Preoperative optimization to prevent periprosthetic joint infection in at-risk patients

Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of arthroplasties worldwide, the number of PJI will increase correspondingly with a significant economic burden to our healthcare system. It is likely impossible to completely eradicate PJI; hence, assessment and optimization of its risk factors to preventing such a disastrous complication will be the key. There are many strategies to prevent PJI in the preoperative, intraoperative, or postoperative phases. The preoperative assessment provides a unique opportunity to screen and diagnose underlying comorbidities and optimize modifiable risk factors before elective surgeries. In this review, we will focus on current literature in preoperative assessment of various modifiable risk factors and share the experience and practical approach in our institution in preoperative optimization to reduce PJI in total joint arthroplasties.

A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis

IV regional anesthesia can offer a more favorable patient recovery profile and shorter postoperative nursing care time and hospital discharge time than an isoflurane-based general anesthetic or brachial plexus block technique for hand surgery.

Analgesic effects of low-dose ropivacaine for interscalene brachial plexus block for outpatient shoulder surgery-a dose-finding study

BACKGROUND AND OBJECTIVES

Interscalene brachial plexus block (ISB) with low-dose bupivacaine provides effective postoperative shoulder analgesia in outpatients. The analgesic effect of low-dose ropivacaine for ISB is unknown.

METHODS

In this double-blind study, 66 outpatients scheduled to undergo arthroscopic shoulder surgery were randomly assigned to receive an ISB with 10 mL of 0.125%, 0.25%, or 0.5% ropivacaine before surgery. Postoperative verbal pain rating score, analgesic consumption, and the extent of motor and sensory block was assessed for 120 minutes after surgery.

RESULTS

The degree of shoulder analgesia was dose dependent. Postoperative pain scores were lowest with 0.5% ropivacaine, and analgesic was not required in the hospital in 70% of the patients who received 0.25% and 0.5% ropivacaine, compared to 30% with 0.125% ropivacaine (P < .03). In the patients who required no analgesic in the hospital, the time to first oral analgesic at home was approximately 10 hours irrespective of ropivacaine concentration. Motor and sensory block distal to the elbow was detected in 25% of the patients in the 0.5% group but none in the 0.125% group.

CONCLUSIONS

Interscalene brachial plexus block with low-dose ropivacaine, 10 mL of 0.25% and 0.5%, provides effective long-lasting shoulder analgesia in a majority of patients after arthroscopic surgery.

What is the relationship between paresthesia and nerve stimulation for axillary brachial plexus block?

BACKGROUND AND OBJECTIVES

To quantify the motor threshold current of a needle following elicitation of paresthesia during axillary brachial plexus block (ABPB).

METHODS

This is a prospective, observational study of ABPB in 72 patients. Having elicited paresthesia, the minimum current required to produce a motor response was noted. The development and success of the block were subsequently followed.

RESULTS

Nineteen blocks were excluded (18 because of arterial puncture and 1 blocked needle). Of the remaining 53 blocks, 41 (77%) produced a motor response at 0.5 mA or less. The median current was 0.17 mA (range, 0.03 to 3.3 mA). The site of initial paresthesia and subsequent motor response were related in 43 (81%) of cases.

CONCLUSIONS

A needle position causing paresthesia produced a motor response at 0.5 mA or less in 77% of cases studied. This current may, therefore, be a reasonable threshold to aim for when performing an ABPB.

Pharmacokinetic profile of epidurally administered methylnaltrexone, a novel peripheral opioid antagonist in a rabbit model

Methylnaltrexone (MNTX) is the first peripheral opioid receptor antagonist used in man to treat acute and chronic opiate-mediated side-effects. We describe in a rabbit model the pharmacokinetics of epidurally administered MNTX 0.66 mg kg(-1), and we tested the hypothesis that epidurally administered MNTX does not penetrate the dura into the subarachnoid space. There were minimal concentrations of MNTX (40 ng ml(-1)) detected in the CSF at 10 and 20 min and none thereafter in comparison with the high serum levels. The serum drug concentration-time profile fitted a two-compartment pharmacokinetic model. Further studies are warranted as epidurally administered MNTX may have the potential to reverse epidural opioid-mediated side-effects whilst preserving analgesia.

Mutational analysis of BRCA1 and BRCA2 genes in Chinese ovarian cancer identifies 6 novel germline mutations

Germline mutations in the BRCA1 and BRCA2 genes predispose women to breast and ovarian cancer. An incidence of 5% and 3.3% respectively has been reported of BRCA1 and BRCA2 mutations in women with ovarian cancer unselected for family history. The contribution of BRCA1 and BRCA2 mutations to ovarian cancer in Chinese women is unknown. A total of 60 samples of ovarian cancer diagnosed in Chinese unselected for age or family history were analyzed for BRCA mutations using the protein truncation test. The entire coding exon of BRCA1 of 53 cases and that of exon 11 of BRCA2 of 43 cases were successfully screened. Six germline (11.3%) mutations (633C>T, 1080delT, 1129delA, 2371-2372delTG, 3976-3979delGTGA, and IVS 22+7 A>G) were detected in BRCA1. One germline mutation (3337C>T) (2.1%) was detected in BRCA2. None of these seven cases were associated with strong family history of breast and/or ovarian cancer. Five out of our six BRCA1 mutations and the one BRCA2 mutation identified are novel. Our 11.3% incidence of BRCA1 mutations in ovarian cancer found amongst Chinese with insignificant family history is apparently higher than that previously reported in other populations. It suggests that BRCA1 mutation may play a significant role in the development of sporadic ovarian cancer in Chinese women.

Determining minimum effective anesthetic concentration of hyperbaric bupivacaine for spinal anesthesia

We determined the minimum effective anesthetic concentration (MEAC) of bupivacaine for spinal anesthesia, defined as the median effective concentration at which a spinal anesthetic produces surgically equivalent anesthesia within 20 min of administration in 50% of human subjects. Two doses of spinal bupivacaine (7.5 mg and 10 mg) were administered to 45 volunteers (19-39 yr) in a randomized, double-blinded fashion. Hyperbaric bupivacaine solutions of 0.1% to 0.75% containing 8.25% dextrose were administered intrathecally and MEAC established by using the Dixon's up-and-down method. Complete anesthesia was defined as: 1) pinprick anesthesia at or higher than T12; 2) anesthesia to transcutaneous tetanic electric stimulation (50 Hz at 60 mA for 5 s) in the knees; and 3) complete leg paralysis, all occurring in both lower extremities within 20 min of intrathecal injection. We found that the MEAC of spinal bupivacaine was 0.43% (95% confidence interval 0.24-0.62) when 10 mg was administered. At this dose, a concentration as low as 0.1% could provide complete anesthesia, but consistent blockade was obtained only with the 0.7% solution. The 7.5-mg dose failed to provide complete anesthesia consistently, even in the presence of 0.75% (maximum). The current commercially available 0.75% concentration of hyperbaric bupivacaine seems to be clinically optimal when 10 mg is used if complete bilateral lower extremity blockade is desired.

Novel analgesic adjuncts for brachial plexus block: a systematic review

This article reviews current evidence for the efficacy of adding novel analgesic adjuncts to brachial plexus block, the goal of which is to prolong analgesic effect without the disadvantage of systemic side effects or prolonged motor block. It may also allow for a reduction in the total dose of local anesthetic used. Novel adjuncts studied to date include opioids, clonidine, neostigmine, and tramadol. Twenty-four studies were reviewed and assessed by using specific inclusion criteria, and only those studies satisfying these criteria were included in the final assessment. Satisfactory studies were then assessed for inclusion of a systemic control group to determine peripheral effect, as opposed to possible systemic effect, of an adjunct administered peripherally. Evidence regarding the analgesic benefit of opioid adjuncts remains equivocal and more evidence is required before their routine use can be recommended. Clonidine appears to have significant analgesic benefit and to cause minimal adverse effects when used in doses up to 150 microg. Data regarding other drugs, such as tramadol and neostigmine, are not sufficient to allow for any recommendations, and further studies are required.

Quantitative comparison of leakage under the tourniquet in forearm versus conventional intravenous regional anesthesia

We compared the quantitative leakage between forearm and conventional IV regional anesthesia (IVRA). Forearm IVRA remains unpopular because of the theoretical risk of local anesthetic leakage through the interosseous vessels. IVRA was simulated on the forearm or arm during two separate, randomized sessions using a double tourniquet in 14 volunteers. A radiolabeled substance, DISIDA (99m Tc-disofenin) with a structure similar to lidocaine, was injected instead of local anesthetic. Volumes of 0.4 mL/kg (maximum 25 mL), were used for forearm IVRA and 0.6 mL/kg (maximum 45 mL) for conventional IVRA. A gamma camera recorded radioactivity levels in the limb distal to the tourniquet every 30 s while the tourniquet was inflated (25 min) and for 20 min postdeflation. The leakage of radiolabeled substance during inflation was similar in both groups, 6%+/-12% (mean +/- SD) from the forearm and 10%+/-20% from the upper arm. After deflation, mean loss of radioactivity was higher in conventional IVRA, 70%+/-7% vs 57%+/-11% and 82%+/-5% vs 69%+/-11% at 3 and 20 min, respectively (P < 0.001). We conclude that forearm IVRA results in tourniquet leakage comparable to conventional IVRA and is potentially safer because the required dose of local anesthetic is smaller.

IMPLICATIONS

Using a tourniquet on the forearm for IV regional anesthesia does not increase the risk of drug leakage. This is potentially a safer technique compared with conventional IV regional anesthesia because a much smaller dose of local anesthetic is required.

The impact of saline flush of the epidural catheter on resolution of epidural anesthesia in volunteers: a dose-response study

We evaluated the effect of 1, 20, and 40 mL of epidural saline flush on recovery from lidocaine epidural anesthesia. Eight volunteers were studied for three study periods, each separated by 72 h. The volume of saline was randomized, and a new catheter was inserted for each study period. A standardized dose of 20 mL of 2% plain lidocaine was injected for 10 min, followed by an epidural saline flush 30 min later. Sensory block was assessed by pinprick and transcutaneous electrical stimulation and motor block by a modified Bromage scale and isometric maximal force contraction. Times to void and ambulate independently before discharge were recorded. Peak plasma lidocaine concentrations and time to peak concentration were determined. Results from six volunteers showed that epidural saline, 40 mL, significantly altered anesthetic resolution, accelerating the time of complete sensory and motor block regression (P < 0.05). Median peak levels of sensory and motor block and times to void and ambulate were similar among treatment groups. Peak plasma lidocaine concentrations were similar in all treatment groups. Our data suggest that a 40-mL epidural saline injection 30 min after the induction facilitates regression of epidural lidocaine anesthesia, but a 20-mL bolus does not. Epidural saline injection does not affect vascular absorption of epidural lidocaine.

IMPLICATIONS

Epidural catheter flushing with 40 mL of saline, after establishment of epidural lidocaine anesthesia, can facilitate sensory and motor block recovery. However, this does not affect vascular absorption of epidural lidocaine.

Somatic mutations in the BRCA1 gene in Chinese sporadic breast and ovarian cancer

Inherited mutations in the BRCA1 gene confer increased susceptibility to breast and ovarian cancer. Its role in sporadic carcinogenesis is not well defined. Somatic mutations in breast cancers have not been reported and to date there are only three reports of somatic mutations in sporadic ovarian cancers. To investigate the contribution of BRCA1 mutations to sporadic breast and ovarian cancer in the Chinese population, we analysed 62 samples from Chinese women using the protein truncation test. There were 40 cases of breast cancer under age 50 and 22 cases of ovarian cancer, all unselected for family history. There was no age selection for the ovarian cancers. We found two somatic BRCA1 mutations in exon 11, one in a breast cancer and the other in an ovarian cancer, both of which result in truncated proteins. Our results indicate that somatic BRCA1 mutations, like somatic mutations in the BRCA2 gene, though very rare, can be found in both breast and ovarian cancers and support a tumor suppressor function for BRCA1 in sporadic tumors.

Comparison of ropivacaine and lidocaine for intravenous regional anesthesia in volunteers: a preliminary study on anesthetic efficacy and blood level

BACKGROUND

Ropivacaine may be useful for intravenous regional anesthesia, but its anesthetic effectiveness and toxicity have not been evaluated.

METHODS

Two doses of ropivacaine (1.2 and 1.8 mg/kg) and one dose of lidocaine (3 mg/kg) were compared for intravenous regional anesthesia in 15 volunteers. An arm tourniquet was inflated for 30 min after injection and then deflated in two cycles. Sensory block was measured by response to touch, cold, pinprick, and transcutaneous electric stimulation, and motor function was measured by hand grip strength and muscle power. Median, ulnar, radial, and musculocutaneous nerve functions were tested before local anesthetic injection and then at 5-min intervals until blocks resolved. The plasma ropivacaine and lidocaine concentrations were determined from arterial and venous blood samples drawn from the unanesthetized arm.

RESULTS

Sensory and motor blocks were complete within 25 min and 30 min, respectively, in all three treatment groups. However, recovery of sensory and motor block after tourniquet release was slowest in the high-dose ropivacaine group. Anesthesia to pinprick and transcutaneous electric stimulation was sustained in all the volunteers in the high-dose ropivacaine group for 55 min and 85 min, respectively, whereas complete recovery was observed in the lidocaine group (P = 0.008) and partial recovery in the low-dose ropivacaine group (P < 0.05) during the same period. Motor block also was sustained in the high-dose ropivacaine group for 70 min, which was significantly longer than in the lidocaine group (P < 0.05). All volunteers (five of five) given lidocaine and one volunteer given high-dose ropivacaine reported light-headedness and hearing disturbance during tourniquet release when the arterial plasma lidocaine and ropivacaine concentrations were 4.7+/-2.1 microg/ml (mean) and 2.7 micro/ml, respectively.

CONCLUSION

Compared with lidocaine, intravenous regional anesthesia with ropivacaine appears to be comparable but has longer-lasting residual anesthesia.

Secondary lymphoid-tissue chemokine (SLC) is chemotactic for mature dendritic cells

Dendritic cells (DC) take up antigen from the periphery and migrate to the lymphoid organs where they present the processed antigens to T cells. The propensity of DC to migrate changes during DC maturation and is probably dependent on alterations in the expression of chemokine receptors on the surface of DC. Secondary lymphoid tissue chemokine (SLC), a recently discovered chemokine for naïve T cells, is primarily expressed in secondary lymphoid organs and may be important for colocalizing T cells with other cell types important for T-cell activation. We show here that SLC is a potent chemokine for mature DC but does not act on immature DC. SLC also induced calcium mobilization specifically in mature DC. SLC and Epstein-Barr virus-induced molecule 1 ligand chemokine completely cross-desensitized the calcium response of each other, indicating that they share similar signaling pathways in DC. The finding that SLC is a potent chemokine for DC as well as naïve T cells suggests that it plays a role in colocalizing these two cell types leading to cognate T-cell activation.

Local and regional block in postoperative pain control

Local and regional block provides an effective means for the control of postoperative pain. In surgery involving the trunk, it serves as a useful alternative to epidural analgesia. With the increasing use of low molecular weight heparin, the use of peripheral nerve block is increasingly popular for patients undergoing lower limb surgery.

Respiratory effects of low-dose bupivacaine interscalene block

In this double-blind study, interscalene brachial plexus (ISBP) block was performed in 11 volunteers using 10 ml of either 0.25% (n = 6) or 0.5% (n = 5) bupivacaine with epinephrine 1:200,000. Diaphragmatic excursion, respiratory function and neural function were assessed for 90 min. Our results showed that hemidiaphragmatic excursion declined significantly after block in the 0.5% group and paradoxical movement during inspiration was more common than in the 0.25% group. Forced vital capacity and forced expiratory volume in 1 s declined significantly in the 0.5% group (mean 74.6 (SD 13.0)% and 78.2 (19.9)% of baseline, respectively) but not in the 0.25% group. Sensory anaesthesia in the upper limb was found consistently in both groups, although biceps paralysis occurred earlier after 0.5% bupivacaine. We conclude that ISBP block using 10 ml of 0.25% bupivacaine provided upper limb anaesthesia to pinprick in C5-6 dermatomes with only occasional interference with respiratory function.

Analgesic effect of interscalene block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery

BACKGROUND AND OBJECTIVES

Although interscalene brachial plexus block (ISBPB) is often used to provide anesthesia for arthroscopic shoulder surgery, its selective analgesic effect, provided by low-dose local anesthetic, has not been studied. We hypothesized that ISBPB using a low volume and low concentration of bupivacaine can provide effective postoperative analgesia for shoulder surgery without producing significant sensory or motor block elsewhere.

METHODS

In this double-blind study, 30 outpatients scheduled to undergo shoulder arthroscopy were randomly assigned to receive either an ISBPB with 10 mL 0.125% bupivacaine with epinephrine 1:400,000 (n = 15) or 10 mL of normal saline (n = 15). The block was performed preoperative, prior to a standardized general anesthetic. Postoperative pain scores, imorphine and oral analgesic consumption, recovery profile, and patient satisfaction were recorded.

RESULTS

In the ISBPB group, verbal analog pain scores within 120 minutes after surgery were lower, morphine consumption in the postanesthesia care unit was significantly lower (2.7+/-2.6 mg vs 9.5+/-5.2 mg), the time to postoperative administration of the first systemic or oral analgesic was significantly longer (141+/-182 minutes vs 13+/-10 minutes), the degree of motor and sensory block 120 minutes after surgery was minimal, time to reach hospital discharge criteria was earlier, and patient satisfaction with postoperative analgesia at 24-hour follow-up was greater. Thirty-three percent of the patients receiving ISBPB did not require any analgesic prior to hospital discharge.

CONCLUSIONS

Interscalene brachial plexus block with low-dose bupivacaine is a useful and selective analgesic technique for outpatient shoulder arthroscopic surgery.

Positive and negative roles of the tyrosine kinase Lyn in B cell function

The function of Lyn in B cell activation has been studied recently by examining the properties of B cells from mice in which the lyn gene has been inactivated by gene targeting. These mice show evidence of B cell hyperreactivity in vivo, as the number of B lymphoblastoid cells greatly increase with age, IgM levels increase by 10-fold or more, and auto-antibodies to double-stranded DNA and other nuclear antigens become apparent. B cells from lyn -/- mice also exhibit enhanced BCR-induced activation of MAP kinases, intracellular calcium elevation and proliferative responses in vitro. These phenomena may relate to participation of Lyn in events that serve to decrease B cell responses to antigen. Among the leading candidates for these suppressive events are the inhibition of B cell antigen receptor function by Fc gamma RIIb1 and by CD22. Although Lyn also participates positively in the initial events of B cell antigen receptor signal transduction, this function can also be supplied by other tyrosine kinases, presumably other Src-family kinases. In contrast, some aspects of inhibition by CD22 appear to be almost completely dependent upon Lyn and Fc gamma RIIb1 inhibition is also diminished in the absence of Lyn. Thus, the net effect of Lyn action is negative rather than positive for B cell activation.

The molecular mechanism of B cell activation by toll-like receptor protein RP-105

The B cell-specific transmembrane protein RP-105 belongs to the family of Drosophila toll-like proteins which are likely to trigger innate immune responses in mice and man. Here we demonstrate that the Src-family protein tyrosine kinase Lyn, protein kinase C beta I/II (PKCbetaI/II), and Erk2-specific mitogen-activated protein (MAP) kinase kinase (MEK) are essential and probably functionally connected elements of the RP-105-mediated signaling cascade in B cells. We also find that negative regulation of RP-105-mediated activation of MAP kinases by membrane immunoglobulin may account for the phenomenon of antigen receptor-mediated arrest of RP-105-mediated B cell proliferation.

Defective negative regulation of antigen receptor signaling in Lyn-deficient B lymphocytes

BACKGROUND

To elucidate the role of the Src family kinase Lyn in B cell receptor (BCR) signaling, we and others previously generated lyn-/- mice and analyzed their B cell responses. Although the initiation of BCR signaling in lyn-/- B cells is delayed, BCR-induced ERK2 activation and proliferation are enhanced. As the co-receptors Fc gamma RIIb1 and CD22 have been shown to be negative regulators of BCR signaling, we have now examined their functional roles in lyn-/- B cells.

RESULTS

B cells from lyn-/- mice have increased expression of the protein product of the early response gene egr-1, enhanced activation of Jun N-terminal kinase (JNK), and elevated calcium responses upon BCR cross-linking. Tyrosine phosphorylation of Fc gamma RIIb1 in lyn-/- B cells was reduced but negative regulation of the BCR signal by Fc gamma RIIb1 was only modestly impaired. In contrast, tyrosine phosphorylation of CD22 was greatly decreased in lyn-/- B cells, correlating with the inability of CD22 to downregulate the BCR-induced calcium response in these cells. Surprisingly, CD22 remains capable of regulating the ERK2 and JNK pathways in lyn-/- B cells, which may relate to the small residual increase in BCR-induced CD22 phosphorylation.

CONCLUSIONS

BCR signal initiation and negative regulation by Fc gamma RIIb1 is not critically dependent on Lyn. In contrast, Lyn plays a particularly important role in the tyrosine phosphorylation of CD22 and in the consequent inhibition of BCR-induced calcium influx. The net result of the Lyn deficiency in B cells is hyperresponsiveness to antigen stimulation, which may explain the autoimmunity observed in lyn-/- mice.

Hemophilia B in a female carrier due to skewed inactivation of the normal X-chromosome

A novel missense mutation (codon 351, GCT (Ala) --> CCT (Pro)) of the FIX gene was characterised in a young female with mild hemophilia B. She is heterozygous for the FIX mutation inherited from her carrier mother. Analysis of the methyl-sensitive Hpa II sites at the 5' end of the hypoxanthine phosphoribosyltransferase gene showed that skewed inactivation of the X chromosome carrying her normal FIX gene accounted for the hemophilia phenotype.

A comparative study of low-dose hyperbaric spinal lidocaine 0.5% versus 5% for continuous spinal anesthesia

BACKGROUND AND OBJECTIVES

Concerns of cauda equina syndrome have discouraged clinicians to use 5% lidocaine for continuous spinal anesthesia. Earlier reports indicated that single-shot spinal lidocaine 0.5% is effective for minor gynecologic and perianal surgery. In the present study, we evaluate the anesthetic and hemodynamic effects of low dose hyperbaric 0.5% lidocaine for continuous spinal anesthesia and compare with those of the 5% lidocaine solution in patients undergoing urologic surgery.

METHODS

Spinal anesthesia was induced via an indwelling subarachnoid catheter in 42 elderly male patients (range, 57-84 years) undergoing transurethral prostate and bladder procedures. Patients were randomly assigned to receive an initial 30-mg bolus of hyperbaric lidocaine in the form of either 6 mL of 0.5% solution or 0.6 mL of 5% solution. Additional 30-mg boluses (to a total of 90 mg) were given, if necessary, to establish initial sensory block to T10 or higher and lower limb paralysis. Supplemental doses of 30 mg or less were given during surgery, as needed. Dermatomal level of sensory anesthesia and degree of motor blockade were assessed at regular intervals by a blinded observer. Heart rate and blood pressure (mean systolic and diastolic) values were monitored at regular intervals.

RESULTS

Forty patients were studied successfully. Both hyperbaric 0.5% and 5% lidocaine provided adequate surgical anesthesia in 75% (30/40) of patients after a single 30-mg dose. A median peak sensory level of T5 (range, T2-T9) achieved within 11.1 +/- 4.5 minutes in patients receiving the 0.5% solution was significantly higher than the peak sensory level of T7 (range, T4-T12) in the 5% group (P = .043). The duration of surgical anesthesia after a 30-mg dose was similar in both groups--48.1 +/- 12.1 minutes versus 50.8 +/- 16.5 minutes respectively. Of the 30 patients (15 in each group) who received 30 mg initially, 25 required repeat lidocaine dosing through the catheter during surgery. The maximum decrease in heart rate and blood pressure values was within 10% and 20%, respectively, of baseline values in both groups. In the remaining patients (10/40), anesthesia was achieved successfully in five patients in the 0.5% group and three patients in the 5% group after two 30-mg lidocaine boluses (60 mg) and two patients in the 5% group after three 30-mg boluses (90 mg).

CONCLUSIONS

Continuous spinal anesthesia produced by 0.5% lidocaine with 7.5% dextrose is as effective as that produced by the 5% lidocaine solution in elderly patients undergoing urologic surgery. An initial 30-mg bolus delivered via indwelling subarachnoid catheter was sufficient to achieve surgical anesthesia for approximately 50 minutes in most patients. Hemodynamic effects of the two lidocaine solutions were also comparable.

Minimum effective anaesthetic concentration of hyperbaric lidocaine for spinal anaesthesia

PURPOSE

Minimum effective anaesthetic concentration (MEAC) of lidocaine for spinal anaesthesia, defined as the concentration at which a spinal anaesthetic agent produces surgical anaesthesia within 20 min of administration in 50% of patients, was determined in a randomised, double-blind study in young patients undergoing knee and ankle surgery.

METHODS

Using the combined spinal-epidural technique, 48 or 72 mg hyperbaric lidocaine containing dextrose 7.5% was administered intrathecally to 43 patients at concentrations ranging from 0.2-0.9%. The choice of lidocaine concentration was determined by Dixon's up-and-down method. Complete anaesthesia was defined as: (1) pinprick anaesthesia at or higher than T12, (2) anaesthesia to transcutaneous tetanic electric stimulation (50 Hz at 60 mA for five seconds) in the knees and (3) complete leg paralysis; all occurring in both lower extremities within 20 min. Epidural anaesthesia was initiated if anaesthesia was incomplete.

RESULTS

In the 48 mg group, MEAC was 0.54% (95% CI-0.21-0.87). Anaesthetic effect was variable with mean duration of anaesthesia of 29 min (range: 20-50 min) and maximum pinprick sensory level ranging from T2-T10. In the 72 mg group, successful anaesthesia was achieved consistently at a concentration of 0.3%, i.e., MEAC was < 0.3%. Mean duration of complete anaesthesia was 46 min (range: 30-60 min) with maximum sensory level from T3-T8.

DISCUSSION

Spinal anaesthesia can be accomplished with very dilute lidocaine solutions (< 0.9%). The value of MEAC is dose-dependent, i.e., complete anaesthesia can be accomplished with lower concentrations by increasing the dose of spinal anaesthetic administered.

Characterization of the B lymphocyte populations in Lyn-deficient mice and the role of Lyn in signal initiation and down-regulation

Lyn-deficient mice were generated to analyze the role of Lyn in B cell antigen receptor (BCR) signaling. These mice had a reduced number of peripheral B cells with a greater proportion of immature cells and a higher than normal turnover rate. Aged lyn-/- mice developed splenomegaly, produced autoantibodies, and had an expanded population of B lymphoblasts of the B1 lineage. Splenic B cells from young lyn-/- mice initiated early BCR signaling events, although in a delayed fashion. Unexpectedly, lyn-/- B cells exhibited an enhanced MAP kinase activation and an increased proliferative response to BCR engagement. Stimulation of lyn-/- B cells with intact and F(ab')2 anti-IgM revealed defects in at least two mechanisms that negatively regulate BCR signaling, one of which involves Fc gammaRIIb1.

Molecular defects in Hb H hydrops fetalis

The molecular defect in two unique cases of Hb H hydrops fetalis has been characterized. Both cases are due to co-inheritance of a 'non-deletion' defect affecting the alpha2 gene: at codon 30 delta GAG, Glu) and codon 59 (G --> A, Gly --> Asp) respectively, and a zeta-alpha thalassaemia (thal) 1 or alpha thal 1 genotype. These two non-deletion defects, unlike previously described cases, resulted in severe anaemia of the fetuses and emphasize the importance of performing prenatal diagnosis for these families.

Propofol infusion for induction and maintenance of anesthesia in elderly patients: recovery and hemodynamic profiles

STUDY OBJECTIVE

To evaluate the effect of propofol infusion for both induction and maintenance of anesthesia on hemodynamics and recovery in elderly patients compared with conventional thiopental-isoflurane anesthesia.

DESIGN

Randomized, prospective, study.

SETTING

Teaching hospital.

PATIENTS

60 nonpremedicated ASA physical status I, II, and III adult elderly patients scheduled to undergo total hip replacement surgery.

INTERVENTIONS

Patients received either intravenous propofol infusion at 0.75 mg/kg/min or thiopental bolus 2 to 4 mg/kg for induction, followed by variable-rate propofol infusion up to 0.15 mg/kg/min or isoflurane 0.5% to 1.5% for maintenance of anesthesia. Nitrous oxide and fentanyl supplements were given in all patients.

MEASUREMENTS AND MAIN RESULTS

Perioperative hemodynamic changes, patient recovery profile, and myocardial ischemia incidents were assessed in both anesthetic groups. Induction of anesthesia by propofol infusion (1.6 mg/kg) did not produce significant hypotension (-8.3% +/- 5.5%) or bradycardia; these changes were similar to induction by thiopental bolus injection (3.3 mg/kg). Furthermore, increases in blood pressure and heart rate (HR) during endotracheal intubation were limited to 6% following propofol induction compared with 22% for thiopental induction. During maintenance of anesthesia, the decrease in MAP and HR was comparable in both anesthetic groups. Postanesthetic recovery times for patient to achieve wakefulness, mental orientation, and a maximum Aldrete score (10) were significantly faster in the propofol group, by 4 minutes, 6 minutes, and 20 minutes, respectively; however, the time to discharge from the postanesthesia care unit was not different. Holter-monitored perioperative myocardial ischemic events detected in 23% of the patients occurred independent of hemodynamic changes or the type of anesthetic administered.

CONCLUSION

Induction of anesthesia by propofol infusion in elderly patients produces greater attenuation of cardiovascular sympathetic response than thiopental bolus induction. Induction and maintenance of anesthesia by propofol infusion results in more rapid recovery in our elderly patients than thiopental isoflurane anesthesia.

Molecular characterization of haemophilia A in southern Chinese

41 unrelated southern Chinese haemophilia A patients were studied. The 5' promoter region, all 26 exons, their immediate 5' and 3' flanking splice junctions and the 3' untranslated region of the FVIII gene were amplified (including 16 different segments of exon 14) using GC-clamped primers. The GC-clamped PCR products were screened by denaturing gradient gel electrophoresis (DGGE) and fragments showing an abnormal migration pattern were sequenced. 17 mutations were identified, of which four were splicing defects, involving the first 1-6 nucleotide (nt) in the intervening sequences (IVS), six missense mutations, three nonsense mutations and four frameshift mutations. 14 other patients carried the type 1 inversion, affecting the distal copy of the FSA gene at the telomere of the X chromosome and the same gene in intron 22 of the FVIII gene. All the mothers studied (12/14) were carriers of the inversion. Two of these patients with inversion also have a co-existing missense mutation. In most cases the clinical severity of the disease corresponds to the genotype.

Respiratory depression: an adverse outcome during patient controlled analgesia therapy

Patient-controlled analgesia (PCA) is one of the more popular means of controlling postoperative pain. However, there is very little in the literature concerning the adverse outcome of respiratory depression in PCA. This report is a prospective study of 4,000 patients on PCA postoperatively. Nine of these patients experienced respiratory problems while on PCA. The respiratory depressions were associated with drug interactions, continuous narcotic infusion, nurse- or physician-controlled analgesia and inappropriate use of PCA by patients. This report identified the common precipitating factors in PCA-associated respiratory depression and its prevention.

Continuous intravenous administration of ketorolac reduces pain and morphine consumption after total hip or knee arthroplasty

The purpose of this study was to determine the analgesic efficacy, opioid-sparing effect, and tolerability of ketorolac administered as an intravenous (i.v.) bolus followed by a continuous infusion after total hip or knee arthroplasty. After general anesthesia, patients received either placebo or ketorolac 30 mg i.v. as a bolus over 15-30 s followed by a continuous i.v. infusion of ketorolac 5 mg/h for 24 h. All patients received patient-controlled i.v. morphine with no background infusion. Patients were assessed at 2, 4, 6, and 24 postoperatively with respect to analgesia, morphine consumption, side effects, and blood loss. Patients receiving ketorolac reported were less sedated and required fewer antiemetics. There was no difference in blood loss. Patients receiving ketorolac reported better analgesia and used less morphine (35% for hips and 44% for knees) than those receiving placebo.

Impact of patient-controlled analgesia on required nursing time and duration of postoperative recovery

BACKGROUND AND OBJECTIVES

Patient-controlled analgesia (PCA) offers effective postoperative pain management. However, the evidence of economic benefits associated with its use is lacking. Although suggestive, the potential economic advantages of PCA in saving nursing time and shortening hospital stay need objective documentation.

METHODS

This study compared the effects of morphine administered by PCA systems with intramuscular (i.m.) morphine injection on patient analgesic response, satisfaction, nursing time requirements, and postoperative recovery in 23 patients undergoing "open" cholecystectomy and 44 patients undergoing lumbar laminectomy and bony fusion. After the operation, patients in the PCA group received 1.5-2 mg morphine with a lockout of 5-10 minutes on demand, whereas those in the i.m. group received 0.15-0.2 mg/kg every 4 hours on demand. Visual analog scale (VAS) pain scores and satisfaction scores were evaluated at 4-hour intervals while nursing time spent on both analgesia-related and non-analgesia-related activities was recorded continuously by a team of independent observers on the ward. Recovery time profile for the return of bowel function, activities of daily living, ambulation without support, and length of hospital stay was also recorded.

RESULTS

It was found that morphine consumption, VAS, and satisfaction scores were similar in both PCA and i.m. treatment groups following both types of surgery. However, the delay in nurse response to i.m. morphine request ranged from 27.2 +/- to 42.1 +/- 11.8 minutes. The demand of nursing time on analgesia administration was less with PCA. The magnitude of time saving was 10 min/patient/d in cholecystectomy patients and 13 min/patient/d in laminectomy patients. The speed of postoperative patient recovery was similar between the two analgesia groups. Length of hospital stay following cholecystectomy was shorter--92.0 +/- 5.9 hours with PCA versus 128.6 +/- 22.2 hours with i.m. (not statistically significant)--whereas that following laminectomy was not different.

CONCLUSIONS

Data in this study have demonstrated some beneficial effects of PCA on nursing time requirements when it was used following cholecystectomy and lumbar laminectomy at the University of Toronto: however, the magnitude of these benefits was less than previously reported. The effects of PCA on postoperative recovery and hospital stay, however, were not significantly different from i.m. therapy.

Signal transduction by the B-cell antigen receptor

The antigen receptor of B lymphocytes (BCR) plays important roles in recognition of foreign antigens and self-components to allow the immune system to make appropriate antibody responses. The BCR is a complex between membrane immunoglobulin and the Ig-alpha and Ig-beta heterodimer. Site-directed mutagenesis experiments have shown that the mu heavy chain transmembrane domain plays a key role in the association of mIgM with Ig-alpha/Ig-beta. In the absence of complex formation, mIgM is retained in the endoplasmic reticulum, and this function is also specified by the mu chain transmembrane domain. The ability of various mutant mIgM molecules to associate with Ig-alpha/Ig-beta correlates well with their ability to induce signal transduction reactions such as protein tyrosine phosphorylation and phosphoinositide breakdown. Thus, the signaling ability of the BCR appears to reside in the Ig-alpha/Ig-beta heterodimer. The cytoplasmic domains of Ig-alpha and Ig-beta each contain an ITAM sequence, which is defined by its limited homology with subunits of the T-cell antigen receptor and of Fc receptors. Moreover, chimeric proteins containing these ITAMs and surrounding sequences from the cytoplasmic domains of Ig-alpha or Ig-beta exhibit signaling function characteristics of the intact BCR. The Ig-alpha and Ig-beta chimeras are each capable of inducing all of the BCR signaling events tested and thus represent redundant functions. Cross-linking these chimeras leads to their phosphorylation and to binding of the intracellular tyrosine kinases Lyn and Syk. The BCR expressed in the nonlymphoid AtT20 cells, which express the Src-family tyrosine kinase Fyn but not Syk, was not able to trigger vigorous signaling reactions. Introduction of the active form of Syk into these cells restored some signaling events. These results are consistent with a model in which the ITAMs act to initiate the BCR signaling reactions by binding and activating tyrosine kinases.

A post-anesthetic discharge scoring system for home readiness after ambulatory surgery

STUDY OBJECTIVE

To evaluate the validity and reliability of an objective scoring system, the Post-Anesthetic Discharge Scoring System (PADSS), which was compared against existing Clinical Discharge Criteria in the ambulatory surgery unit of our hospital.

DESIGN

randomized, open study.

SETTING

Ambulatory surgery unit at a university teaching hospital.

PATIENTS

247 ambulatory surgery patients undergoing general anesthesia.

INTERVENTIONS

One hour after the operation, the initial assessment using PADSS and the Clinical Discharge Criteria was made by an independent observer. Evaluations were repeated at 30-minute intervals until patients obtained a Post-Anesthetic Discharge Score of at least 9 and fulfilled the Clinical Discharge Criteria.

MEASUREMENTS AND MAIN RESULTS

There was a close correlation between the end of anesthesia to time patients were fit for discharge using either PADSS or the Clinical Discharge Criteria (Pearson's Correlation Coefficient r = 0.89). The internal consistency reliability of PADSS (alpha = 0.65) was superior to that of the Clinical Discharge Criteria (alpha = 0.14).

CONCLUSIONS

We have found PADSS to have superior measurement scaling and diagnostic properties.

The addition of 7.5% glucose does not alter the neurotoxicity of 5% lidocaine administered intrathecally in the rat

BACKGROUND

Recent reports of major and minor neurologic sequelae after spinal anesthesia have generated concern regarding the safety of some currently used intrathecal agents. The role of glucose, if any, in neurotoxic injury associated with spinal anesthesia is not known. The current experiments sought to determine whether the presence of 7.5% glucose alters the neurotoxicity of intrathecally administered 5% lidocaine.

METHODS

Two experiments were performed. First, 48 rats were implanted with an intrathecal catheter and randomly divided into eight equal groups. Each animal received a single intrathecal infusion of 5% lidocaine (groups P1-P4) or 5% lidocaine with 7.5% glucose (G1-G4) for 0.5, 1, 2, or 4 h at a rate of 1 microliter/min. Sensory function was assessed using the tail-flick test; a deficit was defined as a complete lack of response to the heat stimulus at the proximal, mid or distal portion of the tail persisting 4 days after the infusion. In the second experiment, 60 rats were randomly divided into two groups to receive a 1-h intrathecal infusion of 5% lidocaine or 5% lidocaine with 7.5% glucose. Animals were evaluated for increase in the latency of the tail-flick reflex 4 days after infusion.

RESULTS

In the first experiment, the two lidocaine solutions produced similar dose-dependent loss of sensory function. In the second experiment, the two solutions induced similar alterations in tail-flick latency.

CONCLUSIONS

The presence of 7.5% glucose does not affect the potential of intrathecally administered 5% lidocaine to induce sensory impairment. These findings provide further support for the hypothesis that recent injuries after spinal anesthesia resulted from a direct neurotoxic effect of the local anesthetic.

Anesthetic and hemodynamic effects of single bolus versus incremental titration of hyperbaric spinal lidocaine through microcatheter

This study examined anesthetic development and hemodynamic changes during two techniques of hyperbaric lidocaine administration through 27-gauge intrathecal catheters for continuous spinal anesthesia in 55 elderly patients undergoing transurethral prostatic resection. Twenty-five patients were randomly assigned to receive hyperbaric lidocaine 5% solution in a single bolus of 75 mg to achieve blockade to approximately T6, and 30 patients to receive hyperbaric lidocaine 2.5% solution in increments of 25 mg to achieve T6 or to a maximum of three doses. Hemodynamic measurements of arterial pressure, heart rate, cardiac output, stroke volume, and ejection fraction were made serially after the induction of spinal anesthesia. Anesthesia failed to spread beyond the sacral region in 9/25 (36%) patients in the single-dose group (SD), but was successfully induced in all patients given titrated doses (TD) at total doses of 50 mg (n = 15) (TD50) and 75 mg (n = 15) (TD75). The mean maximal level of sensory block in all three groups was comparable: T5, T4, and T6 in groups SD, TD50, and TD75, respectively. The onset and progression of sensory block were rapid and similar in the SD and TD50 groups, in contrast to a gradual, stepwise development of block in group TD75. Grade 3 motor block occurred in response to the first dose of 25 mg lidocaine in 7/30 (23%) patients receiving titrated doses, but the overall incidence of leg paralysis did not differ among the three groups by the end of lidocaine dosing. Mean arterial pressure (MAP) decreased significantly relative to baseline in all three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Persistent sacral sensory deficit induced by intrathecal local anesthetic infusion in the rat

BACKGROUND

Several cases of cauda equina syndrome after continuous spinal anesthesia have been recently reported. One possible etiology is toxic exposure of the sacral roots resulting from intrathecal maldistribution of a relatively large dose of local anesthetic. The current experiments sought to determine whether a local anesthetic solution, injected intrathecally to produce a restricted distribution of anesthesia, could result in a sacral deficit. In addition, we sought to test the hypothesis that, when equal volumes are administered intrathecally, significant differences exist in the potential to three commonly used anesthetic solutions to induce sensory impairment.

METHODS

Thirty-two rats were implanted with intrathecal catheters to permit repetitive infusion of local anesthetic. Animals were randomly assigned to four groups of eight to receive either 5% lidocaine with 7.5% dextrose; 0.75% bupivacaine with 8.25% dextrose; 0.5% tetracaine with 5% dextrose; or normal saline. Each rat received, in sequence, a 1-h (60 microliters), a 2-h (120 microliters), and a 4-h (240 microliters) infusion; the infusions were separated by a 4-day rest period. Sensory function was assessed using the tail-flick test, which was performed immediately before each infusion and 6 days after the last infusion by an investigator blinded to the solution infused.

RESULTS

There was no significant difference in baseline tail-flick latencies for the four groups. Tail-flick latency for the lidocaine group was significantly prolonged when compared with the bupivacaine, tetracaine, and saline groups. This difference was apparent after the first infusion and persisted throughout the study.

CONCLUSIONS

In the rat, restricted anesthetic distribution can be achieved, and sensory impairment may result. These findings further support an etiology of local anesthetic neurotoxicity for recent clinical injuries after continuous spinal anesthesia. The functional model described appears to be suitable for in vivo study of local anesthetic neurotoxicity.

Mechanism of B cell antigen receptor function: transmembrane signaling and triggering of apoptosis

The antigen receptor of B lymphocytes (BCR) plays important roles in virtually every stage in the development, inactivation, or activation of B cells. The BCR is a complex of membrane immunoglobulin (mIg) and a heterodimer of two transmembrane polypeptides called Ig-alpha and Ig-beta. Site directed mutation of the mu immunoglobulin heavy chain has demonstrated that the mu transmembrane domain plays a key role in the assembly of mIgM with Ig-alpha/Ig-beta. In addition, there is a strong correlation between the ability of various mutant mIgM molecules to associate with Ig-alpha/Ig-beta and their ability to induce signal transduction reactions such as protein tyrosine phosphorylation and phosphoinositide breakdown. The cytoplasmic domains of Ig-alpha and Ig-beta share a region of limited homology with each other and with components of the T cell antigen receptor and of the Fc receptor. The presence of regions of the cytoplasmic domains of Ig-alpha or Ig-beta including this conserved amino acid sequence motif is sufficient to confer signaling function on chimeric transmembrane proteins. Both Ig-alpha and Ig-beta chimeras are capable of inducing all of the BCR signaling events tested. Based on these and related observations, we propose that the motifs act to initiate the BCR signaling reactions by binding and activating tyrosine kinases. Among the important events mediated by BCR signaling is induced expression of a series of genes referred to as early response genes. In B cells these include transcription factors and at least one component that regulates signaling events. One of these genes, c-myc, appears to play an important role in mediating apoptosis in B cells stimulated via the BCR complex.

B-cell antigen receptor motifs have redundant signalling capabilities and bind the tyrosine kinases PTK72, Lyn and Fyn

BACKGROUND

The 13 cell antigen receptor (BCR) is a multimeric protein complex consisting of an antigen recognition structure (membrane immunoglobulin) and two associated proteins, lg-alpha and Ig-beta It has been proposed that signalling through the BCR involves Ig-alpha and Ig-beta. Both of these proteins contain within their cytoplasmic domains an amino-acid motif that is present in a number of immune recognition receptors, including the BCR, T-cell antigen receptor and Fc receptor complexes. This motif, termed the antigen-receptor homology motif (ARH1), appears to have signal transduction ability.

RESULTS

We now show that the presence of cytoplasmic regions containing the ARM motif from either Ig-alpha or Ig-beta is sufficient to confer signalling capability on an otherwise non-functional fusion protein. Both Ig-alpha- and Ig-beta-containing chimeras induced, in an apparently redundant fashion, signalling events seen upon membrane immunoglobulin crosslinking, including tyrosine phosphorylation of particular proteins, phosphoinositicle breakdown and calcium mobilization. Furthermore, crosslinking of the chimeras resulted in tyrosine phosphorylation of the Ig-alpha and Tg-beta tails and their association with the tyrosine kinases PTK72, p53/56(lyn) and p59(fyn).

CONCLUSIONS

These observations indicate that Ig-alpha and Ig-beta are responsible for coupling membrane immunoglobulin to intracellular signalling components. Moreover, they demonstrate that a number of tyrosine kinases associate directly with the cytoplasmic domains of both Ig-alpha and Ig-beta. Stimulation of the chimeras, which results in tyrosine phosphorylation of the ig-alpha and Ig-beta tails, is a prerequisite for some of these associations. The implications of these findings for the mechanism by which the BCR initiates the signalling reactions are discussed.

Membrane Ig cross-linking regulates phosphatidylinositol 3-kinase in B lymphocytes

Cross-linking of the B cell AgR results in activation of mature B cells and tolerization of immature B cells. The initial signaling events stimulated by membrane immunoglobulin (mIg) cross-linking are tyrosine phosphorylation of a number of proteins. Among the targets of mIg-induced tyrosine phosphorylation are the tyrosine kinases encoded by the lyn, blk, fyn, and syk genes, the mIg-associated proteins MB-1 and Ig-beta, phospholipase C-gamma 1 and -gamma 2, as well as many unidentified proteins. In this report we show that mIg cross-linking also regulates phosphatidylinositol 3-kinase (PtdIns 3-kinase), an enzyme that phosphorylates inositol phospholipids and plays a key role in mediating the effects of tyrosine kinases on growth control in fibroblasts. Cross-linking mIg on B lymphocytes greatly increased the amount of PtdIns 3-kinase activity which could be immunoprecipitated with anti-phosphotyrosine (anti-tyr(P) antibodies. This response was observed after mIg cross-linking in mIgM- and mIgG-bearing B cell lines and after cross-linking either mIgM or mIgD in murine splenic B cells. Thus, regulation of PtdIns 3-kinase is a common feature of signaling by several different isotypes of mIg. This response was rapid and peaked 2 to 3 min after the addition of anti-Ig antibodies. The anti-Ig-stimulated increase in PtdIns 3-kinase activity associated with anti-Tyr(P) immunoprecipitates could reflect increased tyrosine phosphorylation of PtdIns 3-kinase, increased activity of the enzyme, or both. In favor of the first possibility, the tyrosine kinase inhibitor herbimycin A blocked the increase in ant-Tyr(P)-immunoprecipitated PtdIns 3-kinase activity as well as the anti-Ig-induced tyrosine phosphorylation. Moreover, this response was not secondary to phospholipase C activation but rather seemed to be a direct consequence of mIg-induced tyrosine phosphorylation. Activation of the phosphoinositide pathway by a transfected M1 muscarinic acetylcholine receptor expressed in WEHI-231 B lymphoma cells did not increase the amount of PtdIns 3-kinase activity which could be precipitated with anti-Tyr(P) antibodies. Similarly, inhibition of the phosphoinositide pathway did not abrogate the ability of mIg cross-linking to stimulate this response. Thus, mIg-induced tyrosine phosphorylation regulates PtdIns 3-kinase, an important mediator of growth control in fibroblasts and potentially an important regulatory component in B cells as well.

Membrane Ig cross-linking regulates phosphatidylinositol 3-kinase in B lymphocytes

Cross-linking of the B cell AgR results in activation of mature B cells and tolerization of immature B cells. The initial signaling events stimulated by membrane immunoglobulin (mIg) cross-linking are tyrosine phosphorylation of a number of proteins. Among the targets of mIg-induced tyrosine phosphorylation are the tyrosine kinases encoded by the lyn, blk, fyn, and syk genes, the mIg-associated proteins MB-1 and Ig-beta, phospholipase C-gamma 1 and -gamma 2, as well as many unidentified proteins. In this report we show that mIg cross-linking also regulates phosphatidylinositol 3-kinase (PtdIns 3-kinase), an enzyme that phosphorylates inositol phospholipids and plays a key role in mediating the effects of tyrosine kinases on growth control in fibroblasts. Cross-linking mIg on B lymphocytes greatly increased the amount of PtdIns 3-kinase activity which could be immunoprecipitated with anti-phosphotyrosine (anti-tyr(P) antibodies. This response was observed after mIg cross-linking in mIgM- and mIgG-bearing B cell lines and after cross-linking either mIgM or mIgD in murine splenic B cells. Thus, regulation of PtdIns 3-kinase is a common feature of signaling by several different isotypes of mIg. This response was rapid and peaked 2 to 3 min after the addition of anti-Ig antibodies. The anti-Ig-stimulated increase in PtdIns 3-kinase activity associated with anti-Tyr(P) immunoprecipitates could reflect increased tyrosine phosphorylation of PtdIns 3-kinase, increased activity of the enzyme, or both. In favor of the first possibility, the tyrosine kinase inhibitor herbimycin A blocked the increase in ant-Tyr(P)-immunoprecipitated PtdIns 3-kinase activity as well as the anti-Ig-induced tyrosine phosphorylation. Moreover, this response was not secondary to phospholipase C activation but rather seemed to be a direct consequence of mIg-induced tyrosine phosphorylation. Activation of the phosphoinositide pathway by a transfected M1 muscarinic acetylcholine receptor expressed in WEHI-231 B lymphoma cells did not increase the amount of PtdIns 3-kinase activity which could be precipitated with anti-Tyr(P) antibodies. Similarly, inhibition of the phosphoinositide pathway did not abrogate the ability of mIg cross-linking to stimulate this response. Thus, mIg-induced tyrosine phosphorylation regulates PtdIns 3-kinase, an important mediator of growth control in fibroblasts and potentially an important regulatory component in B cells as well.

Analgesic and pulmonary effects of continuous intercostal nerve block following thoracotomy

This study examined the beneficial effects and potential systemic toxicity from continuous intercostal nerve block by repeated bolus injections of bupivacaine. In this double-blind, randomized study, 20 post-thoracotomy patients were assigned to receive four doses of either: 20 ml 0.5% bupivacaine with epinephrine 5 micrograms.ml-1 (bupivacaine group, n = 10), or 20 ml preservative-free saline (placebo group, n = 10) through two indwelling intercostal catheters every six hours. Patients receiving intercostal bupivacaine injections had greater decreases in visual analogue pain scores (VAS) (P less than 0.05) and lower 24 hr morphine requirements, 16.6 +/- 4.6 mg vs 35.8 +/- 7.2 mg, than patients in the placebo group (P less than 0.05). Higher post-injection values of forced expiratory volume in one second, forced vital capacity and peaked expiratory flow rate were also observed in the bupivacaine group (P less than 0.01). Repeated intercostal bupivacaine administration did lead to systemic accumulation, but the peak bupivacaine level after 400 mg was low at 1.2 +/- 0.2 microgram.ml-1. Thus, the technique of continuous intercostal nerve block described in this study is an effective treatment for the control of post-thoracotomy pain.

Interpleural analgesia after thoracotomy

We examined the effects of the following variables on interpleural analgesia after thoracotomy: addition of epinephrine to local anesthetic, thoracostomy drainage, two-catheter placement, and location of catheter tips. Twenty patients were randomized to have one catheter (paravertebral tip location) or two catheters (paravertebral and lateral thoracic wall tip locations). Interpleural catheters were sutured to the parietal pleura by the surgeon at time of wound closure. Patients were then randomly assigned to receive 20 mL of 0.5% bupivacaine with 1:200,000 epinephrine through the single catheter or 10 mL of 0.5% bupivacaine with or without 1:200,000 epinephrine through each of the two catheters while supine. Bupivacaine concentrations in whole blood and in thoracostomy drainage fluid were assayed by gas chromatography. Actual content of bupivacaine in the drainage fluid was calculated. Degree of analgesia was assessed by verbal numerical pain scores over the first 4 h and opioid demand thereafter. Addition of epinephrine to bupivacaine did not influence the degree of analgesia. Approximately 30%-40% of any administered dose of bupivacaine was lost via the thoracostomy tube over a 4-h period. There was no correlation between the true initial dose (100 mg minus thoracostomy drainage) and Cmax. Use of two catheters resulted in significantly less opioid requirements after an initial 8-h period. Failure to achieve adequate interpleural analgesia in postthoracotomy patients may be related to loss of anesthetic via thoracostomy drainage, presence of extravasated blood and tissue fluid in the pleural space, and possibly sequestration and channeling of flow of local anesthetic by restricted motion of an operated lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence that chemical modification of a positively charged residue at position 189 causes the loss of catalytic activity of iron-containing and manganese-containing superoxide dismutases

The Escherichia coli, Bacillus stearothermophilus, and human manganese-containing superoxide dismutases (MnSODs) and the E. coli iron-containing superoxide dismutase (FeSOD) are extensively inactivated by treatment with phenylglyoxal, an arginine-specific reagent. Arg-189, the only conserved arginine in the primary sequences of these four enzymes, is also conserved in the three additional FeSODs and five of the six additional MnSODs sequenced to date. The only exception is Saccharomyces cerevisiae MnSOD, in which it is conservatively replaced by lysine. Treatment of S. cerevisiae MnSOD with phenylglyoxal under the same conditions used for the other SODs gives very little inactivation. However, treatment with low levels of 2,4,6-trinitrobenzenesulfonate (TNBS) or acetic anhydride, two lysine-selective reagents that cause a maximum of 60-80% inactivation of the other four SODs, gives complete inactivation of the yeast enzyme. Total inactivation of yeast MnSOD with TNBS correlates with the modification of approximately five lysines per subunit, whereas six to seven acetyl groups per subunit are incorporated on complete inactivation with [14C]-acetic anhydride. It appears that the positive charge contributed by residue 189, lysine in yeast MnSOD and arginine in all other SODs, is critical for the catalytic function of MnSODs and FeSODs.

Inactivation of human thrombin by water-soluble carbodiimides. The essential carboxyl has a pKa of 5.6 and is one other than Asp-189

Human thrombin is inactivated by 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDC) or 1-ethyl-3-(4-azonia-4,4-dimethylpentyl)carbodiimide (EAC) by a second order process. A plot of the pseudo-first order rate constant for inactivation by 20 mM EDC at different pH values from 4.2 to 7.7 at 25 degrees C shows that this inactivation is due to the modification of a protonated carboxyl with a pKa of 5.6. The rate of inactivation by EDC at pH 6.0 is reduced, but not eliminated by saturating levels of the competitive inhibitor dansyl-L-arginine N-(3-ethyl-1,5-pentanediyl)amide, suggesting that the essential carboxyl modified is one other than Asp-189 in the substrate specificity pocket of thrombin. Complete inactivation by 14C-EAC correlates with the incorporation of approximately 2.5-3 EACs per thrombin.