Combined subarachnoideal-extradural anesthesia for high-risk patients during surgery on the musculo-skeletal system

Background. Patients in advanced age undergoing surgery for musculo-skeletal disorders are at risk for failure of vital systems under anesthesia. Thus the choice of anesthetic technique for high-risk patients can have a vital impact on treatment outcome. Material and method. Our research involved 344 patients ranging in age from 69 to 93 (mean 76.4 +/- 7.8) at high risk during extensive orthopedic surgery on the lower limbs. The patients were divided into three groups depending on the anesthetic technique used: Group I - general anesthesia with esophageal intubation or laryngeal mask; Group II - subarachnoid anesthesia; and Group III - combined subarachnoid-extradural anesthesia. The Goldman heart risk and ASA anesthesia risk were determined for each patient. The frequency and type of post-operative complications were also specified. Results. Altogether complications occurred in 15.6% of the patients: 6.1% in Group I, 6.8% in Group II, and 2.9% in Group III. Acute myocardial ischemia and infarct occurred only in patients with high Goldman indices. Pulmonary complications were seen in groups I and II, but not in Group III. Conclusions. Combined subarachnoid-extradural anesthesia enables deeper anesthesia during a prolonged operation, and thus makes it possible to avoid general anesthesia. The post-surgical application of continuous extradural analgesia using bupivacaine with phentanyl enables the introduction of respiratory rehabilitation and rapid mobilization, reducing the number of cardiac and pulmonary complications, and by the same token shortening the duration of hospitalization.     

Combined transurethral resection of the prostate and inguinal herniorrhaphy

From 1983 to 1985, ten men had combined transurethral resection of the prostate (TURP) and inguinal herniorrhaphy; hernia repair immediately preceded transurethral resection. Eight men had unilateral inguinal hernia repair and two had bilateral inguinal herniorrhaphy. Four men had additional procedures done concurrently. Follow-up ranged from 14 to 33 months (mean 22.4 months). There were no recurrent hernias or infections of the hernia incision. These results suggest that combined TURP and inguinal herniorrhaphy can be safely accomplished during a single period of anesthesia.     

Ranitidine-induced changes in the renal and hepatic clearances of procainamide are correlated

Ranitidine, procainamide and its active N-acetyl metabolite (NAPA) are renally secreted bases which can compete for carrier-mediated transport processes. The effect of ranitidine on the disposition of procainamide and NAPA was evaluated in 13 healthy men. Subjects were randomized to receive p.o. procainamide (1000 mg) alone (base line) and after p.o. ranitidine, 150 mg twice a day for 4 days. Blood and urine samples were collected at frequent intervals for 24 hr after the procainamide dose. There were no significant differences in the mean pharmacokinetic parameters of procainamide and NAPA after ranitidine coadministration compared to base line. However, individual changes did occur and regression analysis revealed a correlation between base-line procainamide renal clearance (CLR) and the change (delta) in CLR after ranitidine (r = 0.69, P less than .01). Subsequently, individuals were separated into Group I (n = 7) if they had a decrease or Group II (n = 6) if they had an increase in procainamide CLR after ranitidine. Mean +/- S.D. base-line procainamide CLR was 539 +/- 114 ml/min for Group I vs. 410 +/- 61 ml/min for Group II (P less than .01). During ranitidine coadministration, Group I had a 23% decrease in mean procainamide CLR (P less than .05), whereas Group II had a 21% increase (P less than .05). There were no significant differences in the metabolic clearance (CLM) of procainamide between the two groups at base line. However, Group I had a 45% increase (P less than .01) whereas Group II had a 41% decrease (P less than .05) in mean procainamide CLM with concomitant ranitidine.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prehospital use of the Glasgow Coma Scale in severe head injury

To determine the prognostic value of prehospital Glasgow Coma Scale (GCS) scores in severe blunt head injuries, the GCS at the scene of injury (INGCS) and the GCS in the emergency department (EDGCS) were compared with neurologic outcomes in 33 consecutive head-injured patients. Patients were categorized according to final outcome: Group I (n = 7) had no neurologic deficits, group II (n = 3) had only minor neurologic deficits, group III (n = 11) had major neurologic deficits, and group IV (n = 12) died. Mean INGCS was not significantly different for any of the four groups (range 4.14 to 4.67). However, mean EDGCS was significantly higher (P less than .05) for group I (9.43 +/- 4.08) than for group IV (5.17 +/- 3.13), and mean EDGCS for groups I and II (8.8 +/- 3.99) were significantly higher (P less than .05) than that of groups III and IV (5.7 +/- 2.88). The net change in GCS (EDGCS--INGCS) was significantly higher (P less than .05) for groups I and II (4.5 +/- 4.4) than for groups III and IV (1.3 +/- 2.91). We conclude that INGCS alone has no prognostic value, but that EDGCS and any prehospital change in GCS may have prognostic value for severely head-injured patients.     

Characteristics of patients with late onset systemic lupus erythematosus in Turkey

Systemic lupus erythematosus (SLE) is a multi-system autoimmune disorder mainly affecting young women. In this study, we aimed at investigating the clinical, laboratory and management characteristics of our SLE patients with an age of onset > or =50. Twenty patients with late onset SLE (> or =50 years) were identified from the records, on the basis of their first SLE-related symptoms (Group I). A hundred consecutive SLE patients with initial symptoms before the age of 50 were also selected as controls (Group II). Clinical, laboratory and management characteristics of the patients were recorded according to pre-defined protocol and compared by chi(2), Student's t-test and Fisher's exact test. Comparison of the demographic findings between the Group I (F/M: 18/2) and the Group II (F/M: 90/10) were as follows: the mean age of disease onset was 53.9 +/- 4.5 years vs. 26.3 +/- 9.2 years, mean time of follow-up was 44.2 +/- 40.5 months vs. 50.1 +/- 47.4 months, mean damage index was 0.6 +/- 0.6 vs. 0.58 +/- 1.4. There was no significant difference between the two groups with regard to clinical, laboratory parameters, damage index and immunosuppressive treatment characteristics. SLE-related manifestations were similar in two groups except fever (10% in the Group I vs. 41% in the Group II; p = 0.01). The only two patients with pulmonary fibrosis were found in the Group I (p = 0.027). The clinical and laboratory characteristics and the disease outcome in SLE patients with an age of onset > or =50 years did not show significant differences from the control SLE patients with a younger age of onset.     

Steady-state pharmacokinetics of intramuscular imipenem-cilastatin in elderly patients with various degrees of renal function.

We studied the concentrations in plasma and pharmacokinetics of imipenem and cilastatin in elderly patients (greater than 65 years old) who had various degrees of renal function and who were hospitalized with soft tissue infections. Three groups of patients received imipenem-cilastatin (500/500 mg) intramuscularly every 12 h: group I consisted of eight patients with a creatinine clearance (CLCR) of greater than 50 ml/min (range, 51 to 84 ml/min; mean, 65.8 ml/min); group II consisted of three patients with a CLCR of 20 to 50 ml/min; and group III consisted of two patients with a CLCR of less than 20 ml/min. Imipenem and cilastatin concentrations were measured at steady state on day 5. Mean peak and trough plasma imipenem concentrations were 5.28 +/- 1.78 and 1.43 +/- 0.76 micrograms/ml in group I, 6.25 +/- 0.78 and 2.50 +/- 0.00 micrograms/ml in group II, and 14.3 +/- 0.71 and 6.85 +/- 1.06 micrograms/ml in group III, respectively. Mean peak and trough plasma cilastatin concentrations were 11.8 +/- 2.85 and 0.31 +/- 0.43 microgram/ml in group I, 15.5 +/- 2.48 and 2.03 +/- 2.05 micrograms/ml in group II, and 24.5 +/- 6.72 and 10.7 +/- 5.94 micrograms/ml in group III, respectively. Mean imipenem AUCss (area under the concentration-time curve over a dosage interval at steady state) values were 38.7 +/- 7.9 micrograms.h/ml for group I, 52.3 +/- 7.3 micrograms.h/ml for group II, and 143.7 +/- 11.9 micrograms.h/ml for group III. Mean cilastatin AUCss values were 45.6 +/- 12.5 micrograms.h/ml for group I, 93.8 +/- 51.2 micrograms.h/ml for group II, and 217.5 +/- 57.8 micrograms.h/ml for group III. Cilastatin mean apparent body clearance values (normalized to weight) were 2.78 +/- 0.67 ml/min for group I, 1.43 +/- 0.81 ml/min for group II, and 0.71 +/- 0.24 ml/min for group III. Imipenem open-lactam metabolite levels were all below the level of detective of the assay (<3.9 micrograms/ml). There was a progressive increase in plasma imipenem and cilastatin levels and AUCss and there was a decline in body clearance as renal function declined.     

Enhanced blood pressure and renal hemodynamic effect of chronic versus acute lisinopril administration in the rabbit.

This study was aimed at evaluating the factors responsible for the marked renal hemodynamic effect of 6-day treatment with lisinopril. Blood pressure (BP) and renal blood flow (RBF) were monitored in six groups of rabbits. Animals treated with lisinopril for 6 days (Group I) had lower BP (77 +/- 3 mm Hg) than normal controls (Groups II/III, 106 +/- 3 mm Hg, P < .05) or those given lisinopril acutely (Group IV, 93 +/- 8 mm Hg, P < .05). In addition, RBF was higher in Group I (81 +/- 2 ml/min) than in Groups II/III (54 +/- 5 ml/min, P < .05) or Group IV (66 +/- 8 ml/min, P < .05). Intrarenal arterial infusion of a B2 bradykinin receptor antagonist, D-Arg-O-[Hyp-3-Thi-5,8-D-Phe-7]bradykinin, had no effect on either BP or RBF in Group I. Administration of lisinopril for 6 days also resulted in attenuation of the vasoconstrictor responses to renal nerve stimulation (Group V). Intravenous infusion of D-Arg-O-[Hyp-3-Thi-5,8-D-Phe-7]bradykinin had no effect on the responses to nerve stimulation in lisinopril-treated rabbits (Group V) or their controls (Group VI). Moreover, D-Arg-O-[Hyp-3-Thi-5,8-D-Phe-7]bradykinin given i.v. did not alter the BP or RBF in Groups V and VI. The results indicate that angiotensin converting enzyme inhibition over a 6-day period is more effective than acute inhibition in lowering BP and dilating the renal vascular bed. The use of bradykinin antagonists did not indicate kinin involvement in the long-term effect of lisinopril on BP and RBF.     

Simultaneous cardio-cerebral ultrasonic measurement technique for assessing the interrelationship between cardiac and cerebral circulations in elderly subjects: a preliminary study.

To assess the interrelationship between the cardiac and cerebral circulations, simultaneous measurements of cardiac output (CO) and common carotid blood flow volume (CCBFV) was performed by M-mode echocardiography of the left ventricle, and quantitative ultrasonic Doppler blood flowmetry of the common carotid artery. The subjects studied were 12 healthy persons living in a home for the elderly ranging in age from 62 to 99 years. These subjects were divided into two groups: those who were in their 90s (Group I, 5 females) with a mean age of 93.6 +/- 3.5 years (mean +/- SD), and those who were in their 60s to 80s (Group II, 1 male and 6 females) with a mean age of 77.1 +/- 8.1 years. The average CO in Group I was 2.85 +/- 0.37 L/min, and 4.18 +/- 0.52 L/min in Group II. The average CCBFV was 4.74 +/- 0.64 dl/min in Group I, and 4.44 +/- 1.01 dl/min in Group II. The ratio of CCBFV to CO was 16.6 +/- 1.32% in Group I, and 10.6 +/- 1.45% in group II. Good linear correlations of y = 1.44x +0.65 (r = 0.82) in Group I and y = 1.58x - 2.15 (r = 0.81, p less than 0.05) in Group II were observed between CO (x) and CCBFV (y). No such close correlations were observed between CCBFV and other indices of left ventricular function such as circumferential fiber shortening or fractional shortening of the diameter of the left ventricle (r less than or equal to 0.56, p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

疝环充填式无张力疝修补术在中老年腹股沟疝的临床应用对照研究

目的:研究疝环充填式无张力疝修补术在中老年男性腹股沟疝的临床应用价值。方法:将1999年1月～2006年1月中的298例中老年男性腹股沟疝病人,分为A、B两组。A组148例为实验组,采用环充填式无张力疝修补术术式;B组150例为对照组,采用传统疝修补术术式。随访5～7年。结果:术后A、B两组的手术时间没有统计学意义(P>0.05);A组的术后疼痛程度轻于B组(P<0.01);A组下床活动时间、生活自理时间、住院时间优于B组(P<0.01);A组的手术直接并发症发生率和间接并发症发生率均低于B组(P<0.01);A组术后复发率明显低于B组(P<0.01);但A组的住院费用明显高于B组(P<0.01)。结论:疝环充填式无张力疝修补术治疗中老年腹股沟疝,在减轻病人术后疼痛、缩短术后康复时间、减少术后并发症、降低手术复发率方面优于传统疝修补术式。     

Effects of electroacupuncture on intraoperative and postoperative analgesic requirement

Acupuncture has been shown to be effective in experimental and clinical acute pain settings. This study aims to evaluate the effect of preoperative electroacupuncture (EA) on intraoperative and postoperative analgesic (alfentanil and morphine) requirement in patients scheduled for gynaecologic lower abdominal surgery. Ninety patients were randomly assigned to one of three groups: Group I (control group)--received placebo EA for 45 minutes before induction of general anaesthesia (GA); Group II--preoperative EA instituted 45 minutes before induction of GA; Group III--45 minutes of postoperative EA. The Bispectral Index monitor was used intraoperatively to monitor the hypnotic effect of anaesthetic drugs, and alfentanil was titrated to maintain the blood pressure and pulse rate within +/- 15% of basal values. Postoperative pain was managed by intravenous morphine via a patient-controlled analgesia (PCA) device. Patients in Group II (0.44 +/- .15microg/kg/min) received less alfentanil than those in Group III (0.58 +/- .22 microg/kg/min) (p = p.024), but not significantly less than those in Group I 10.51 +/- 0.21 microg/kg/min) (p = 0.472). Postoperative morphine consumption was numerically lower in Group II compared with the other groups; however, the difference was statistically significant only during the period of 6-12 hours between Group II [0.03 (0.05) mg/kg] and Group I [0.10 (0.11) mg/kg] (p = 0.015), and Group II and Group III [0.08 (0.10) mg/kg] (p = 0.010). The 24-hour cumulative morphine consumption for Group II (0.52 +/- .19mg/kg) was less than that for either Group I I0.68 +/- 38mg/kg) or Group III (0.58 +/- .27mg/kg), but the difference did not reach significance. In conclusion, preoperative EA leads to a reduced intraoperative alfentanil consumption, though this effect may not be specific, and has a morphine sparing effect during the early postoperative period.     

The increased proximal tubular reabsorption of sodium and water is maintained in long-term insulin-dependent diabetics with early nephropathy

Proximal tubular reabsorption of sodium and water was investigated in long-term insulin-dependent diabetic patients with normoalbuminuria (group I, n = 19), microalbuminuria (group II, n = 39), diabetic nephropathy (group III, n = 12) and in 13 healthy age-matched subjects. Glomerular filtration rate was measured with the single injection, 51Cr-EDTA technique. The fluid flow rate out of the proximal tubules was assessed by the renal lithium clearance. Although glomerular filtration rate was significantly elevated in the diabetic patients (Group I: 122 +/- 16, Group II: 121 +/- 18, Group III: 110 +/- 17, Controls: 105 +/- 13 ml/min X 1.73 m2), lithium clearance was similar in the four groups (Group I: 19 +/- 6, Group II: 22 +/- 7, Group III: 19 +/- 5, Controls: 23 +/- 4 ml/min X 1.73 m2). Both absolute and fractional proximal reabsorption of sodium and water was enhanced in diabetes. Indices of distal tubular function did not differ between controls and patients with insulin-dependent diabetes. Sodium clearance was about the same in the four groups. Our study suggests that the enhanced proximal reabsorption of sodium and water in insulin-dependent diabetic patients is still observed despite the presence of incipient or overt diabetic nephropathy.     

Role of thyroid hormone in postnatal circulatory and metabolic adjustments

To assess the role of the early postnatal surge in plasma thyroid hormone concentrations on cardiovascular and metabolic adaptations, we measured cardiac output, total oxygen consumption, and plasma triiodothyronine (T3) concentrations in three groups of lambs in the first 6 h after delivery. 15 fetal lambs were prepared at gestational ages of 128-129 d by placing catheters in the brachiocephalic artery, descending aorta, distal inferior vena cava, left atrium, and pulmonary artery so that measurements could be made soon after delivery. They were divided into three groups: Group I comprised five control animals; Group II consisted of five fetuses in which thyroidectomy was performed at surgery at 129 d gestation; and Group III consisted of five animals in which thyroidectomy was performed at term gestation during delivery by caesarian section, prior to severing the umbilical cord. The lambs in Group I exhibited a rapid postnatal rise in T3 concentrations, similar to that described previously, reaching a peak value of about 5 ng/ml. Although the postnatal surge in T3 concentration was arrested in Group II and III animals, Group II had no detectable plasma T3, while the Group III animals had T3 concentrations of about 0.8 ng/ml, which were within the range previously reported for term lamb fetuses. The lambs in group II showed 40-50% lower left ventricular outputs (190 vs. 297 ml/kg per min), systemic blood flows (155 vs. 286 ml/kg per min), and oxygen consumptions (9.8 vs. 20.2 ml/kg per min) as compared with Group I animals over the entire 6-h period. The lambs in Group II also had significantly lower heart rates (131 vs. 192 beats/min) and mean systemic arterial pressures (56 vs. 72 torr). However, there were no significant differences for any of these measurements between the Group III and Group I lambs. The reduction in cardiac output in the Group II animals were reflected in a significantly lower blood flow to the peripheral circulation, but there were no significant differences in blood flow to other organs in the three groups. These studies indicate that plasma thyroid concentrations in the 2-3 wk prior to delivery and not the increase in thyroid hormone concentrations which occur after birth are important for postnatal cardiovascular and metabolic adjustments. We speculate that lack of circulating triiodothyronine in late gestation may affect postnatal cardiovascular adaptation by modifying normal beta adrenergic receptor development.     

The effect of increased gastrin release on lower esophageal sphincter pressure

The present study was performed to induce release of endogenous gastrin from the chronic isolated antrum, and to note the effect of endogenous gastrin on lower esophageal sphincter pressure (LESP). Fifteen mongrel dogs weighing 15-20 kg were divided into 3 groups by the type of operation: 5 dogs with antral excision and B-II gastrojejunostomy (Group I); 5 dogs with a denervated antral pouch and B-II (Group II); and 5 dogs with an innervated antral pouch and B-II (Group III). Fasting serum gastrin levels (SGL) and LESP were determined preoperatively (basal) and at 2 and 4 weeks postoperatively. SGL was measured by radioimmunoassay using an antibody to human gastrin I. LESP was determined by pullthrough technique using an assembly of 3 polyvinyl tubes perfused with water at 0.6 ml/min and connected to external transducers. The mean SGL at 2 and 4 weeks after operation in Group I and in Group II were not significantly different from basal SGL. The SGL rose significantly at 2 weeks and 4 weeks in Group III (p less than 0.05). The mean LESP at 2 and 4 weeks did not significantly change from the basal LESP in Group I, Group II and Group III. The present data show that increased endogenous gastrin was produced only in the presence of an innervated antral pouch, and the increased gastrin level, however, did not affect LESP.     

Simvastatin and fluvastatin reduce interleukin-6 and interleukin-8 lipopolysaccharide (LPS) stimulated production by isolated human monocytes from chronic kidney disease patients.

BACKGROUND: Statins reduce lipid levels, inflammation and cardiovascular events in patients with coronary artery disease; CKD patients show increased risk of cardiovascular and increased plasma levels of IL-6 and IL-8. AIM: To evaluate the in vitro effect of simvastatin (S) or fluvastatin (F) on the lipopolysaccharide (LPS) stimulated secretion of IL-6 and IL-8 from monocytes of chronic kidney disease patients (CKD) in K-DOQI stages 3-5. METHODS AND SUBJECTS: Monocytes enriched peripheral blood (PBMC) from 28 CKD (15 in K-DOQI stages 3-4, Group I, and 13 in K-DOQI stage 5 on hemodialysis, Group II) and 10 healthy subjects (HS), were isolated by Ficoll-gradient centrifugation. Cells were incubated with LPS 100 ng/ml or with LPS plus increasing doses of statins (from 10(-6) to 10(-8) M ) for 24 h. Surnatant IL-6 and IL-8 concentrations were determined by EIA. RESULTS: Basally the mean concentration of IL-6 and IL-8 was higher in patients than in HS and in Group II than in Group I (IL6: HS 285 +/- 77 pg/ml, Group I 365 +/- 178 pg/ml, Group II 520 +/- 139 pg/ml- IL8 HS 180 +/- 75 pg/ml, Group I 1722 +/- 582 pg/ml, Group II 4400 +/- 1935 pg/ml). After addition of LPS the mean concentration of IL-6 and IL-8 increased in all groups (IL6: HS 1740 +/- 178 pg/ml, Group I 3754 +/- 672 pg/ml, Group II 4800 +/- 967 pg/ml; IL8: HS 450+/-132 pg/ml, Group I 9700+/-2837 pg/ml, Group II 11608 +/- 2316 pg/ml). After the addition of LPS plus increasing doses of S or F from 10(-10) to 10(-6) M, a significantly lower cytokine concentration compared to the data after LPS alone was observed (IL6: HS 45%, Group I 75%, Group II 50%; IL8: HS 100%, Group I 65%, Group II 35%). CONCLUSIONS: These data confirm that cytokine release is increased in CKD patients and that is highest in the most severe patients. Furthermore they suggest that fluvastatin or simvastatin can be used in order to reduce the high cardiovascular risk.     

Activity of [des-Aspartyl1]-Angiotensin II in Primary Aldosteronism

This study describes the effects of [des-Aspartyl(1)]-angiotensin II ([des-Asp]-AII) on blood pressure and aldosterone production in patients with primary aldosteronism due to aldosterone-producing adrenal adenoma (APA) and idiopathic adrenal hyperplasia (IHA), and in normotensive control subjects. 10 patients with primary aldosteronism, 7 with APA and 3 with IHA, and 6 normotensive control subjects were placed on a constant 150-meq sodium diet for 4 days. [des-Asp]-AII was infused for 30 min at 6, 12, and 18 pmol/kg per min. Three groups of patients were identified on the basis of aldosterone response to [des-Asp]-AII. Group I, composed of normotensive control subjects, showed incremental increases in plasma aldosterone concentration from 6+/-1 to 14+/-3 ng/100 ml (P < 0.01) with [des-Asp]-AII infusion. Group II, composed of patients with primary aldosteronism, showed incremental increases in plasma aldosterone concentration from 33+/-8 to 65+/-13 ng/100 ml (P < 0.05) with 12 pmol/kg per min of [des-Asp]-AII. Group III, also composed of patients with primary aldosteronism, showed no increase of plasma aldosterone concentration with [des-Asp]-AII. Groups I and II showed similar percentage increases in plasma aldosterone concentration (P = NS). Group III showed significantly lower aldosterone responses than group I (P < 0.01). Group II included all patients with IHA and two patients with APA. Group III included only patients with APA. The blood pressure responses to [des-Asp]-AII of subjects in group I did not differ significantly from those of groups II or III.Thus, patients with IHA and a subgroup of patients with APA showed responsiveness to [des-Asp]-AII which was limited to adrenal cortical stimulation of aldosterone biosynthesis. This suggests that adrenal responsiveness to angiotensin is a major control mechanism in some forms of primary aldosteronism. The differential adrenal responsiveness to [des-Asp]-AII in patients with APA indicates either that there are two distinct subpopulations of APA, or that alteration in tumor response to angiotensin occurs during the natural progression of the disease history.     

Decreased ultrafiltration coefficient of glomeruli isolated from volume-depleted rats

Decreased glomerular ultrafiltration coefficient (Kf or LpA) has been demonstrated in micropuncture studies of rats subjected to dietary sodium restriction and diuretics. To define the alterations in glomerular filtration characteristics in isolation from systemic hemodynamic influences, we studied filtration of isolated rat glomeruli in vitro. Control rats were maintained on standard laboratory chow and tap water until sacrifice. Experimental rats in groups I, II, and III were maintained on a sodium-deficient diet for 3 to 7 weeks. Further volume depletion was induced in groups II and III as follows: Group II rats were given furosemide, 30 mg/kg, intraperitoneally for 3 consecutive days prior to sacrifice; group III rats were given furosemide, 240 mg/kg, and killed (a) after about 4 hr when diuresis had resulted in 8% to 10% weight loss, (b) after 18 hr during which sodium restriction was continued, or (c) after 18 hr during which they were permitted to drink NaCl solution (0.9 gm/dl). Group IV rats were fed standard laboratory Chow and were subjected to hemorrhage of about 3% body weight and sacrificed after 18 hr of fasting. Plasma protein, serum creatinine and electrolytes, and FENa were measured in each rat prior to sacrifice. Filtration was induced in isolated glomeruli by applying a transcapillary oncotic gradient of about 12 mm Hg. A video recording of individual glomeruli was made during filtration, and glomerular diameter, volume, filtering surface area, Kf, and Lp were estimated from measurements of the video image. Kf was decreased during volume depletion induced by sodium restriction and furosemide or by hemorrhage. Kf averaged 4.0 +/- 0.2 nl/min . mm Hg in control rats (n = 10), 3.4 +/- 0.2 nl/min . mm Hg in group I (n = 8), 3.3 +/- 0.1 nl/min . mm Hg in group II (n = 12), 2.2 +/- 0.1 nl/min . mm Hg in group IIIa (n = 4), 2.6 +/- 0.3 nl/min . mm Hg in group IIIb (n = 4), and 2.3 +/- 0.2 nl/min . mm Hg in group IV (n = 3). Kf returned to control values after volume repletion with orally administered NaCl solution and averaged 4.3 +/- 0.3 nl/min . mm Hg in group IIIc (n = 4). We conclude that Kf falls in a graded and reversible fashion during volume depletion. Modulation of Kf, as well as previously described alterations in renal cortical perfusion, may contribute to decreased GFR in volume depletion.     

改良Kugel修补术在腹股沟疝中的临床应用

目的：探讨改良Kugel修补术在治疗腹股沟疝中的临床应用。方法：回顾性分析我院2012—09—2013—09采用改良Kugel术式修补的腹股沟疝患者55例。观察患者手术时间、住院时间、术后并发症及复发情况。结果：55例均治愈。手术时间（54±15）rain,住院时间（4±1．5）d,术后恢复快,无切口感染、出血、阴囊水肿等并发症。随访6个月,无1例复发。结论：改良Kugel修补术是一种安全有效的微创、无张力疝修补术式,手术时间短,术后恢复快,并发症少,复发率低。     

Pharmacokinetics of cefotaxime and its active metabolite in children with renal dysfunction.

We studied cefotaxime (CTX) and desacetylcefotaxime (dCTX) pharmacokinetics in 19 children (ages, 7 to 16 years) with various degrees of renal function. The patients were stratified into three groups according to 24-h urinary creatinine clearance (CLCR) values: group I, CLCR greater than 80 ml/min/1.73 m2 (n = 7); group II, CLCR from 30 to 80 ml/min/1.73 m2 (n = 6); and group III, CLCR less than 30 ml/min/1.73 m2 (n = 6). A single 50-mg/kg dose of CTX was given intravenously to each patient after which blood and urine samples were collected and analyzed for CTX and dCTX by high-performance liquid chromatography. Safety was assessed by pre- and poststudy blood chemistries and urinalysis. The mean values for total body clearance of CTX for groups I, II, and III were 158.1 +/- 38.8, 118.3 +/- 50.8, and 84.8 +/- 11.7 ml/min/1.73 m2, respectively (P less than 0.01). Renal clearance also decreased across groups, I, II, and III, with values of 77.5 +/- 20.2, 41.3 +/- 18.5, and 11.4 +/- 7.7 ml/min/1.73 m2 respectively (P less than 0.0001). Both the CTX fraction nonrenally cleared and elimination half-life increased with decreasing renal function. The CTX volume of distribution at steady state was not affected by renal disease. The renal clearance values of dCTX were 146.4 +/- 71.4, 64.5 +/- 32.1, and 14.4 +/- 8.7 ml/min/1.73 m2 for groups I, II, and III, respectively (P less than 0.0004). Elimination half-life values were 2.04 +/- 0.39, 3.87 +/- 1.93, and 6.19 +/- 3.22 h for the respective groups (P less than 0.006). Both the maximum concentration of dCTX in plasma and time to reach the maximum concentration of dCTX in plasma were increased with decreased CLCR. The results of this study indicate that dosage adjustment may be necessary for CTX in children with renal dysfunction. On the basis of the pharmacokinetics and antimicrobial activities of the parent drug and its metabolite, dosage reductions of 25 to 50% in children with moderate renal impairment (CLCR from 30 to 80 ml/min/1.73 m2) and 50 to 75% in children with severe renal impairment (CLCR < 30 ml/min/1.73 m2) are recommended.     

Comparison of a restricted transfusion schedule with erythropoietin therapy versus a restricted transfusion schedule alone in very low birth weight premature infants

OBJECTIVE: Erythropoietin (EPO) is commonly used in very low birth weight neonates to minimize blood transfusions during hospitalization. Data are limited comparing the use of EPO along with a restricted transfusion schedule versus a restricted transfusion schedule alone. We compared the effects of a restricted transfusion schedule with EPO versus a restricted transfusion schedule alone during two consecutive 6-month periods. METHODS: In period I, infants born at <30 weeks gestational age (GA) or <1,500 g birth weight (BW) were treated prophylactically for six weeks with EPO 1,000 U/kg/wk in three divided doses and blood transfusions were given using a restricted transfusion schedule. This was the called the EPO Group. In period II, a restricted transfusion schedule was utilized, but EPO was not administered. This constituted the No EPO Group. No other changes in clinical practice were introduced in either period. RESULTS: There were 30 neonates in the EPO Group and 20 in the No EPO Group. There were no significant differences in sex, race, mean birth weight (1,074 +/- 283 versus 965 +/- 330 g), mean gestational age (28.9 +/- 2.96 versus 27.8 +/- 2.86 wks), 5 minute Apgar score (7.8 +/- 1.2 versus 7.6 +/- 1.1), or mean hematocrit (48.2% +/- 6.05 versus 48.6% +/- 6.31) at admission. There were no significant differences in the total number of transfusions between the two periods. In the EPO Group, 8/30 patients received 27 transfusions. Six transfusions violated guidelines based on hematocrit level. EPO was discontinued in three infants secondary to treatment-related neutropenia. There were two deaths unassociated with EPO treatment. Excluding deaths, 6 patients received 16 transfusions. In the No EPO Group, 8/20 patients received 13 transfusions. Two transfusions violated guidelines based on hematocrit. There were three deaths and one patient transfer. Excluding these four patients, 6 infants received 11 transfusions (P < or = 1.) Among survivors, there were no significant differences in mean total length of stay (49.3 +/- 22.7 versus 53.2 +/- 26.4 d), mean discharge weight (2,144 +/- 405 versus 2,358 +/- 458 g), or average weight gain/d (20.7 +/- 5.44 versus 22.6 +/- 6.81 g), between the two groups respectively, nor were there significant differences when all babies were included in the analysis. There was a significant difference in mean hematocrit at discharge, respectively, (38.3% +/- 6.84 versus 31.4% +/- 6.26; P = 0.003) in survivors. CONCLUSIONS: A restricted transfusion schedule without EPO use was associated with lower mean hematocrit at discharge, but not with an increased frequency of transfusions, nor significant differences in length of stay, discharge weight, or average daily weight gain. A restricted transfusion schedule alone avoided side effects and costs associated with EPO. Indications for transfusion and what constitutes appropriate levels of hemoglobin still require clinical investigation, including long-term clinical outcomes.     

Sodium balance as a determinant of prostacyclin production by isolated rat aorta

The present study investigates whether the synthesis of prostacyclin (PGI2) in isolated rat aorta is dependent on the state of sodium balance of the animals. Three groups of ten rats each were included into the study. Two of them were fed a diet low in NaCl for 10 days with group I receiving 0.9% saline and group II distilled water as drinking fluid. Group III received a regular rat chow containing approximately 0.8 mmol day-1 of sodium, also for 10 days. At the end of the dietary protocol, systolic arterial blood pressure was significantly higher in group I (109.9 +/- 2.4 mmHg) as compared to group II (101.0 +/- 2.4 mm Hg; P less than 0.05) and group III animals (102.2 +/- 1.6 mm Hg; P less than 0.05). Generation of PGI2-like activity was determined in portions of the animals' isolated aorta using a platelet aggregation bioassay following incubation in 0.05 M Tris buffer (pH 9.3) for 12, 15, and 30 min, respectively. During these incubation times, generation of PGI2-like activity averaged 48.6 +/- 3.5, 57.8 +/- 4.3 and 68.3 +/- 3.2 pmol mg-1 in group III animals, which had received the regular rat chow, with similar values in the low salt group II (50.2 +/- 2.5, 57.7 +/- 2.7 and 72.9 +/- 3.7 pmol mg-1). Aortic generation of PGI2-like material was significantly suppressed in the high salt group I (37.5 +/- 2.8, 46.2 +/- 3.2 and 61.3 +/- 4.0 pmol mg-1; P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)