胃转流术治疗2型糖尿病的近期效果

目的 研究胃转流术(gastric bypass,GBP)对2型糖尿病(type 2 diabetes mellitus,T2DM)的治疗作用.方法 分析2009年9月至2010年9月在第四军医大学西京医院住院的32例T2DM患者接受GBP的临床资料,比较手术前后空腹血糖(FBG)、餐后2h血糖(2hPG)、糖化血红蛋白(HbAlc)及体质量、血压和脂肪肝的变化.结果 本组32例患者在GBP后无严重并发症.术后1、6、12个月的FBG[(7.8±2.2)mmol/L、( 7.7±2.2)mmol/L、(7.2±1.8) mmol/L]均低于术前的PBG[ (11.1±2.7)mmol/L],P＜0.05;术后l、6、12个月的2hPG[( 10.2±2.6) mmol/L、(10.5±2.8)mmol/L、(10.5±3.1)mmol/L]均低于术前的2hPG[ (14.0±3.5)mmol/L],P＜0.05;术后1、6、12个月的HbAlc[(7.6％±1.4％)、(7.5％±1.7％)、(7.1％±1.9％)]均低于术前的HbAlc[(9.0％±2.3％)],P＜0.05.BMI＜ 25 kg/m2的非超重者的术后12个月FBG[(6.9±1.5) mmol/L]、2hPG[ (10.0±3.2)mmol/L]、HbAlc[(6.9％±1.9％)]均低于术前的FBG[( 10.7±2.9) mmol/L]、2hPG[(14.3±4.1) mmol/L]、HbAlc[(8.8％±2.0％)],P＜0.05;BMI≥25 kg/m2的非超重者的术后12个月FBG[ (7.5 ±2.3)mmol/L]、2hPG[ (11.3 ±2.9)mmol/L]、HbAlc[(7.3％±1.9％)]均低于术前的FBG[ (11.7±2.3)mmol/L]、2hPG[( 13.5±2.4)mmol/L]、HbAlc[(9.2％±2.7％)],P＜0.05.6例合并有高血压的T2DM患者术后1年血压正常5例.17例合并有脂肪肝的T2DM患者术后1年脂肪肝减轻8例.结论 GBP对T2DM患者的糖代谢失常及合并症有明显的治疗作用.     

外源性腺苷三磷酸对移植胰腺再灌注损伤保护作用的实验研究

目的　探讨外源性三磷酸腺苷 (ATP)对大鼠移植胰腺再灌注损伤的作用及其机制。方法　应用同系大鼠异位全胰十二指肠移植模型 ,供体胰腺分别用EuroCollin液 (EC)或EC液添加ATP约 12～ 2 0ml(2～ 4℃ )进行低温灌注保存 6 0min ,光镜观察胰腺组织结构变化 ,放射自显影鉴定外源性ATP是否进入胰腺细胞内 ,高压液相色谱法 (HPLC)检测保存后移植物ATP和总腺苷核苷酸(TAN)。移植 2 4h后 ,检测血糖、血清中脂肪酶、淀粉酶 ,测定移植胰腺组织中髓过氧化酶 (MPO)活性 ,并进行组织学观察。结果　实验组保存的胰腺组织结构损伤明显轻于对照组。保存后实验组胰腺组织ATP和TAN水平 [(5 6 6± 0 37) μmol/ g ,(8 6 2± 0 88) μmol/g]明显高于对照组 [(2 82±0 2 4 ) μmol/ g ,(4 34± 0 4 1) μmol/ g],差异具有显著性 (P <0 0 5 )。放射自显影显示外源性 [α 3 2 P]ATP进入胰腺细胞内。移植胰腺早期功能指标检测 ,实验组血糖值 [(9 3± 2 2 )mmol/L]明显低于对照组 [(14 1± 2 9)mmol/L],实验组血清脂肪酶 [(139± 13)U/L]明显低于对照组 [(2 96± 2 5 )U/L],实验组胰腺组织MPO[(1 19± 0 16 )U/ g ]明显低于对照组 [(2 2 5± 0 2 8)U/ g],差异均具有显著意义 (P <0 0 5 )。结论　外源性ATP用于胰腺     

Roux-en-Y胃旁路术改善非肥胖性2型糖尿病患者的糖脂代谢

目的 观察Roux-en-Y胃旁路术对非肥胖性2型糖尿病患者血糖和血脂代谢的影响.方法 共37例非肥胖2型糖尿病患者接受Roux-en-Y胃旁路术,观察其手术前、手术后3个月和6个月的体质量指数、糖化血红蛋白、空腹血糖、胰岛素、C肽、胰岛素抵抗指数、甘油三酯、总胆固醇、高密度脂蛋白和低密度脂蛋白含量的变化,并比较口服葡萄糖后2 h血糖、胰岛素和C肽的变化.结果 本组37例患者无严重围手术期并发症.手术前、手术后3个月和6个月体质量指数变化之间相比差异均无统计学意义(P>0.05);手术前、手术后3个月和6个月空腹血糖[(8.8±0.9)mmol/L、(7.0±2.0)mmol/L、(6.3±0.6)mmol/L,P<0.01]、糖化血红蛋白[(8.2%±1.2%、7.0%±0.8%、6.2%±0.7%,P<0.01]、空腹胰岛素[(10.6±1.2)mU/L、(9.0±0.9)mU/L、(9.0±0.8)mU/L,P<0.05]、空腹C肽[(1.9±0.5)nmol/L、(1.2±0.6)nmol/L、(1.2±0.4)nmol/L,P<0.01]、空腹甘油三酯[(3.3±0.8)mmol/L、(2.7 ±0.9)mmol/L、(2.6±0.7)mmol/L,P<0.05]、空腹总胆固醇[(6.5±1.8)mmol/L、(4.6±0.9)mmol/L、(4.2±1.0)mmol/L,P<0.05]、空腹低密度脂蛋白[(3.6±1.2)mmol/L、(2.8±0.8)mmol/L、(2.7±0.2)mmol/L,P<0.01]、餐后2 h血糖[(18.6±3.0)mmol/L、(12.7±2.3)mmol/L、(11.4±2.0)mmol/L,P<0.01]、胰岛素抵抗指数[(3.2±1.7)、(2.6±1.6)、(2.5±1.3),P<0.05]之间相比差异均有统计学意义.空腹高密度脂蛋白[(1.2±0.1)mmol/L、(1.4±0.4)mmol/L、(1.4±0.2)mmol/L,P<0.01]、餐后2 h胰岛素[(17.2±3,4)mU/L、(26.3±4.7)mU/L、(28.6±4.1)mU/L,P<0.01]、2 h C肽[(4.2±1.0)nmol/L、(6.3±1.5)nmol/L、(6.2±1.4)nmol/L,P<0.01]在手术后均明显升高.结论 Roux-en-Y胃旁路术可改善非肥胖性2型糖尿病患者血糖和血脂代谢,且与体质量指数变化无关.

Abstract：

Objective To evaluate Roux-en-Y gastric bypass operation on carbohydrate and lipid metabolism in type 2 diabetes mellitus patients with BMI range of 24 -29. Methods Thirty seven cases of type 2 diabetes mellitus patients undergoing Roux-en-Y gastric bypass operation were studied. Body mass index (BMI), glycosylated hemoglobin ( GHbAlc), fasting glucose ( FPG), fasting insulin (FIns) and C-peptide( FC-p), HOMA-IR, oral glucose tolerance (OGTT) including 2 hour insulin (2hIns) and C-peptide (2hC-p) , plasma levels of total cholesterol (TC), triglycerides(TG), high density lipoprotein( HDL-c)and low density lipoprotein ( LDL-c) were measured preoperatively and on 3 months, 6 months, later postoperatively. Result There was no statistically significant difference between BMI values measured preoperatively and postoperatively (P>0. 05 ). Serum levels measured in pre-operative and third and sixth post-operative months were: FPG (8. 8 ± 0. 9, 7. 0 ± 2. 0, 6. 3 ± 0. 6, P<0. 01) ( mmol/L) , GHbAlc (8.2±1.2, 7.0±0.8, 6.2±0.7, P<0.01)(%), FIns(10. 6 ±1. 2, 9.0±0.9, 9.0±0.8, P<0.05)(mU/L), FC-p(1.9±0.5, 1.2 ±0.6, 1.2 ±0.4, P<0. 01) (nmol/L), TG(3.3 ±0.8, 2.7 ±0.9,2.6±0.7, P<0.05)(mmol/L), TC(6.5±1.8, 4.6±0.9, 4.2 + 1.0, P<0. 05) (mmol/L)and LDL-c (3. 6 ±1.2, 2. 8 ±0.8, 2. 7 ±0.2, P<0.01) (mmol/L), 2 hour glucose after OGTT(2hPG) (18. 6 ±3.0, 12.7 ±2.3, 11.4±2.0, P<0. 01) (mmol/L), HOMA-IR(3. 2 ± 1. 7, 2.6±1.6, 2. 5 ±1.3, P<0. 05). Postoperative levels of HDL-c (1. 2 ± 0. 1, 1. 4 ± 0. 4, 1. 4 ± 0. 2, P<0. 01) ( mmol/L) , 2hIns (17. 2 ±3.4, 26. 3 ±4.7, 28. 6 ±4.1, P<0. 01) (mU/L)and 2hC-p(4. 2 ± 1. 0, 6. 3 ± 1. 5, 6. 2 ± 1.4,P<0. 01 ) ( nmol/L) were significantly higher than that of the pre-operative values ( P<0. 01 ).Conclusions Roux-en-Y gastric bypass significantly improves the metabolism of carbohydrate and lipid in type 2 diabetes patients with BMI 24-29, and the effects are not associated with weight loss.     

肝脏缺血-再灌注2相损伤对胰岛β细胞分泌功能的影响

目的 研究大鼠肝脏缺血-再灌注2相损伤对胰岛β细胞分泌功能的影响.方法 36只SD大鼠随机分为假手术组(C组)和IR组,每组18只.IR组制成肝脏缺血1 h再灌注12 h的70%肝脏I/R损伤模型.每组取10只大鼠,再灌注12 h后采血,测定血糖及血胰岛素浓度并计算胰岛素分泌指数.每组另各取8只大鼠,进行高血糖钳夹试验.结果 IR组血糖水平明显高于C组[(9.02±1.37)mmol/L vs.(5.52±0.95)mmol/L](P<0.01),胰岛素浓度也显著高于C组[(116.45±10.87)mU/L vs.(73.65±22.87)mU/L](P<0.01),但IR组胰岛素分泌指数显著低于C组[(462.80±46.28) vs.(1 046.54±30.21)](P<0.01).高血糖钳夹试验显示,IR组2相胰岛素分泌量显著低于C组[(83.17±6.01)mU/L vs.(99.80±10.81)mU/L](P<0.05),葡萄槠代谢率也明显低于C组[(29.68±4.92)mg·kg-1·min-1 vs.(53.16±3.45)mg·kg-1·min-1](P<0.01),胰岛素敏感性指数显著低于C组[(30.97±8.11) vs.(64.34±7.21)](P<0.01).结论 肝脏缺血-再灌注损伤12 h后,大鼠胰岛β细胞分泌功能受损,外周组织的胰岛素敏感性明显下降.     

舒洛地特对糖尿病大鼠肾脏病变的保护作用与机制探讨

目的 观察舒洛地特对糖尿病大鼠肾脏组织核因子NF-κB活性及单核细胞趋化蛋白1(MCP-1)表达的影响,探讨舒洛地特对糖尿病肾病的保护机制.方法 高脂高糖喂养联合小剂量链脲佐菌素腹腔注射建立Wistar大鼠糖尿病模型,并按随机数字表法分为非治疗组(DM)及舒洛地特治疗组( DMS).非糖尿病大鼠作为正常对照组(NC).12周后杀检,测定血糖、血肌酐、尿素氮、三酰甘油、胆固醇;免疫比浊法测定24h尿白蛋白;光镜下观察肾小球形态和结构,计算平均肾小球体积;免疫组化法检测肾组织MCP-1表达;Western印迹方法测定NF-κB活性.结果 与NC组比较,DM组及DMS组血糖、三酰甘油、胆固醇均显著升高(均P＜ 0.01);DMS组与DM组比较,以上指标差异无统计学意义.与NC组相比,DM组及DMS组血肌酐、尿素氮、24 h尿白蛋白显著升高(均P＜0.01).与DM组比较,DMS组血肌酐[(39.1±0.88) μmol/L比(41.0±2.16) μmol/L,P＜0.05]、尿素氮[(9.12±1.06) mmol/L比(9.87±0.19) mmol/L,P＜0.05]、24h尿白蛋白[(19.92±0.96) mg/24 h比(25.99±0.52) mg/24 h,P＜ 0.01]均显著降低.与NC组比较,DM组平均肾小球体积显著增加[(7.47±1.11)×105 μm3比(4.22±1.09)×105μm3,P＜ 0.01];DMS组平均肾小球体积[(6.64±0.71 )×105 μm3,P＜0.05]较DM显著降低,但仍显著高于对照组(P＜0.01).与NC组相比,DM组肾组织MCP-1表达显著升高[( 12.17±1.94 )/HPF比(1.19±0.70)/HPF,P＜0.01];与DM组比较,DMS组肾组织MCP-1表达[(9.22±1.61 )/HPF,P＜0.01]显著降低,但仍高于NC组(P＜0.01).与NC组相比,DM组肾组织NF-κB活性显著升高[(0.89±0.07)比(0.24±0.03),P＜0.01];与DM比较,DMS组肾组织NF-κB活性[(0.27±0.01),P＜0.01]显著降低,与NC组比较,差异无统计学意义.结论 舒洛地特对糖尿病肾病具有防治作用,抑制NF-κB活性及MCP-1表达可能是其作用机制之一.     

牙周基础治疗对2型糖尿病合并慢性牙周炎患者糖脂代谢及炎症反应的影响

目的:探讨牙周基础治疗对2型糖尿病(Type 2 diabetes mellitus,T2DM)合并慢性牙周炎患者糖脂代谢及炎症反应的影响。方法:按照随机数字表法将2019年1月-2019年12月笔者医院收治的150例T2DM合并慢性牙周炎患者分为对照组与观察组,每组75例。对照组患者进行糖尿病常规治疗,观察组患者在糖尿病常规治疗的基础上进行牙周基础治疗,均连续治疗3个月。比较两组糖代谢指标[空腹血糖(Fasting blood-glucose,FBG)、餐后2h血糖(2h postprandial blood glucose,2hPG)、糖化血红蛋白(Glycosylated hemoglobin,HbA1c)],脂代谢指标[总胆固醇(Total cholesterol,TC)、甘油三酯(Triglyceride,TG)、低密度脂蛋白(Low density lipoprotein,LDL)、高密度脂蛋白(High density lipoprotein,HDL)]及炎症因子[肿瘤坏死因子-α(Tumor necrosis factor-α,TNF-α)、白细胞介素-1β(Interleukin-1β,IL-1β)、IL-6、IL-10]的变化。结果:治疗后,观察组的FBG[(5.99±0.40)mmol/L vs(6.87±0.80)mmol/L]、2hPG[(7.41±0.46)mmol/L vs (8.93±0.90)mmol/L]、HbA1c[(6.45±0.58)%vs(7.84±0.66)%]水平均明显低于对照组(P0.05);观察组的TG[(0.98±0.22)mmol/L vs(2.20±0.79)mmol/L]水平明显低于对照组(P0.05);观察组的TNF-α[(1.15±0.32)pg/ml vs(2.87±0.65)pg/ml]、IL-1β[(0.40±0.15)pg/ml vs(3.71±0.94)pg/ml]水平明显低于对照组(P0.05),IL-10[(11.25±1.44)pg/ml vs(7.82±1.90)pg/ml]水平明显高于对照组(P0.05)。结论:牙周基础治疗对T2DM合并慢性牙周炎患者的糖脂代谢及炎症反应具有明显的改善作用。     

急性胰腺炎后胰腺内分泌变化临床研究

目的:观察研究急性胰腺炎后胰腺内分泌变化。方法:选取既往无糖尿病病史的急性胰腺炎住院患者60例为急性胰腺炎组,既往无糖尿病病史正常体检者30人为对照组。测定入院时、入院次日晨空腹、入院后第3 d晨空腹、入院后第7 d晨空腹血糖、胰岛素和C肽,比较两组结果。结果:急性胰腺炎组血糖在入院时[(7.2±1.4)mmol/L]、24 h[(7.3±2.3)mmol/L]、3 d[(9.4±1.6)mmol/L]较对照组[(4.3±1.8)mmol/L]升高,具有统计学意义,入院后7 d血糖([4.5±1.2)mmol/L]较对照组无明显升高。急性胰腺炎组血清胰岛素在入院后24 h([10.0±3.0)μIU/m L]、3 d([9.5±2.6)μIU/m L]较对照组[(11.4±0.6)μIU/m L]降低,具有统计学意义(P0.05),入院时[(11.8±2.7)μIU/m L]及入院后7 d[(11.9±2.7)μIU/m L]血清胰岛素较对照组无明显变化。急性胰腺炎组血清C肽在入院后24 h[(1.3±0.6)ng/m L]、3 d[(1.3±0.3)ng/m L]较对照组[(1.5±0.5)ng/m L]降低,入院时[(1.4±0.3)ng/m L]及入院后7 d[(1.5±0.3)ng/m L]血清C肽较对照组无明显变化。急性胰腺炎组血糖值随着发病时间延长呈现先升后降趋势,发病后7 d血糖基本恢复。血清胰岛素及C肽值则呈现先降后升趋势。结论:急性胰腺炎患者随着病情发展血糖先升后降,胰岛素及C肽先降后升,提示急性胰腺炎患者胰腺内分泌功能失调。     

血清游离脂肪酸水平与2型糖尿病患者肾小球滤过率的相关性

目的:探讨2型糖尿病(T2DM)患者体内血清游离脂肪酸(free fatty acid,FFA)水平与其肾脏功能的关系。方法:回顾性分析2017年01月～2018年06月上海市第八人民医院肾内科的120例T2DM患者资料,根据患者肾小球滤过率(estimated glomerular filtration rate,e GFR)水平[采用改良的肾脏病饮食改善公式(MDRD)估测]将患者分为3组,A组[e GFR≥90 ml·min-1·1. 73 m-2]40例; B组[(90 ml·min-1·1. 73 m-2 e GFR≥60 ml·min-1·1. 73 m-2]40例; C组[e GFR60 ml·min-1·1. 73 m-2]40例。检测各组生化指标,分析3组患者血清FFA水平与其e GFR的关系。结果:三组患者年龄、性别、血糖、BMI等一般资料差异无统计学意义,C组患者FFA水平[(542. 30±77. 55)μmol/L]明显高于A组[(360. 24±71. 41)μmol/L]及B组[(485. 40±78. 08)μmol/L](P 0. 05)。多重线性回归分析显示,FAA、空腹血糖、血尿酸(UA)、糖尿病病程、平均动脉压及尿白蛋白肌酐比增高是引起导致T2DM患者e GFR下降的独立影响因素(P均0. 05)结论:2型糖尿病患者血清FFA水平的升高是其肾功能下降的独立危险因素,可能在其糖尿病肾病的进展中起到重要作用。     

痛风患者不同糖代谢状态β细胞功能及代谢特征分析

目的:探讨痛风患者不同糖代谢状态时的胰岛素抵抗(IR)与胰岛β细胞功能的演变,分析痛风合并糖代谢紊乱的代谢特征.方法:2006年1月至2009年6月来我院就诊的96例痛风病人据75g口服葡萄糖耐量试验结果分为糖耐量正常组(NGT组,n=35)、糖调节受损组(IGR组,n=27)及糖尿病组(DM组,n=34).测量身高、体重、血压,测定空腹血糖、空腹胰岛素、糖化血红蛋白(HbA1c)、血清尿酸、胆固醇、甘油三酯及C反应蛋白,计算体重指数(BMI)、稳态模型胰岛素抵抗指数(HOMA-IR)、胰岛β细胞功能指数(HOMA-B)和胰岛素敏感指数(ISI).结果:DM组、IGR组和NGT组的BMI[分别为(27.36±4.10)、(25.52±3.87)及(23.64±3.19)kg/m2]、餐后2小时血糖(2hPG)[分别为(18.25±7.03)、(10.12±0 85)及(6.75±0.45)mmol/L]、空腹胰岛素[分别为(17.58±6.35)、(14.92±5.72)及(8.51±4.56)IU/ml]、HbA1c[分别为(10.18±3.24)、(6.54±3.28)及(5.12±2.21)%]、总胆固醇[分别为(5.84±1.09)、(5.23±0.97)及(4.62±1.08)mmol/L]、甘油三酯[分别为(3.93±1.23)、(3.09±1 01)及(2.37±0.95)mmol/L]、C反应蛋白[分别为(4.98±2.02)、(3.79±1.29)及(3.07±1.26)mg/L]、HOMA-IR[分别为(1.22±0.21)、(1.12±0.20)及(0.93±0.14)]比较,DM组和IGR组均高于NGT组,而DM组及IGR组ISI[分别为(0.023±1.23)及(0.024±0.017)]均低于NGT组(0 052±0.026),差异有统计学意义(P<0.05).NGT组、IGR组和DM组HOMA-B 指数[分别为(87.6±25.1)、(126.46±34.2)及(173.75±32 1)]差异有统计学意义(F=11.892,P<0.05).DM组糖尿病家族史阳性率(41.17%)高于NGT组(11.4%).Logistic回归分析显示,年龄、BMI、SBP、甘油三酯、C反应蛋白、ISI与糖尿病独立相关,而尿酸与糖尿无相关性.结论:痛风患者发生糖尿病表现为严重的胰岛素抵抗并β细胞功能缺陷,而痛风合并糖耐量异常(IGR)者主要表现为胰岛素抵抗,胰岛分泌功能受损较轻.重度胰岛素抵抗、胰岛β细胞分泌功能障碍、BMI增加、C反应蛋白增高、脂代谢异常、遗传易感性是痛风患者合并糖尿病的主要代谢特征.     

控制体重对肥胖型多囊卵巢综合征患者的疗效观察

目的探讨肥胖型多囊卵巢综合征(PCOS)患者控制体重的疗效。方法选择BMI≥25的多囊卵巢综合征患者122例,随机分成二甲双胍联合达英-35对照组与体重控制实验组,治疗6个月后观察两组体重指数、内分泌代谢指标及妊娠结局。结果 (1)对照组与实验组治疗后代谢指标LH、TT、CHO、TG、LDL及FPG、1hPG、GAUC、FINS、HOMA-IR均较治疗前显著下降,具有统计学意义(P0.05)。(2)实验组患者BMI[(24.39±2.13)kg/m2]、FINS[(7.94±2.41)mU/L]、1hINS[(93.32±40.32)mU/L]、2hINS[(65.27±32.34)mU/L]、IAUC[(129.69±35.37)mU/L·h]较药物对照组[分别为(26.02±2.05)kg/m2、(15.02±2.11)mU/L、(136.32±62.31)mU/L、(99.27±70.34)mU/L、(193.98±98.75)mU/L·h]下降明显(P0.05),差异有统计学意义。(3)实验组月经恢复率(75.00%vs.54.72%,P0.05)及排卵率(64.58%vs.43.40%,P0.05)优于对照组。结论控制体重能有效改善患者糖脂代谢异常,尤其是胰岛素敏感性增加,总疗效优于复合药物治疗。     

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.     

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.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

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.