RANKL、OPG在初发系统性红斑狼疮患者中的表达及意义

目的 研究初发系统性红斑狼疮(systemic lupus erythematosus,SLE)患者外周血淋巴细胞中细胞核因子-kB受体激活剂配体(receptor activator of nuclear factor kappa B ligand,RANKL)、护骨素(osteoprotegerin,OPG)基因mRNA的表达情况,探讨其表达水平与初发SLE患者骨质疏松的关系.方法 选择初发SLE患者45例及正常对照42例,运用实时定量PCR方法检测患者外周血淋巴细胞RANKL、OPG的mRNA表达水平.采用双能X线骨密度仪分别检测患者腰椎(L1～4)和股骨近端2个部位的骨密度,单因素分析RANKL、OPG基因mRNA表达水平与SLE患者骨密度的关系.结果 SLE患者RANKL、OPG基因mRNA表达水平较正常对照组明显减低(P＜0.01);SLE患者2个部位的骨密度均低于正常对照组(P＜0.05),骨量异常发生率为28.89%,骨量异常降低的SLE患者OPG基因mRNA的表达水平比骨量正常的患者显著降低,两者间的差异有统计学意义(P＜0.01);而RANKL基因mRNA表达水平的差异无统计学意义(P＞0.05);OPG基因ndtNA表达水平与初发SLE患者骨密度间存在正相关(r=0.461;P=0.001),即OPG表达水平越低,骨量减少越明显;而BANKL基因mRNA表达降低与初发SLE患者骨密度无明显相关性(r=-0.189,P=0.214);初发SLE患者疾病活动度与骨量减少、RANKL及OPG基因表达水平间不存在相关性(r=0.293,P=0.138;r=-0.099,P=0.493;r=0.138,P=0.493).结论 初发SLE患者骨量减少的发病率较正常人群增高,并且初发SLE患者体内RANKL和OPG基因表达存在异常;其中OPG表达水平的降低可能与初发SLE患者的骨量减少有密切关系.     

一期手术与二期手术治疗先天性巨结肠的Meta分析

目的比较一期手术和二期手术治疗先天性巨结肠（HD）的术后并发症及排便功能。 方法通过检索Pubmed、Web of Science、中国知网、万方中文数据库，筛选出2018年6月之前发表的符合标准的一期手术与二期手术治疗HD的对比研究。应用STATA 14.0软件对纳入文献的相关数据进行Meta分析，同时对纳入文献进行发表偏倚检验及敏感性分析。 结果共筛选出10篇文献633例患者，包括9篇英文和1篇中文回顾性对比研究。Meta分析结果显示：在术后并发症方面，一期手术组与二期手术组在吻合口狭窄（OR=0.56，95% CI：0.29~1.09，P=0.087）、吻合口瘘（OR=1.01，95% CI：0.16~6.51，P=0.995）、肠梗阻（OR=0.88，95% CI：0.44~1.75，P=0.708）、直肠脱垂（OR=1.29，95% CI：0.35~4.82，P=0.705）、手术部位感染（OR=0.61，95% CI：0.31~1.20，P=0.152）、再次手术（OR=1.19，95% CI：0.66~2.16，P=0.563）的发生率比较，差异均无统计学意义，而二期手术组的术后小肠结肠炎（HAEC）发生率明显低于一期手术组（OR=2.09，95% CI：1.34~3.25，P=0.001）。在排便功能方面，两组术后排便功能良好率（OR=1.08，95% CI：0.58~2.01，P=0.804）、污粪（OR=0.60，95% CI：0.26~1.42，P=0.249）和大便失禁（OR=0.52，95% CI：0.17~1.55，P=0.237）的发生率比较，差异均无统计学意义，但一期手术组术后便秘发生率显著低于二期手术组（OR=0.49，95% CI：0.30~0.81，P=0.006）。 结论一期手术治疗HD避免了二期手术相关的吻合口并发症，而且便秘的发生率明显低于二期手术，但是HAEC发生率明显高于二期手术。     

绝经后女性体质量指数、体成分与骨密度的变化特征及关系

目的 探讨绝经后女性年龄、体质量指数（body mass index, BMI）及体成分的变化特征及与骨质疏松症之间的关系。方法 选取广州中医药大学第三附属医院2019年12月–2021年1月门诊收集的98名绝经后女性的体成分及骨密度资料,根据受试者的年龄和BMI分组,比较各年龄组及各BMI组的体成分差别,通过Spearman分析年龄、BMI及体成分对骨质疏松情况的影响,利用多元线性回归研究整体骨密度和整体骨矿含量的影响因素。结果 各个年龄组的整体骨密度（P＜0.001）及整体骨矿含量（P＜0.05）随年龄增加而下降,而各个BMI组的整体骨矿含量（P＜0.05）、整体肌肉质量（P＜0.001）、整体脂肪质量（P＜0.001）随BMI增加而增加。Spearman相关分析显示,随着年龄增加（P=0.005,r=0.281）,骨质疏松程度越严重;而随着BMI（P=0.019,r= – 0.237）、整体骨矿含量（P＜0.001,r= – 0.719）、肌肉质量（P=0.014,r= – 0.249）和脂肪质量（P=0.013,r= – 0.249）的增加,患骨质疏松的程度越轻。多元线性回归分析结果显示,年龄与绝经后女性整体骨密度（P=0.002,B= – 0.004）及整体骨矿含量呈负相关（P=0.000,B= – 0.013）;而整体肌肉质量（P=0.018,B=0.022）和整体脂肪质量（P=0.037,B=0.027）则与绝经后女性整体骨矿含量呈正相关。结论 年龄是绝经后女性患骨质疏松症的危险因素,而BMI、肌肉质量和脂肪质量是保护因素,有助于提高整体骨密度和整体骨矿含量。     

绝经后股骨颈骨折患者全髋置换术后影响因素分析

目的 探讨接受全髋关节置换术（total hip replacement，THA）患者的一般情况、合并症和围手术期因素，了解这些因素与术后住院时间（length of stay，LOS）的相关性。方法 回顾性分析2015年1月至2019年12月于苏州大学附属第二医院接受THA的绝经后股骨颈骨折患者病历资料。共纳入患者637例，平均年龄（70.6±6.5）岁，平均体质量指数（body mass index, BMI)为（28.2±5.7）kg/m2，术后LOS中位数为7（6，8）d，术后LOS长于中位数的有263例（占41.3%）。采用Logistic 回归方法分析影响LOS的相关因素。结果 ①运用单因素分析方法分析了影响THA的LOS因素，其中年龄、BMI、入院时间、ASA（美国麻醉医师协会）分级、合并症、术前等待时间、手术时间、贫血、术后低蛋白血症、术后不良事件这十项指标有统计学意义（P<0.05）；②将P<0.1的因素纳入二元Logistic回归模型进行多因素分析，其中年龄>70岁（OR : 1.513 ；95% CI：1.032~2.260 ；P<0.001）、BMI< 18.5 kg/m2（OR : 1.577； 95% CI：1.073~2.319 ；P=0.021）、周五或周六入院（OR : 1.558 ；95% CI : 1.154~2.412；P=0.007）、ASA III/IV级（OR : 2.076 ；95% CI : 1.472~2.926；P<0.001）、合并术前贫血（OR : 1.665 ；95% CI : 1.338~2.072；P<0.001）、合并术后不良事件（OR : 1.814 ；95% CI : 1.174~2.803；P=0.007）这六项指标为LOS延长的独立危险因素。结论 术后住院时间（LOS）与老年人术后恢复状况关系密切，绝经后股骨颈骨折患者THA术后LOS延长与部分人口学、合并症、围手术期指标、入院时间等因素相关；其中有六项指标是独立危险因素。     

胃癌外周血TWA1 mRNA的表达与预后价值

目的检测胃癌（GC）患者外周血TWA1 mRNA表达水平，分析其与患者长期预后的关系。 方法选择2016年6月至2017年6月于西宁市第二人民医院诊治的97例GC患者，实时荧光定量PCR（RT-PCR）检测外周血TWA1表达量，随访并记录患者无进展生存期（PFS）。受试者工作特征（ROC）曲线判定TWA1 mRNA的阈值，分组比较TWA1 mRNA不同表达患者的PFS情况。Cox回归模型评估TWA1 mRNA水平对GC患者预后的预测价值。 结果随访（20.91±5.76）个月，随访率为94.79%（91/94），平均PFS（21.83±5.13）个月。TWA1 mRNA对GC患者PFS判定的曲线下面积为0.781（95% CI：0.687~0.875，P<0.001），截断值为1.27。TWA1 mRNA高表达患者的PFS显著短于低表达患者（χ²=14.415，P<0.01）。淋巴结转移（HR=3.328，95% CI：2.098~5.971，P=0.044）、TNM Ⅲ~Ⅳ期（HR=3.400，95% CI：1.114~4.795，P=0.011）及外周血TWA1 mRNA高表达（HR=7.429，95% CI：1.711~32.263，P=0.007）是影响患者PFS的独立危险因素。 结论外周血TWA1的表达与GC患者PFS显著相关，TWA1 mRNA水平对GC患者随访预后情况具有较好的预测价值。     

绝经后女性肌少症和骨质疏松症对平衡能力的影响

摘要：目的 探讨绝经后女性肌少症和骨质疏松症对平衡能力的单独及联合影响。方法 从北京市社区招募符合要求的绝经后女性332人，分为正常组238人、肌少症组27人、骨质疏松症组44人、肌少-骨质疏松症组23人。根据亚洲肌少症工作组（AWGS）的诊断标准诊断肌少症，采用世界卫生组织（WHO）的骨质疏松症诊断标准诊断骨质疏松症，采用闭眼单脚站立时间（SST）评估静态平衡能力，通过定时起立-行走测试（TUGT）评估动态平衡能力，采用二元Logistic回归分析肌少症及骨质疏松症与平衡不良之间的关系。结果 肌少症和肌少-骨质疏松症患者静态和动态平衡不良发生率显著高于骨质疏松症患者和正常人（P<0.05），骨质疏松症患者与正常人静态和动态平衡不良发生率无显著差异（P>0.05）。二元Logistic回归分析结果显示，肌少症和肌少-骨质疏松症是静态平衡不良（OR=5.747, 95% CI: 1.871~17.651, P=0.002；OR=6.989, 95% CI: 1.902~25.685, P=0.003）的独立危险因素，也是动态平衡不良的独立危险因素（OR=6.843, 95% CI: 2.671~17.535, P=0.000；OR=9.779, 95% CI: 3.317~28.836, P=0.000），且患有肌少-骨质疏松症者静态平衡不良和动态平衡不良发生风险显著高于仅患有肌少症者；单独患有骨质疏松症对静态和动态平衡不良发生风险均无显著影响（P>0.05）。结论 患肌少症或肌少-骨质疏松症都会增加绝经后女性静态和动态平衡不良的发生风险；肌少症和骨质疏松症对绝经后女性静态平衡不良和动态平衡不良的发生具有协同效应。     

绝经后骨质疏松B细胞、T细胞亚群、免疫调控因子与骨密度相关性研究

目的 研究绝经后骨质疏松（Ⅰ型骨质疏松）T细胞亚群（调节性T细胞CD3+/CD4+/CD25+）、B细胞（CD3-/CD19+）、免疫调控因子（TNF-α、TGF-β、IL-17）与骨密度相关性。阐明B细胞、T细胞亚群、免疫调控因子与骨质疏松发生、发展的关系,为骨质疏松诊断、治疗提供分子生物学依据。方法 采用双能X线骨密度仪检测受试者腰椎正位（L1~4）骨密度,采用流式细胞检测技术对B细胞、T细胞亚群进行分析,采用酶联免疫分析检测免疫调控因子。结果 绝经后骨质疏松组调节性T淋巴细胞亚群占CD4+T淋巴细胞的比例低于非骨质疏松组（P<0.05）,绝经后骨质疏松组外周血B淋巴细胞（CD3-/CD19+）的百分比低于非骨质疏松组,但差异无统计学意义（P＞0.05）。绝经后骨质疏松症患者血清免疫调控因子（TNF-α、TGF-β、IL-17）水平与非骨质疏松女性差异明显（P<0.05）。结论 T淋巴细胞、B 淋巴细胞与免疫调控因子协同作用,通过影响破骨细胞、成骨细胞分化、增殖,调节骨重建。骨质疏松与机体免疫系统密切关联。     

结直肠癌患者ERAS方案和术后住院时间的相关性分析

［摘要］ 目的 研究结直肠癌患者实施ERAS流程后影响术后住院时间的相关因素。方法 收集2015年5月~2018年9月间广东省第二人民医院普外二科接受手术治疗的结直肠癌患者411例，将患者根据《结直肠手术应用加速康复外科中国专家共识（2015版）》方案，完成ERAS标准流程。观察术后住院时间与术前肠道准备、术前碳水化合物摄入、预防性抗生素使用、术中预防低体温措施、目标导向性液体治疗、硬膜外置管、术后早期活动、术后早期进食、非甾体镇痛药使用、早期拔除引流管、年龄、性别、体重指数、美国麻醉医师协会麻醉分级、贫血、手术部位、手术方式、手术时间、术后有无ICU监护、并发症发生情况之间的相关性。利用二分类Logistic回归分析各变量与术后住院时间之间的相关性。结果 年龄、性别、糖尿病、体重指数、新辅助化疗、术前贫血均与术后住院时间无显著相关性，其P值分别为0.705、0.563、0.078、0.674、0.323、0.782。而术前延长术后住院时间的因素为美国麻醉医师协会麻醉分级≥3分（P<0.001， OR=8.000， 95% CI 4.080~15.686）。手术相关因素如手术的方式、手术时间长于180 min与术后住院时间延长密切相关（P=0.025， OR=0.464， 95% CI 0.237~0.907；P<0.001，OR=15.370， 95% CI 7.828~30.175）。而术后的重症监护室监护治疗并不显著影响术后住院时间（P=0.645， OR=0.791，95% CI 0.291~2.148）；术后早期活动延迟与术后住院时间延长相关（P<0.001， OR=12.149， 95% CI 5.284~27.931）；而术前碳水化合物的摄入也对术后住院时间有影响（P=0.001， OR=0.343， 95% CI 0.179~0.658），当然其可使术后患者的住院时间缩短（相关系数为?1.050）。而硬膜外置管镇痛、术中液体平衡及术后早期进食及术后并发症与住院时间并无显著关联。结论 制定更加高效合理的结直肠癌围手术期ERAS方案可缩短患者住院时间，加速患者康复。     

加速康复外科理念在肝移植围术期应用效果的Meta分析

背景与目的：加速康复外科（ERAS）是一种多学科合作模式,其已被证实在多学科应用安全有效,但ERAS理论在肝移植领域仍处于探索阶段。本研究旨在系统评价ERAS在肝移植患者围术期的应用效果。 方法：利用PubMed、Cochrane、Embase、CNKI、维普和万方及临床试验注册平台和灰色文献数据库检索相关文献,检索时间为建库至2020年7月8号。由2名研究者独立筛选文献、提取资料并评价偏倚风险后,应用Stata 16.0进行Meta分析。 结果：最终纳入21篇文献,共2 136例患者,其中1 008例患者接受ERAS干预（ERAS组）,1 128例行传统围手术期管理（传统组）;随机对照试验研究13篇,临床对照试验研究8篇。Meta分析结果显示,与传统组比较,ERAS组术后总并发症发生率（OR=0.31,95% CI=0.22~0.43,P<0.001）以及排斥反应（OR=0.26,95% CI=0.13~0.53,P<0.001）、胸腔积液（OR=0.31,95% CI=0.17~0.57,P<0.001）、胆汁漏（OR=0.19,95% CI=0.05~0.65,P=0.008）、感染（OR=0.28,95% CI=0.16~0.50,P<0.001）和肺部感染（OR=0.53,95% CI=0.33~0.86,P=0.010）并发症发生率均明显降低;住院时间（WMD=-5.76,95% CI=-6.89~-4.63,P<0.001）、ICU治疗时间（WMD=-2.26,95% CI=-3.21~-1.31,P<0.001）、手术时间（WMD=-41.07,95% CI=-67.82~-14.32,P=0.003）和无肝期（WMD=-5.78,95% CI=-11.50~-0.07,P=0.047）均明显缩短,术中失血量（WMD=-794.67,95% CI=-1 302.96~-286.39,P=0.002）明显减少,患者满意度明显提高。 结论：ERAS在肝移植术围术期应用安全有效,可促进患者术后康复。     

解剖性切除与非解剖性切除治疗肝细胞癌患者疗效的Meta分析

背景与目的：目前手术切除仍然是肝细胞癌（HCC）的首选治疗,但采用解剖性切除（AR）还是非解剖性切除（NAR）争议很大。本研究通过Meta分析方法评价AR与NAR在治疗HCC患者的有效性与安全性,以获得循证学证据为临床提供参考。 方法：计算机检索多个国内外数据库,收集比较关于AR与NAR治疗HCC临床疗效的文献,检索时限均为建库至2020年9月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用 RevMan 5.3软件进行Meta分析。 结果：最终纳入33篇研究,包括1个随机对照试验（RCT）和32个队列研究,共6 132例患者,其中AR组3 029例,NAR组3 103例。Meta分析结果显示：与NAR组比较,AR组术后早期复发率（OR=0.67,95% CI=0.49~0.92,P=0.01）和肝内局部复发率（OR=0.35,95% CI=0.20~0.59,P=0.000 1）均降低,1、2、3、5年无瘤生存率（DFS）（OR=1.26,95% CI=1.12~1.42,P=0.000 1;OR=1.31,95% CI=1.17~1.46,P<0.000 01;OR=1.32,95% CI=1.19~1.48,P<0.000 01;OR=1.40,95% CI=1.23~1.58,P<0.000 01）和5年总生存率（OS）（OR=1.16,95% CI=1.03~1.31,P=0.02）均提高,但两组术后肝内远处复发率（OR=1.11,95% CI=0.80~1.54,P=0.54）,肝外转移发生率（OR=0.97,95% CI=0.78~1.22,P=0.83）,1、2、3年OS和术后并发症发生率等的差异均无统计学意义（OR=1.01,95% CI=0.85~1.22,P=0.88;OR=1.15,95% CI=0.99~1.33,P=0.06;OR=1.13,95% CI=1.00~1.28,P=0.06;OR=0.98,95% CI=0.81~1.17,P=0.79）。亚组分析显示,对于合并微血管侵犯（MVI）的HCC,AR组术后1、2、3、5年DFS（OR=1.36,95% CI=1.07~1.73,P=0.01;OR=1.55,95% CI=1.23~1.95,P=0.000 2;OR=1.78,95% CI=1.38~2.30,P<0.000 01;OR=2.07,95% CI=1.46~2.94,P<0.000 1）和2、3、5年OS（OR=1.54,95% CI=1.07~2.21,P=0.02;OR=1.46,95% CI=1.11~1.92,P=0.007;OR=1.52,95% CI=1.13~2.03,P=0.005）均高于NAR组。 结论：当前证据表明,与NAR比较,AR能减少HCC患者术后早期复发和肝内局部复发,提高术后DFS和远期OS。尤其对合并MVI的患者,AR在近远期疗效均明显优于NAR,推荐在临床中应用。受纳入研究数量和质量限制,上述结论还需多中心、大样本随机对照试验予以验证。     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.     

Risiko Schlaganfall — Öffentlichkeitsarbeit und Aufklärung dringend erforderlich

Zusammenfassung Das wesentliche — und zugleich noch wenig ausgeschöpfte — Potenzial der Schlaganfallmedizin liegt in der langfristigen Prophylaxe. Durch Beeinflussung von Lifestylefaktoren wie Ernährungsgewohnheiten, Zigarettenkonsum und körperlichem Training durch entsprechende Aufklärung ließe sich ein erheblicher Teil an zerebralen Ereignissen vermeiden. Ein weiterer in Deutschland noch zu wenig beachteter Faktor ist die konsequente Blutdruckeinstellung. Breitgestreute Aufklärung könnte außerdem potenziellen Patienten helfen, bereits auftretende Warnsymptome wie die transiente ischämische Attacke richtig einzuschätzen, um eine rechtzeitige Behandlung zu ermöglichen.