间充质干细胞治疗椎间盘退行性变的研究进展

<正>椎间盘退行性变(IDD)是引起下腰痛的主要病因之一~([1]),IDD导致的椎间隙狭窄是下腰痛重要发病机制~([2-3])。成人椎间盘是人体最大的无血管组织且细胞含量较少~([4])。IDD不同于正常衰老,衰老属于生理现象,不引起疼痛,而IDD则会引起髓核细胞(NPC)活性下降、数量减少,椎间隙高度丢失等,从而产生下腰痛。IDD的非手术治疗~([5])和手术     

可调节式骨科手术架在强直性脊柱炎伴脊柱后凸畸形矫形中的应用

正强直性脊柱炎(ankylosing spondylitis,AS)是一种慢性炎症性疾病~([1]),通常会导致脊柱畸形和关节强直,晚期常需手术治疗,以恢复矢状面平衡、脊柱力线和视野,以期获得满意的外观和临床效果~([2])。脊柱截骨手术常需在俯卧位下施行~([3]),因部分患者长期处于脊柱后凸畸形及下肢关节非功能位强直~([4]),造成手术体位摆放困难,且AS常伴有中轴骨骨质疏松及周围韧带骨化~([5]),在体位摆放过程中,轻微外力亦会造成医源性骨折发生~([6]),在脊柱截骨矫形术中,在截骨端闭合过程易造成脊髓剪切、螺钉拔出~([7])。     

环状RNA在椎间盘退变中的作用研究进展

正腰痛(low back pain,LBP)目前已成为全球范围内致残的第二大病因,给人们带来了极大的经济负担~([1])。目前LBP的具体机制尚未明确,一般认为椎间盘退变(intervertebral disc degeneration,IVDD)是导致腰痛的主要病因~([2])。椎间盘作为人体最大的无血管组织,由中央的髓核、外周的纤维环及上下软骨终板构成。研究~([3～5])发现,IVDD与多种因素有关:一方面,与椎间盘解剖结构及营养供应具有独特性有关;另一方面,炎性反应、髓核细胞凋亡、细胞外基     

骨水泥强化椎弓根螺钉内固定术后骨水泥肺栓塞1例报告

<正>骨水泥强化椎弓根螺钉内固定术(cement augmented pedicle screw instrumentation, CAPSI)主要应用于骨质疏松性胸腰椎骨折或脊柱退行性疾病并骨质疏松的患者~([1,2])。虽骨水泥渗漏引起的肺栓塞极为少见,但存在潜在致命风险~([3])。据以往文献报道,经皮椎体后凸成形术(PKP)和经皮椎体成形术(PVP)后骨水泥渗漏后肺栓塞的发生率为3.5%～     

肾性骨病中西医治疗研究进展

正肾性骨病(renal osteodystrophy,ROD),又称"慢性肾脏病-矿物质-骨代谢性疾病(CKD-MBD)"~([1])是肾功能减退时引起骨骼的严重损害,主要临床表现为骨质疏松、骨软化、纤维性骨炎、骨性关节炎、骨硬化、骨性佝偻病以及病理性骨折等,可兼见皮肤、血液、神经及心血管系统损害。其病理过程主要为从甲状旁腺激素(PTH)分泌过度导致的高转化损害到正常或低PTH水平相关的低动力损害以及混合性损害的以钙磷等矿     

富含半胱氨酸的分泌型酸性蛋白基因敲除动物模型在腰椎间盘退变所致下腰痛研究中的应用

正椎间盘退变(intervertebral disc degeneration,IVDD)是一种由遗传因素、机械因素及环境因素等共同导致椎间盘(intervertebral disc,IVD)细胞衰老及细胞外基质(extracellular matrix,ECM)合成与分解代谢失衡的过程,常与下腰痛(low back pain,LBP)及其伴随出现的精神睡眠障碍密切相关~([1,2])。动物模型的建立为深入理解IVDD的发生与进展,     

根腔灌注椎体成形配套器械的研制及初步临床应用

<正>近年来,经皮椎体成形术(percutaneous vertebroplasty,PVP)已广泛应用于治疗骨质疏松性压缩骨折、血管瘤、转移性瘤等椎体疾患,取得了显著临床疗效~([1、2])。但是,PVP术中骨水泥渗漏造成的脊髓、神经根受压等并发症难以避免~([3])。为了预防PVP术中骨水泥渗漏的发生,临床上采取骨水泥分步灌注和球囊、网袋空腔灌注等方法~([4]),但这些方法的骨水泥灌注在椎体内均是无方向性的,难以调控,操作烦琐,治疗费用高。为此我们研制了一种根腔灌注椎体     

甲状旁腺素与2型糖尿病肾脏病相关性研究进展

正糖尿病肾脏病(diabetic kidney disease,DKD)是全球引起慢性肾脏病发生最主要的病因,也是导致糖尿病(diabetiic mellitus,DM)患者病死率高的主要原因之一。在美国人群研究中,大约有45%的终末期肾脏病患者有DKD~([1])。大量临床资料表明,DKD会出现钙磷代谢紊乱~([2])。甲状旁腺素(parathyroid hormone,PTH)是人体中调节钙磷代谢的重要激素,主要作用靶器官为骨、肾脏和肝脏~([3]),最近有研究表明其与心血管系统也有关~([4])。现在普遍认为PTH通过钙离子敏感受体(calcium sensing receptor,CaSR)、晚期糖基化产     

椎间盘源性腰痛的研究进展

正慢性腰痛是一种常见疾病,根据报道~([1-2])慢性腰痛的发病率约为80%,其病因极为复杂,腰肌劳损、腰椎病变、泌尿系统感染等许多疾病都会引起长期反复的腰痛,既往学者们通常认为腰椎间盘突出症是其主要病因,而随着研究的深入,目前不少学者认为由腰椎间盘内破裂引起的椎间盘源性腰痛是慢性腰痛的最常见原因~([3])。椎间盘源性腰痛的诊断与治疗水平近年来取得了很大进步,各种手术和微创治疗方法不断被发现,笔者就椎间盘源性腰痛的研究进展作一综述,报道如下。     

高黏度与低黏度骨水泥经皮椎体成形术治疗骨质疏松性椎体压缩骨折的疗效对比

<正>胸腰椎压缩性骨折是骨质疏松患者中常见的骨折类型~([1]),经皮椎体成形术(PVP)以其创伤小、疼痛迅速缓解、并发症少等优点,经过20余年发展已成为骨质疏松性椎体新鲜压缩骨折的主要治疗方法,尽管骨水泥渗漏发生率低,但仍是其常见并发症~([2])。近年来,为减少骨水泥渗漏发生,有学者将高黏度骨水泥应用于PVP。研究表明~([3]),高粘度骨水泥具有瞬间的高粘度、较低的聚合温度、可注射     

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.