Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient

The Peripheral Nerve Block working group of the Belgian Association for Regional Anesthesia has revised and updated the “Clinical guidelines for the practice of peripheral nerve block in the adult” which were published in 2013.

F376A/M388A-solulin, a new promising antifibrinolytic for severe haemophilia A

INTRODUCTION

Haemophilia is a major bleeding disorder due to a deficiency of procoagulant factor VIII (type A) or IX (type B). The treatment is substitutive and based on infusion of factor concentrates. Main limitations of this therapy are cost, short factor half-life and the development of inhibitors (up to 30% of severe HA patients). An important aggravating factor of haemophilia is due to a premature fibrinolysis, directing attention to the therapeutic potential of suitable antifibrinolytics. Thrombomodulin (TM) is a key player of the coagulation cascade by activating protein C (an inhibitor of thrombin generation, thus antagonizing coagulation) and of the fibrinolytic cascade by activating thrombin activatable fibrinolysis inhibitor TAFI (thus reducing fibrinolysis). Solulin is a soluble form of TM that shows both capabilities.

AIM

Here, we developed a new generation of solulin variants (F376A-, M388A- and F376A/M388A-solulin) with a decreased ability to activate protein C and a conserved capacity to activate TAFI.

METHODS

We produced and characterized solulin variants in vitro. In addition, F376A/M388A-solulin was tested ex vivo, using blood samples of haemophilic A patients, with thromboelastography.

RESULTS

The solulin variants (F376A, M388A and the double-mutant F376A/M388A) lost their abilities to activate protein C but are still capable to activate TAFI. Thrombelastography showed increased clot firmness and stability, that, as opposed to wild-type solulin, was maintained even at high concentrations of F376A/M388A-solulin (100 nm).

CONCLUSION

In sum, these results open new opportunities for the development of specific medication for haemophilic patients.

["Heart, arteries and women" an innovative care pathway for women at high risk: First evaluation at one year]

INTRODUCTION

Cardiovascular diseases remain the first cause of death in women. To improve women's health cardiologists and gynaecologists should work together on women's specific cardiovascular risk factor.

METHOD

Our study evaluated a care pathway named "heart, arteries and women". One hundred and ninety-one women were included for vascular (n=55) or hypertensive (n=136) explorations from January the first to December the 31st of 2013. We studied their clinical presentation and medical management.

RESULTS

All women were at high cardiovascular risk (38% of them at very high risk). The average age was 52 years old. A woman on three had experienced high blood pressure or diabetes during pregnancy. One on two was postmenopausal woman. We stopped twelve estrogen-progesterone contraceptions; 60% didn't have gynaecological follow-up; 146 had high blood pressures (73% at night, 50% had no dipping blood pressure profile and 15 were newly diagnosed for hypertension). Sleep apnoea syndrome was suspected in half women. Medical therapies were optimized especially for women with atheroma in which 30 to 46% were properly treated (P=0.0005). Only 18% of the gynecologists received conclusive reports.

CONCLUSION

At one year, our care pathway "heart, arteries and women" allowed to optimize medical therapy and clinical management. Everyone should be aware of this program.

High nonlinear figure-of-merit amorphous silicon waveguides

The nonlinear response of amorphous silicon waveguides is reported and compared to silicon-on-insulator (SOI) samples. The real part of the nonlinear coefficient γ is measured by four-wave-mixing and the imaginary part of γ is characterized by measuring the nonlinear loss at different peak powers. The combination of both results yields a two-photon-absorption figure of merit of 4.9, which is more than 7 times higher than for the SOI samples. Time-resolved measurements and simulations confirm the measured nonlinear coefficient γ and show the absence of slow free-carrier effects versus ns free-carrier lifetimes in the SOI samples.

Hydrolysis of factor VIII mediated by catalytic antibodies occurs in haemophilia A patients with or without factor VIII inhibitors

The major complication of the substitutive treatment of haemophilia A (HA) is the development of antifactor VIII (FVIII) antibodies. Most of these antibodies neutralize FVIII procoagulant activity, and are identified as FVIII inhibitor. A subgroup of these antibodies, 'catalytic antibodies', catalyses the FVIII hydrolysis. We investigated the frequency and the activity of catalytic antibodies, according to the phenotype of HA and the presence or absence of FVIII inhibitor. IgG from 16 patients with inhibitor and 17 patients without inhibitor were purified. Rates of FVIII hydrolysis and inhibitor titres were evaluated. Anti-FVIII catalytic antibodies were detected in 63.6% of patients with HA, irrespective of the HA phenotype and the presence of FVIII inhibitor. The frequency was significantly higher for severe HA patients (73.3%) and patients with inhibitor (87.5%), but their FVIII-proteolytic activity was not significantly different from patients with mild or moderate HA and patients without inhibitor. The evolution of both catalytic and inhibitory activities was studied for 11 patients with FVIII inhibitor. We observed two profiles. In the profile 1, 18.2% of patients, the catalytic activity and the inhibitor titre coevolved. In contrast, a dissociated evolution of these two parameters was observed in 72.8% patients in profile 2. These data confirm the importance of anti-FVIII catalytic activity in patients with severe, moderate and mild HA. Interestingly, most of the patients presented a dissociated profile, suggesting that anti-FVIII antibodies might not systematically act as FVIII inhibitors.

[Tako-Tsubo syndrome during normal human immunoglobolin perfusion]

This is a case of an 82 year old female patient with myasthenia gravis, who following treatment with Human Normal Immunoglobulin (Tegeline(®)), developed dyspnoea, chest pain without cardiac insufficiency, inverted T wave on ECG with slight increase in Troponine T 0.43ng/mL (<0.2ng/mL normal value in our hospital) and marked increase in Pro-BNP 4900 (Nl≤450pg/mL for an age greater than 65 years old). Her coronary angiogram showed hypokinesia of apical area but was otherwise normal. Also, MRI ruled out inflammatory and ischemic cardiac diseases. The most likely diagnosis for us was Tako-Tsubo syndrome in relation with injection of Human Normal Immunoglobulin (Tegeline(®)) according to the Mayo clinic criteria.

[Acquired von Willebrand syndrome: from diagnosis to treatment]

Acquired von Willebrand syndrome is a rare bleeding disorder, which has been related in various diseases including lymphoproliferative disorders or autoimmune diseases. Its diagnosis is an important step before treatment of patients and particularly in case of bleeding. We report four cases from Caen Hemophilia Treatment Center, diagnosed and treated from 1999 to 2008. Mucocutaneous bleeds in every case were the same as in hereditary von Willebrand disease. All patients had no personal or family history of bleeding. Phenotype was identified as type 2 von Willebrand disease with a loss of high molecular weight multimers. Anti-von Willebrand factor inhibitor screening was positive for three patients. The etiological diagnosis was one chronic lymphocytic leukaemia, two monoclonal gammapathies of undetermined significance (MGUS) and one undetermined case. The management of patients need two stages: first infusions of factor von Willebrand/factor VIII concentrates to stop bleeds, then treatment of the underlying disease such as chemotherapy, corticotherapy and treatment with high doses of polyvalents immunoglobulins. In every case, treatment was effective and improved patient's quality of life.

FISH mapping of de novo apparently balanced chromosome rearrangements identifies characteristics associated with phenotypic abnormality

We report fluorescence in situ hybridization (FISH) mapping of 152, mostly de novo, apparently balanced chromosomal rearrangement (ABCR) breakpoints in 76 individuals, 30 of whom had no obvious phenotypic abnormality (control group) and 46 of whom had an associated disease (case group). The aim of this study was to identify breakpoint characteristics that could discriminate between these groups and which might be of predictive value in de novo ABCR (DN-ABCR) cases detected antenatally. We found no difference in the proportion of breakpoints that interrupted a gene, although in three cases, direct interruption or deletion of known autosomal-dominant or X-linked recessive Mendelian disease genes was diagnostic. The only significant predictor of phenotypic abnormality in the group as a whole was the localization of one or both breakpoints to an R-positive (G-negative) band with estimated predictive values of 0.69 (95% CL 0.54-0.81) and 0.90 (95% CL 0.60-0.98), respectively. R-positive bands are known to contain more genes and have a higher guanine-cytosine (GC) content than do G-positive (R-negative) bands; however, whether a gene was interrupted by the breakpoint or the GC content in the 200 kB around the breakpoint had no discriminant ability. Our results suggest that the large-scale genomic context of the breakpoint has prognostic utility and that the pathological mechanism of mapping to an R-band cannot be accounted for by direct gene inactivation.

Factor VIII (FVIII) gene mutations in 120 patients with hemophilia A: detection of 26 novel mutations and correlation with FVIII inhibitor development

BACKGROUND

As the publication of the sequence of the factor VIII gene (FVIII) in 1984, a large number of mutations that cause hemophilia A (HA) have been identified. Thanks to the advances in the detection of mutations, it is now possible to identify a putative FVIII sequence alteration in the vast majority of patients with HA.

OBJECTIVES

Our main objective was to report on the spectrum of FVIII mutations and their distribution throughout the gene in 120 patients with HA.

METHODS

Screening of FVIII mutations was performed using direct sequencing. Newly described missense mutations were further studied by molecular modeling.

RESULTS

A total of 47 different HA causative FVIII mutations have been identified, 26 of which are described for the first time. These novel mutations include 14 missense and six nonsense mutations, two small deletions, one large deletion and three splice-site mutations. We further investigated the development of FVIII-specific inhibitors in all patients with HA. We found that four novel mutations (Ser882X, Tyr1786Ser, Ala2218Thr and a splice-site defect in intron 22) were associated with inhibitor development.

CONCLUSION

These data extend our insight into the mechanisms by which novel amino acid substitutions may lead to HA, and how HA patient genotypes influence the risk of FVIII inhibitor development.

[Does antiaggregant therapy have a place in type II heparin-induced thrombocytopenia?]

We report a case of type II heparin-induced thrombocytopenia, which occurred after heart surgery in a 71-year-old female patient with several cardiovascular risk factors. The diagnosis of heparin-induced thrombopenia was suspected because association of multifocal arterial and venous thrombosis and detection of antiplatelet-factor 4 antibodies with a drop of more than 50% in the platelet count. Until diagnostic of heparin-induced thrombocytopenia was made, clopidogrel was introduced because of well-documented ischemia in middle-cerebral artery territory. The platelets subsequently increased by near 30%. The diagnosis of heparin-induced thrombocytopenia was finally confirmed a few days later by detection of antiplatelet-factor 4 antibodies associated with a positive platelet aggregation test for unfractionated heparin. Heparin was replaced by sodium danaparoid. These measures did not change the unfavorable outcome and death of the patient. The increase in the platelet count after fortuitous clopidogrel introduction raises the question of the role of antiaggregant agents in association with anticoagulants for the treatment of type II heparin-induced thrombocytopenia.

Comparison of the effects of intrathecal ropivacaine, levobupivacaine, and bupivacaine for Caesarean section

BACKGROUND

This study aimed to detect if intrathecal (i.t.) ropivacaine and levobupivacaine provided anaesthesia (satisfactory analgesia and muscular relaxation) and postoperative analgesia of similar quality to bupivacaine in patients undergoing Caesarean section.

METHODS

Ninety parturients were enrolled. A combined spinal-epidural technique was used. Patients were randomly assigned to receive one of the following isobaric i.t. solutions: bupivacaine 8 mg (n=30), levobupivacaine 8 mg (n=30), or ropivacaine 12 mg (n=30), all combined with sufentanil 2.5 microg. An i.t. solution was considered effective if an upper sensory level to pinprick of T4 or above was achieved and if intraoperative epidural supplementation was not required. Sensory changes and motor changes were recorded.

RESULTS

Anaesthesia was effective in 97, 80, and 87% of patients in the bupivacaine 8 mg, levobupivacaine 8 mg, and ropivacaine 12 mg groups, respectively. Bupivacaine 8 mg was associated with a significantly superior success rate to that observed in the levobupivacaine group (P<0.05). It also provided a longer duration of analgesia and motor block (P<0.05 vs levobupivacaine and ropivacaine).

CONCLUSIONS

The racemic mixture of bupivacaine combined with sufentanil remains an appropriate choice when performing Caesarean sections under spinal anaesthesia.

Structure and texture of anisotropic nematic gels

Anisotropic nematic gels are prepared via in situ polymerization of diacrylate monomers in an oriented nematic liquid crystal (LC) matrix. The structure of the gels is studied from micrometer to nanometer scales by optical microscopy, small angle neutron scattering, and theta/2theta light scattering. A strong anisotropy is evidenced at all scales without electric field for both mesogenic and nonmesogenic monomers. The gel network can be pictured as an ordered but strongly distorted and polydisperse structure with two characteristic sizes: the mean size of the polymer objects and a correlation length between these objects, corresponding to the mean-size of the LC domains, which are estimated from neutron and light scattering results to be of the order of some tens of nanometers and some micrometers, respectively. Moreover, a sheet-like structure of the polymer network is evidenced. When an electric field is applied, one part of the LC switches while the other part remains anchored to the polymer network. The electric field dependence of the volume fraction of anchored LC is estimated from the analysis of the light scattering data. We emphasize systematic correlations between structure and electro-optical properties of the gels.

Efficacy of selamectin against biting lice on dogs and cats

The efficacy of selamectin was evaluated against naturally acquired Trichodectes canis infestations on dogs and against Felicola subrostratus infestations on cats. Twenty dogs and 18 cats were randomly allocated to treatment with either a placebo or selamectin (6 mg/kg), administered topically once only on day 0. The treatment had no adverse effects in either the dogs or the cats. Efficacy was assessed by counting the live lice (adults and nymphs) on each animal by using a coat-parting technique on days -3, 7, 14, 21, 28, 35 and 42 for the dogs, and on days -1, 7, 21, 35 and 42 for the cats. On day 43, the number of live lice on each dog was also assessed by using a whole-body combing technique. Selamectin was 100 per cent effective in killing biting lice on the dogs and cats throughout the period of assessment; the louse counts on the treated dogs and cats were significantly lower than the pretreatment counts (P = 0.0001) and were also significantly lower than on the placebo-treated dogs (P < 0.05) and cats (P = 0.0001). There was a marked reduction in the prevalence of clinical signs associated with ectoparasite infestation in the treated dogs and no clinical signs were observed in any of the treated cats.

Cost related to replacement therapy during hospitalization in haemophiliacs with or without inhibitors: experience of six French haemophilia centres

Replacement therapy in haemophiliacs has a major economic impact on health establishments. We assessed in this prospective study the cost of clotting factor concentrate therapy for haemophilia A or B patients. We compared the overall costs of treated patients with or without inhibitors. In six French haemophilia centres, 278 consecutive hospitalizations were collected and analysed between June 97 and June 99. Haemophilia must be considered as the main cost factor during hospitalization. The severity of bleeds and surgical procedures increase the total cost. Furthermore, the daily and total costs are closely linked to the presence or the absence of inhibitors. This study should enable the hospital administration to evaluate the necessary resources to the clotting factor therapy in haemophiliacs with or without inhibitors during hospitalization.

Intrathecal ropivacaine and clonidine for ambulatory knee arthroscopy: a dose-response study

BACKGROUND

The aim of this study was to evaluate the association of a small dose of intrathecal ropivacaine with small doses of intrathecal clonidine for ambulatory surgery.

METHODS

One hundred twenty patients, classified as American Society of Anesthesiologists physical status I and scheduled for knee arthroscopy, were studied. Patients were randomly assigned to receive 4 ml of one of the following double-blinded isobaric intrathecal solutions: 8 mg of ropivacaine (group 1; n =30); 8 mg ropivacaine plus 15 microg clonidine (group 2; n =30); 8 mg ropivacaine plus 45 microg clonidine (group 3; n =30); and 8 mg ropivacaine plus 75 microg clonidine (group 4; n =30). The level and duration of sensory anesthesia were recorded, along with the intensity and duration of motor block. Patient and surgeon were interviewed to evaluate the quality of anesthesia.

RESULTS

Intrathecal ropivacaine (8 mg alone) produced short sensory anesthesia and motor blockade (132 +/- 38 min and 110 +/- 35 min; mean +/- SD). However, the quality of anesthesia was significantly lower than in any other group (P < 0.05). Ropivacaine (8 mg) plus 75 microg clonidine produced significantly longer sensory and motor anesthesia (195 +/- 40 min and 164 +/- 38 min; P < 0.05). However, this was associated with systemic effects, such as sedation and reduction of arterial blood pressure. Ropivacaine (8 mg) plus 15 microg clonidine did not prolong sensory or motor blockade, afforded high quality anesthesia, and was not associated with detectable systemic effects.

CONCLUSION

Small-dose intrathecal clonidine (15 microg) plus 8 mg intrathecal ropivacaine produces adequate and short-lasting anesthesia for knee arthroscopy.

Inhibitory effects of dronedarone on muscarinic K+ current in guinea pig atrial cells

Dronedarone (SR33589), an amiodarone-like noniodinated antiarrhythmic agent, is undergoing clinical trials in atrial fibrillation. Because vagal activation plays a role in the pathophysiology of supraventricular arrhythmias, we have assessed the ability of dronedarone (0.01, 0.1, and 1 microM), compared with amiodarone (0.1, 1, and 10 microM) to inhibit the muscarinic acetylcholine receptor-operated K+ current (I(K(ACh))) in single cells isolated from guinea pig atria (patch-clamp technique). I(K(ACh)) was activated by extracellular application of carbachol (10 microM) or by intracellular loading with GTP-gamma-S (100 microM). Dronedarone and amiodarone reduced the carbachol-induced I(K(ACh)) with an IC50 (concentration required for 50% inhibition) slightly above 10 nM and 1 microM, respectively. Dronedarone also inhibited the GTP-gamma-S induced K+ current by 28% and 58% at 0.01 and 0.1 microM, respectively. These data suggest that dronedarone inhibits I(K(ACh)) by depressing the function of K(ACh) channel itself or associated GTP-binding proteins. Compared with amiodarone, dronedarone is approximately 100 times more potent on I(K(ACh)) and seems more selective in inhibiting I(K(ACh)) with respect to its antagonism of other inward and outward currents reported in the literature. This relative high potency of dronedarone to reduce I(K(ACh)) may be involved, at least in part, in the antiarrhythmic action of dronedarone against atrial fibrillation.

The comparative toxicity of ropivacaine and bupivacaine at equipotent doses in rats

We compared the toxicity of systemic local anesthetics bupivacaine and ropivacaine administered at equivalent and equipotent doses. In the first experiments, 18 male Wistar rats were anesthetized with thiopental and maintained under positive controlled ventilation. Electrocardiogram, electroencephalogram, and invasive arterial blood pressure were continuously recorded. The animals were randomly assigned to receive 3 mg x kg(-1) x min(-1) bupivacaine, 3 mg x kg(-1) x min(-1) ropivacaine IV (equivalent group), or 4.5 mg x kg(-1) x min(-1) ropivacaine (equipotent group). The timing of the occurrence of local anesthetic-induced toxic events (defined as the first QRS modification, dysrhythmia, seizures, moderate and severe bradycardia and hypotension, final systole) was recorded and the dose calculated. Eighteen additional rats, treated according to the same protocol were killed at the time of moderate, severe, and final hypotension for blood sampling and plasma bupivacaine and ropivacaine concentration measurement. In a third experiment, 15 awake rats (5 per group) received IV bupivacaine or ropivacaine (same infusion as in the first experiments) until seizure. At this moment, rats were allowed to recover from local anesthetic intoxication. In the first experiment, except for the first QRS modification, all the other toxic manifestations occurred at significantly larger doses (P<0.05) in the two ropivacaine groups in comparison to the bupivacaine group. In awake rats, all the animals intoxicated by ropivacaine easily recovered. In the bupivacaine group, two animals required cardiopulmonary resuscitation before any seizure activity could be detected, and only three rats survived. We conclude that, in the model used, ropivacaine, even at an equipotent dose, is less toxic than bupivacaine.

Switching behavior and electro-optical properties of liquid crystals in nematic gels

Anisotropic nematic gels are prepared via in situ polymerization of diacrylate monomers in an orientated nematic liquid crystal (LC) matrix. The switching behavior of the LC molecules under electric field is probed in polarized Raman spectroscopy and straight theta-2straight theta elastic light scattering experiments. The electro-optical characteristics of the gels are directly related to the electric field dependence of the fraction of switched molecules. The electro-optical contrast relates to the coexistence of switched LC domains and LC domains anchored to the polymer network.

Hemodynamic and antiadrenergic effects of dronedarone and amiodarone in animals with a healed myocardial infarction

The hemodynamic and antiadrenergic effects of dronedarone, a noniodinated compound structurally related to amiodarone, were compared with those of amiodarone after prolonged oral administration, both at rest and during sympathetic stimulation in conscious dogs with a healed myocardial infarction. All dogs (n = 6) randomly received orally dronedarone (10 and 30 mg/kg), amiodarone (10 and 30 mg/kg), and placebo twice daily for 7 days, with a 3-week washout between consecutive treatments. Heart rate (HR), mean arterial pressure (MBP), positive rate of increase of left ventricular pressure (+LVdP/dt), echocardiographically assessed left ventricular ejection fraction (LVEF), and fractional shortening (FS), as well as chronotropic response to isoproterenol and exercise-induced sympathetic stimulation were evaluated under baseline and posttreatment conditions. Resting values of LVEF, FS, +LVdP/dt, and MBP remained unchanged whatever the drug and the dosing regimen, whereas resting HR was significantly and dose-dependently lowered after dronedarone and to a lesser extent after amiodarone. Both dronedarone and amiodarone significantly reduced the exercise-induced tachycardia and, at the highest dose, decreased the isoproterenol-induced tachycardia. Thus, dronedarone and amiodarone displayed a similar level of antiadrenergic effect and did not impair the resting left ventricular function. Consequently, dronedarone might be particularly suitable for the treatment and prevention of various clinical arrhythmias, without compromising the left ventricular function.

Cellular and in vivo electrophysiological effects of dronedarone in normal and postmyocardial infarcted rats

We studied the effects of dronedarone (SR 33589) on the action potentials, membrane ionic currents, and arrhythmic activity in control rats and in rats after myocardial infarction, a model known to develop anomalous electrical activity. Dronedarone increased action potential duration in normal hearts. It had little effect on the action potentials that were already prolonged in the postmyocardial infarcted (PMI) rats. Particularly, dronedarone reduced the late sustained K(+) current, I(K) (or Isus) by 69%. Dronedarone induced only a tonic block of I(K). Similar relative inhibitions of I(K) by dronedarone were obtained in young, sham, and PMI rats, even if I(K) was less in sham than in young and further reduced in PMI rats. The EC(50) values were 0.78 and 0.85 microM in sham and PMI rats. Dronedarone induced a weak increase in the fast transient outward current, I(to). Time-to-peak and inactivation time constant of I(to) were decreased by dronedarone that also induced a marked slowing of I(to) recovery from inactivation. Similar effects were observed on the reduced I(to) recorded in PMI rats. Holter monitoring study in control, unthetered animals showed that dronedarone had no proarrhythmic effect. On rats, which after myocardial infarction exhibited ventricular premature beats, dronedarone significantly decreased beat occurrence during the 7-day treatment; this effect was sustained for two more weeks. Thus, dronedarone exerts antiarrhythmic effects on PMI rat heart. Its effects are attributable for the most part to the inhibition of outward K(+) currents and the increase in effective refractory period.

Epidural clonidine or bupivacaine as the sole analgesic agent during and after abdominal surgery: a comparative study

BACKGROUND

The rationale of this study was to compare high-dose epidural clonidine with a more commonly used agent, such as bupivacaine. This was performed to give a more objective idea of the relative analgesic potency of epidural clonidine.

METHODS

Sixty patients undergoing intestinal surgery during propofol anesthesia were studied. At induction, the patients received epidurally a dose of 10 micrograms/kg [corrected] clonidine in 7 ml saline followed by an infusion of 6 micrograms [corrected] x kg(-1) x h(-1) (7 ml/h) (group 1, n = 20), a dose of 7 ml bupivacaine, 0.5%, followed by 7 ml/h bupivacaine, 0.25% (group 2, n = 20), or a dose of 7 ml bupivacaine, 0.25%, followed by 7 ml/h bupivacaine, 0.125% (group 3, n = 20). Intraoperatively, increases in arterial blood pressure or heart rate not responding to propofol (0.5 mg/kg) were treated with intravenous alfentanil (0.05 mg/kg). Additional doses of propofol were given to maintain an adequate bispectral index. The epidural infusions were maintained for 12 h. In cases of subjective visual analogue pain scores up to 5 cm at rest or up to 8 cm during coughing, the patients were given access to a patient-controlled analgesia device.

RESULTS

During anesthesia, patients in group 1 required less propofol than those in groups 2 and 3 (78 [36-142] mg vs. 229 [184-252] mg and 362 [295-458] mg; P < 0.05) and less alfentanil than patients in group 3 (0 [0-0] mg vs. 11 [6-20] mg; P < 0.05). Analgesia lasted 380 min (range, 180-645 min) in group 1 versus 30 min (range, 25-40 min) in group 2 and 22 min (range, 12.5-42 min) in group 3 (P < 0.05). There was no suggestion of a hemodynamic difference among the three groups except for heart rates that were significantly reduced in patients in group 1. Sedation scores were significantly higher in this group during the first 2 h postoperatively.

CONCLUSION

Our results show that high doses of epidural clonidine potentiate general anesthetics and provide more efficient postoperative analgesia than the two bupivacaine dosage regimens investigated.

A double-blind comparison of 0.125% ropivacaine with sufentanil and 0.125% bupivacaine with sufentanil for epidural labor analgesia

BACKGROUND

This study intends to evaluate the benefits of the administration of intermittent bolus doses of ropivacaine (0.125%) compared with bupivacaine (0.125%) after addition of sufentanil for analgesia during labor.

METHODS

One hundred thirty American Society of Anesthesiologists physical status 1 or 2 parturients were studied. The 90 initial patients were assigned randomly to receive 10 ml bupivacaine, 0.125%, plus 7.5 microg sufentanil (initial bupivacaine 0.125% group) or ropivacaine, 0.125%, plus 7.5 microg sufentanil (ropivacaine 0.125% group). Forty additional patients were recruited and received 0.125% bupivacaine plus 7.5 microg sufentanil (additional bupivacaine 0.125% group) or 0.100% bupivacaine plus 7.5 microg sufentanil (additional bupivacaine 0.100% group). The duration of analgesia, visual analogue scores for pain, motor blockade (using a six-point modified Bromage scale), patient satisfaction scores, nausea, pruritus, heart rate, and blood pressure were recorded.

RESULTS

Bupivacaine 0.125% and ropivacaine 0.125% coadministered with sufentanil provided rapid and complete analgesia. Onset of analgesia occurred after +/-15 min and lasted +/-90 min. After the third epidural injection, patients in the ropivacaine group experienced significantly less severe motor blockade than patients in the initial bupivacaine 0.125% group. At this point, 93% of the patients in the ropivacaine group were free from motor impairment versus 66% in the bupivacaine group (P<0.05). Comparable levels of motor blockade were obtained in both additional groups. Patients' evaluation of their analgesia was worst in the bupivacaine 0.100% group.

CONCLUSIONS

Ropivacaine 0.125% with sufentanil affords reliable analgesia with minimal motor blockade.

Expression and function of tap in the gustatory and olfactory organs of Drosophila

We have recently described the identification of a gene, tap, which encodes a bHLH protein expressed in one neuron of each larval chemosensory organ. Here we show that tap is expressed at a late stage in the development of one type of adult chemosensory organ, the gustatory bristles of the leg, wing and proboscis. We also show that tap is expressed very early in the development of a second type of chemosensory receptors, the olfactory organs of the antenna. The results of behavioral experiments suggest that the ectopic expression of tap affects the response to sugar and salt.

tap, a Drosophila bHLH gene expressed in chemosensory organs

We have isolated a Drosophila bHLH gene, tap, that is expressed in a small subset of neurons when they undergo differentiation. In the peripheral nervous system, tap is expressed exclusively in one of the neurons that innervate each larval chemosensory organ, possibly controlling the specific properties of that neuron. Sequence comparisons suggest that tap is most closely related to two bHLH genes identified in several vertebrate species, neurogenin and neuroD, which are involved respectively in neural determination and in neuronal differentiation.

SR47063, a potent channel opener, activates KATP and a time-dependent current likely due to potassium accumulation

(i) We studied the effects of a new cromakalim analogue, SR47063, in guinea-pig ventricular cells. The experiments were carried out in whole-cell patch clamp with internal and external solutions supposedly similar to the physiological ones. (ii) SR47063 reversibly activated a time-independent current reversing near the potassium equilibrium potential, and a time-dependent current reversing at a more positive potential. Both currents were blocked by application of glibenclamide. (iii) The time-independent and the time-dependent currents were activating for the same concentration of agonist in every cell, this concentration being very different from cell to cell. (iv) The amplitude of the time-dependent current was shown to depend directly neither on agonist concentration nor on potential, but rather on the amplitude of the current flowing during the prepulse before the test pulse. (v) We conclude that SR47063 is a potent KATP channel opener acting at concentrations lower than one micromolar, and that the time-dependent current is likely due to accumulation and depletion of potassium in restricted areas of the cells.

[Mesentric venous thrombosis. Risk factors, treatment and outcome. An analysis of 18 cases]

Eighteen patients with an acute thrombosis of the splanchnic veins were reviewed. Most of apparently idiopathic cases of splanchnic vein thrombosis are related to an increased coagulation related to a congenital or acquired defect of haemostasis. The aim of this study was to assess the effects of a new and effective treatment. Nine male and 9 female patients (range of age: 19 to 81 years) experienced a mesenteric venous thrombosis. There were 14 mesenteric vein thromboses with infarction, two transient mesenteric venous ischaemias without bowel infarction and two acute thromboses of the splanchnic veins without bowel ischaemia. A coagulopathy was detected in seven patients: oral contraception, protein C (PC) or antithrombin III (AT III) congenital deficiencies, acquired deficiency of AT III, PC and protein S (PS), polycythaemia in the post-partum period and primary myeloproliferative disorder. No coagulopathy was associated with thrombosis in eight cases: mesenteric haematoma, splenomegaly, cirrhosis, appendicectomy, cholescytectomy, chronic heart failure, treatment with beta-adrenergic receptor antagonist and digitalis, stenosis of the portal anastomosis after liver transplantation. Twelve patients required surgery: eight intestinal bowel resections with immediate anastomosis, four resections without immediate anastomosis. Only one patient underwent a second look for a repeat bowel resection. No death occurred in the early postoperative period and 17 out of 18 patients were alive after 12 years. An oral anticoagulant therapy was undertaken from two months to seven years. However, three patients suffered a recurrent thrombosis. Two of them required a long-term anticoagulation. Six patients experienced a portal hypertension and oral anticoagulants were discontinued in three of them because of bleeding oesophageal varices. Six patients were treated only by unfractionated heparin (UFH) or low molecular weight heparin (LMWH) followed by oral anticoagulants. After laparotomy, two were only treated with UFH without any bowel resection, as mesenteric venous ischaemia was too extensive. These observations suggest that the choice between an appropriate medical or surgical treatment is important and must be discussed. Since 1989, the therapeutic choice has been modified by ultrasonography and contrast enhanced computed tomographic scan which confirms diagnosis, allows to follow up and check the effects of anticoagulation and to choose the time for surgery. When the diagnosis is established and the patient's risk is low, the IU . kg(-1) . d(-1) to obtain an antifactor Xa activity between 0.3 and 0.6 antiXa IU mL(-1). When the diagnosis is uncertain and the patient's risk if high a laparotomy is required.(ABSTRACT TRUNCATED AT 400 WORDS)

Free cortisol in serum assayed by temperature-controlled ultrafiltration before fluorescence polarization immunoassay

A method is described for a temperature-controlled ultrafiltration procedure to measure free cortisol in serum. A special thermometer with a sensor was developed, measuring the temperature directly in the ultrafiltration device. The sensor is screwed on the axis of the centrifuge rotor, and the centrifuge is placed in a temperature-controlled box so that the temperature of the sample is kept at 37 degrees C +/- 0.1 degrees C. The overall CV of the free cortisol assay ranges from 2.2% to 11.4%, of which the ultrafiltration contributes only 2.2-3.6%. Increasing amounts of cortisol-binding protein, as found in women using estrogen-containing oral contraceptives, have minor but significant effects on the free cortisol concentrations in serum. Serum free cortisol concentrations in a reference population (n = 114; central 95 percentiles) were 12-43 nmol/L (4-9.5% of total cortisol); in the group of the oral-contraceptive users (n = 27), the reference interval was 11-53 nmol/L (1.5-4.5%).

Free cortisol in serum assayed by temperature-controlled ultrafiltration before fluorescence polarization immunoassay

A method is described for a temperature-controlled ultrafiltration procedure to measure free cortisol in serum. A special thermometer with a sensor was developed, measuring the temperature directly in the ultrafiltration device. The sensor is screwed on the axis of the centrifuge rotor, and the centrifuge is placed in a temperature-controlled box so that the temperature of the sample is kept at 37 degrees C +/- 0.1 degrees C. The overall CV of the free cortisol assay ranges from 2.2% to 11.4%, of which the ultrafiltration contributes only 2.2-3.6%. Increasing amounts of cortisol-binding protein, as found in women using estrogen-containing oral contraceptives, have minor but significant effects on the free cortisol concentrations in serum. Serum free cortisol concentrations in a reference population (n = 114; central 95 percentiles) were 12-43 nmol/L (4-9.5% of total cortisol); in the group of the oral-contraceptive users (n = 27), the reference interval was 11-53 nmol/L (1.5-4.5%).

The endogenous digoxin-like factor enhances bupivacaine toxicity in rats

BACKGROUND AND OBJECTIVES

The influence of the immunoreactive endogenous digoxin-like factor (IEDLF) on the systemic toxic effects of bupivacaine was studied in a rodent model.

METHODS

During 5 weeks, IEDLF secretion was promoted in 10 Wistar male rats by allowing them to drink saline 0.5% in place of water. Ten other animals drank desionized water (control). At the time of experimentation, the two groups of rats were mixed to allow blind observation. Anesthesia was induced with barbiturate, and controlled ventilation was started. A blood sample was drawn for IEDLF assessment just before bupivacaine was infused at a constant rate of 2 mg/kg per minute. Data were analyzed for statistical significance using Student's t-test. A p value less than 0.05 was considered significant.

RESULTS

Two rats in the saline group died during the induction of anesthesia. An IEDLF activity was found in the eight remaining rats in this group. Threshold doses of bupivacaine's toxic effects (first ventricular arrhythmia, first seizure activity, 25% fall of baseline heart rate, 25% of baseline mean arterial blood pressure, isoelectric electroencephalogram) were significantly lower for the rats with an endogenous digoxin-like activity. There were, however, no significant differences in the lethal dose of bupivacaine.

CONCLUSION

In hyperoxic nonacidotic male rats, IEDLF increases the cardiac and central nervous system toxicity of bupivacaine.

Digoxin enhances bupivacaine toxicity in rats

The influence of digoxin on the systemic toxic effects of bupivacaine was studied in a rodent animal model. The experiment was undertaken with consideration to clinical situations such as pregnancy that are associated with the secretion of an endogenous digoxin-like factor. Twenty Wistar male rats, under barbiturate anesthesia and controlled ventilation, received either 5 micrograms/kg intravenous digoxin (n = 10) or saline (n = 10), blinded to the observer. Digoxin serum concentration was 1.8 +/- 0.24 ng/ml in the study group. Thirty minutes after digoxin or saline was administered, bupivacaine was infused at a constant rate of 2mg/kg/minute. The threshold doses of bupivacaine toxic effects (first ventricular arrhythmia, 25% fall of baseline heart rate, 25% fall of baseline mean arterial blood pressure, first seizure activity, isoelectric electroencephalogram, and asystole) were significantly lower in the digoxin group, as were the lethal bupivacaine serum concentrations. Digoxin, in hyperoxic nonacidotic rats, increases the cardiac and central nervous system toxicity of bupivacaine. Based on the known electrophysiologic actions of these two drugs, a synergistic toxic interaction is demonstrated.

Imaging of myocardial infarction in dogs and humans using monoclonal antibodies specific for human myosin heavy chains

The use of three different monoclonal antibodies specific for human ventricular myosin heavy chains in the visualization of the location and extent of necrosis in dogs with experimental acute myocardial infarction and in humans is described. Using a classic immunohistochemical method or ex vivo analysis of heart slices in dogs with acute myocardial infarction subjected to intravenous injection of unlabeled antimyosin antibodies or antimyosin antibodies labeled with indium-111, it was observed that all antibody fragments specifically reached the targeted necrotic zone less than 2 h after antibody injection and remained bound for up to 24 h. In a limited but significant number of cases (5 of the 12 humans and 11 of 43 dogs), it was possible to image the necrotic zone in vivo as early as 2 to 4 h after antibody injection. In other cases, individual blood clearance variations retarded or even prevented in vivo necrosis detection. Higher antimyosin fixation values were obtained in the necrotic zones in dogs with a rapid blood clearance relative to that of the other dogs. It is concluded that antimyosin antibodies always reached necrotic areas within 2 h. If blood clearance was rapid, in vivo imaging of the necrotic area was possible 2 to 6 h after necrosis, even in humans. In some cases, however, uncontrolled individual variations in the timing required for sufficient blood clearance hampered this rapid in vivo detection of myocardial necrosis.

Detection of Borrelia burgdorferi in biological samples using the polymerase chain reaction assay

Oligonucleotide primers were used in the polymerase chain reaction assay to amplify specific DNA regions of the Borrelia burgdorferi 49-kb linear plasmid. One set of primers identifies a 442-bp DNA fragment in the OspA gene and a second pair of amplimers, a 176-bp DNA piece located in the OspB gene. The last set of primers, OspBpc3/pc4, outperformed the other pair in discriminating pathogenic North American or European isolates from related bacterial species, detected down to 4 spirochaetes, and was suitable for the identification of B. burgdorferi in biological samples, such as synovial and cerebrospinal fluids.

Effects of SR 44866, a potassium channel opener, on action potentials of rabbit, guinea pig, and human heart fibers

The effects of various concentrations (3 x 10(-8) - 1 x 10(-5) M) of SR 44866, a K+ channel opener, on action potential (AP) characteristics were investigated in isolated rabbit sinoatrial node (SAN), rabbit Purkinje fibers, guinea pig ventricle, human atrium, and human papillary muscle. SR 44866 (up to 1 x 10(-5) M), like cromakalim and pinacidil, did not modify SAN AP and automaticity of the rabbit heart. In atrial, Purkinje and ventricular fibers of animal and human hearts, SR 44866 did not significantly change membrane resting potential, AP amplitude, or maximum rate of phase 0 (dV/dtmax). The main AP modifications induced by SR 44866 were concentration-dependent reductions in plateau amplitude and AP duration (APD): IC50 2 x 10(-7), 7 x 10(-7), 1.4 x 10(-6), 2.5 x 10(-6), and much greater than 10(-5) M for human atrium, human ventricle, guinea pig ventricle, rabbit Purkinje, and rabbit atrium, respectively. In isolated guinea pig heart, SR 44866 induced decreases in contractions (IC50 1.7 x 10(-6) M) and coronary perfusion pressure (CPP) (IC50 2.1 x 10(-8) M) with a very slight reduction (5% at 1 x 10(-6) M) in spontaneous heart rate (HR). Negative inotropic effect (guinea pig) and APD shortenings (guinea pigs and humans) of SR 44866 (1 x 10(-6) and 3.10(-6) M) were antagonized by glibenclamide (3 x 10(-7) to 3 x 10(-6) M), a specific blocker of cardiac K+ATP channels. The data support the hypothesis that SR 44866 activates ATP-sensitive K+ channels, which are present in the atria and ventricles of the human heart but not in pacemaker cells of rabbit SAN.

Assay of serum cardiac myosin heavy chain fragments in patients with acute myocardial infarction: determination of infarct size and long-term follow-up

To evaluate the correlation between myosin heavy chain release and the necrosis mass, serum levels of myosin heavy chain fragments were determined serially in 55 patients with acute myocardial infarction. Eight of these patients were successfully treated with thrombolytic agents: the others were not treated. The same myosin titration was applied to the sera of 25 dogs with an experimental myocardial infarction. Six of the dogs were successfully treated with thrombolytic agents. The time courses of the myosin concentrations are typical and monophasic for all patients with a noncomplex myocardial infarction. The values for the kinetic parameters of myosin release are comparable to those previously reported. We have now determined that cumulative myosin release significantly correlates with cumulative creatine kinase (CK), CK-MB, and lactate dehydrogenase release, as well as with thallium-201 distribution, as determined for different patient groups. Thrombolytic treatment does not seem to qualitatively upset myosin kinetics. The results obtained in dogs with or without thrombolysis conclusively indicate that myosin release is a quantitative index of the necrosis mass. From a practical point of view, a few serial determinations of serum levels of myosin heavy chains are enough to estimate the necrosed mass in patients with acute myocardial infarction. More generally, serum myosin titration could be useful in detecting any cardiac disturbance involving myocardial injury resulting in membrane leakage of cardiac cells.

Systemic and regional haemodynamic interactions between K+ channel openers and the sympathetic nervous system in the pithed SHR

1. The interactions between two K+ channel openers, cromakalim and SR 44866 (infused i.v. at equihypotensive doses), and the sympathetic nervous system at the systemic and regional (mesentery, kidney, hindlimb) vascular levels were investigated in the pithed spontaneously hypertensive rat (SHR) by use of the pulsed Doppler technique. 2. The two K+ channel openers did not affect postsynaptic alpha 1- but slightly reduced postsynaptic alpha 2-adrenoceptor mediated systemic pressor and regional vasoconstrictor responses. 3. Both drugs significantly decreased the systemic pressor and regional vasoconstrictor responses elicited by spinal cord stimulation. These sympathoinhibitory effects were not homogeneously distributed among the different vascular beds, the decreasing rank order being: mesentery greater than kidney greater than hindlimb. Simultaneously, the spinal cord stimulation-induced tachycardia remained unaffected. 4. After treatment with K+ channel openers, restoration of initial blood pressure and vascular tone values by infusion of prostaglandin F2 alpha (PGF2 alpha) and vasopressin respectively did not affect and abolished the sympathoinhibitory effects of cromakalim and SR 44866. 5. We conclude that in SHRs the two K+ channel openers that we investigated exert similar sympathohibitory effects which affect some vascular beds more than others. These effects are not dependent upon the arterial blood pressure level and are most likely prejunctionally located.