Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BackgroundEnhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.PurposeThis multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.Study DesignThis is a review article.MethodsUnder the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.ResultsTwo hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.ConclusionBased on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.     

Monoketocholate can decrease transcellular permeation of methotrexate across Caco‐2 cell monolayers and reduce its intestinal absorption in rat

Objectives Bile salts have been shown to decrease the absorption of methotrexate in the rat intestine by an unknown mechanism. We aimed to examine this effect. Methods We assessed apical‐to‐basolateral (AP‐BL) permeation of methotrexate (5 μM) across Caco‐2 cell monolayers pretreated with various concentrations (0, 0.25, 0.5, 1, 3 and 5 mm ) of sodium cholate or its semisynthetic analogue, sodium 12‐monoketocholate. We also determined the effect of orally administered 12‐monoketocholate on the intestinal absorption of methotrexate in rats to evaluate a possible in‐vitro–in‐vivo correlation. Key findings It was found that sodium cholate and sodium 12‐monoketocholate decreased the AP‐BL permeation of methotrexate at low concentrations (maximal inhibition at 0.25 and 1 mm , respectively) and increased it at higher concentrations. Determination of [¹⁴C] mannitol permeation and electrical resistance of monolayers during experiments showed that membrane integrity was not compromised at low concentrations of bile salts but was disrupted at higher concentrations. Subsequently, we examined the effect of the simultaneous oral administration of sodium 12‐monoketocholate (4, 20, 40 and 80 mg/kg) on the intestinal absorption of methotrexate in rats after an oral dose (5 mg/kg). The pharmacokinetic study showed that 12‐monoketocholate at 4 and 20 mg/kg did not change the methotrexate area under the serum concentration–time curve whereas sodium 12‐monoketocholate at 40 and 80 mg/kg significantly reduced it. Conclusions Sodium 12‐monoketocholate appears to decrease the intestinal absorption of methotrexate in rats by inhibition of transcellular active transport.     

Le FortⅠ型并中线骨切开术作为颅底手术入路

颅底分为若干区,摘除颅底中线部肿瘤的手术入路特别困难.本文报告采用改良的Le FortⅠ型并中线骨切开术,将上颌骨分为左右两段的手术经验. 本组包括9例患者,年龄15～53岁,平均33.8岁.计脊索瘤、动脉瘤各2例,纤维性发育不良、恶性血管外皮细胞瘤、血管纤维瘤、成感觉神经细胞瘤和垂体腺瘤各1例. 根据病变生物学行为,MRI和CT精确定位以及病变的解剖状况,选择合适的入路术式,包括①经口内腭部切口,行或不行硬腭骨切开术;②采用Le Fort工型骨切开术并自中线切开软、硬腭,将上颌骨分为左右两半,显露病变;③采用阶梯形下颌骨切开术并自中线切开舌和口底显露病变.手术在全麻并气管切开情况下进行.术前戴入牙弓夹板. 上颌两半式Le Fort Ⅰ型骨切开术,切口从悬雍垂中线旁开始,经腭中线向前止于中线牙龈乳头旁.全层切开软腭至鼻侧,将两侧软腭瓣翻起,保护腭大血管.经口腔前庭分离鼻底粘膜后,用往复锯切开硬腭.而后从右第一双尖牙到对侧第一双尖牙切开上颌前庭粘骨膜.继于上颌两中切牙乳头中线旁行垂直切开粘骨膜,翻瓣.弯制小夹板并在上颌骨相应部位钻孔备复位时用.行标准Le FortⅠ型骨切开术后,在中切牙间行垂直骨切开,使上颌骨分成左右两半.以位于两侧颊部腭软组织瓣为蒂,将左右两侧上颌骨段向外旋转,用Codman自持牵开器固定.去除鼻中隔后组织,经咽后壁行中线垂直切口达颅底,行神经外科手术. 术后用纤维蛋白胶、脂肪、阔筋膜覆盖硬脑膜,关闭咽切口.利用颌间牵引复位两上颌骨段,戴入导板行颌间固定,坚固内固定.如行下颌骨切开术和舌、口底劈开术,则缝合舌及口底,用小夹板行下颌骨坚固内固定. 术后所有患者随访两年,没有发生与手术有关的死亡病例.1例因钻孔引起的脑脊髓液漏继发术后脑膜炎,经抗菌素治愈.另1例脑脊液漏患者仅需行脑脊液分流.还有1例纤维性发育不良患者,术后3周口、鼻腔大出血,血管造影发现右颈内动脉岩部假动脉瘤.因病变与颈内动脉关系密切,切除较困难,确定脑血管侧枝循环丰富后,用Silverstone夹阻断右颈内动脉,未发生后遗症,随访3年一直稳定.所有病例上颌骨骨段复位后均保持活力,无因手术导致明显的鼻音或口鼻瘘以及错者. 近脑干的颅底肿瘤患者术后生命期长短取决于合适的首次手术,而后者则依赖于无障碍的颅底入路.颅底中线为自然裂隙平面,无重要神经、血管结构,且能直接进入颅底中央手术区.术前进行过选择性血管栓塞的病例不适合采用Le FortⅠ型骨切开进路,以免发生上颌骨段的血供障碍. 作者不主张所有患中线病变者均行三种联合术式进入颅底.经口入路是三联入路的常规步骤,它提供了到达斜坡下肿瘤的捷径.Le FortⅠ型并中线切开进路是三联入路的核心,能很好地暴露斜坡上方及侧方.对需要充分暴露肿瘤上、下极者,经下颌骨入路则是最后的手段.上述术式的联合安全性达100%. [李鹏摘 王大章校]     

Bioavailability and hypoglycemic activity of the semisynthetic bile acid salt, sodium 3alpha,7alpha-dihydroxy-12-oxo-5beta-cholanate, in healthy and diabetic rats.

Previous studies in our laboratory have shown that the semisynthetic bile acid derivative, sodium 3alpha,7alpha-dihydroxy-12-oxo-5beta-cholanate (MKC), has hypoglycemic activity. The aim of this study was to investigate the relationship between the pharmacokinetics and hypoglycemic activity of MKC in healthy and diabetic rats. Groups of healthy and alloxan-induced diabetic rats were dosed intravenously (i.v.) and orally with MKC (4 mg/kg). Blood samples were taken before administration of the dose and at 20, 40, 60, 80, 120, 150, 180, 210 and 240 minutes post-dose. MKC serum concentration was measured by HPLC, and pharmacokinetic parameters determined using the WinNonlin program. The absolute bioavailability of MKC was found to be low in healthy and diabetic rats (29 and 23% respectively) and was not significantly different between the two groups. Mean residence time (MRT), volume of distribution (Vd) and half-life (t1/2) of MKC after oral administration were significantly lower in diabetic than in healthy rats (21, 31 and 29% respectively). After the i.v. dose, the change in blood glucose concentration was not significant in either healthy or diabetic rats. After the oral dose, the decrease in blood glucose concentration was significant, reaching a maximum decrease from baseline of 24% in healthy rats and 15% in diabetic rats. The results suggest that a first-pass effect is crucial for the hypoglycemic activity of MKC, indicating that a metabolite of MKC and/or interference with metabolism and glucose transport is responsible.     

Narrowband UVB phototherapy for small plaque parapsoriasis

BACKGROUND: Narrowband UVB (NB-UVB) phototherapy has been shown to be effective for the treatment of various dermatoses. OBJECTIVE: To analyze the effects of NB-UVB phototherapy for small plaque parapsoriasis (SPP). METHODS: The response of 45 patients (24 females, 21 males, age range 20-58 years) with histologically confirmed SPP were assessed. NB-UVB therapy was given 3-4 times weekly. The initial treatment dose was 70% of the minimal erythema dose. The doses were increased gradually with a standard increment of 20/10/0. Clinical response was determined as follows: complete response (CR), at least 90% clearing of skin lesions; partial response (PR), at least 50% but less than 90% clearing and no response (NR), less than 50% clearing. The follow-up period was 6-24 months after the treatment. RESULTS: NB-UVB treatment led to CR in 33 of 45 patients (73.3%) with a mean cumulative dose of 14.3 J/cm(2) (range 3.2-24.1 J/cm(2)) after a mean number of 29 exposures (range 16-51 sessions); PR in 12 of 45 (26.6%) with a cumulative dose of 15.6 J/cm(2) (range 10.4-23.3 J/cm(2)) after a mean number of 29.4 exposures (range 25-50 sessions). Nineteen patients with CR had skin phototype II, 13 had type III and 1 had type I. Among the patients with PR, 7 had skin phototype II and 5 had type III. Postinflammatory hyperpigmentation was observed in 51% of the patients. Relapses occurred in six patients within a mean time of 7.5 months (2-12 months). CONCLUSION: NB-UVB phototherapy has several advantages over treatment with broadband UVB and PUVA. NB-UVB therapy for patients with SPP is an effective, safe and practical alternative treatment modality. Further larger studies with longer follow-up periods are necessary to determine the proper clinical response and long-term complications of NB-UVB therapy in this disease.