Randomized Assessment of the Optimal Time Interval Between Programmed Intermittent Epidural Boluses When Combined With the Dural Puncture Epidural Technique for Labor Analgesia.

BACKGROUND: The dural puncture epidural (DPE) and programmed intermittent epidural bolus (PIEB) techniques are recent advances in neuraxial labor analgesia. Previous studies have investigated the PIEB optimal interval for effective analgesia when a standard epidural technique is used to initiate labor analgesia. However, it is unknown whether these findings are applicable when DPE is used. METHODS: Patients were randomized into 1 of 5 groups with PIEB intervals of 35, 40, 45, 50, or 55 minutes. Labor analgesia was initiated on request with a DPE technique by epidural injection over 2 minutes of 15 mL of ropivacaine 0.1% with sufentanil 0.5 µg/mL after a dural puncture with a 25-gauge Whitacre needle. Effective analgesia was defined as no additional requirement for a patient-controlled bolus during the first stage of labor. The PIEB interval that was effective in 50% of patients (EI50) and 90% of patients (EI90) was estimated using probit regression. RESULTS: One hundred laboring parturients received the DPE technique of whom 93 proceeded to have analgesia maintained with PIEB using 10 mL boluses of ropivacaine 0.1% and sufentanil 0.5 µg/mL. Totals of 89.5% (17/19), 84.2% (16/19), 82.4% (14/17), 52.6% (11/19), and 36.8% (7/19) of patients in groups 35, 40, 45, 50, and 55, respectively, received effective PIEB analgesia. The estimated values for EI50 and EI90 were 52.5 (95% CI, 48.4-62.6) minutes and 37.0 (95% CI, 28.4-40.9) minutes, respectively. CONCLUSION: The estimate of the PIEB optimal interval for effective analgesia after the DPE technique was comparable to that reported in previous studies when analgesia was initiated using a conventional epidural technique.

Determination of the Optimal Volume of Programmed Intermittent Epidural Bolus When Combined With the Dural Puncture Epidural Technique for Labor Analgesia: A Random-Allocation Graded Dose-Response Study.

BACKGROUND: The dural puncture epidural (DPE) and the programmed intermittent epidural bolus (PIEB) techniques are recent innovations for labor analgesia. The optimal volume of PIEB during traditional epidural analgesia has been investigated previously but it is unknown whether these findings are applicable to DPE. This study aimed to determine the optimal volume of PIEB for effective labor analgesia after initiation of analgesia using DPE. METHODS: Parturients requesting labor analgesia received dural puncture with a 25-gauge Whitacre spinal needle and then had analgesia initiated with 15 mL of ropivacaine 0.1% with sufentanil 0.5 µg/mL. Analgesia was maintained using the same solution delivered by PIEB with boluses given at a fixed interval of 40 minutes starting 1 hour after the completion of the initial epidural dose. Parturients were randomized to 1 of 4 PIEB volume groups: 6, 8, 10, or 12 mL. Effective analgesia was defined as no requirement for a patient-controlled or manual epidural bolus for 6 hours after the completion of the initial epidural dose or until full cervical dilation. The PIEB volumes for effective analgesia in 50% of parturients (EV50) and 90% of parturients (EV90) were determined using probit regression. RESULTS: The proportions of parturients with effective labor analgesia were 32%, 64%, 76%, and 96% in the 6-, 8-, 10-, and 12-mL groups, respectively. The estimated values for EV50 and EV90 were 7.1 (95% confidence interval [CI], 5.9-7.9) mL and 11.3 (95% CI, 9.9-15.2) mL, respectively. There were no differences in side effects, including hypotension, nausea and vomiting, and fetal heart rate (FHR) abnormalities among groups. CONCLUSION: Under the conditions of the study, after initiation of analgesia using DPE, the EV90 of PIEB for effective labor analgesia using ropivacaine 0.1% with sufentanil 0.5 µg/mL was approximately 11.3 mL.

Comparison of the dural puncture epidural and the standard epidural techniques in patients having labor analgesia maintained using programmed epidural boluses: a prospective double-blinded randomized clinical trial.

BACKGROUND: The dural puncture epidural technique has been shown in some studies to improve the onset and quality of the initiation of labor analgesia compared with the standard epidural technique. However, few studies have investigated whether this technique confers advantages during the maintenance of analgesia. This randomized double-blinded controlled study compared dural puncture epidural analgesia with standard epidural analgesia when analgesia was maintained using programmed intermittent epidural boluses. METHODS: 400 parturients requesting epidural labor analgesia were randomized to have analgesia initiated with a test dose of 3 mL lidocaine 1.5% with epinephrine 15 µg, followed by 12 mL ropivacaine 0.15% mixed with sufentanil 0.5 µg/mL using the dural puncture epidural or the standard epidural technique. After confirming satisfactory analgesia, analgesia was maintained with ropivacaine 0.1% and sufentanil 0.5 µg/mL via programmed intermittent epidural boluses (fixed volume 8 mL, intervals 40 min). We compared local anesthetic consumption, pain scores, obstetric and neonatal outcomes and patient satisfaction. RESULTS: A total of 339 patients completed the study and had data analyzed. There were no differences between the dural puncture epidural and standard epidural groups in ropivacaine consumption (mean difference -0.724 mg, 95% CI of difference -1.450 to 0.001 mg, p=0.051), pain scores, time to first programmed intermittent epidural bolus, the number of programmed intermittent epidural boluses, the number of manual epidural boluses, obstetric outcome or neonatal outcome. Patient satisfaction scores were statistically higher in the dural puncture epidural group but the absolute difference in scores was small. CONCLUSION: Our findings suggest that when labor analgesia is maintained using the programmed intermittent epidural bolus method, there is no significant advantage to initiating analgesia using the dural puncture epidural compared with the standard epidural technique. TRIAL REGISTRATION NUMBER: ChiCTR2200062349.

Determination of the Relative Potency of Norepinephrine and Phenylephrine Given as Infusions for Preventing Hypotension During Combined Spinal-Epidural Anesthesia for Cesarean Delivery: A Randomized Up-And-Down Sequential Allocation Study.

Purpose: The relative potency of norepinephrine and phenylephrine given as boluses to treat hypotension during spinal anesthesia for cesarean delivery has been reported but few data are available for infusions. This study aimed to determine the relative potency of norepinephrine and phenylephrine when given by infusion for preventing hypotension during combined spinal-epidural anesthesia for cesarean delivery. Methods: This was a prospective, randomized, double-blind, up-and-down sequential allocation study. Patients were randomly allocated to receive a prophylactic infusion of norepinephrine or phenylephrine started immediately after induction of anesthesia. The first patients received either norepinephrine 0.1 µg/kg/min or phenylephrine 0.5 µg/kg/min. An effective infusion rate was defined when no hypotension occurred before delivery. For each subsequent patient, the norepinephrine infusion rate was decreased or increased by 0.01 µg/kg/min or the phenylephrine infusion rate was decreased or increased by 0.05 µg/kg/min according to whether the infusion was effective or ineffective respectively in the previous patient. Values for the infusion rate that was effective in preventing hypotension in 50% of patients (ED50) for norepinephrine and phenylephrine were estimated using up-and-down sequential analysis and relative potency was estimated. Probit regression was used as a backup and sensitivity analysis. Results: The ED50 values for norepinephrine and phenylephrine calculated by the up-and-down method were 0.061 (95% CI 0.054-0.068) µg/kg/min and 0.368 (95% CI 0.343-0.393) µg/kg/min respectively. The estimated relative potency ratio for ED50 for norepinephrine to phenylephrine was 6.03:1 (95% CI 5.26:1 to 6.98:1). Conclusion: Under the conditions of this study, norepinephrine given by infusion was about 6 times more potent than phenylephrine. This information is useful for clinical practice and further comparative studies of norepinephrine versus phenylephrine. Clinical Trial Registration: http://www.chictr.org.cn/showproj.aspx, identifier [ChiCTR2200056237].

A Randomized Double-Blinded Dose-dependent Study of Metaraminol for Preventing Spinal-Induced Hypotension in Caesarean Delivery.

Purpose: Prophylactic infusion of a vasopressor is preferred as a rational choice in clinical practice in Cesarean delivery. Metaraminol is one of most common vasopressors used in obstetric clinical practice. However, the dose-response of metaraminol has not been fully determined and the optimal infusion dose is unknown. Therefore, this study aimed to determine the median effective dose (ED50) and 90% effective dose (ED90) of weight-based fixed-rate metaraminol infusions for preventing spinal-anesthesia-induced hypotension in patients having combined spinal-epidural anesthesia for elective Caesarean delivery. Methods: One hundred and seventeen patients with singleton pregnancies were enrolled and randomly allocated into one of five groups in this study. Patients received prophylactic metaraminol infusion at a fixed rate of 0, 0.25, 1.0, 1.75 or 2.5 µg/kg/min in each group immediately after induction with intrathecal 10 mg of hyperbaric bupivacaine mixed with 5 µg of sufentanil. An effective prophylactic dose was defined as no occurrence of hypotension during the period of spinal introduction and neonatal delivery. Values for ED50 and ED90 of prophylactic infusion of metaraminol were calculated using probit regression. Characteristics of spinal anesthesia and side effects were recorded. Results: The ED50 and ED90 values of weight-based fixed rate of metaraminol infusion were 0.64 (95% CI, 0.04-1.00) µg/kg/min and 2.00 (95% CI, 1.58-2.95) µg/kg/min respectively. The incidence of hypotension decreased with an increased infusion rate of metaraminol in the five groups (test for trend, p < 0.001). The incidence of hypotension was similar between group 0 and 0.25, but significant higher than other groups; the incidence of hypotension was also similar between group 1.0 and 1.75, but higher than group 2.5. The incidence of reactive hypertension was significantly higher in group 2.5 compared to the other groups. Physician interventions were more frequent in group 0, 0.25 and 2.5 than in group 1.0 and 1.75 (adjusted p < 0.001). No difference was found in neonatal outcomes, including Apgar score and pH value of the umbilical artery. Conclusion: In summary, we have compared four different prophylactic weight-based infusion doses of metaraminol for preventing post-spinal hypotension in Cesarean delivery. The ED50 and ED90 values of metaraminol infusion for preventing spinal anesthesia-induced hypotension were 0.64 µg/kg/min and 2.00 µg/kg/min, respectively. This finding may be helpful for guiding clinical practice and further research.

[Aneuploid analysis of chromosomes 3, 8, 10, 20 and Y in esophageal squamous cell carcinoma].

Although the diagnostic and therapeutic modalities of esophageal squamous cell carcinoma (ESCC) have been improved considerably, the five-year survival rate is still not satisfied. To detect the numberial aberrations of the chromosomes in ESCC, fluorescence in situ hybridization (FISH) was performed on interphase nuclei prepared from 220 esophageal carcinoma tissues with specific centromeric probes for chromosomes 3, 8, 10, 20 and Y. The main aberrations of the euchromosomes was chromosome gain, including trisome, tetrasome, and polysome. The gain rates of the four euchromosome were 84.9%, 77.5%, 63.7% and 83.2%, and the frequencies of polysome for each euchromosome were 24.6%, 34.9%, 23.4% and 31.7%, respectively. Loss of chromosome Y was observed in 61.2% of male patients. The combination of the four chromosome probes 3, 8, 10 and 20 detected 74.5% of ESCC and the combination of 3, 8, 20 and Y detected 85.0%. These results indicated that both sets of the four centromeric probe combinations provide candidate biomarkers for the diagnosis of esophageal squamous cell carcinoma.

Chromosomal aneuploidies and combinational fluorescence in situ hybridization probe panels are useful for predicting prognosis for esophageal squamous cell carcinoma.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is a common cancer type in China. In this study, we aimed to develop aneuploidy markers for diagnosis and prognosis of ESCC. METHODS: Chromosomal aneuploidies were detected in 493 primary tumors and 61 precancerous lesions by fluorescence in situ hybridization with chromosome enumeration probes (CEP), and cut-off values were set by receiver operating characteristic (ROC) curves. RESULTS: According to the cut-off values, chromosomes 3, 8, 10, 12, 17 and 20 presented frequent gains, with rates of 70.1, 69.7, 58.9, 66.9, 67.5 and 77.2 % in tumors and of 32.1, 26.8, 33.9, 41.2, 44.0 and 42.0 % in precancerous lesions. Loss of chromosome Y was detected in 72.0 % of male patients. An optimal four-probe panel CEP3/12/17/20 was established for detecting ESCC (sensitivity: 86.1 %), and CEP3/10/12/20 for precancerous lesions (sensitivity: 48.0 %). Gain of CEP8 was significantly correlated with lymph node metastasis (LNM) and late stages (P = 0.002 and 0.001), and loss of CEPY with age (P = 0.002, male). Kaplan-Meier survival curves indicated that patients with positive CEP10/17 (pT1 + T2, P = 0.041) and CEP8/17 (stages IIb + III + IV, P = 0.002) had poor overall survival. Combinations of LNM/stage and CEP panels could divide patients into more subgroups, including LNM + CEP3/17, LNM + CEP10/17, LNM + CEP3/10/17, stage + CEP3/17, stage + CEP10/17 and stage + CEP3/10/17 (P = 0.0004, 0.0003, 0.0001, 0.005, 0.001 and 0.0008, respectively). Multivariate Cox regression analysis confirmed that the above combinational models were independent prognostic factors. CONCLUSIONS: Our data suggest that the combinational probe sets may have potential for detection and prognostic prediction of ESCC.

[Application of multicolor fluorescence in situ hybridization to early diagnosis of esophageal squamous cell carcinoma].

BACKGROUND & OBJECTIVE: Detection of chromosome aberrations has been applied to diagnose some tumors. However, there are no chromosomal markers for the diagnosis of esophageal carcinoma so far. This study was to analyze aberrations of some chromosomes in esophageal squamous cell carcinoma (ESCC) and its premalignant lesions, thus to explore the application of multicolor fluorescence in situ hybridization (M-FISH) for the early diagnosis and risk prediction of precursor lesions of ESCC. METHODS: Aberration statuses of chromosomes 3, 8, 10, 12, 17 and 20 were investigated in 124 esophageal tissue samples from 113 patients using M-FISH with chromosome-specific centromere DNA probes. The relationship between chromosome gains and clinicopathologic parameters was analyzed. RESULTS: Copy number gains on chromosomes 3, 8, 10, 12, 17 and 20 in ESCC were 80.9% (93/115), 81.0% (94/116), 70.5% (79/112), 75.9% (85/112), 68.7% (79/115) and 82.8% (48/58), respectively. No statistical relations were found between chromosome aberrations and clinicopathologic parameters (P>0.05). Polysomy rates of the six chromosomes in precursor lesions were 62.5% (5/8), 75.0% (6/8), 62.5% (5/8), 87.5% (7/8), 87.5% (7/8) and 100% (3/3); while those in early-stage ESCC were 80.0% (12/15), 93.8% (15/16), 71.4% (10/14), 64.3% (9/14), 75.0% (12/16) and 63.6% (7/11). CONCLUSIONS: Positive aneuploidy rates of chromosomes 3,8,10,12,17 and 20 are highly detected in both ESCC and its precursor lesions. M-FISH is helpful in the early diagnosis of ESCC, thus it may be used as a method to predict the risk to ESCC.