Ghrelin通过调控NF-κB/NLRP3焦亡信号通路抑制前交叉韧带成纤维细胞焦亡的机制研究

目的 探究胃饥饿素（Ghrelin）调控核因子κB（nuclear factor kappa-B，NF-κB）/NOD样受体热蛋白结构域相关蛋白3（NOD-like receptor thermal protein domain associated protein 3，NLRP3）信号通路在前交叉韧带成纤维细胞焦亡中的作用。方法 前交叉韧带成纤维细胞分为对照组、肿瘤坏死因子α（tumor necrotic factor-α，TNF-α）炎症模型组、TNF-α+Ghrelin干预组，通过CCK-8确定TNF-α和Ghrelin干预的剂量和时间，Transwell法检测细胞迁移能力，Western Blot检测细胞焦亡相关蛋白含半胱氨酸的天冬氨酸蛋白水解酶-1（cysteinyl aspartate specific proteinase，Caspase-1）、白细胞介素18（Interleukin-18，IL-18）、白细胞介素1β（Interleukin-1β，IL-1β）、消皮素D（gasdermin D，GSDMD）的表达，q-PCR检测Caspase-1、IL-18、IL-1β、GSDMD mRNA表达水平，Western Blot检测磷酸化P65（p-P65）和NLRP3的表达。结果 绘制CCK-8结果曲线，确定Ghrelin的干预浓度为20 ng/mL，TNF-α干预浓度为20 ng/mL，干预时间都为48 h；与对照组相比，TNF-α炎症模型组的细胞迁移能力明显降低（P＜0.001），细胞焦亡相关蛋白表达显著增高（P＜0.05），p-P65和NLRP3的表达显著增高（P＜0.05），Ghrelin干预后细胞迁移能力明显提高（P＜0.001），细胞焦亡相关蛋白显著降低（P＜0.05），p-P65和NLRP3的表达显著降低（P＜0.05）。结论 Ghrelin能够显著抑制前交叉韧带成纤维细胞焦亡，改善其迁移能力，这可能是通过调控NF-κB/NLRP3实现的。     

杜仲多糖通过抑制NF-κB通路减轻IL-1β诱导的软骨细胞损伤

目的:探讨杜仲多糖对白细胞介素1β（interleukin-1β，IL-1β）诱导的软骨细胞损伤的影响及可能机制。方法：体外培养小鼠软骨细胞ATDC5，用含10μg/ml IL-1β处理ATDC5制作骨关节炎软骨细胞炎症模型，随机分为空白组、模型组、模型+杜仲多糖低浓度组、模型+杜仲多糖中浓度组和模型+杜仲多糖高浓度组。其中空白组细胞用常规培养基培养，模型组细胞用含10μg/ml IL-1β的培养基培养，模型+杜仲多糖低浓度组、模型+杜仲多糖中浓度组和模型+杜仲多糖高浓度组细胞分别用含100、200、400 μg/ml杜仲多糖与10μg/ml IL-1β的培养基共同培养。分别培养24、48、72 h后，CCK-8法检测细胞活力。培养48 h后，流式细胞术和DAPI染色检测细胞凋亡，ELISA法检测细胞培养上清液中肿瘤坏死因子α（tumor necrosis factor-α，TNF-α），一氧化氮（netric oxide，NO），γ干扰素（interfero-γ，IFN-γ）和白细胞介素6（interleukin-6，IL-6）的表达，DCFH-DA法检测细胞中活性氧含量，Western-blot法检测金属蛋白酶组织抑制因子1（tissue inhibrtor of metalloproteinase，TIMP-1），基质金属蛋白酶13（mitochondrial membrane protential，MMP-13）及NF-κB信号通路相关P65，磷酸化P65（p-P65）的蛋白表达，免疫荧光染色观察NF-κB P65细胞定位。结果：与空白组比较，模型组ATDC5细胞活力及TIMP-1蛋白表达降低（P<0.05），细胞凋亡率，TNF-α、NO、IFN-γ和IL-6水平，活性氧（reactive oxygen species，ROS）含量，MMP-13和p-P65的蛋白表达及细胞核内P65⁺数量均升高（P<0.05）。与模型组比较，模型+杜仲多糖低浓度组、模型+杜仲多糖中浓度组和模型+杜仲多糖高浓度组ATDC5细胞活力及TIMP-1蛋白表达升高（P<0.05），而细胞凋亡率、TNF-α、NO、IFN-γ和IL-6水平、ROS含量、MMP-13和p-P65的蛋白表达及细胞核内P65⁺数量均降低（P<0.05）。结论：杜仲多糖可促进白细胞介素1β诱导的软骨细胞ATDC5增殖，并抑制其凋亡、炎症反应和基质降解，其作用机制可能与抑制NF-κB通路的激活有关。     

锂剂促进自噬保护受损神经细胞的研究

目的：研究锂剂能否通过促进细胞自噬发挥神经细胞保护作用。方法：将SH-SY5Y神经细胞分为4组,包括对照组（正常换液）,模型组（培养液含有200 μmol/L H₂O₂的培养液）,锂剂组（培养液含200 μmol/L H₂O₂及1.0 mmol/L LiCl的培养液）,3-MA干预组（培养液含200 μmol/L H₂O₂、1.0 mmol/L LiCl及5 mmol/L 3-MA的培养液）。培养6 h后进行MTT检测及Beclin 1、LC3b免疫组化染色,评估细胞存活情况及自噬水平。结果：3-MA干预组细胞存活率较模型组降低（P<0.05）,锂剂组细胞存活率较模型组提高（P<0.05）。经过3-MA干预后,细胞存活率较对照组、模型组及锂剂组均有所降低（P<0.05）。经过H₂O₂处理后,细胞Beclin 1、LC3b染色面积增大,染色加深。经锂剂处理后细胞Beclin 1、LC3b染色面积进一步增大,染色更深。3-MA干预组细胞Beclin 1、LC3b染色面积较对照组大、染色深,但细胞染色面积较模型组和锂剂组均小,且染色更为浅淡。结论：锂剂能够促进受损神经细胞存活,促进自噬作用是锂剂发挥神经保护作用的机制之一。     

高迁移率族蛋白1通过PINK1/Parkin介导的线粒体自噬促进骨髓干细胞的趋化及成骨分化

目的 探讨高迁移率族蛋白1（HMGB1）通过PTEN诱导假定激酶1（PINK1）/帕金蛋白(Parkin)介导的线粒体自噬对骨髓干细胞的趋化及成骨分化的影响。方法 将人骨髓间充质干细胞（hBMSCs）分为7组：control组、siRNA-NC组、siRNA-HMGB1组、pcDNA-NC组、pcDNA-HMGB1组、pcDNA-HMGB1+siRNA-NC组、pcDNA-HMGB1+siRNA-PINK1组。采用Transwell检测细胞迁移能力;茜素红染色检测各组细胞中钙结节数目;ELISA检测骨桥蛋白（OPN）、碱性磷酸酶（ALP）的含量;RT-qPCR检测各组细胞中成骨细胞特异性转录因子（Osterix）、HMGB1及Runt相关转录因子2（RUNX2）、转录因子CCAAT/增强子结合蛋白（C/EBPα）、过氧化物酶体增殖物激活受体γ（PPARγ）水平;透射电镜检测线粒体自噬小体数目;Western Blot检测hBMSCs中Parkin及微管相关蛋白1A/1B-轻链3（LC3Ⅱ/Ⅰ）、选择性自噬接头蛋白62（P62）和自噬关键分子酵母Atg6同系物（Beclin1）等线粒体自噬相关蛋白的表达。结果 HMGB1通过PINK1/Parkin介导的线粒体自噬对hBMSCs的趋化作用研究表明：与pcDNA-NC组相比,pcDNA-HMGB1组HMGB1表达、细胞迁移率、线粒体自噬数目及自噬相关蛋白Beclin-1、LC3B-Ⅱ/Ⅰ的表达增加,Parkin、P62等蛋白的表达降低（P＜0.05）;与siRNA-NC组相比,siRNA-HMGB1组HMGB1表达、细胞迁移率、线粒体自噬数目及Beclin-1、LC3B-Ⅱ/Ⅰ等表达降低,Parkin、P62表达增高（P＜0.01）。HMGB1通过PINK1/Parkin介导的线粒体自噬对hBMSCs的成骨分化作用研究结果显示：与pcDNA-NC组相比,pcDNA-HMGB1组钙结节数量、Osterix及RUNX2含量、ALP及OPN的表达升高（P＜0.01）,PPARγ、C/EBPα的表达降低（P＜0.05）;与pcDNA-HMGB1+siRNA-NC组相比,pcDNA HMGB1+siRNA-PINK1组钙结节数量、Osterix及RUNX2含量、ALP及OPN的表达降低（P＜0.05）,PPARγ、C/EBPα的表达升高（P＜0.05）。结论 HMGB1高表达能通过PINK1/Parkin介导的线粒体自噬促进hBMSCs的趋化、成骨细胞分化及抑制成脂细胞分化,可能是骨质疏松症的潜在治疗靶点。     

营养指导对全髋关节置换术老年病人预后的影响

目的 探讨营养指导对全髋关节置换术（total hip arthroplasty, THA）老年病人预后的影响。方法 选择2016年1月至2017年1月我院骨关节外科收治的因股骨颈骨折行择期THA的194例老年病人纳入观察组,2015年1月至2016年1月因股骨颈骨折行择期THA的152例老年病人纳入对照组,对照组给予常规饮食指导,观察组在营养科会诊后给予个性化饮食指导。比较两组病人入院第1天及术后第10天的血清前白蛋白（PA）、白蛋白（ALB）、血红蛋白（Hb）、血电解质水平、感染率及住院时间。结果 观察组168例（男96例、女72例）完成试验,对照组118例（男67例、女51例）完成试验。术后第10天,观察组的PA、ALB和Hb分别为（0.352±0.074） g/L、（34.077±1.291） g/L、（117.846±7.208） g/L,显著高于对照组的（0.262±0.049） g/L、（32.750±1.067） g/L、（106.932±1.723） g/L,差异均有统计学意义（P均＜0.05）;除了Ca²⁺外,观察组病人Na⁺、K⁺和Mg²⁺的水平均显著高于对照组,差异均有统计学意义（P均＜0.05）。观察组的住院时间为（11.84±3.26） d,期间发生感染5例（5/168,3.05%）;对照组的住院时间为（13.32±4.54） d,发生感染12例（12/118,10.17%）,差异有统计学意义（t=-2.960,P=0.003;χ²=5.142,P=0.013）。结论 术后营养指导可以改善THA老年病人的术后营养状况及预后,降低并发症发生率,有利于病人术后快速康复。     

胸腺肽β4对氧化应激诱导的脊髓源性神经干/祖细胞损伤的作用及机制

目的：探讨胸腺肽β4（thymosin beta 4,Tβ4）在过氧化氢（hydrogen peroxide,H₂O₂）诱导的脊髓源性神经干/祖细胞（neural stem/progenitor cells,NSPCs）氧化应激损伤中的作用及机制。方法：分离Sprague-Dawley （SD）成年雄性大鼠中的原代NSPCs,将其分为对照组（未处理的NSPCs细胞）,H₂O₂处理组（500 μM H₂O₂损伤的NSPCs细胞）,Tβ4处理3组（H₂O₂处理组基础上分别用1、2.5、5 μg/ml Tβ4处理的NSPCs细胞）,TAK-242处理组[H₂O₂处理组基础上用Tβ4（5 μg/ml）和Toll样受体4（Toll-like receptors 4,TLR4）抑制剂TAK-242处理的NSPCs细胞]。采用髓样分化因子88（myeloid differentiation factor 88,MyD88）过表达慢病毒感染NSPCs细胞,构建MyD88过表达细胞系,并经H₂O₂和Tβ4处理。qRT-PCR和Western blot检测Tβ4,TLR4,MyD88的表达水平;MTT法和乳酸脱氢酶（lactate dehydrogenase,LDH）试剂盒检测细胞活力;采用Fluo-3/AM探针法检测细胞内Ca²⁺水平;流式细胞术和半胱氨酸天冬氨酸蛋白酶-3（Caspase-3）和Caspase-9试剂盒检测细胞凋亡水平;相应试剂盒分别检测活性氧（reactive oxygen species,ROS）含量,超氧化物歧化酶（superoxi dedismu-tase,SOD）活性和谷胱甘肽（glutathione,GSH）含量。酶联免疫吸附测定法检测白细胞介素（interleukin,IL）-6和IL-1β的含量。结果：H₂O₂损伤的NSPCs中Tβ4的表达降低（P<0.05）。与H₂O₂处理组相比,Tβ4处理3组和TAK-242处理组NSPCs的细胞活力、Ca²⁺浓度显著增加（P<0.05）,LDH释放量、细胞凋亡显著减少（P<0.05）,ROS和促炎细胞因子的生成显著减少（P<0.05）,TLR4和MyD88蛋白表达水平显著降低（P<0.05）。MyD88过表达后NSPCs细胞活力,SOD活性和GSH含量降低,LDH释放量、细胞凋亡显著增加（P<0.05）;而MyD88过表达后NSPCs经Tβ4处理后,细胞活力、SOD活性和GSH含量升高,LDH释放量以及细胞凋亡降低（P<0.05）。结论：Tβ4通过抑制TLR4,MyD88途径减轻H₂O₂诱导的NSPCs氧化应激、凋亡和炎症等损伤。     

小针刀通过足三里对肌痛共病抑郁大鼠行为学及海马NLRP3和IL-1β表达的影响

目的：观察小针刀刺激足三里穴对肌痛共病抑郁大鼠行为学及海马区Nod样受体蛋白3（Nod-likereceptor protein,NLRP3）和白介素1β（interleukin-1β,IL-1β）表达的影响。

方法：采用急性利血平腹腔注射法制备肌痛共病抑郁大鼠动物模型,将24只SD雄性大鼠随机分为正常组、模型组、小针刀组和阿米替林组,每组6只,分别给予对应处理。检测各组大鼠Open field行为学以及机械痛敏程度,智能热板仪检测各组大鼠热缩足阈值,应用Western blotting免疫印迹法检测大鼠海马NLRP3和IL-1β表达量。

结果：与模型组比较,小针刀组大鼠足底机械痛阈明显改善（P<0.01）;与阿米替林组比较,针刀刺激足三里可显著提高大鼠热缩足阈值（P<0.05）。在Open field行为学大鼠水平运动距离及穿格次数比较中,小针刀组大鼠旷场水平运动总距离明显增加（P<0.05）;与模型组比较,大鼠穿格次数有增多趋势,但差异无统计学意义（P>0.05）。模型组大鼠海马体NLRP3和IL-1β表达均明显升高（P<0.05）,小针刀组IL-1β表达明显降低（P<0.05）;针刺足三里可抑制大鼠海马NLRP3的表达,但与模型组比较,差异无统计学意义（P>0.05）。

结论：小针刀可以改善利血平导致的肌痛共病抑郁大鼠的病理状态,其作用机制可能与抑制中枢海马内NLRP3炎性小体和IL-1β的表达有关。     

体内埋置光纤介导的光生物调节对脊髓损伤后小鼠继发性炎症反应和功能恢复的影响

目的 研究体内埋置光纤介导的光生物调节对脊髓损伤小鼠组织修复和运动功能恢复的影响。方法 构建小鼠T9节段钳夹损伤及光生物调节治疗模型,将小鼠随机分为假手术（Sham）组、脊髓损伤（SCI）组、光生物调节治疗（SCI+PBM）组。用实时荧光定量PCR（qPCR）和酶联免疫吸附测定（ELISA）法检测损伤区炎症因子的表达情况。免疫荧光染色及原位末端标记（TUNEL）法观察损伤区神经元存活和轴突再生情况。采用巴索小鼠量表（Basso mouse scale,BMS）及足印记评估脊髓损伤小鼠后肢运动功能恢复情况。结果 与SCI组比较,SCI+PBM组小鼠损伤区的白细胞介素-1α（interleukin-1α,IL-1α）、白细胞介素-1β（interleukin-1β,IL-1β）和肿瘤坏死因子-α（tumor necrosis factor-α,TNF-α）的表达水平显著降低（P＜0.01）,总凋亡和神经元凋亡百分比显著降低（P＜0.001）,轴突到损伤中心的距离显著缩小（P＜0.001）,BMS评分和足印记步长明显优于SCI组（P＜0.01）。结论 体内埋置光纤介导的光生物调节可抑制小鼠脊髓损伤区继发性炎症反应,促进损伤区神经元存活及轴突再生,并最终促使损伤小鼠后肢运动功能的恢复。     

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.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

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.