甲状腺微小乳头状癌颈部淋巴结转移的危险因素分析

目的:探讨甲状腺微小乳头状癌(PTMC)颈部淋巴结转移的危险因素。方法:回顾性分析贵州医科大学附属医院甲状腺外科2014年1月—2016年3月收治的169例PTMC患者临床病理资料。结果:169例患者均行预防性中央区淋巴结清扫,其中54例(32.0%)发生中央区淋巴结转移,单因素分析发现中央区淋巴结转移与年龄45岁、多灶性肿瘤、侵出包膜有关(均P0.05),多因素分析显示,年龄、多灶性肿瘤、侵出包膜都是中央区淋巴结转移的独立危险因素(均P0.05)。30例行中央区淋巴结加侧颈区淋巴结清扫,其中18例(10.7%)发生侧颈区淋巴结转移,单因素分析显示,肿瘤最大径、侵出包膜、多灶性肿瘤、中央区淋巴结转移与侧颈区淋巴结转移有关(均P0.05),多因素分析显示,肿瘤侵出包膜为侧颈区淋巴结转移的高危因素(P0.05);11例(6.5%)发生中央区并侧颈区淋巴结转移,侵出包膜、多灶性肿瘤为中央区并侧颈区淋巴结共同发生转移的高危因素(均P0.05)。高分辨率颈部淋巴结B超对中央区淋巴结转移的灵敏度、特异度分别为14.8%、96.5%,其对侧颈区淋巴结转移的灵敏度、特异度分别为94.4%、83.3%。结论:年龄45岁、多灶性肿瘤、侵出包膜是PTMC颈部淋巴结转移的危险因素。高分辨率颈部淋巴结B超可以作为甲状腺癌颈部淋巴结转移术前评估的重要手段。     

300例cN0甲状腺微小乳头状癌的随访研究

目的探讨中央区淋巴结清扫对临床无淋巴结转移(cN0)的甲状腺微小乳头状癌(PTMC)患者预后的影响。方法根据纳入和排除标准回顾性搜集2007年1月1日至2016年5月31日期间在中山市人民医院普外二科行手术治疗的cN0 PTMC患者300例,根据其是否实施了中央区淋巴结清扫分为未清扫组(147例)和清扫组(153例)2组,分析2组患者在术后并发症发生率、复发率、转移率等方面的差异,并且分析影响cN0 PTMC中央区淋巴结转移的危险因素。结果所有患者术后均无淋巴漏及手术死亡发生。清扫组术后病理检查结果见中央区淋巴结转移59例(38.6%)。未清扫组随访(83.0±20.7)个月,清扫组随访(79.5±26.2)个月(t=1.283,P=0.203)。随访期间,2组均无骨转移、肺转移等远处转移发生;未清扫组有5例复发,清扫组有1例复发,2组患者复发率比较差异无统计学意义(χ^2=3.008,P=0.089);2组患者无病生存曲线比较差异无统计学意义(χ^2=2.565,P=0.109)。清扫组患者的包膜侵犯率(P=0.026)、钙化率(P<0.001)、术后并发症声音嘶哑发病率(P=0.013)、手足麻木发病率(P<0.001)均明显高于未清扫组。多因素分析结果显示,多灶(OR=24.57,P<0.001)、肿瘤直径>5 mm(OR=5.46,P=0.019)及包膜侵犯(OR=9.42,P=0.002)是影响cN0 PTMC中央区淋巴结转移的独立危险因素。结论从本研究结果看,单纯甲状腺切除治疗cN0 PTMC是安全的,但对于中央区淋巴结的变化仍需要更长期的随访。对肿瘤直径>5 mm、多灶、有包膜侵犯的cN0 PTMC患者较易发生中央区淋巴结转移,可根据患者病情进行综合评估,施行个体化的精确治疗,而不能将所有患者按照统一模式进行治疗。     

cN0期甲状腺乳头状微小癌中央区淋巴结隐性转移危险因素

目的:探讨cN_0期甲状腺乳头状微小癌(PTMC)的临床特点及中央区淋巴结隐性转移的危险因素。方法:回顾性分析372例行甲状腺切除术及预防性中央区淋巴结清扫cN_0期甲状腺乳头状癌(PTC)患者临床资料,将其中250例PTMC患者(肿瘤直径≤1.0 cm)作为研究组,122例普通PTC患者(肿瘤直径1.0-2.0 cm)作为对照组,通过比较两组患者临床病理及影像学资料,分析PTMC的临床特点及中央区淋巴结隐性转移的危险因素。结果:研究组与对照组中央区颈部淋巴结转移率分别为32.8%(82/250)和42.6%(52/122),差异无统计学意义(P0.05)。单因素分析显示,研究组中央淋巴结转移与肿瘤大小、多灶性肿瘤、包膜侵润有关(均P0.05),而与结节的超声特征及其他因素无关(均P0.05);对照组中央淋巴结转移与各研究因素均无明显关系(均P0.05)。多因素分析发现,肿瘤大小(OR=2.916,95%CI=1.19-4.37)、多灶性肿瘤(OR=1.230,95%CI=0.68-2.75)、包膜侵润(OR=1.923,95%CI=1.06-3.70)是PTMC中央区淋巴结转移的危险因素(均P0.05)。结论:cN_0期PTMC中央区淋巴结转移率与普通PTC相似,肿瘤大小、多灶性肿瘤、包膜侵润是cN_0期PTMC淋巴结转移的危险因素。     

甲状腺微小癌颈淋巴结转移危险因素分析及手术范围的探讨

目的:探讨影响甲状腺微小癌(TMC)颈淋巴结转移的危险因素以及颈淋巴结清扫的范围。方法:回顾性分析2009年1月—2013年6月收治的269例TMC患者资料,患者均在原发灶根治的同时行中央区淋巴结清扫,27例患者行颈侧区淋巴结清扫,分析患者各临床病理因素与颈淋巴结转移的关系。结果:269例患者中107例(39.8%)发生颈淋巴结转移,其中中央区淋巴结转移103例(96.3%),颈侧区淋巴结转移25例(23.4%)。单因素分析显示,男性、肿瘤直径5.0 mm、包膜侵犯与TMC颈淋巴结转移有关(均P0.05);多因素分析显示,肿瘤直径5.0 mm(OR=3.358,P0.05)、包膜侵犯(OR=5.230,P0.05)是颈淋巴结转移的独立危险因素。结论:对于肿瘤直径5.0 mm或有包膜侵犯的TMC患者,中央区淋巴结转移的几率增加,行中央区淋巴结清扫是必要的。     

cNO期甲状腺微小乳头状癌中央区淋巴结转移的危险因素及预防性清扫的临床分析

目的 探讨临床颈淋巴结阴性(cN0期)甲状腺微小乳头状癌中央区淋巴结转移的临床特点及预防性清扫的意义及可行性,为临床治疗提供参考.方法 回顾性分析2011年7月-2015年12月在连云港市东方医院普外科接受手术的277例cN0期甲状腺微小乳头状癌患者的临床资料,评估预防性中央区淋巴结清扫的必要性,采用x2检验及Logistic回归分析中央区淋巴结转移与患者的性别、年龄、肿瘤数目、肿瘤大小、包膜浸润、单双侧肿瘤的关系.277例患者全部行原发灶根治性切除加患侧中央区淋巴结清扫术,清扫标本送检常规病理检查.结果 甲状腺微小乳头状癌中央区淋巴结转移阳性率为36.8％(102/277),在男性患者(P=0.023)、年龄＜45岁(P＜0.001)和肿瘤直径＞0.5 cm(P =0.019)中阳性率高;通过多变量分析可以表明男性患者(OR =2.63,P＜0.001)、年龄＜45岁(OR =2.25,P=0.016)、肿瘤直径＞0.5 cm(OR =2.13,P=0.009)均能独立作为CLN转移的危险因素.15例(5.4％)出现暂时性喉返神经麻痹,43例(15.5％)出现暂时性甲状旁腺功能低下,无永久性喉返神经麻痹和甲状旁腺功能低下并发症患者.结论 预防性中央区淋巴结的清扫有助于准确进行肿瘤的分期分级以及危险度的评估,对患者术后治疗随访方案的选择有重要意义,对于男性、年龄＜45岁、肿瘤直径＞0.5 cm、有包膜浸润的患者应常规行中央区淋巴结清扫.     

甲状腺乳头状癌预防性中央区淋巴结清扫可行性分析

目的 探讨预防性中央区淋巴结清扫术在临床颈淋巴结阴性(cN0)甲状腺乳头状癌治疗中的价值.方法 对82例cN0甲状腺乳头状癌行原发灶根治性切除,同时行患侧中央区淋巴结清扫术,清扫标本常规送病理检查.结果 cN0甲状腺乳头状癌患者中央区淋巴结转移率56.1%(46/82),中央区淋巴结转移与肿瘤大小(χ2=4.98,P<0.05),原发灶侵犯包膜(χ2=8.76,P<0.05)及年龄>45岁者(χ2=6.62,P<0.05)有关,82例均无永久性喉返神经损伤和永久性甲状旁腺功能低下等并发症发生.结论 cN0甲状腺乳头状癌行中央区淋巴结清扫术是必要的和安全的处理方式.     

BRAF V600E突变在cN0期PTMC颈中央区淋巴结转移中的预测价值

目的探讨BRAF^V600E突变在cN0期甲状腺微小乳头状癌(PTMC)颈中央区淋巴结转移(CLNM)的临床意义及预测价值。 方法回顾性分析2017年1月至2020年1月经手术治疗、病理证实的222例cN0期PTMC患者的临床资料,分析BRAF^V600E突变阳性与PTMC患者CLNM的相关性。应用SPSS 23.0统计软件分析数据,单因素分析采用χ²检验分析,多因素分析采用Logistic回归分析;P<0.05为差异有统计学意义。 结果222例PTMC患者94例(42.3%)存在CLNM;肿瘤大小、肿瘤多灶性、包膜侵犯、BRAF^V600E突变是CLNM的独立危险因素(P<0.05),发生CLNM的风险更高;BRAF^V600E突变(OR＝2.445,95%CI：1.557～3.840)是影响CLNM最重要的独立危险因素。 结论PTMC具有较高的CLNM,BRAF^V600E突变阳性时应常规行预防性中央区淋巴结清扫术;BRAF^V600E突变可有效预测cN0期PTMC患者是否存在CLNM。     

合并桥本甲状腺炎的甲状腺微小乳头状癌患者中央区淋巴结转移危险因素分析

目的:探讨合并桥本甲状腺炎(HT)的甲状腺微小乳头状癌(PTMC)患者中央区淋巴结转移(CLNM)的危险因素,并制定合理的淋巴结清扫范围。方法:回顾性分析2018年9月—2021年9月内蒙古自治区人民医院收治的448例PTMC患者病历资料,其中男94例,女354例,男女比例为1.00∶3.77,年龄21~82岁,平均(46.9±11.0)岁。按照是否合并桥本甲状腺炎(HT)分为HT-PTMC组(n=142)和非HT-PTMC组(n=306)。采用单因素分析和多因素分析方法探究患者性别、年龄、肿瘤直径、病灶数目(单灶/多灶)、是否有包膜侵犯、气管前/气管旁淋巴结、喉前淋巴结、侧颈淋巴结转移情况等临床病理特征是否与中央区淋巴结转移相关,使用SPSS20.0软件进行统计分析并建立Logistic回归方程,采用该数学模型评估诊疗预测价值。结果:HT-PTMC组与非HT-PTMC组在年龄、性别、喉前淋巴结和侧颈部淋巴结是否转移方面,差异有统计学意义(P<0.05);单因素分析结果显示肿瘤直径、病灶数目、包膜侵犯、钙化、侧颈淋巴结转移与HT-PTMC患者CLNM具有相关性(P<0.05);多因素Logistic回归分析显示肿瘤直径增大和包膜侵犯是CLNM的独立危险因素(P<0.05);根据上述独立危险因素建立Logistic回归数学模型:(Y=-1.974+0.191×肿瘤直径+1.139×包膜侵犯)对预测HT-PTMC患者CLNM的ROC曲线下面积为0.669(95%CI:0.571~0.766),当取约登指数最大时,预测的灵敏度为0.460,特异度为0.859。结论:合并HT的PTMC患者,术前有证据显示肿瘤直径增大或包膜侵犯,中央区淋巴结转移风险增高,推荐预防性中央区淋巴结清扫。     

多灶性甲状腺微小乳头状癌临床病理特征及预防性中央区淋巴结清扫的意义

目的:探讨多灶性甲状腺微小乳头状癌(PTMC)临床病理特征及预防性中央区淋巴结清扫的意义。方法:回顾湘雅医院甲状腺外科2013年7月—2016年12月收治的270例PTMC患者资料,比较多灶PTMC与单灶性PTMC患者临床病理因素的差异,并分析多灶性PTMC中央区淋巴结转移的危险因素。结果:270例患者中共120例多灶性PTMC(44.4%)。与单灶性PTMC患者比较,多灶性PTMC患者男性比例增加、中央区淋巴结转移与包膜侵犯发生率明显升高(均P0.05)。多灶PTMC患者的肿瘤最大直径(5~10mmvs.5mm)及是否存在包膜侵犯与中央区淋巴结转移发生率有关(均P0.05),而病灶的数目(2vs.≥3)及分布(单侧vs.双侧)与中央区淋巴结的转移发生率无关(均P0.05)。结论:多灶性PTMC较单灶PTMC具有较差的临床病理特征,中央区淋巴结转移风险增加。多灶性PTMC行预防性中央区淋巴结清扫是很有必要的,尤其对于是肿瘤较大、有包膜侵犯的患者。     

选择性中央区淋巴结清扫治疗cNO甲状腺乳头状癌的临床价值

目的探讨选择性中央区淋巴结清扫术在临床颈淋巴结阴性（cN0）的甲状腺乳头状癌患者中的治疗价值。方法回顾性分析中国医科大学附属第一医院2007年1月至2011年12月期间收治的326例cN0甲状腺乳头状癌患者的临床资料,并对影响中央区淋巴结转移的相关因素进行分析。结果本组326例cN0甲状腺乳头状癌患者的中央区淋巴结转移率为35．89％（117／326）。年龄在〈45岁、肿瘤直径〉1cm及原发灶浸润包膜的cN0甲状腺乳头状癌患者的淋巴结转移率明显高于年龄≥45岁、肿瘤直径≤1cm及原发灶未浸润包膜的oN0甲状腺乳头状癌患者（年龄：46．56％比28．72％,P=0．001;肿瘤直径：44．44％比26．45％,P=0．001;包膜浸润：50．00％比33．09％,P=0．020）。进一步的多因素分析显示,年龄〈45岁和肿瘤直径〉1cm是cN0甲状腺乳头状癌中央区淋巴结转移的独立危险因素（P〈0。05）。术后6例出现暂时性喉返神经损伤,18例并发暂时性甲状旁腺功能低下,4例出现暂时性喉上神经损伤,1例并发急性喉头水肿,无永久性喉神经损伤、甲状旁腺功能低下等并发症发生。术后266例（81．60％）获得随访,随访7～67个月（平均31．2个月）,有3例发生侧颈区淋巴结转移。结论cN0甲状腺乳头状癌行选择性中央区淋巴结清扫术是必要的、安全的处理方式,建议对cN0甲状腺乳头状癌常规行患侧中央区淋巴结清扫术,特别是年龄〈45岁和肿瘤直径〉1cm的cN0甲状腺乳头状癌患者。     

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.