretion rate of thymidine glycol increased gradually reaching a maximum around 48 h. The excretion rate remained elevated until the end of the observation period of 10 days. Severe proteinuria with an excretion rate of up to 7.2 g of total protein per mmol creatinine was also observed immediately after transplantation and declined within the first 24 h of allograft function (0.35+/-0.26 g/mmol creatinine). The protein excretion pattern, based on separation of urinary proteins on sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE), as well as excretion of individual biomarker proteins, indicated nonselective glomerular and tubular damage. The increased excretion of thymidine glycol after kidney transplantation may be explained by ischaemia-reperfusion induced oxidative DNA damage of the transplanted kidney.

Glutathione transferases in the urine: sensitive methods for detection of kidney damage induced by nephrotoxic agents in humans

With the aid of immunohistochemical methods the localization of the various isoenzymes of glutathione S-transferase was investigated. The alpha isoenzyme was present solely in the proximal tubular cells of the human kidney, while the pi form was restricted to the distal convoluted tubules, the thin loop of Henle, and the collecting ducts. Damage to the epithelial cell membranes results in the increased excretion of these enzymes with the urine. The alpha and pi isoenzymes have been isolated in a highly purified form and used for the production of polyclonal antisera. Subsequently, radioimmunological and ELISA techniques were developed for quantitation of these proteins in the urine; the methods exhibited a high specificity and were sufficiently sensitive to determine nanogram quantities or less. Disease affecting tubular function, cyclosporine A treatment, administration of nephrotoxic antibiotics, and exposure to cadmium all resulted in characteristic changes in the pattern of the glutathione transferase isoenzymes present in urine. Such effects were seen also in patients who had previously been exposed to nephrotoxic agents, but in whom conventional tests for kidney function were apparently normal. Thus, it appears that radioimmunologic or immunochemical quantitation of alpha and pi forms of the enzyme can be used as sensitive and relatively simple markers for the early detection of toxic effects with respect to the renal tubuli.

Influence of hearing of 22 G Whitacre and 22 G Quincke needles

Audiograms were performed pre-operatively and 2 days postoperatively in 48 patients given spinal anaesthesia for transurethral resection of the prostate. Hearing levels were examined at 1000 Hz and below. Either 22 G standard design (Quincke) needles (n = 25) or 22 G pencil-point design (Whitacre) needles (n = 23) were used. Hearing loss of 10 dB or more at two or more frequencies were observed in six of 25 patients in the Quincke group and in two of 23 patients in the Whitacre group. The mean hearing level was more reduced in the Quincke group. The shape of the tip of the spinal needle seems to be of some importance to the effects on hearing level that may occur after spinal anaesthesia.

Modulation of metabolism in HepG2 cells upon treatment with cyclosporin A and Nva2-cyclosporin

HepG2 cells were cultured in the presence of different concentrations of cyclosporin A (CsA) or Nva2-cyclosporin (Nva2-Cs) for up to 20 days. At a low concentration (2 micrograms/ml) of CsA or Nva2-Cs, the [3H]thymidine incorporation into DNA and the rate of incorporation of [3H]leucine into total protein decreased by 20-25%. Concentrations of 10 micrograms/ml resulted in a 70% reduction of the [3H]thymidine incorporation in comparison with controls. Low concentrations of CsA resulted in mitochondria in the condensed state together with autophagosomes, large vacuoles, and elevated numbers of coated vesicles, as shown by electron microscopy. Low concentrations of Nva2-Cs resulted in swollen mitochondria, increased autophagocytosis, and increased numbers of intermediate filaments and microtubules. Higher doses of these substances (5 micrograms/ml) caused disarrangement of mitochondrial cristae, vesiculation of the endoplasmic reticulum, an elevated number of free polysomes, and accelerated autophagocytosis. Labeling of phospholipids and triglycerides with [3H]glycerol and of cholesterol and dolichol with [3H]acetate was decreased after exposure of HepG2 cells to CsA, or, in particular, Nva2-Cs. Phospholipids secreted from the cells into the medium exhibited an increased level of labeling, but the specific radioactivity of the neutral lipids in the medium was significantly decreased. Treatment of HepG2 cells with either CsA or Nva2-Cs doubled the mitochondrial cytochrome oxidase and carnitine acetyl-transferase, as well as microsomal NADPH-cytochrome c reductase activities. Such treatment also increased the cyanide-insensitive beta-oxidation of fatty acids in peroxisomes, as well as cytoplasmic DT-diaphorase and glutathione transferase activities. Prolonged treatment of the cells with CsA did not result in any cumulative effect. HepG2 cells appear to be suitable for studying the effects of cyclosporins on cellular structure and metabolism and in this system the two drugs studied here exhibited similar effects.

Hearing loss after spinal anesthesia is related to needle size

Audiograms were performed preoperatively and 2 days postoperatively in 28 patients given spinal anesthesia for transurethral resection of the prostate. In 14 patients 22-gauge and in 14 patients 26-gauge spinal needles were used. Hearing loss of 10 dB or more at any frequency was observed in 13 of 14 patients in the 22-gauge group and in 4 of 14 patients in the 26-gauge group. There was a statistically significant reduction in hearing level in the low-frequency range in patients in whom the 22-gauge needle was used. Hearing loss was unilateral at five frequencies and bilateral at one frequency. No cases of postspinal headache occurred. Audiometry may be a more sensitive indication of cerebrospinal fluid leak than postspinal headache.

Effects of epidural bupivacaine and epidural morphine on bowel function and pain after hysterectomy

A comparison was made of the effects of continuous epidural analgesia with bupivacaine and intermittent epidural morphine on bowel function after abdominal hysterectomy. The duration of postoperative ileus was assessed as the time from the end of operation to the first postoperative passage of flatus and feces. Twenty-two patients were randomly allocated to two equal groups. An "epidural morphine" group received general anesthesia and epidural morphine for postoperative pain relief, and an "epidural bupivacaine" group was given combined general anesthesia and epidural anesthesia with 0.5% bupivacaine intraoperatively and epidural analgesia with 0.25% bupivacaine postoperatively. Epidural morphine or bupivacaine was given for 42 h postoperatively. Pain intensity (visual analog scale) was low in both groups, but lower (P less than 0.05) in the epidural bupivacaine group. The time to first passage of flatus was 22 +/- 16 h in the epidural bupivacaine group and 56 +/- 22 h in the epidural morphine group (P less than 0.001). The time to first postoperative passage of feces was shorter (P less than 0.05) in the former than in the latter 57 +/- 44 h vs 92 +/- 22 h). The patients of the epidural bupivacaine group started intake of oral fluids earlier (P less than 0.01) and to a greater extent (P less than 0.05) than those in the epidural morphine group. It is concluded that the duration of postoperative ileus after hysterectomy is shorter when epidural bupivacaine is given for postoperative pain relief than when this is achieved by epidural morphine.

Thoracolumbar epidural anaesthesia blocks the circulatory response to laryngoscopy and intubation

Laryngoscopy and endotracheal intubation cause a stress reaction resulting in an increase in heart rate and systemic blood pressure. This haemodynamic response is considered to be due to a sympathetic discharge caused by stimulation of the upper respiratory tract. This stress reaction during laryngoscopy and endotracheal intubation was studied in patients with total thoracolumbar epidural anaesthesia (EDA). Nine patients with thoracolumbar EDA including at least the segments T1 to L2 were compared to seven patients without EDA during induction of general anaesthesia. The epidural anaesthesia was achieved with 2% mepivacaine with adrenaline. General anaesthesia was induced with thiopentone 4-5 mg/kg followed by 100 mg suxamethonium. The highest blood pressure value during the first 2 min after intubation was compared to the value immediately before intubation. The epidural anaesthesia caused a reduction of the mean arterial blood pressure (MAP) by 25%, and a reduction of the heart rate (HR) by 7%, but neither the induction with thiopentone nor the laryngoscopy and intubation caused any changes in mean arterial blood pressure or heart rate. However, in the control group MAP increased 29% and HR 16% following intubation. Thus, the T1-L2 epidural anaesthesia with 2% mepivacaine with adrenaline blocked the blood pressure reaction to laryngoscopy and intubation, and consequently the efferent sympathetic nervous system was completely blocked.

Circulatory effects of short-term hypercapnia during thoracolumbar epidural anaesthesia

In ten elderly patients subjected to extensive thoracolumbar epidural anaesthesia, circulatory changes were studied before and during sympathetic stimulation. Induced hypercapnia was used as a sympathetic stimulus. After establishment of the epidural anaesthesia, which extended from T1 to L2, there were decreases in heart rate, mean arterial blood pressure, cardiac output and systemic vascular resistance. Hypercapnia before the epidural block increased heart rate, arterial blood pressure and cardiac output, while hypercapnia after established epidural block induced only a slight increase in arterial blood pressure. The results indicate that in spite of an extensive epidural block, there are some "escaped" sympathetic nerve fibres that can be mobilized during sympathetic stimulation.

Haemodynamic effects of intravenous bupivacaine during high thoracic epidural anaesthesia

Administration of small doses of bupivacaine epidurally at the upper thoracic level will partially block the cardiac sympathetic nerves but not the sympathetic outflow via the adrenals. Local anaesthetics have direct systemic effects on the myocardium and the systemic circulation. The present study aimed to examine the effect of high thoracic epidural anaesthesia (TEA) in elderly patients, and to examine the effect of raising plasma bupivacaine concentrations in these patients, who had earlier had the sympathetic innervation of the heart blocked by thoracic epidural anaesthesia. Fifteen elderly patients scheduled for thoracotomy took part in the study. All received high thoracic epidural anaesthesia including the upper five thoracic dermatomes. When epidural block was established, ten patients received bupivacaine 3 mg/min intravenously for 20 min, while five patients received a corresponding volume of normal saline solution. After TEA was established, heart rate, mean arterial blood pressure and cardiac output decreased. When bupivacaine was given to these patients intravenously during the block, mean arterial blood pressure increased, while cardiac output decreased still more. The mechanisms behind these effects seem to be a direct constriction of the systemic blood vessels and a depressive effect on the myocardium, which was blocked from the influence of the cardiac sympathetic nerves by the high thoracic epidural block.

Circulatory effects of short-term hypercapnia during high thoracic epidural anaesthesia in elderly patients

Circulatory changes and the degree of sympathetic block were evaluated in 15 elderly patients with high thoracic epidural anaesthesia (T1-T5). Bupivacaine 5-6 ml 0.5% was injected via an epidural catheter at the T3-level. The quality of the sympathetic block was determined with the Valsalva manoeuvre. Induced hypercapnia was used to quantify the degree of sympathetic block. Following thoracic epidural anaesthesia (TEA), cardiac output, stroke volume and arterial blood pressure decreased. During hypercapnia, heart rate and arterial blood pressure increased both before and after established TEA. Thus the block of the sympathetic innervation to the heart with a high TEA using 0.5% bupivacaine was not sufficient to prevent mobilization of circulatory reserves during sympathetic stimulation. The most likely explanation is considered to be the lack of neural block of the efferent nerves leading to the adrenal medulla and the peripheral vascular bed.

Respiratory effects of high thoracic epidural anaesthesia

The respiratory effects of high thoracic epidural anaesthesia (TEA) were studied in nine healthy volunteers by means of spirometry, nitrogen single-breath test and flow-volume loop. After the baseline measurements an epidural catheter was inserted at T4 level, and 5 ml of 0.5% bupivacaine were injected. This volume led to sensory block within dermatomes T1-T5. Total lung capacity, vital capacity and inspiratory capacity decreased slightly but significantly during TEA. Expiratory reserve volume was not affected. Maximal inspiratory flow at 50% VC decreased 24%. Maximal expiratory flow at 75% VC and peak expiratory flow were not changed. N2 difference during a constant flow rate of 0.5 l/s and forced expiratory volume in 1 s were not changed, which indicates that there were no changes of bronchial tone. The respiratory effects of high TEA in this study were caused by the motor block of the intercostal muscles.

Circulatory changes during high thoracic epidural anaesthesia--influence of sympathetic block and of systemic effect of the local anaesthetic

Circulatory changes during high thoracic epidural anaesthesia (TEA) were studied in nine healthy volunteers by means of echocardiography and systolic time intervals. The subjects also underwent a physical work test with bicycle ergometry. To evaluate the systemic effect of the local anaesthetic (bupivacaine), the same subjects were investigated 3 weeks later when a corresponding dose of the local anaesthetic was injected intramuscularly instead of epidurally. On the first occasion, after baseline measurements an epidural catheter was inserted at T4 level and 5 ml of 0.5% bupivacaine were injected. This volume led to sensory block within dermatomes T1-T5. On the second occasion all subjects received 8 ml of 0.5% bupivacaine intramuscularly. Heart rate (HR) and systolic blood pressure decreased during TEA, both at rest and during exercise. Following i.m. injection, HR decreased at rest but remained unchanged during exercise. The systolic blood pressure was not affected but the diastolic blood pressure increased during the exercise test. After administration of TEA, stroke volume (SV) decreased 22% and cardiac output (CO) 33%. Following i.m. injection of bupivacaine, SV decreased 8% and CO 20%. The pre-ejection period/left ventricular ejection time ratio increased 23% during TEA and 16% after i.m. injection. The results indicate that the circulatory changes did not seem to be caused entirely by the cardiac sympathetic block, but were due partly to the systemic effect of bupivacaine.