In vivo experience with peroral endoscopic myotomy: An essential activity for developing the technique in humans. / Miotomía endoscópica peroral, experiencia in vivo: imprescindible para desarrollo de la técnica en humanos.

INTRODUCTION AND OBJECTIVES: Achalasia is the most widely studied esophageal motility disorder. No treatment has achieved completely satisfactory results. The laparoscopic Heller esophagomyotomy is currently the most accepted technique. With the advent of minimally invasive surgery, the appearance of peroral endoscopic myotomy (POEM) has promising results. The primary aim of our study was to perform peroral endoscopic esophagomyotomy in animal experimentation models to perfect the technique and later apply it to humans. The secondary aims were to evaluate the intraoperative and postoperative complications and to describe the anatomopathologic findings. MATERIALS AND METHODS: An experimental study was conducted on 8 live porcine models that were followed for 30 days to identify postoperative complications. Necropsy was then performed to evaluate the histopathologic findings. The international requirements and regulations for animal experimentation were met. RESULTS: The technique was carried out in all the models. There was one intraoperative death. Pneumothorax was observed in 50% of the units in experimentation and subcutaneous cervical emphysema in 75%, with no significant clinical repercussions. Histologic muscle layer (myotomy) involvement was above the gastroesophageal junction in 87% of the cases and below it in 25%. CONCLUSION: Peroral endoscopic esophagomyotomy is a feasible, albeit complex, procedure that requires advanced training, and thus should be performed in highly specialized centers. Specific skills in advanced therapeutic endoscopic procedures of this type must continue to be developed through continuing education (ideally in in vivo models), to then be performed on humans.

Resultado de un programa de rehabilitación pulmonar sobre la adherencia y la técnica inhalatoria en pacientes con enfermedad respiratoria crónica / Result of a pulmonary rehabilitation program on adherence and inhalation technique in patients with chronic respiratory disease

Introducción: Los programas de rehabilitación pulmonar deben incluir actividades educativas encaminadas a que el paciente conozca la enfermedad y reciba el adiestramiento que le permita abordar adecuadamente su tratamiento. Objetivo: Analizar la adherencia y la técnica inhalatoria en pacientes remitidos al programa de rehabilitación pulmonar de la Fundación Neumológica Colombiana y evaluar los cambios que se presentaron en éstas al finalizar el programa ambulatorio. Metodología: Estudio no experimental preprueba postprueba en pacientes mayores de 18 años. Se calificó la técnica inhalatoria utilizando la escala EDEN y la adherencia utilizando preguntas adaptadas de la escala de adherencia a la medicación de Morisky. Resultados: Se analizaron 320 pacientes; el porcentaje de pacientes que utilizaba correctamente los dispositivos inhalados al iniciar el programa de rehabilitación osciló entre 9% y19%; el error más común en todos los dispositivos fue no expulsar el aire antes de iniciar la inhalación. Después del programa de rehabilitación el porcentaje de pacientes que empleaban una técnica inhalatoria correcta fue en promedio 61% para inhaladores de dosis medida y 83% para dispositivos de polvo seco. La adherencia a los inhaladores antes del programa fue 58%, siendo descuido y olvido las principales razones que explican la no adherencia. Al finalizar el programa 86% de los pacientes eran adherentes. Conclusiones: Un porcentaje bajo de pacientes remitidos al programa de rehabilitación pulmonar aplicaba correctamente la técnica inhalatoria, la instrucción educativa dentro de un programa de rehabilitación pulmonar mejoró la técnica y la adherencia a los inhaladores en un porcentaje importante de pacientes.

Introduction: Pulmonary rehabilitation programs must include educational activities focused on the acquisition of necessary knowledge and skills to control the disease and approach treatment appropriately. Objective: To analyze treatment adherence and inhalation technique in patients referred to pulmonary rehabilitation program of Fundación Neumológica Colombiana and evaluate changes in them at the end of the outpatient program. Methodology: Pretest - posttest design in patients older than 18 years. The inhalation technique was assessed using the EDEN scale, and adherence was scored with modified questions from the Morisky medication adherence scale. Results: We analyzed 320 patients. The percentage of patients who used inhalers correctly before starting the rehabilitation program ranged between 9% and 19%; the most common mistake was not exhale the air before starting inhalation. Upon completion of the program the percentage of patients performing a correct inhalation technique ranged between 61% for metered dose inhalers to 83% for dry powder inhalers. Adherence to inhalers before the program was 58%, with neglect and forget being the main reasons encountered. It improved in 86% of evaluated patients. Conclusion: A small percentage of patients referred to pulmonary rehabilitation program applied the inhalation technique correctly; educational instruction in a pulmonary rehabilitation program improved the technique and adherence to inhalers in a significant percentage of patients.

Increased blood ammonia in hypoxia during exercise in humans.

The effect of acute hypoxia on blood concentration of ammonia ([NH3]b) and lactate (la-]b) was studied during incremental exercise(IE), and two-step constant workload exercises (CE). Fourteen endurance-trained subjects performed incremental exercise on a cycle ergometer under normoxic (21% O2) and hypoxic (10.4% O2) conditions. Eight endurance-trained subjects performed two-step constant workload exercise at sea level and at a simulated altitude of 5000 m (hypobaric chamber, P(B)=405 Torr; P(O2)=85 Torr) in random order. In normoxia, the first step lasted 25 minutes at an intensity of 85 % of the individual ventilatory anaerobic threshold (AT(vent), ind) at sea level. This reduced workload was followed by a second step of 5 minutes at 115% of their AT(vent), ind. This test was repeated into a hypobaric chamber, at a simulated altitude of 5,000 m. The first step in hypoxia was at an intensity of 65 % of AT(vent), ind., whereas workload for the second step at simulated altitude was the same as that of the first workload in normoxia (85 % of AT(vent), ind). During IE, [NH3]b and [la-]b were significantly higher in hypoxia than in normoxia. Increases in these metabolites were highly correlated in each condition. The onset of [NH3]b and [la-]b accumulation occurred at different exercise intensity in normoxia (181W for lactate and 222W for ammonia) and hypoxia (100W for lactate and 140W for ammonia). In both conditions, during CE, [NH3]b showed a significant increase during each of the two steps, whereas [la-]b increased to a steady-state in the initial step, followed by a sharp increase above 4 mM x L(-1) during the second. Although exercise intensity was much lower in hypoxia than in normoxia, [NH3]b was always higher at simulated altitude. Thus, for the same workload, [NH3]b in hypoxia was significantly higher (p<0.05) than in normoxia. Our data suggest that there is a close relationship between [NH3]b and [la-]b in normoxia and hypoxia during graded intensity exercises. The accumulation of ammonia in blood is independent of that of lactate during constant intense exercise. Hypoxia increases the concentration of ammonia in blood during exercise.

Erythropoietin acute reaction and haematological adaptations to short, intermittent hypobaric hypoxia.

This study aimed to determine whether brief hypoxic stimuli in a hypobaric chamber are able to elicit erythropoietin (EPO) secretion, and to effectively stimulate erythropoiesis in the short term. In two different experiments, a set of haematological, biochemical, haemorheological, aerobic performance, and medical tests were performed in two groups of healthy subjects. In the first experiment, the mean plasma concentration of EPO ([EPO]) increased from 8.7 to 13.5 mU.ml-1 (55.2%; P < 0.01) after 90 min of acute exposure at 540 hPa, and continued to rise until a peak was attained 3 h after the termination of hypoxia. In the second experiment, in which subjects were exposed to a simulated altitude of up to 5500 m (504 hPa) for 90 min, three times a week for 3 weeks, all haematological indicators of red cell mass increased significantly, reaching the highest mean values at the end of the programme or during the subsequent 2 weeks, including packed cell volume (from 42.5 to 45.1%; P < 0.01), red blood cell count (from 4.55 x 10(6) to 4.86 x 10(6).l-1; P < 0.01), reticulocytes (from 0.5 to 1.4%; P < 0.01), and haemoglobin concentration (from 14.3 to 16.2 g.dl-1; P < 0.01), without an increase in blood viscosity. Arterial blood oxygen saturation during hypoxia was improved (from 60% to 78%; P < 0.05). Our most relevant finding is the ability to effectively stimulate erythropoiesis through brief intermittent hypoxic stimuli (90 min), in a short period of time (3 weeks), leading to a lower arterial blood desaturation in hypoxia. The proposed mechanism for these haematological and functional adaptations is the repeated triggering effect of EPO production caused by the intermittent hypoxic stimuli.

Acclimatization near home? Early respiratory changes after short-term intermittent exposure to simulated altitude.

OBJECTIVE: With the ultimate goal of finding a straightforward protocol for acclimatization at simulated altitude, we evaluated the early effects of repeated short-term exposure to hypobaric hypoxia on the respiratory response to exercise in hypoxia. METHODS: Nine subjects were exposed to a simulated altitude of 5000 m for 2 hours a day for 14 days. Arterial oxygen saturation (SaO2), expired volume per minute (VE), respiratory rate, tidal volume (VT), and heart rate were measured during rest and during exercise (cycloergometer, at 30% of maximum oxygen consumption at sea level), both in normoxia and at 5000 m of simulated altitude on the first and 15th days. On the same days, blood samples were obtained for hematological tests. RESULTS: During exercise in hypoxia, SaO2 rose from 65 to 71% (P = .02), and VE rose from 55.5 to 67.6 L.min-1 (P = .02) due to an increase in VT from 2 to 2.6 L (P = .003). No significant differences were found in any of the variables studied at rest either in normoxia or in hypoxia or in exercise in normoxia after the exposure program. In the second week, changes in packed cell volume and blood hemoglobin concentration were nonsignificant. CONCLUSIONS: After short-term intermittent exposure to hypobaric hypoxia, subjects increased their ventilatory response and SaO2 during exercise at simulated altitude. These changes may be interpreted as acclimatization to altitude. The monitoring of ventilatory response and SaO2 during moderate exercise in hypobaric hypoxia may be used to detect the first stages of acclimatization to altitude.

Intermittent hypobaric hypoxia induces altitude acclimation and improves the lactate threshold.

The physiological responses to short-term intermittent exposure to hypoxia in a hypobaric chamber were evaluated. The exposure to hypoxia was compatible with normal daily activity. The ability of the hypoxia program to induce hematological and ventilatory adaptations leading to altitude acclimation and to improve physical performance capacity was tested. Six members of a high-altitude expedition were exposed to intermittent hypoxia and low-intensity exercise (in cycle-ergometer) in the INEFC-UB hypobaric chamber over 17 d, 3-5 h x d(-1), at simulated altitude of 4,000 m to 5,500 m. Following this hypoxia exposure program, significant increases were found in packed cell volume (41 to 44.6%; p<0.05), red blood cells count (4.607 to 4.968 10(6) cells x microL(-1); p<0.05), and hemoglobin concentration (14.8 to 16.4 g x dL(-1); p<0.05), thus implying an increase in the blood oxygen transport capacity. Significant differences in exercise blood lactate kinetics and heart rate were also observed. The lactate vs. exercise load curve shifted to the right and heart rate decreased, thus indicating an improvement of aerobic endurance. These results were associated with a significant increase in the ventilatory anaerobic threshold (p<0.05). Significant increases (p<0.05) in pulmonary ventilation, tidal volume, respiratory frequency, O2 uptake, CO2 output and ventilatory equivalents to oxygen (VE/Vo2) and carbon dioxide (VE/co2) were observed at the ventilatory threshold and within the transitional zone of the curves. We conclude that short-term intermittent exposure to moderate hypoxia, in combination with low-intensity exercise in a hypobaric chamber, is sufficient to improve aerobic capacity and to induce altitude acclimation.

La manipulación colónica laparoscópica y la exfoliación celular: investigación experimental / Laparoscopic colic manipulation and malignant cells exfoliation: experimental research

La manipulación traumática del colon portador de una neoplasia, durante la ejecución de una colectomía laparoscópica podría aumentar la exfoliación de células malignas dentro de la cavidad peritoneal, y por consiguiente ser una de las causas de los implantes cutáneos. Objetivo: Desarrollar un modelo de cáncer colónico experimental con similitud al del hombre y determinar si la manipulación laparoscópica instrumental del carcinoma de colon y recto comparada con la laparotomía, aumenta la exfoliación de células malignas en la cavidad peritoneal, instrumental y trócares. Material y Métodos: Se desarrolló un protocolo de cáncer colorrectal experimental con inyección subcutánea de 1-2 Dimethylhydrazina a una dosis de 20 mg/kg de peso, semanalmente y durante 20 semanas, en 40 ratas Wistar, sexo masculino. Se operaron a la semana 21º, dividiéndolas en 2 grupos (1 y 2). Grupo 1 (n 23) sometidas a laparotomía y manipulación instrumental del colon. Grupo 2 (n 17) se efectuó neumoperitoneo con CO2 hasta una presión de 12 mm Hg, laparoscopia y manipulación instrumental del colon y recto.

La manipulación colónica laparoscópica y la exfoliación celular: investigación experimental / Laparoscopic colic manipulation and malignant cells exfoliation: experimental research

La manipulación traumática del colon portador de una neoplasia, durante la ejecución de una colectomía laparoscópica podría aumentar la exfoliación de células malignas dentro de la cavidad peritoneal, y por consiguiente ser una de las causas de los implantes cutáneos. Objetivo: Desarrollar un modelo de cáncer colónico experimental con similitud al del hombre y determinar si la manipulación laparoscópica instrumental del carcinoma de colon y recto comparada con la laparotomía, aumenta la exfoliación de células malignas en la cavidad peritoneal, instrumental y trócares. Material y Métodos: Se desarrolló un protocolo de cáncer colorrectal experimental con inyección subcutánea de 1-2 Dimethylhydrazina a una dosis de 20 mg/kg de peso, semanalmente y durante 20 semanas, en 40 ratas Wistar, sexo masculino. Se operaron a la semana 21º, dividiéndolas en 2 grupos (1 y 2). Grupo 1 (n 23) sometidas a laparotomía y manipulación instrumental del colon. Grupo 2 (n 17) se efectuó neumoperitoneo con CO2 hasta una presión de 12 mm Hg, laparoscopia y manipulación instrumental del colon y recto. Un tercer grupo lo constituyeron las ratas controles (n 5). Se realizó citología de: líquido de lavado peritoneal pre y post manipulación intestinal, del instrumental convencional y laparoscópico, de la aguja de Verres y de los trócares. Se efectuó el estudio histológico del colon y recto, ganglios mesentéricos, hígado y peritoneo. Resultados: El 80 por ciento de las ratas desarrollaron adenocarcinomas de colon. No existió diferencia significativa entre la exfoliación celular de ambos grupos de animales. Conclusiones: El carcinoma colorrectal inducido por la 1-2 Dimethylhydrazina tiene características muy similares al del ser humano y es un modelo válido para la investigación. La manipulación instrumental con una prolija técnica durante los procedimientos laparoscópicos no aumenta la exfoliación celular

Intermittent hypobaric hypoxia stimulates erythropoiesis and improves aerobic capacity.

PURPOSE: The purpose of the study was to examine the effect of a very short intermittent exposure to moderate hypoxia in a hypobaric chamber on aerobic performance capacity at sea level and the erythropoietic response. The effects of hypobaric hypoxia alone and combined with low-intensity exercise were also compared. METHODS: Seventeen members of three high-altitude expeditions were exposed to intermittent hypoxia in a hypobaric chamber over 9 d at simulated altitude, which was progressively increased from 4000 to 5500 m in sessions ranging from 3 to 5 h x d(-1). One group (N = 7; HE group) combined passive exposure to hypoxia with low-intensity exercise on a cycle ergometer. Another group (N = 10; H group) was only exposed to passive hypoxia. Before and after the exposure to hypoxia, medical status, performance capacity, and complete hematological and hemorheological profile of subjects were evaluated. RESULTS: No significant differences were observed between the two groups (HE vs H) in any of the parameters studied, indicating that hypoxia alone was responsible for the changes. After the acclimation period, a significant increase in exercise time (mean difference: +3.9%; P < 0.01), and maximal pulmonary ventilation (+5.5%; P < 0.05) was observed during the maximal incremental test at sea level. Individual lactate-velocity curves significantly shifted to the right (P < 0.05), thus revealing an improvement of aerobic endurance. A significant increase was found in PCV (42.1-45.1%; P < 0.0001), RBC count (5.16 to 5.79 x 10(6) x mm(-3); P < 0.0001), reticulocytes (0.5 to 1.1%; P < 0.0001) and hemoglobin (Hb) concentration (14.2 to 16.7 g x dL(-1); P < 0.002). CONCLUSIONS: It was concluded that short-term hypobaric hypoxia can activate the erythropoietic response and improve the aerobic performance capacity in healthy subjects.

Effect of recovery duration on the force-velocity relationship.

The aim of this study was to investigate the effect of different Recovery Duration (RD) between each sprint (30 s, 1 min, 3 min, 5 min, 10 min and 24 h) during the force-velocity test and to analyse associated anaerobic parameters such as maximal anaerobic power and blood lactate concentrations. Twelve male physical education students aged from 18 to 26 years took part in this study. Maximal anaerobic power (Pmax) was not statistically different whatever the recovery duration (from 885 to 938 watts, for RD 30 s to RD 24 h, respectively). This was associated with a tendency during the longer RD tests for optimal velocity to decrease (p = ns) while optimal force increased (p < 0.05). Blood lactate concentrations were regularly increased from 1.7 to a 9 mmol x l(-1) plateau at sprint 4 for RD tests < 10 min and were quite stable from the second sprint with an associated value from 2.2 to 4.7 mmol x l(-1) for RD 10 min and RD 24 h. In spite of statistically different values for [L]s between the tests, the power developed for each sprint remained unchanged. These data indicate that the attainment of maximal power seems independent from the recovery duration (> 10 s) and the pre-blood lactate values observed between each sprint during the force-velocity test. The way to reach Pmax was different between the tests. Different partition of energetic pathways are suggested. In conclusion, the force-velocity test could be performed with a shorter and the arbitrary five minutes recovery duration.

[Pulmonary toxicity of gold salts]. / Toxicidad pulmonar por sales de oro.

Pulmonary toxicity associated with gold salt treatment of rheumatoid arthritis is unusual. Only 60 cases had been reported before 1986. This disorder consists primarily of pulmonary interstitial involvement, characterized by hypersensitivity pneumonitis which can lead to variable degrees of pulmonary fibrosis. However, this disease has a good prognosis if treated properly with the simple interruption of gold salts or with corticosteroids, with complete cure in the majority of cases. A case with good response to corticosteroid therapy is reported and the differential diagnosis with pulmonary fibrosis associated with rheumatoid arthritis is analyzed.

Toxicidad pulmonar por sales de oro. / [Pulmonary toxicity of gold salts]

Pulmonary toxicity associated with gold salt treatment of rheumatoid arthritis is unusual. Only 60 cases had been reported before 1986. This disorder consists primarily of pulmonary interstitial involvement, characterized by hypersensitivity pneumonitis which can lead to variable degrees of pulmonary fibrosis. However, this disease has a good prognosis if treated properly with the simple interruption of gold salts or with corticosteroids, with complete cure in the majority of cases. A case with good response to corticosteroid therapy is reported and the differential diagnosis with pulmonary fibrosis associated with rheumatoid arthritis is analyzed.

Toxicidad pulmonar por sales de oro / Pulmonary toxicity of gold salts

La toxocidad pulmonar por la sales de oro usadas en el tratamiento de la artritis reumatoidea es exepcional. Sólo 60 casos han sido recopilados en la literatura mundial hasta 1986. La afección consiste fundamentalmente en patología pulmonar intersticial, caracterizada por una neuromonitis por hipersensibilidad que puede llevar a grados variables de fibrosis pulmonar. Sin embargo, esta afección tratada oportunamente tiene buen prognóstico, ya que con la simple suspensión de las sales de oro o la administración conjunta de corticoides, la lesión revierte en la mayoría de los casos en su totalidad. Se presenta un caso con buena respuesta a la terapéutica coricoidea y se analizan las diferencias con la fibrosis pulmonar asociada a la artritis reumatoidea (AU)

Toxicidad pulmonar por sales de oro / Pulmonary toxicity of gold salts

La toxocidad pulmonar por la sales de oro usadas en el tratamiento de la artritis reumatoidea es exepcional. Sólo 60 casos han sido recopilados en la literatura mundial hasta 1986. La afección consiste fundamentalmente en patología pulmonar intersticial, caracterizada por una neuromonitis por hipersensibilidad que puede llevar a grados variables de fibrosis pulmonar. Sin embargo, esta afección tratada oportunamente tiene buen prognóstico, ya que con la simple suspensión de las sales de oro o la administración conjunta de corticoides, la lesión revierte en la mayoría de los casos en su totalidad. Se presenta un caso con buena respuesta a la terapéutica coricoidea y se analizan las diferencias con la fibrosis pulmonar asociada a la artritis reumatoidea

[Gastroduodenal lesions in rheumatoid arthritis. Evaluation and treatment]. / Lesiones gastroduodenales en artritis reumatoidea. Evaluación y tratamiento.

In a group of 70 patients of both sexes been treated with antiinflammatory drugs, affected by Rheumatoid Arthritis in activity, we have found the presence of lesions, erosions and gastroduodenal ulcers in 40% by endoscopic examination (26% erosions and 14% ulcers), without any relation with clinical symptoms. Those patients who received larger doses than 30mgr./kg./day of AAS suffered most frequently lesions (43.8%). These 28 patients with lesions have been studied prospectively in a double blind method, and treated twice a day with 150 mgs. doses of Ranitidine or Placebo, throughout a period of 5 weeks without discontinuing the treatment with anti-inflammatories (AAS, Indomethacin, steroids). At the end of the trial those patients who failed in healing their lesions were treated with Ranitidine in the same doses for another period of 5 weeks. The treatment with Ranitidine in doses of 300 mgr/day has resulted curative of the gastroduodenal lesions, although maintaining the aggressive drugs, in the 87% of the patients. We have observed that the treatment with Placebo is less effective and that difference has high statistical significance (p 0.005).

Lesiones gastroduodenales en artritis reumatoidea. Evaluación y tratamiento. / [Gastroduodenal lesions in rheumatoid arthritis. Evaluation and treatment]

In a group of 70 patients of both sexes been treated with antiinflammatory drugs, affected by Rheumatoid Arthritis in activity, we have found the presence of lesions, erosions and gastroduodenal ulcers in 40

by endoscopic examination (26

erosions and 14

ulcers), without any relation with clinical symptoms. Those patients who received larger doses than 30mgr./kg./day of AAS suffered most frequently lesions (43.8

). These 28 patients with lesions have been studied prospectively in a double blind method, and treated twice a day with 150 mgs. doses of Ranitidine or Placebo, throughout a period of 5 weeks without discontinuing the treatment with anti-inflammatories (AAS, Indomethacin, steroids). At the end of the trial those patients who failed in healing their lesions were treated with Ranitidine in the same doses for another period of 5 weeks. The treatment with Ranitidine in doses of 300 mgr/day has resulted curative of the gastroduodenal lesions, although maintaining the aggressive drugs, in the 87

of the patients. We have observed that the treatment with Placebo is less effective and that difference has high statistical significance (p 0.005).