Anesthetic management for lower extremity vascular bypass procedures: The impact of general or regional anesthesia on clinical outcomes

PURPOSE

Postoperative complications after major surgery, especially vascular procedures, are associated with a significant increase in costs and mortality. Previous studies evaluating general anesthesia versus regional or neuraxial anesthesia for infrainguinal bypass have produced conflicting results. The main aim of the present study is to review current evidence on the application of regional or general anesthesia in patients undergoing infrainguinal bypass surgery and its potential favorable effects on postoperative outcomes.

CONTENTS

Patients undergoing vascular surgery often have multiple comorbidities, and it is important to outline both benefits and risks of regional anesthesia techniques. Neuraxial anesthesia in vascular surgery allows overall avoidance of general anesthesia and does provide short-term benefits beyond analgesia. Previous observational studies suggest that neuraxial anesthesia for lower limb revascularization may reduce morbidity and length of stay. However, evidence of long-term benefits is lacking in most procedures and further work is still warranted.

CONCLUSIONS

Neuraxial anesthesia is usually an effective anesthesia technique for infrainguinal bypass surgery. Elderly patients and those with underlying respiratory problems may display some benefit from neuraxial anesthesia. Further evaluation within institutions should be performed to identify which patients would most benefit from regional techniques. Notably, systemic antithrombotic and anticoagulation therapy is common among this population and may affect anesthetic choices.

Cerebrospinal fluid purinomics as a biomarker approach to predict outcome after severe traumatic brain injury

Severe traumatic brain injury (TBI) is associated with high rates of mortality and long-term disability linked to neurochemical abnormalities. Although purine-derivatives play important roles in TBI pathogenesis in preclinical models, little is known about potential changes in purine levels and their implications in human TBI. We assessed cerebrospinal fluid (CSF) levels of purines in severe TBI patients as potential biomarkers that predict mortality and long-term dysfunction. This was a cross-sectional study performed in 17 severe TBI patients (Glasgow Coma Scale < 8) and 51 controls. Two to four hours after admission to ICU, patients were submitted to ventricular drainage and CSF collection for quantification of adenine and guanine purine-derivatives by HPLC. TBI patients survival was followed up to 3 days from admission. A neurofunctional assessment was performed through the modified Rankin Scale (mRS) two years after ICU admission. Purine levels were compared between control and TBI patients, and between surviving and non-surviving patients. Relative to controls, TBI patients presented increased CSF levels of GDP, guanosine, adenosine, inosine, hypoxanthine, and xanthine. Further, GTP, GDP, IMP, and xanthine levels were different between surviving and non-surviving patients. Among the purines, guanosine was associated with improved mRS (p=0.042; r= -0.506). Remarkably, GTP displayed predictive value (AUC=0.841, p=0.024) for discriminating survival vs. non-survival patients up to three days from admission. These results support TBI-specific purine signatures, suggesting GTP as a promising biomarker of mortality, and guanosine as an indicator of long-term functional disability.

Allopurinol for fibromyalgia pain in adults: A randomized controlled trial

BACKGROUND

Allopurinol is a potent inhibitor of the enzyme xanthine oxidase used in the treatment of hyperuricemia and gout. Because it is well known that purines exert multiple affects on pain transmission, we hypothesized that the inhibition of xanthine oxidase by allopurinol could be a valid strategy to treat pain in humans. This study aimed to compare the analgesic efficacy of oral allopurinol versus placebo as an adjuvant therapy in patients displaying fibromyalgia.

METHODS

This randomized, double-blinded, placebo-controlled study included 60 women with the diagnosis of fibromyalgia. Patients were randomly assigned to receive either oral allopurinol 300 mg (n = 31) or placebo (n = 29) twice daily during 30 days. The patients were submitted to evaluation for pain sensitivity, anxiety, depression, and functional status before treatment, and 15 and 30 days thereafter.

RESULTS

Oral administration of allopurinol 300 mg twice daily was ineffective in improving pain scores measured by several tools up to 30 days of treatment (P > 0.05). Additionally, no significant effects of allopurinol over anxiety, depressive symptoms, and functional status of fibromyalgia patients were observed in the present study.

CONCLUSIONS

Although previous findings indicated that allopurinol could present intrinsic analgesic effects in both animals and humans, this study showed no benefit of the use of oral allopurinol as an adjuvant strategy during 30 days in women displaying fibromyalgia. However, considering previous promising results, new prospective studies are still valid to further investigate allopurinol and more selective purine derivatives in the management of pain syndromes.

Risk factors for postoperative pulmonary complications and prolonged hospital stay in pulmonary resection patients: a retrospective study

Background

Postoperative pulmonary complications are the main cause of morbidity and mortality after pulmonary resection. This study was undertaken to determine the risk factors associated with postoperative pulmonary complications (PPCs) and length of hospital stay (LOS) in pulmonary resection patients in a tertiary teaching hospital in Brazil.

Methods

A retrospective data gathering from 196 patients who underwent pulmonary resection between 2012 and 2016 was conducted. Demographic and hospital admission data were collected from patients with complete medical records. Univariate analysis was performed, followed by Poisson’s regression for predicting the prevalence of postoperative pulmonary complications and length of hospital stay.

Results

Thirty-nine patients (20%) displayed pulmonary complications in the postoperative period. The risk factors associated with an increased prevalence of postoperative pulmonary complications in a multivariate analysis were: American Society of Anesthesiologists physical status (ASA) ≥ 3 (PR 4.77, p = 0.03, 95% CI: 1.17 to 19.46), predicted diffusion capacity of the lungs for carbon monoxide – corrected single breath (PR 0.98, p < 0.001, 95% CI: 0.96 to 0.99) and age of the patient (PR 1.04; p = 0.01; 95% CI: 1.01 to 1.06). Those associated with an increased prevalence of prolonged hospital stay were: duration of surgical procedure longer than five hours (PR 6.94, p = 0.01, 95% CI: 1.66 to 12.23), male sex (PR 5.72, p < 0.001, 95% CI: 1.87 to 9.58), and presence of postoperative pulmonary complications (PR 11.92, p < 0.001, 95% CI: 7.42 to 16.42).

Conclusions

The rate of postoperative pulmonary complications in the study population is in line with the world average. Recognizing risk factors for the development of PPCs may help optimize allocation resources and preventive efforts.

S100B protein and neuron-specific enolase as predictors of postoperative cognitive dysfunction in aged dogs: a case-control study

OBJECTIVE

Postoperative cognitive dysfunction (POCD) may be related to brain injury. S100B protein and neuron-specific enolase (NSE) have been investigated as potential biochemical markers of neural cell injury in animals and humans. This study aimed to investigate the association between POCD, brain injury and serum concentrations of S100B and NSE after periodontal surgery in aged dogs.

STUDY DESIGN

Prospective observational animal study.

ANIMALS

A total of 24 male and female dogs undergoing periodontal surgery.

METHODS

Dogs were separated into two groups based on age: control group, 10 dogs ≤ 8 years and aged group, 14 dogs > 8 years. Cognitive function was measured preoperatively and on the seventh postoperative day using the Canine Cognitive Dysfunction Rating scale and the Age-Related Cognitive and Affective Disorders scale. S100B protein and NSE serum concentrations were measured before and immediately after the surgery.

RESULTS

POCD was not observed after surgery in the present study. Serum concentrations of S100B and NSE were increased postoperatively in the control group but not in the aged group (p = 0.04 and 0.03, respectively). Preoperative S100B serum concentrations were significantly higher in the aged group (p = 0.01).

CONCLUSIONS

There was no association between POCD and high concentrations of S100B and NSE in dogs. However, increased postoperative serum concentrations of S100B and NSE were found in the control group after surgery, an effect that may indicate neural damage.

CLINICAL RELEVANCE

The results suggest that anesthesia and oral surgery are associated with higher postoperative serum concentrations of S100B and NSE in dogs ≤ 8 years old, which may indicate neural damage. Serum concentrations of S100B were elevated in aged dogs before anesthesia, a finding that might be related to chronic preoperative brain damage.

Elevated glutamate and lactate predict brain death after severe head trauma

Objective

Clinical neurological assessment is challenging for severe traumatic brain injury (TBI) patients in the acute setting. Waves of neurochemical abnormalities that follow TBI may serve as fluid biomarkers of neurological status. We assessed the cerebrospinal fluid (CSF) levels of glutamate, lactate, BDNF, and GDNF, to identify potential prognostic biomarkers of neurological outcome.

Methods

This cross‐sectional study was carried out in a total of 20 consecutive patients (mean [SD] age, 29 [13] years; M/F, 9:1) with severe TBI Glasgow Coma Scale ≤ 8 and abnormal computed tomography scan on admission. Patients were submitted to ventricular drainage and had CSF collected between 2 and 4 h after hospital admission. Patients were then stratified according to two clinical outcomes: deterioration to brain death (nonsurvival, n = 6) or survival (survival, n = 14), within 3 days after hospital admission. CSF levels of brain‐derived substances were compared between nonsurvival and survival groups. Clinical and neurological parameters were also assessed.

Results

Glutamate and lactate are significantly increased in nonsurvival relative to survival patients. We tested the accuracy of both biomarkers to discriminate patient outcome. Setting a cutoff of >57.75, glutamate provides 80.0% of sensitivity and 84.62% of specificity (AUC: 0.8214, 95% CL: 54.55–98.08%; and a cutoff of >4.65, lactate has 100% of sensitivity and 85.71% of specificity (AUC: 0.8810, 95% CL: 54.55–98.08%). BDNF and GDNF did not discriminate poor outcome.

Interpretation

This early study suggests that glutamate and lactate concentrations at hospital admission accurately predict death within 3 days after severe TBI.

Mechanisms involved in the antinociception induced by spinal administration of inosine or guanine in mice

It is well known that adenine-based purines exert multiple effects on pain transmission. Recently, we have demonstrated that guanine-based purines may produce some antinociceptive effects against chemical and thermal pain in mice. The present study was designed to investigate the antinociceptive effects of intrathecal (i.t.) administration of inosine or guanine in mice. Additionally, investigation into the mechanisms of action of these purines, their general toxicity and measurements of CSF purine levels were performed. Animals received an i.t. injection of vehicle (30mN NaOH), inosine or guanine (up to 600nmol) and submitted to several pain models and behavioural paradigms. Guanine and inosine produced dose-dependent antinociceptive effects in the tail-flick, hot-plate, intraplantar (i.pl.) glutamate, i.pl. capsaicin and acetic acid pain models. Additionally, i.t. inosine inhibited the biting behaviour induced by spinal injection of capsaicin and i.t. guanine reduced the biting behaviour induced by spinal injection of glutamate or AMPA. Intrathecal administration of inosine (200nmol) induced an approximately 115-fold increase on CSF inosine levels. This study provides new evidence on the mechanism of action of extracellular guanine and inosine presenting antinociceptive effects following spinal administration. These effects seem to be related, at least partially, to the modulation of A1 adenosine receptors.

Changes in Purines Concentration in the Cerebrospinal Fluid of Pregnant Women Experiencing Pain During Active Labor

Labor pain has been reported as a severe pain and can be considered as a model of acute visceral pain. It is well known that extracellular purines have an important role in pain signaling in the central nervous system. This study analyzes the relationship between extracellular purines and pain perception during active labor. A prospective observational study was performed. Cerebrospinal fluid (CSF) levels of the purines and their metabolites were compared between women at term pregnancy with labor pain (n = 49) and without labor pain (Caesarian section; n = 47). Control groups (healthy men and women without chronic or acute pain-n = 40 and 32, respectively) were also investigated. The CSF levels of adenosine were significantly lower in the labor pain group (P = 0.026) and negatively correlated with pain intensity measured by a visual analogue scale (r = -0.48, P = 0.0005). Interestingly, CSF levels of uric acid were significantly higher in healthy men as compared to women. Additionally, pregnant women showed increased CSF levels of ADP, GDP, adenosine and guanosine and reduced CSF levels of AMP, GTP, and uric acid as compared to non-pregnant women (P < 0.05). These findings suggest that purines, in special the nucleoside adenosine, are associated with pregnancy and labor pain.

Clinical evaluation of the flotrac/Vigileo system for continuous cardiac output monitoring in patients undergoing regional anesthesia for elective cesarean section: a pilot study

BACKGROUND

Spinal anesthesia for cesarean delivery may cause severe maternal hypotension and a decrease in cardiac output. Compared to assessment of cardiac output via a pulmonary artery catheter, the FloTrac/Vigileo system may offer a less invasive technique. The aim of this study was to evaluate cardiac output and other hemodynamic measurements made using the FloTrac/Vigileo system in patients undergoing spinal anesthesia for elective cesarean section.

METHODS

A prospective study enrolling 10 healthy pregnant women was performed. Hemodynamic parameters were continuously obtained at 15 main points: admission to surgery (two baseline measurements), after preload, after spinal anesthesia administration and 4 time points thereafter (4, 6, 8 and 10 min after anesthesia), at skin and uterine incision, newborn and placental delivery, oxytocin administration, end of surgery, and recovery from anesthesia. Hemodynamic therapy was guided by mean arterial pressure, and vasopressors were used as appropriate to maintain baseline values. A repeated measures ANOVA was used for data analysis.

RESULTS

There was a significant increase in heart rate and a decrease of stroke volume and stroke volume index up to 10 min after spinal anesthesia (P < 0.01). Importantly, stroke volume variation increased immediately after newborn delivery (P < 0.001) and returned to basal values at the end of surgery. Further hemodynamic parameters showed no significant changes over time.

DISCUSSION AND CONCLUSIONS

No significant hemodynamic effects, except for heart rate and stroke volume changes, were observed in pregnant women managed with preload and vasopressors when undergoing elective cesarean section and spinal anesthesia.

Changes in purines concentration in the cerebrospinal fluid of patients experiencing pain: a case-control study

This study analyzes the relationship between extracellular purines and pain perception in humans. Cerebrospinal fluid (CSF) levels of purines and their metabolites were compared between patients displaying acute and/or chronic pain syndromes and control subjects. The CSF levels of IMP, inosine, guanosine and uric acid were significantly increased in the chronic pain group and correlated with pain severity (P<0.05). Patients displaying both chronic and acute pain presented similar changes in the CSF purines concentration (P<0.05). However, in the acute pain group, only CSF inosine and uric acid levels were significantly increased (P<0.05). These findings suggest that purines, in special inosine, guanosine and uric acid, are associated with the spinal mechanisms underlying nociception.

Mechanisms involved in the antinociception induced by systemic administration of guanosine in mice

BACKGROUND AND PURPOSE

It is well known that adenine-based purines exert multiple effects on pain transmission. However, less attention has been given to the potential effects of guanine-based purines on pain transmission. The aim of this study was to investigate the effects of intraperitoneal (i.p.) and oral (p.o.) administration of guanosine on mice pain models. Additionally, investigation into the mechanisms of action of guanosine, its potential toxicity and cerebrospinal fluid (CSF) purine levels were also assessed.

EXPERIMENTAL APPROACH

Mice received an i.p. or p.o. administration of vehicle (0.1 mM NaOH) or guanosine (up to 240 mg x kg(-1)) and were evaluated in several pain models.

KEY RESULTS

Guanosine produced dose-dependent antinociceptive effects in the hot-plate, glutamate, capsaicin, formalin and acetic acid models, but it was ineffective in the tail-flick test. Additionally, guanosine produced a significant inhibition of biting behaviour induced by i.t. injection of glutamate, AMPA, kainate and trans-ACPD, but not against NMDA, substance P or capsaicin. The antinociceptive effects of guanosine were prevented by selective and non-selective adenosine receptor antagonists. Systemic administration of guanosine (120 mg x kg(-1)) induced an approximately sevenfold increase on CSF guanosine levels. Guanosine prevented the increase on spinal cord glutamate uptake induced by intraplantar capsaicin.

CONCLUSIONS AND IMPLICATIONS

This study provides new evidence on the mechanism of action of the antinociceptive effects after systemic administration of guanosine. These effects seem to be related to the modulation of adenosine A(1) and A(2A) receptors and non-NMDA glutamate receptors.

Is superior hypogastric plexus block effective for treatment of chronic pelvic pain?

BACKGROUND AND OBJECTIVES

Hypograstric plexus block has been considered a safe and effective alternative for treat patients with chronic pelvic pain. Published studies available at MedLine on the subject were included and evaluated in this review.

CONTENTS

Some studies have documented superior hypogastric plexus block effectiveness in relieving pain and decreasing opioid consumption, mainly in cancer patients. However, studies had failures in method or design.

CONCLUSIONS

New prospective and better-designed studies are still needed to confirm the effectiveness of hypogastric plexus block in relieving pelvic pain. These studies shall have stricter inclusion criteria, longer follow-up, and evaluation of other symptoms and quality of life before and after the procedure. Superior hypogastric plexus block should be recommended as alternative and not as primary therapy.

Anti-nociceptive properties of the xanthine oxidase inhibitor allopurinol in mice: role of A1 adenosine receptors

BACKGROUND AND PURPOSE

Allopurinol is a potent inhibitor of the enzyme xanthine oxidase, used primarily in the treatment of hyperuricemia and gout. It is well known that purines exert multiple effects on pain transmission. We hypothesized that the inhibition of xanthine oxidase by allopurinol, thereby reducing purine degradation, could be a valid strategy to enhance purinergic activity. The aim of this study was to investigate the anti-nociceptive profile of allopurinol on chemical and thermal pain models in mice.

EXPERIMENTAL APPROACH

Mice received an intraperitoneal (i.p.) injection of vehicle (Tween 10%) or allopurinol (10-400 mg kg(-1)). Anti-nociceptive effects were measured with intraplantar capsaicin, intraplantar glutamate, tail-flick or hot-plate tests.

KEY RESULTS

Allopurinol presented dose-dependent anti-nociceptive effects in all models. The opioid antagonist naloxone did not affect these anti-nociceptive effects. The non-selective adenosine-receptor antagonist caffeine and the selective A(1) adenosine-receptor antagonist, DPCPX, but not the selective A(2A) adenosine-receptor antagonist, SCH58261, completely prevented allopurinol-induced anti-nociception. No obvious motor deficits were produced by allopurinol, at doses up to 200 mg kg(-1). Allopurinol also caused an increase in cerebrospinal fluid levels of purines, including the nucleosides adenosine and guanosine, and decreased cerebrospinal fluid concentration of uric acid.

CONCLUSIONS AND IMPLICATIONS

Allopurinol-induced anti-nociception may be related to adenosine accumulation. Allopurinol is an old and extensively used compound and seems to be well tolerated with no obvious central nervous system toxic effects at high doses. This drug may be useful to treat pain syndromes in humans.

The NMDA antagonist MK-801 induces hyperalgesia and increases CSF excitatory amino acids in rats: reversal by guanosine

Excitatory amino acids (EAAs) and their receptors play a central role in the mechanisms underlying pain transmission. NMDA-receptor antagonists such as MK-801 produce antinociceptive effects against experimental models of chronic pain, but results in acute pain models are conflicting, perhaps due to increased glutamate availability induced by the NMDA-receptor antagonists. Since guanosine and riluzole have recently been shown to stimulate glutamate uptake, the aim of this study was to examine the effects of guanosine or riluzole on changes in nociceptive signaling induced by MK-801 in an acute pain model. Rats received an i.p. injection of vehicle, morphine, guanosine, riluzole or MK-801 or a combined treatment (vehicle, morphine, guanosine or riluzole+MK-801) and were evaluated in the tail flick test, or had a CSF sample drawn after 30 min. Riluzole, guanosine, and MK-801 (0.01 or 0.1 mg/kg) did not affect basal nociceptive responses or CSF EAAs levels. However, MK-801 (0.5 mg/kg) induced hyperalgesia and increased the CSF EAAs levels; both effects were prevented by guanosine, riluzole or morphine. Hyperalgesia was correlated with CSF aspartate and glutamate levels. This study provides additional evidence for the mechanism of action of MK-801, showing that MK-801 induces hyperalgesia with parallel increase in CSF EAAs levels.

Proposal of a guanine-based purinergic system in the mammalian central nervous system

Guanine-based purines have been traditionally studied as modulators of intracellular processes, mainly G-protein activity. However, they also exert several extracellular effects not related to G proteins, including modulation of glutamatergic activity, trophic effects on neural cells, and behavioral effects. In this article, the putative roles of guanine-based purines on the nervous system are reviewed, and we propose a specific guanine-based purinergic system in addition to the well-characterized adenine-based purinergic system. Current evidence suggest that guanine-based purines modulate glutamatergic parameters, such as glutamate uptake by astrocytes and synaptic vesicles, seizures induced by glutamatergic agents, response to ischemia and excitotoxicity, and are able to affect learning, memory and anxiety. Additionally, guanine-based purines have important trophic functions affecting the development, structure, or maintenance of neural cells. Although studies addressing the mechanism of action (receptors and second messenger systems) of guanine-based purines are still insufficient, these findings point to the guanine-based purines (nucleotides and guanosine) as potential new targets for neuroprotection and neuromodulation.

Quinolinic Acid-induced Seizures Stimulate Glutamate Uptake into Synaptic Vesicles from Rat Brain: Effects Prevented by Guanine-based Purines

Glutamate uptake into synaptic vesicles is a vital step for glutamatergic neurotransmission. Quinolinic acid (QA) is an endogenous glutamate analog that may be involved in the etiology of epilepsy and is related to disturbances on glutamate release and uptake. Guanine-based purines (GBPs) guanosine 5'-monophosphate (GMP and guanosine) have been shown to exert anticonvulsant effects against QA-induced seizures. The aims of this study were to investigate the effects of in vivo administration of several convulsant agents on glutamate uptake into synaptic vesicles and investigate the role of MK-801, guanosine or GMP (anticonvulsants) on glutamate uptake into synaptic vesicles from rats presenting QA-induced seizures. Animals were treated with vehicle (saline 0.9%), QA 239.2 nmoles, kainate 30 mg/kg, picrotoxin 6 mg/kg, PTZ (pentylenetetrazole) 60 mg/kg, caffeine 150 mg/kg or MES (maximal transcorneal electroshock) 80 mA. All convulsant agents induced seizures in 80-100% of animals, but only QA stimulated glutamate uptake into synaptic vesicle. Guanosine or GMP prevented seizures induced by QA (up to 52% of protection), an effect similar to the NMDA antagonist MK-801 (60% of protection). Both GBPs and MK-801 prevented QA-induced glutamate uptake stimulation. This study provided additional evidence on the role of QA and GBPs on glutamatergic system in rat brain, and point to new perspectives on seizures treatment.

Effects of preanesthetic administration of midazolam, clonidine, or dexmedetomidine on postoperative pain and anxiety in children

BACKGROUND

A growing interest in the possible influences of pre- and postoperative anxiety and pain scores as outcomes of surgical treatment and benefits of anxiety or pain-reducing interventions has emerged. The aim of this study was to evaluate the influence of three different premedication regimens on postoperative pain and anxiety in children.

METHODS

A prospective, randomized, open-label clinical trial enrolled 60 schoolchildren. They were randomized for premedication with oral midazolam 0.5 mgxkg(-1), oral clonidine 4 microgxkg(-1), or transmucosal dexmedetomidine (DEX) 1 mug.kg(-1), submitted to a pre- and postoperative evaluation of anxiety with the State-Trait Anxiety Inventory for Children and asked to report any pain in verbal and visual analog scales. We also evaluated secondary outcomes such as parents' anxiety, sedation, separation from parents, adverse effects and hemodynamic status.

RESULTS

Dexmedetomidine and clonidine were related to lower scores of pain than midazolam. alpha(2)-agonists produced lower scores of peroperative mean arterial pressure and heart rate than midazolam. Both groups had similar levels of postoperative state-anxiety in children. There was no difference in preanesthesia levels of sedation and response to separation from parents between groups.

CONCLUSIONS

These findings indicate that children receiving clonidine or DEX preoperatively have similar levels of anxiety and sedation postoperatively as those receiving midazolam. However, children given alpha(2)-agonists had less perioperative sympathetic stimulation and less postoperative pain than those given midazolam.

Methotrexate induces seizure and decreases glutamate uptake in brain slices: Prevention by ionotropic glutamate receptors antagonists and adenosine

Methotrexate (MTX)-induced neurotoxicity may occur after intrathecal or systemic administration at low, intermediate and high doses for the treatment of malignant or inflammatory diseases. The mechanisms of MTX neurotoxicity are not totally understood, and appear to be multifactorial. In this study we characterized a model of MTX-induced seizures in mice to evaluate the convulsive and toxic MTX properties. Additionally, the effect of MTX-induced seizures on the activity of glutamate transporters, as well as the anticonvulsant role of MK-801, DNQX and adenosine on glutamate uptake in brain slices was investigated . MTX induced tonic-clonic seizures in approximately 95% of animals and pre-treatment with MK-801, DNQX and adenosine prevented seizure in 80%, 62% and 50% of animals, respectively. Moreover, MTX leads 59% of mice to death, which was prevented in 100% and 94% when animals received MK-801 and DNQX, respectively. Glutamate uptake decreased by 20% to 30% in cortical slices after MTX-induced seizures. Interestingly, when seizures were prevented by MK-801, DNQX or adenosine, glutamate uptake activity remained at the same level as the control group. Thus, our results demonstrate the involvement of the glutamatergic system in MTX-induced seizures.

Apolipoprotein E4 genotype increases the risk of postoperative cognitive dysfunction in patients undergoing coronary artery bypass graft surgery

AIM

The aim of this study was to investigate the association between the presence of ApoE4 and the incidence of postoperative cognitive dysfunction (POCD) after cardiac surgery.

METHODS

Eighty-seven adult patients undergoing elective coronary artery bypass graft surgery were observed prospectively at a university tertiary care hospital. All patients were evaluated with the Mini-Mental State Examination (MMSE) and the Glasgow Coma Scale (GCS) for cognitive function and mental status preoperatively, 24 h after surgery and at postoperative day 6. Patients were genotyped for the ApoE polymorphism. The association between ApoE genotype and MMSE evolution was studied by using repeated measures ANOVA.

RESULTS

Both the presence of at least one ApoE4 allele and POCD were verified in 21.8% of subjects. The presence of the ApoE4 allele was significantly associated with a worse MMSE score evolution (P=0.04).

CONCLUSION

This study suggests an association between ApoE4 and early POCD, but further studies are needed to clarify a causative association. Such new studies should include a more homogenous patient sample and a longer follow-up.

Comparison between intermittent and continuous measurement of cardiac output after acute normovolemic hemodilution in pigs

Continuous cardiac output (CO) and mixed venous oxygen saturation (SvO2) determined through the pulmonary artery catheter may be helpful in monitoring hemodynamic conditions in critically ill patients. This study aimed to evaluate CO and SvO2 in a model of acute normovolemic hemodilution (ANH), analyzing the accuracy of the continuous versus intermittent method for CO and SvO2 measurement in pigs. Twenty-three pigs were enrolled to three groups: control, ANH with 6% hydroxyethyl starch (HES), or ANH with lactated Ringer's (LR) solution. After hemodilution, we showed that SvO2 was reduced in both groups, mainly in LR animals (P < 0.05). Regarding the evaluation of CO, we showed an increase in both groups submitted to ANH (P < 0.05). Through Bland-Altman analysis, we showed that the continuous CO catheter presented lower values than the intermittent method after hemodilution, mainly with HES (P < 0.001), and there was no difference in the measurement of SvO2. The ANH promoted a decrease in SvO2 and an increase in CO values, mainly in animals submitted to hemodilution with HES. The use of continuous and intermittent (laboratory) measurement of SvO2 showed clinical applicability and good agreement, an effect not reproduced by the CO measurement. New studies are needed to further investigate the agreement between the continuous and intermittent methods for the measurement of CO in adverse hemodynamic conditions such as ANH.

Biochemical brain markers and purinergic parameters in rat CSF after seizure induced by pentylenetetrazol

Cellular and molecular mechanisms involved in the generation of seizures and the magnitude of neural cells injury are not fully understood. We evaluated astrocyte and/or neuronal injury in rats in the pentylenetetrazol model of acute seizures by measuring S100B and NSE levels in cerebrospinal fluid. Additionally, we determined ADP and GDP hydrolysis by soluble nucleoside triphosphate diphosphohydrolase in the cerebrospinal fluid, and the concentration of nucleosides adenosine, inosine and guanosine as putative markers of brain injury. After pentylenetetrazol-induced seizures: (i) S100B values increased from 10 to 30 min, returning to control levels at 24 h; NSE levels presented a biphasic increase: an increase at 10 to 30 min returning to control levels, and again at 240 min followed by a decline at 24 h; (ii) nucleotidase activities increased from 10 min, returning to control levels at 240 min; (iii) guanosine and inosine levels increased exclusively after 30 min. In summary, this study showed biochemical changes in the cerebrospinal fluid occurring after seizures induced by pentylenetetrazol. Such events may have a modulating effect upon seizure expression, particularly nucleoside triphosphate diphosphohydrolase activities and nucleoside concentrations, but are nevertheless followed by neural death as evidenced by the increase in NSE and S100B levels.

In vivo quinolinic acid increases synaptosomal glutamate release in rats: reversal by guanosine

Glutamate, the main excitatory neurotransmitter in the mammalian central nervous system (CNS), plays important role in brain physiological and pathological events. Quinolinic acid (QA) is a glutamatergic agent that induces seizures and is involved in the etiology of epilepsy. Guanine-based purines (GBPs) (guanosine and GMP) have been shown to exert neuroprotective effects against glutamatergic excitotoxic events. In this study, the influence of QA and GBPs on synaptosomal glutamate release and uptake in rats was investigated. We had previously demonstrated that QA "in vitro" stimulates synaptosomal L-[3H]glutamate release. In this work, we show that i.c.v. QA administration induced seizures in rats and was able to stimulate synaptosomal L-[3H]glutamate release. This in vivo neurochemical effect was prevented by i.p. guanosine only when this nucleoside prevented QA-induced seizures. I.c.v. QA did not affect synaptosomal L-[3H]glutamate uptake. These data provided new evidence on the role of QA and GBPs on glutamatergic system in rat brain.

Intracerebroventricular guanine-based purines protect against seizures induced by quinolinic acid in mice

Acute and chronic administration of the nucleoside guanosine have been shown to prevent quinolinic acid (QA) and alpha-dendrotoxin-induced seizures, as well as to impair memory and anxiety in rats and mice. In this study, we investigated the effect of i.c.v. administration of guanine-based purines (GTP, GDP, GMP, and guanosine) against seizures induced by the NMDA agonist and glutamate releaser quinolinic acid in mice. We also aimed to study the effects of the poorly hydrolysable analogs of GTP (GppNHp and GTPgammaS) and GDP (GDPbetaS) in this seizure model. QA produced seizures in 100% of mice, an effect partially prevented by guanine-based purines. In contrast to GTP (480 nmol), GDP (320-640 nmol), GMP (320-480 nmol) and guanosine (300-400 nmol), the poorly hydrolysable analogs of GTP and GDP did not affect QA-induced seizures. Thus, the protective effects of guanine nucleotides seem to be due to their conversion to guanosine. Altogether, these findings suggest a potential role of guanine-based purines for treating diseases involving glutamatergic excitotoxicity.

Effects of chronic administered guanosine on behavioral parameters and brain glutamate uptake in rats

Oral and intraperitoneal administration of the nucleoside guanosine have been shown to prevent quinolinic acid- (QA) and alpha-dendrotoxin-induced seizures, impair memory, and impair anxiety in rats and mice. We investigated the effect of 2-weeks ad lib orally administered guanosine (0.5 mg/ml) on seizures induced by QA, inhibitory avoidance memory, and locomotor performance in rats. We also studied the mechanism of action of guanosine through the measurement of its concentration in the cerebrospinal fluid (CSF) and its effect on glutamate uptake in cortical slices of rats. QA produced seizures in 85% of rats, an effect partially prevented by guanosine (53% of seizures; P = 0.0208). Guanosine also impaired retention on the inhibitory avoidance task (P = 0.0278) and decreased locomotor activity on the open field test (P = 0.0101). The CSF guanosine concentration increased twofold in the treated group compared to that in the vehicle group (P = 0.0178). Additionally, QA promoted a 30% decrease in glutamate uptake as compared to that with intracerebroventricular saline administration, an effect prevented by guanosine in animals protected against QA-induced seizures. Altogether, these findings suggest a potential role of guanosine for treating diseases involving glutamatergic excitotoxicity such as epilepsy. These effects seem to be related to modulation of glutamate uptake.

Increased cerebrospinal fluid levels of S100B protein in rat model of mania induced by ouabain

Bipolar disorder is a chronic and severe mental disorder. Recently, new animal models have emerged to further investigate underlying mechanisms of bipolar disorder such as ouabain-induced hyperactivity in rats. In this study, we investigated the cerebrospinal fluid levels of S100B protein as a putative marker of astrocytic activity in bipolar mania induced by intracerebroventricular administration of ouabain in rats. Ouabain induced a two-fold increase in crossing responses in the open field test and increased 30% the cerebrospinal fluid concentration of S100B, as compared to vehicle group. Our findings reinforce the role of astroglial cells in the pathogenesis of bipolar disorder and S100B protein as a marker of bipolar mania.

Anticonvulsant effect of GMP depends on its conversion to guanosine

Studies on the purinergic system normally deal with adenine-based purines, namely, adenine nucleotides and adenosine. However, a guanine-based purinergic system may also have important neuromodulatory roles. Guanine-based purines exert trophic effects on neural cells, protect brain slices in a model of hypoxia and stimulate glutamate uptake. In vivo, both guanosine 5'-monophosphate (GMP) and guanosine (GUO) protected against seizures. In this study, we investigated if the anticonvulsant effect of GMP is mediated by guanosine and if guanosine or GMP treatments were able to increase adenosine levels. Intraperitoneal (i.p.) treatments with 7.5 mg/kg GMP or guanosine prevented 50% of seizures by quinolinic acid (QA) and increased guanosine cerebrospinal fluid (CSF) levels around twofold and threefold, respectively; GMP and adenosine levels remained unchanged. Intracerebroventricular treatment with 960 nmol GMP prevented 80% of seizures and the 5'-nucleotidase inhibitor alpha-beta-methyleneadenosine 5'-diphosphate (AOPCP), when injected 3 min before, reduced this anticonvulsant effect to 30% protection as well as significantly decreased the conversion of GMP into guanosine measured in the CSF. This study shows that the previously reported effect of GMP as an anticonvulsant seems to be related to its ability to generate guanosine through the action of ecto-5'-nucleotidase.

Relation of cervical length at 22-24 weeks of gestation to demographic characteristics and obstetric history

Preterm delivery is the main cause of neonatal death and ultrasonographic cervical assessment has been shown to be more accurate than digital examination in recognizing a short cervix. This is a cross-sectional study, involving 1131 women at 22-24 weeks of pregnancy, designed to determine the distribution of cervical length and to examine which variables of demographic characteristics and obstetric history increase the risk of a short cervix (15 mm or less). The distribution of maternal demographic and obstetric history characteristics among patients with cervical length pound 15 mm was analyzed and compared to the findings for the general population. Risk ratios (RR) between subgroups were generated from this comparison. Median cervical length was 37 mm and in 1.5% of cases it was 15 mm or less. The proportion of women with a short cervix (< or =15 mm) was significantly higher among patients with a low body mass index (RR = 3.5) and in those with previous fetal losses between 16-23 weeks (RR = 33.1) or spontaneous preterm deliveries between 24-32 weeks (RR = 14.1). We suggest that transvaginal sonographic measurement of cervical length be performed as part of a routine midtrimester ultrasound evaluation. There are specific variables of demographic characteristics and obstetric history which increase the risk of detecting a short cervix at 22-24 weeks.

Effects of undernutrition on glutamatergic parameters in rat brain

Early restriction of nutrients during the perinatal period has marked repercussions on CNS ontogeny, leading to impaired functions. This study investigated the effects of pre- and postnatal (up to 75 days) undernutrition (diet: 8% protein; normonourished group: 25% protein) on some glutamatergic and behavioral parameters of rats. Undernutrition reduced: (i) seizures caused by ICV quinolinic acid (QA) administration; (ii) Na-independent [3H]glutamate binding in cell plasma membranes of cerebral cortex, and (ii) basal [3H]glutamate release from synaptosomal preparation. Behavioral parameters related to locomotion, anxiety, or memory were not affected. These results indicate that our model of undernutrition decreased the sensitivity to QA as convulsing agent and point to some putative glutamatergic parameters involved in this effect.

Preoperative predictors of moderate to intense acute postoperative pain in patients undergoing abdominal surgery

BACKGROUND

Pain is a sensory and emotional experience that is influenced by physiologic, sensory, affective, cognitive, socio-cultural, and behavioral factors. Consistent with the perspective to improve the postoperative pain control, the present study has the purpose of assessing the effect of presurgical clinical factors, psychological and demographic characteristics as predictors for reporting moderate to intense acute postoperative pain.

METHODS

A prospective cohort study was performed with 346 inpatients undergoing abdominal elective surgery (ASA physical status I-III, age range 18-60 years). The measuring instruments were Pain Visual Analog Scale, the State-Trait Anxiety Inventory, and the Montgomery-Asberg Depression Rating Scale. Multivariate conditional regression modeling was used to determine independent predictors for moderate to intense acute postoperative pain.

RESULTS

Moderate to intense acute postoperative pain was associated with status ASA III (odds ratio (OR) = 1.99), age (OR = 4.72), preoperative moderate to intense pain (OR = 2.96), chronic pain (OR = 1.75), high trait-anxiety and depressive mood moderate to intense (OR = 1.74 and OR = 2.00, respectively). Patients undergoing surgery to treat cancer presented lower risk for reporting moderate to intense pain OR = 0.39, as well as those that received the epidural analgesia and multimodal analgesia with systemic opioid (OR = 0.09 and OR = 0.16, respectively).

CONCLUSIONS

The identification of predictive factors for intense acute postoperative pain may be useful for designing specific preventive interventions to relieve patient suffering. Especially because few of these variables are accessible for medical intervention, which would improve the clinical outcomes and quality of life of patients at risk of moderate to intense acute postoperative pain.