Anesthetic drugs modulate feeding behavior and hypothalamic expression of the POMC polypeptide precursor and the NPY neuropeptide.

BACKGROUND: Several hypnotic drugs have been previously identified as modulators of food intake, but exact mechanisms remain unknown. Feeding behavior implicates several neuronal populations in the hypothalamic arcuate nucleus including orexigenic neuropeptide Y and anorexigenic pro-opiomelanocortin producing neurons. The aim of this study was to investigate in mice the impact of different hypnotic drugs on food consumption and neuropeptide Y or pro-opiomelanocortine mRNA expression level in the hypothalamic arcuate nucleus. METHODS: Saline control, isoflurane, thiopental, midazolam or propofol were administered to C57Bl/6 mice. Feeding behavior was evaluated during 6 h. In situ hybridization of neuropeptide Y and pro-opiomelanocortine mRNAs in the hypothalamus brain region was also performed. Data were analyzed by Kruskal Wallis test and analysis of variance (p < 0.05). RESULTS: Midazolam, thiopental and propofol induced feeding behavior. Midazolam and thiopental increased neuropeptide Y mRNA level (respectively by 106 and 125%, p < 0.001) compared with control. Propofol and midazolam decreased pro-opiomelanocortine mRNA level by 31% (p < 0,01) compared with control. Isoflurane increased pro-opiomelanocortine mRNA level by 40% compared with control. CONCLUSION: In our murine model, most hypnotics induced food consumption. The hypnotic-induced regulation of neuropeptide Y and pro-opiomelanocortine hypothalamic peptides is associated with this finding. Our data suggest that administration of some hypnotic drugs may affect hypothalamic peptide precursor and neuropeptide expression and concomittantly modulate food intake. Thus, this questions the choice of anesthetics for better care management of patients undergoing major surgery or at risk of undernutrition.

[Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of anesthesiology and intensive care (SFAR) and the French College of gynaecologists and obstetricians (CNGOF)]. / Republication de : recommandations formalisées d'experts. Prise en charge de la patiente avec une pré-éclampsie sévère­RFE communes Société française d'anesthésie-réanimation (SFAR)­Collège national des gynécologues et obstétriciens français (CGNOF).

OBJECTIVE: To provide national guidelines for the management of women with severe preeclampsia. DESIGN: A consensus committee of 26 experts was formed. A formal conflict of interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last SFAR and CNGOF guidelines on the management of women with severe preeclampsia was published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analyzed according to the GRADE® methodology. RESULTS: The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1±), 9 have a moderate level of evidence (GRADE 2±), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS: There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe preeclampsia.

Major complications after 400 continuous popliteal sciatic nerve blocks for post-operative analgesia.

BACKGROUND: A continuous popliteal sciatic nerve block (CPSNB) has been performed with increasing frequency for post-operative analgesia after foot surgery. Major complications associated with the placement of a perineural catheter remain rarely studied. The aim of this study was to prospectively determine the incidence of major complications (neurological and infectious) in post-operative adult patients with a continuous popliteal catheter inserted by the anatomical posterior approach for analgesia after foot surgery. METHODS: All popliteal catheters were placed pre-operatively under sterile conditions with the aid of a nerve stimulator technique. The primary outcome measure was the incidence of major complications including infection and neuropathy. As a secondary outcome, adverse effects as well as other complications were also evaluated. Data were expressed as median [25th-75th percentiles]. RESULTS: A total of 400 patients were included in the study during a 2-year period. The median time the catheter remained indwelling was 47 h [23, 54]. Major complications included three events (0.75%) with one infection (0.25%) and two neuropathies (0.50%). Three blocks were unsuccessful and the catheter insertion was difficult in 12 patients (3%). During the CPSNB procedure, one patient reported slight paraesthesia during stimulation. Patient satisfaction was scored at 4 for 89%, 3 for 6% and 2 for 5% on the analogue scale. CONCLUSIONS: Major complications after the use of CPSN are not in fact rare. The incidence of severe neuropathy or infection complications is, respectively, 0.50% and 0.25%. However, the insertion of CPSN could be considered effective and is associated with only a few minor complications.

Role of androgens and glucocorticoids in the regulation of diazepam-binding inhibitor mRNA levels in male mouse hypothalamus.

In peripheral organs, gonadal and adrenal steroids regulate diazepam-binding inhibitor (DBI) mRNA expression. In order to further investigate the involvement of peripheral steroid hormones in the modulation of brain DBI mRNA expression, we studied by semiquantitative in situ hybridization the effect of adrenalectomy (ADX) and castration (CX) and short-term replacement therapy on DBI mRNA levels in the male mouse hypothalamus. Cells expressing DBI mRNA were mostly observed in the arcuate nucleus, the median eminence and the ependyma bordering the third ventricle. In the median eminence and the ependyma bordering the third ventricule, the DBI gene expression was decreased in ADX rats and a single injection of corticosterone to ADX rats induced a significant increase in DBI gene expression at 3 and 12 h time intervals without completely restoring the basal DBI mRNA expression observed in intact mice. In the arcuate nucleus, ADX and corticosterone administration did not modify DBI mRNA expression. CX down-regulated DBI gene expression in the ependyma bordering the third ventricle. The administration of dihydrotestosterone (3-24 h) completely reversed the inhibitory effect of CX. In the median eminence and arcuate nucleus, neither CX or dihydrotestosterone administration modified DBI mRNA levels. These results suggest that the effects of glucocorticoids on the hypothalamo-pituitary-adrenocortical axis and androgens on the hypothalamo-pituitary-gonadal axis are mediated by DBI.

Residents in tutored practice exchange groups have better medical reasoning as measured by script concordance test: a controlled, nonrandomized study.

STUDY OBJECTIVE: Clinical reasoning by anesthesiology residents in emergency situations where optimal management is uncertain could be improved by setting up a tutored practice exchange group. This study attempted to evaluate the impact of a practice exchange group (PEG), tutored by a senior anesthesiologist, on anesthesiology residents in emergency situations. Changes in clinical reasoning were measured by script concordance tests (SCT). DESIGN: We conducted a controlled, non-randomized study. SETTING AND PARTICIPANTS: Participants are residents in anesthesiology in Rouen, Caen and Amiens University Hospitals. INTERVENTIONS: Two resident groups were made up without randomization. The first group was the control group and consisted of residents from Amiens University Hospital and Caen University Hospital. The second study group (PEG group) consisted of residents from Rouen University Hospital, who followed weekly PEG sessions. Two groups had the same learning objectives except the PEG. MEASUREMENTS: In both the control group and the study group, each resident's clinical reasoning was assessed in the same formal manner by SCT. The primary outcome measurement of this study was to compare SCT results in the study group with PEG training (PEG group) with those without (control group). MAIN RESULTS: Performance in the SCT, expressed as degree of concordance with the expert panel (95% CI), was better in the PEG group (64% [62.1%-66%]) than in control group (60% [57.5%-62.8%])) (P= .004). CONCLUSION: Our study strongly suggests that an expert-directed, peer-conducted educational training program may improve the clinical reasoning of anesthesiology residents as measured by SCT.

In vivo action of a new octadecaneuropeptide antagonist on neuropeptide Y and corticotropin-releasing hormone mRNA levels in rat.

It has been reported that several of the effects induced by an octadecaneuropeptide (ODN), derived from an 86-amino-acid polypeptide termed diazepam-binding inhibitor, could be mediated by activation of a metabotropic receptor. In order to investigate the role and mechanism of action of ODN in the regulation of corticotropin-releasing factor (CRH) and neuropeptide Y (NPY) expression in the paraventricular nucleus and arcuate nucleus, respectively, we studied the effects of the acute intracerebroventricular administration of ODN (2 microg/rat) and the ODN antagonist to metabotropic receptor, cyclo(1-8)[Dleu5]OP (20 microg/rat), on the gene expression of the two neuropeptides in castrated male rat. ODN administration resulted in a 45% increase in CRH mRNA expression, an effect which was reversed by cyclo(1-8)[Dleu5]OP. When cyclo(1-8)[Dleu5]OP was administered alone, it induced a 19% decrease in CRH mRNA levels. ODN administration induced a 17% decrease in NPY mRNA expression while cyclo(1-8)[Dleu5]OP increased by 21% the hybridization signal. The administration of both ODN and ODN antagonist completely abolished the depressing effect of ODN on NPY mRNA. These data suggest that the effects of ODN on CRH and NPY mRNA might be mediated by interaction with metabotropic receptors. Moreover, since cyclo(1-8)[Dleu5]OP can by itself influence the expression of two peptide mRNAs, it might be suggested that ODN is exerting a tonic influence on NPY and CRH neurons.

[Evaluation of continuous nerve block for postoperative pain management in orthopaedic surgery]. / Evaluation de la mise en place d'un protocole d'analgésie postopératoire par cathéter périnerveux.

OBJECTIVE: After orthopaedic surgery, continuous nerve block analgesia provides effective postoperative pain relief. The practical use of these techniques may present problems. The purpose of this study was to assess the development of continuous block procedure for postoperative pain based on quality standard management and the effectiveness of initial training as an adjunct for introduction of these techniques. MATERIALS AND METHODS: A staff committee of anaesthesiologists established a specific practical working protocol. The medical and paramedical teaching sessions were immediately evaluated using a questionnaire. RESULTS: 214 consecutive patients were included. The incidence of side effects and complications were higher in the beginning of protocol. Constant improvement of these results was observed throughout the study. The rate patients with pain were 10%. The analysis of medical evaluation should permit to determine an acceptable level of quality. Most patients were satisfied with their management. CONCLUSION: Pain management quality assurance program provided an improvement in efficacy of postoperative pain management in our protocol. Further, evaluation may be required to assess the complete benefits of this new protocol as regards postoperative pain.

In vivo action of a new octadecaneuropeptide (ODN) antagonist on gonadotropin-releasing hormone gene expression in the male rat brain.

It has been reported that several of the effects induced by octadecaneuropeptide (ODN) could be mediated by an activation of a metabotropic receptor. In order to investigate the role and mechanism of action of ODN in gonadotropin-releasing hormone (GnRH) neuron regulation, we studied the effects of the acute i.c.v. administration of ODN and of a new ODN antagonist to metabotropic receptor, cyclo(1-8)[Dleu(5)]OP, on GnRH mRNA expression as evaluated by in situ hybridization in castrated male rats. The administration of ODN produced a decrease in the hybridization signal while the administration of cyclo(1-8)[Dleu(5)]OP alone produced an 18% increase. When administrated concomitantly with ODN, the antagonist both inhibited the depressing effect of ODN and induced a 22% increase over the values detected in ODN-treated rats. The data suggest that the effect of ODN on GnRH mRNA expression might be mediated by interaction with metabotropic receptors.

Effect of intracerebroventricular administration of the octadecaneuropeptide on the expression of pro-opiomelanocortin, neuropeptide Y and corticotropin-releasing hormone mRNAs in rat hypothalamus.

Intracerebroventricular (i.c.v.) administration of the octadecaneuropeptide (diazepam-binding inhibitor [33-50]; ODN) exerts a potent anorexigenic effect in the rat. We studied the effect of ODN on three neuropeptides involved in feeding behaviour: the orexigenic peptide neuropeptide Y (NPY) and two anorexigenic peptides, corticotropin-releasing hormone (CRH) and the pro-opiomelanocortin (POMC)-derived peptide alpha-melanocyte-stimulating hormone. The effect of i.c.v. administration of ODN (0.1 microg/kg and 1 microg/kg) on mRNA expression of the peptides in male rat hypothalamus was evaluated by semiquantitative in situ hybridization. In the arcuate nucleus, NPY-expressing neurones were mostly found in the inner zone in close proximity of the third ventricle. ODN at the dose of 0.1 microg/kg induced a significant decrease of 17.4% in NPY mRNA expression, while the depressing effect was more marked (31.4%) with the highest dose of ODN (1 microg/kg). POMC-expressing neurones were more laterally located in the arcuate nucleus. Administration of ODN at 0.1 microg/kg and 1 microg/kg doses induced increases of 33.5% and 27.4% in POMC mRNA expression, respectively. Labelling obtained with the CRH cRNA probe was essentially distributed throughout the medial parvocellular area of the hypothalamic paraventricular nucleus. ODN, at doses of 0.1 and 1 microg/kg, resulted in 17.8% and 32.8% decreases in CRH mRNA expression, respectively. The present data suggest that ODN might exert its anorexigenic effect by increasing mRNA expression of POMC and decreasing mRNA expression of NPY in the arcuate nucleus.

Influence of medical speciality and experience on interpretation of helicoidal thoracic computed tomography in blunt chest trauma.

OBJECTIVE: To compare the quality of interpretation of chest helicoidal computed tomography (HCT) by physicians with different levels of experience and medical specialty. DESIGN: Prospective observational study. SETTING: Trauma critical care unit at a French university hospital (US equivalent: level 1). PATIENTS: HCT of 50 consecutive patients with blunt chest trauma were assessed by four groups of physicians [residents in anaesthesiology (n=5), residents in radiology (n=5), senior anaesthesiologists (n=5), and senior radiologists (n=5)]. Interpretation from each physician was compared with a grid obtained from an expert interpretation by a senior radiologist and a senior anaesthesiologist. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: No group of observers performed better than another in their interpretation of lung and parietal injuries on HCT. In contrast, senior radiologists were better than anaesthesiologists for the diagnosis of pneumomediastin. However, residents in radiology performed better than other physicians in detecting the presence of gastric and tracheal tubes. CONCLUSIONS: Compared with anaesthesiologists, senior radiologists seem more expert in the diagnosis of HCT mediastinal injuries whereas residents in radiology were better at detecting resuscitation materials in thoracic trauma patients. This article reinforces the usefulness of the interpretation of the HCT by a senior radiologist in the case of blunt chest trauma. This also reinforces the usefulness of an aspect team of radiologists and anaesthesiologists in the case of trauma. The logical usefulness of a systematic interpretation of the images should be borne in mind.

[Acute acalculous cholecystitis following hepatic artery embolism in multiple trauma]. / Cholécystite aiguë alithiasique après embolisation de l'artère hépatique dans un contexte de polytraumatisme.

We have reported a case of acute acalculous cholecystitis occurring after hepatic artery embolization in a woman sustaining multiple traumatic injuries. Although many classical factors such as shock, sepsis, transfusion or narcotic administration may be involved in the genesis of gall-bladder necrosis, we have discussed the possible involvement of hepatic artery embolization in the ischaemic process. Indeed, this mechanism has already been reported in non traumatic patient following hepatic tumor chemoembolization.

Remote cerebellar hemorrhage as an early and potentially lethal complication of a discal lumbar herniation surgery.

Remote cerebellar hemorrhage (RCH) is an infrequent but serious complication after lumbar herniation surgery. Little is known about this complication but excessive cerebrospinal fluid (CSF) leakage is thought to be a leading cause of RCH. We describe the case of a patient suffering from a life-threatening RCH, which occurred a few hours after lumbar disc herniation surgery.

[Interaction between hypnotic agents and the hypothalamic-pituitary-adrenocorticotropic axis during surgery]. / Modulation de l'axe hypothalamo-hypophyso-surrénalien par l'utilisation des agents hypnotiques dans le contexte chirurgical.

During stress, the relationship between the central nervous system and the immune system is essential to maintain homeostasis. The main neuroendocrine system involved in this interaction is the hypothalamic-pituitary-adrenal axis (HPA), which via the synthesis of glucocorticoids will modulate the intensity of the inflammatory response. Anaesthetic agents could be interacting with the HPA axis during surgery. Although etomidate currently remains in the center of the discussions, it seems, at least experimentally, that most hypnotics have the capacity to modulate the synthesis of adrenal steroids. Nevertheless, with the large literature on this subject, etomidate seems to be the most deleterious hypnotic agent on the HPA axis function. Its use should be limited when HPA axis is already altered.

[Magnesium sulfate in the prophylaxis of eclampsia: a retrospective study]. / Évaluation de l'utilisation du sulfate de magnésium dans la prévention secondaire de l'éclampsie: étude rétrospective sur 39 cas.

INTRODUCTION: The use of magnesium sulfate (MgSO(4)) has been advocated since 2000 in France in the management of eclampsia. The aim of this study was to determine the frequency of use of this treatment for eclampsia in a French department. PATIENTS AND METHODS: All patients obstetrical patients admitted to Critical Care Units of Seine-Maritime for eclampsia over a period of 7 years (2002-2008) were included. Obstetric data, the treatment used for eclampsia and pre-eclampsia and maternofetal complications were collected. The primary outcome parameter was the use of MgSO(4) in the secondary prevention of eclampsia. RESULTS: Thirty-nine patients were included. Nineteen patients (48%) had eclampsia in prepartum, three (8%) in per-partum and 17 (44%) in post-partum periods. The use of MgSO(4) in the secondary prevention of eclampsia was observed in 92% of cases (36/39). Primary prevention was seen in 8% of cases. The duration of treatment was 2 days (1-7 days). The maternal and perinatal mortality was respectively 2.5 and 11%. CONCLUSION: In this study, the use of MgSO(4) in the secondary prevention is frequent. This result emphasizes the importance of the recommendations of learned societies in the homogenization of the management of rare but serious conditions such as eclampsia.

[Evaluation of the impact of prescription analgesic during the anaesthesia consultation on the incidence of postoperative pain at home in ambulatory orthopaedic surgery]. / Évaluation de l'impact d'une prescription d'antalgiques réalisée lors de la consultation d'anesthésie sur l'incidence de la douleur à domicile en chirurgie ambulatoire orthopédique.

INTRODUCTION: Postoperative pain at home in ambulatory surgery is a major problem. To improve its management, the French society of anaesthesia emphasizes the importance of writing prescriptions for analgesic during the preanaesthetic consultation. The objective of this study was to assess the impact of this prescription on the incidence of postoperative pain at home in ambulatory orthopaedic surgery. PATIENT AND METHODS: We conducted a prospective evaluation in the ambulatory surgery unit of Rouen University Hospital. We were able to identify two periods of 1 year with implementation of a systematic prescription of analgesics during the postoperative period (P1) or during the preanaesthetic consultation (P2). The evaluation of this measurement was made by a telephone survey conducted the day after surgery. The main parameter was the incidence of postoperative pain at home defined by the occurrence of a pain greater to 3/10 on a numerical scale (FR). Secondary parameters were demographic and anaesthetic data, the incidence of moderate pain (FR ≤ 3), treatment adherence and patient satisfaction. RESULTS: We included 638 patients and 531 were analysed: 28% of patients had an EN greater than 3 the day following surgery. There is no difference between the two periods (30% for P1 versus 27% for P2). The analysis of subgroups showed that in the general anaesthesia group, 30% of patients had an EN greater than 3 for P1 versus 18% for P2 (P<0.01). Furthermore, 55% of patients expressed moderate pain (FR ≤ 3) for P1 versus 22% for P2 (P<0.01). Moreover, 89% of patients reported having an adequate analgesic treatment. The overall observance was 64%, 53% for P1 versus 75% for P2 (P<0.01). DISCUSSION: The systematic prescription of analgesics during the preanaesthetic consultation does not decrease the intensity of moderate to severe pain. On the other hand, this procedure seems to be positive for the people who underwent a general anaesthesia.

Acute food deprivation reduces expression of diazepam-binding inhibitor, the precursor of the anorexigenic octadecaneuropeptide ODN, in mouse glial cells.

In the central nervous system of mammals, the gene encoding diazepam-binding inhibitor (DBI) is exclusively expressed in glial cells. Previous studies have shown that central administration of a DBI processing product, the octadecaneuropeptide ODN, causes a marked inhibition of food consumption in rodents. Paradoxically, however, the effect of food restriction on DBI gene expression has never been investigated. Here, we show that in mice, acute fasting dramatically reduces DBI mRNA levels in the hypothalamus and the ependyma bordering the third and lateral ventricles. I.p. injection of insulin, but not of leptin, selectively stimulated DBI expression in the lateral ventricle area. These data support the notion that glial cells, through the production of endozepines, may relay peripheral signals to neurons involved in the central regulation of energy homeostasis.

[False capillary hyperglycaemia and true iatrogenic postoperative hypoglycaemia]. / Fausse hyperglycémie capillaire et vraie hypoglycémie iatrogène postopératoire.

We describe a case-report of a 64-year-old woman who presented an acute iatrogenic hypoglycaemia after gynecological surgery. An inadequate keeping of Dextrostix led to wrong hyperglycaemia measurement and inappropriate insulin administration. The mistake was treated with complete recovery.