2006年 · 第119卷第11期

Neurosurgery especially intracranial surgery is characterized by periods of intense stimulation alternating with periods of minimal pain.Manipulation of the brain itself is not painful to the patient, but the scalp, skull, and meninges are well innervated with pain fibers. Traction on cerebral arteries as well as sensory cranial nerves can be painful. Therefore, the most appropriate choice of drugs or measures for neuroanesthesia should be dependent on a clear understanding of the pharmacological effects of anesthetics as well as the requirements for anesthesia/analgesia in general and the individual neurosurgical case. Besides, the ultimate aim of neuroanesthesia is to provide optimal intracranial operating conditions, maintain an appropriate cerebral hemodynamics to ensure enough cerebral perfusion, protect against ischemic insults and prevent postoperative complications. The anesthetic techniques and the anesthetics used in neuroanesthesia are all geared to these objectives.The changes of neuroanesthesia that have occurred in the past decades show a steady evolution of anesthetic care both in the operating room and the neurocritical care setting。

Abstract：Background The automatic, threshold tracking, pacing algorithm developed by St. Jude Medical, verifies ventricular capture beat by beat by recognizing the evoked response following each pacemaker stimulus. This function was assumed to be not only energy saving but safe. This study estimated the extension in longevity obtained by AutoCapture (AC) compared with pacemakers programmed to manually optimized, nominal output.Methods Thirty-four patients who received the St. Jude Affinity series pacemaker were included in the study.The following measurements were taken: stimulation and sensing threshold, impedance of leads, evoked response and polarization signals by 3501 programmer during followup, battery current and battery impedance under different conditions. For longevity comparison, ventricular output was programmed under three different conditions: (1) AC on; (2) AC off with nominal output, and (3) AC off with pacing output set at twice the pacing threshold with a minimum of 2.0 V. Patients were divided into two groups: chronic threshold is higher or lower than 1 V. The efficacy of AC was evaluated.Results Current drain in the AC on group, AC off with optimized programming or nominal output was (14.33±2.84) mA, (16.74±2.75) mA and (18.4±2.44) mA, respectively (AC on or AC off with optimized programming vs. nominal output, P ＜ 0.01). Estimated longevity was significantly extended by AC on when compared with nominal setting [(103 ± 27) months, (80 ± 24) months, P ＜ 0.01). Furthermore, compared with the optimized programming, AC extends the longevity when the pacing threshold is higher than 1 V.Conclusion AC could significantly prolong pacemaker longevity; especially in the patient with high pacing threshold。

Abstract：Background Recent advances in real-time three-dimensional echocardiography (RT3DE) offer the potential to assess the left ventricular (LV) dyssynchrony simultaneously by analyzing the 17 segments time-volume curves.The purpose of this study was to test the feasibility and accuracy of RT3DE for quantitative evaluation of left ventricular systolic synchronicity.Methods Twenty-four patients with dilated cardiomyopathy (DCM) and twenty-five healthy volunteers were enrolled in this study. Full volume RT3DE was performed by using Philips IE33 with X3-1 probe. The global and 17-segmental time-volume curves were obtained by the on-line Qlab software (version 4.2). The time to minimal systolic volume in each segment (Tmsv) was taken to derive the following indexes of systolic asynchrony: Tmsv 16-SD, Tmsv 16-Dif, Tmsv 12-SD, Tmsv 12-Dif, Tmsv 6-SD and Tmsv 6-Dif, which meant the standard deviation or the maximal difference of Tmsv among the 16, 12 and 6 segments of the left ventricle respectively. The software also provided with each of the above parameters as a percentage of the cardiac cycle.Results Tmsv 16-SD, Tmsv 12-SD and Tmsv 6-SD were all significantly larger in the DCM group than those of the control group [Tmsv 16-SD: (52.9±40.6) ms vs (8.8±6.2) ms; Tmsv 12-SD: (29.5±30.8) ms vs (6.9±4.0) ms;Tmsv 6-SD: (28.9±34.6) ms vs (7.0±4.7) ms, all P≤0.001]. Tmsv 16-Dif, Tmsv 12-Dif and Tmsv 6-Dif were also significantly larger in the DCM group. There were close negative relations between the LVEF determined by RT3DE and each of the indexes of systolic asynchrony, among which the indexes of Tmsv-16-SD% and Tmsv-16-Dif% correlated most closely (r=-0.703 and r =-0.701, respectively). The DCM patients had significantly larger EDV and ESV, with significantly reduced LVEF compared with the healthy subjects.Conclusion RT3DE provides a simple, useful and unique approach to assess the systolic synchronicity of allthe left ventricular segments simultaneously。

Abstract：Background The development of the targeted signal transduction inhibitor STI571 has prompted us to treat chronic myeloid leukemia in different ways. Since STI571 may reverse multidrug-resistance of K562/MDR cells in vitro, we studied the effect of STI571 on multidrug-resistant K562 cells in vivo.Methods Multidrug-resistant human leukemia cell line K562-n/VCR expresses both bcr/abl fusion gene and multi-drug resistance (mdrl) gene. It is a vincristine resistant cell line subcloned from the vincristine (VCR)sensitive cell line K562-n induced by vincristine in vitro. K562-n and K562-n/VCR cells were inoculated subcutaneously into both sides of nude mice breast (5 × 106 cells/each) to establish a human leukemia xenograft model. The incidence and volume of tumor were observed. In the tumor-bearing nude mice, anti-tumor drugs vincristine, daunorubicin (DNR), STI571, and STI571 plus VCR for the treatment of mdrl and bcr/abl double positive leukemia were studied respectively.Results The tumor incidence was 100% in the nude mice inoculated with either K562-n or K562-n/VCR. The transcription of the mdrl gene and expression of P-gp were negative in K562-n cells but positive in K562-n/VCR cells. The intracellular accumulation of DNR in K562-n cells was higher than that in K562-n/VCR cells (P＜0.05).The tumor incidence of K562-n/VCR cells in nude mice was much higher than that of K562-n cells in chemotherapy groups, and the mean volume of the tumors was also larger (P＜0.05). STI571 combined with VCR significantly suppressed the proliferation of K562-n/VCR cells.Conclusions The MDR characteristics of K562-n/VCR in vivo were the same as in vitro. STI571 had a significant tumor-suppressing effect on VCR-sensitive leukemia cells and a moderate effect on MDR leukemia cells. VCR combined with STI571 had an excellent tumor-suppressing effect on both K562-n/VCR and K562-n in the human-nude mice xenograft model。

Abstract：Background The hematopoietic microenvironment (HM) plays a critical role in malignant cell growth, patient survival, and response to chemotherapy in hematologic malignancies. However, mechanisms associated with this environmental influence remain unclear. In this study, we investigated the role of bone marrow derived mesenchymal stem cells (MSCs) in U937 cell line, to find out the relations between leukemia drug resistance and the MSCs.Methods U937 cells were cultured in suspension or grew adherently with MSCs. The cell growth curve was drawn and the cell cycle was measured by flow cytometry. Apoptosis and sensitivity of U937 to daunoblastina (DNR) were quantified by DNA ladder detection and trypan blue exclusion assays, respectively. The gene expression profile chip technology was used to determine and analyze the changes in apoptosis-related gene expression after adherent culture and the expression of MDR1 mRNA was assessed by reverse transcriptional polymerase chain reaction (RT-PCR) at the same time.Results In the adherent culture, the proliferation of the U937 cells was inhibited, the G0/G1 phase cells increased (F=64.9726, P＜0.0001), G2/M phase cells were decreased (F=98.1361, P＜0.0001) and the natural apoptosis rate was decreased (F=24.0866, P＜0.0001) compared with those in the suspended culture. U937 cell viability was enhanced and cell apoptosis was blocked during DNR treatment in adherent culture with MSCs.Thirty-nine differently expressed genes were screened from the 487 apoptosis related genes in the adherent culture U937 cells. Among the 37 upregulated genes, Bcl-XL was upregulated most significantly. Two genes were downregulated. Adherent culture did not induce MDR1 mRNA expression in U937 cells.Conclusions MSCs play a role in modulating the proliferation of U937 cells and response of U937 cells to DNR, and Bcl-XL apoptosis-inhibiting gene may be most important in determining the sensitivity of leukemic cells to treatment, which is not related to MDR1。

Abstract：Background Intubating laryngeal mask airway (ILMA) offers a new approach for orotracheal intubation and is expected to produce less cardiovascular stress responses. However, the available studies provide inconsistent results. The purpose of this study was to identify whether there is a clinically relevant difference in hemodynamic responses to orotracheal intubation by using ILMA and direct laryngoscope (DLS).Methods A total of 53 adult patients, ASA physical status Ⅰ-Ⅱ, scheduled for elective plastic surgery under general anesthesia requiring the orotracheal intubation, were randomly allocated to either DLS or ILMA groups.After a standard intravenous anesthesia induction, orotracheal intubation was performed. Noninvasive blood pressure and heart rate were recorded before (baseline values) and after anesthesia induction (post-induction values), at intubation and every minute for the first 5 minutes after intubation. The data were analyzed using Chisquare test, paired and unpaired Student's t test, and repeated-measures analysis of variance as appropriate.Results The mean intubation time in the ILMA group was longer than that in the DLS group (P＜0.05). The blood pressure and heart rate increased significantly after intubation in the two groups compared to the postinduction values (P＜0.05), but the maximum value of blood pressure during the observation did not exceed the baseline value, while the maximum value of heart rate was higher than the baseline (P＜0.05). During the observation, there were no significant differences in blood pressure and heart rate among each time point and in the maximum values between the two groups.Conclusions Orotracheal intubations by using ILMA and DLS produce similar hemodynamic response. ILMA has no advantage in attenuating the hemodynamic responses to orotracheal intubation compared with DLS。

Abstract：Background Some patients still suffer from implicit memory of intraoperative events under adequate depth of anaesthesia. The elimination of implicit memory should be a necessary aim of clinical general anaesthesia.However, implicit memory cannot be tested during anaesthesia yet. We propose bispectral index (BIS) and auditory evoked potential index (AEPI), as predictors of implicit memory during anaesthesia.Methods Thirty-six patients were equally divided into 3 groups according to the Observer's Assessment of Alertness/Sedation Score: A, level 3; B, level 2 ;and C, level 1. Every patient was given the first auditory stimulus before sedation. Then every patient received the second auditory stimulus after the target level of sedation had been reached. BIS and AEPI were monitored before and after the second auditory stimulus presentation. Four hours later, the inclusion test and exclusion test were performed on the ward using process dissociation procedure and the scores of implicit memory estimated.Results In groups A and B but not C, implicit memory estimates were statistically greater than zero (P＜0.05).The implicit memory scores in group A did not differ significantly from those in group B (P＞0.05). Implicit memory scores correlated with BIS and AEPI (P＜0.01). The area under ROC curve is BIS＞ AEPI. The 95% cutoff points of BIS and AEPI for predicting implicit memory are 47 and 28, respectively.Conclusions Implicit memory does not disappear until the depth of sedation increases to level 1 of OAA/S score. Implicit memory scores correlate well with BIS and AEPI during sedation. BIS is a better index for predicting implicit memory than AEPI during propofol induced sedation。

Abstract：Background Cerebral ischemia-reperfusion/hypoxia-reoxygenation insult triggers lots of pathophysiological and biochemical events that separately affect the evolution of cerebral damage. Accordingly, all known effective neuroprotective measures should be taken to get the optimal efficacy of therapy. This study was undertaken to investigate whether diazoxide (DZ) preconditioning combined with the following hypothermia could contribute to synergistic neuroprotection compared with either hypothermia or DZ preconditioning alone.Methods Cultured for 9-10 days in vitro, the hippocampal neurons of SD rats were preconditioned with DZ 0 μmol/L or DZ 250 μmol/L for 1 hour per day and this treatment lasted for 3 days. Subsequently, neurons were subjected to deprivation of oxygen for 4 hours at 37℃, 34℃, 30℃ and 22℃, respectively. This experiment consisted of 8 groups (4 temperature groups and 4 combination groups) and each group contained 12-well or 2-dish cells. Survival rate, expression of Bcl-2, fluorescence magnitude of intracellular calcium, and concentration of malondialdehyde (MDA) were determined at 24 hours after reoxygenation.Results The survival rate and expression of Bcl-2 were both increased in individually hypothermic conditions compared with those at 37℃ (P＜0.05), whereas intracellular calcium and MDA did the opposite exhibition simultaneously (P＜0.05). 22℃ contributed to a higher survival rate and greater expression of Bcl-2 in comparison with other hypothermia (P＜0.05). Preceding administration of 250 μmol/L DZ took the similar effects on the neurons like hypothermia. Moreover, compared with individual hypothermia or DZ preconditioning,the neuronal survival rate and expression of Bcl-2 in the combination group were increased significantly (P＜0.05), whereas the calcium fluorescence density and concentration of MDA were reduced further (P＜0.05).250 μmol/L DZ preconditioning combined with 22℃ provided a maximal neuroprotection.Conclusions Compared with either individual hypothermia or DZ preconditioning, the combination of both treatments conferred synergistic protection for cultured hippocampal neurons in vitro against hypoxiareoxygenation insult。

Abstract：Objective To review the relationship between the immune system and the mechanism of pain.Data sources Related researches published in the period of 1987-2005 were systematically reviewed.Study selection Articles about the immune system and pain were selected.Data extraction Data were mainly extracted from 74 articles which are listed in the reference section of this review.Results Pain was classically viewed as being mediated solely by neurons. However, growing evidence has showed the possible relationships between the immune system and the central nervous system. In this article, we reviewed the role of the immune system in the development of pain, together with the importance of the glia in this process. These findings suggest a novel approach to pain control in the future.Conclusions The immune system plays a potential but important role in the development of pain。

Multiple myeloma (MM) is a uniformly fatal disease characterized by a clonal proliferation of neoplastic plasma cells in the bone marrow and is the second most commol hematological malignancy.1 At present, a cure for multiple myeloma has not been achieved with chemotherapeutic regimen, and many patients die of drug-resistant disease. Thus, the development of new effective anticancer agents to treat both early and advanced MM seems to be an attractive perspective.…… Biography：Correspondence to: Dr. CHEN Zhi-chao, Institute of Hematology,Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China (Tel:86-27-85726387. Fax: 86-27-85726387. Email: chenzc2001@yahoo.com.cn)

Promethazine, a first generation antihistamine,has an antiarrhythmic effect on ischemia-reperfusion inducing arrhythmias1 and experimental arrhythmias.2 However, terfenadine as a second generation of antihistamine, has been reported to elicit hypotension, bradycardia, prolongation of the QTc interval and torsades de pointes (TdP) like ventricular arrhythmia.3 This may be due to the blockage on rectifier postassium current (Ik) of terfenadine, resulting in the prolongation of the action potential duration (APD) and dispersion of the repolarization duration, which might provoke a specific form of polymorphic ventricular tachydysrhythmia, i.e. TdP.4 In clinical practice,however, the class Ⅲ antiarrhythmic agents, which target on the Ik and prolong the action potential duration and QTc interval, rarely lead to arrhythmias.Other actions must be considered to underlie the arrhythmogenic tendency of terfenadine besides its inhibition on Ik. Though both promethazine and terfenadine block the H1 receptor, there must be a different pharmacology profile between the two compounds on ion channels of cardiac myocytes.Whole-cell patch clamp technique was used to investigate the effects of these two antagonists of the H1 receptor on the main ion currents in cardiac electrical activities.…… Foundation Item：This study was supported by a grant from Education Government Foundation of Shanxi Province, China(No. 2003105)。

Patients undergoing orthotopic liver transplantation may develop significant haemodynamic instability, especially during anhepatic phase and immediately after reperfusion of the graft. The haemodynamic instability may be caused directly by myocardial depression due to pathogenic substances released from the liver, or by acute blood loss.1 Creatine kinase(CK) and its MB fraction (CK-MB) are sensitive and specific indicators to reflect myocardial damage.2 Cardiac troponin I (cTnl) is a specific and sensitive marker of myocardial necrosis.3 This study assessed perioperative cardiac function using three indicators (CK,CK-MB,and CTnl) to evaluate perioperative myocardial damage.$4This study was supported by grants from the National Natural Science Foundation of China (No. 30271254) and Guangdong Medical Development Foundation (No. 2004B35001005)。

Carotid artery angioplasty and stenting (CAS) has been performed with increasing frequency for the treatment of extracranial carotid occlusive diseases (ECOD) in recent years. Its feasibility and safety are supported by the Stenting and Angioplasty with Protection in Patient at High Risk for Endarterectomy (SAPPHIRE) trial,1 which revealed a lower incidence of death, stroke and myocardial infarction compared with carotid endarterectomy (CEA) in high-risk patients. However, it is a pity that up to now, initial results of this endovascular procedure have yet been infrequently documented in China. This retrospective study was to analyze the short-term results of CAS to treat ECOD in a single medical center。

The traditional Chinese acupuncture has been reported to alleviate pain and is widely accepted as a complement therapy for pain relief in the world.1In 1996, a novel acupuncture strategy, Fu's subcutaneous needling (FSN), was developed from the traditional Chinese acupuncture, but quite different from it.2 In FSN, needles are penetrated and swayed in the subcutaneous layer, but not the muscular layer. The choosing of its insertion points doesn't obey the principles of traditional Chinese medicine. To date, FSN has been widely used by clinicians in China for its good job in pain management though the systemic and rigorous studies are still lack。

Primary cardiac hemangioendothelioma is extremely rare.1-3 Up to now less than twenty cases have been reported in English literature, the data about this kind of cardiac tumors are scanty. In this report, a case of a huge hemangio-endothelioma that arose from the right atrium and was successfully resected is presented。

Stiff-person syndrome (SPS, also called stiff-man syndrome) is a rare neurological disease with autoimmune features. It is characterized by fluctuating and progressive muscle rigidity, and episodic spasm that prominently involve axial and limb musculature.1,2 Herein we report a case of anesthetic management of a patient with SPS for thymectomy and review several other cases。