Protective Effect of N-Acetyl-Cysteine (NAC) in Lipopolysaccharide (LPS)-Associated Inflammatory Response in Rat Neonates.

OBJECTIVE: Increased inflammatory response may be associated with adverse clinical outcomes, especially in the neonatal period. The aims of this study were to determine whether N-acetyl-cysteine (NAC), an anti-inflammatory agent, attenuates the inflammatory response in young rats and to determine the most effective route of administration. METHODS: Four groups of Sprague-Dawley rats (in each group four rats) were studied at 30 days of age. One hour following intraperitoneal (IP) injection of lipopolysaccharide 50 µg/kg, the rats were randomized to subcutaneous (SC), per os (PO), or intraperitoneal (IP) injection of NAC 300 mg/kg, or saline. The control group received saline injection (IP). Three hours following the N-acetyl-cysteine injection the rats were sacrificed, then serum tumor necrosis factor-α (TNF-α) and IL-6 levels were determined by ELISA. RESULTS: Lipopolysaccharide significantly increased the neonatal serum IL-6 and TNF-α (2051.0±349 and 147.0±25.8 pg/mL, respectively; P<0.01) levels compared to 10 pg/mL in the controls. N-acetyl-cysteine administered one hour following lipopolysaccharide injection significantly attenuated the inflammatory response. Intraperitoneal administration of NAC decreased IL-6 and TNF-α concentration to 294.6 and 17.1 pg/mL, respectively, and was more effective than SC or PO administration. CONCLUSIONS: N-acetyl-cysteine attenuated the inflammatory response in the neonatal rats, and IP was the most effective administration route.

Combined spinal and general anesthesia vs general anesthesia for robotic sacrocervicopexy: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Gynecologic laparoscopic surgery is frequently accompanied by early postoperative pain. This study assessed the effect of combined general and spinal anesthesia on postoperative pain score, analgesic use, and patient satisfaction following robotic surgeries. METHODS: This was a randomized controlled trial. Thirty-eight consecutive women who underwent robotic surgeries for pelvic organ prolapse (sacrocolpopexy with or without subtotal hysterectomy) were randomly assigned to receive general anesthesia (control group, n = 20) or combined general with spinal anesthesia (study group, n = 18). Pain scores were assessed at rest and while coughing using a visual analog scale (VAS) 0-10. Dosage of analgesic medication consumption was retrieved from patients' charts. RESULTS: There were no statistically significant differences between the two groups with respect to demographic data and intraoperative hemodynamic parameters. In the postanesthesia care unit (PACU) mean total IV morphine and meperidine dosages were significantly lower for the study than the control group (0.33 vs 7.59 mg, 1.39 vs 27.89 mg, respectively, P < 0.003, <0.001, respectively). In addition, a significantly lower percentage of patients belonging to the study group demanded analgesic medications while in the PACU (33 vs 53 %, P = 0.042). Pain scores in the PACU and during postoperative day 1 were significantly lower in the study group than in the control group (delta VAS 1.9 vs 3.0, P = 0.04). Satisfaction with pain treatment among both patients and nurses was significantly higher in the study group. CONCLUSIONS: Reported levels of pain and analgesic use during the first 24 h following robotic gynecologic surgery were significantly lower following general and spinal anesthesia compared to general anesthesia alone.

Implementation of a new procedure: laparoscopic versus robotic sacrocolpopexy.

PURPOSE: The purpose of this study was to compare the implementation process and the learning curves of laparoscopic and robotic-assisted laparoscopic sacrocolpopexy (LSC and RSC, respectively) for vaginal apex prolapse. METHODS: A retrospective study of the first 40 LSC and first 40 RSC procedures performed at one medical center. The primary outcomes were intraoperative bleeding, operative time, and hospitalization. Secondary outcomes were surgical complications. The independent t test, paired t test, χ(2) test, Fisher's exact test and Pearson's correlation were used to analyze the data. We assumed that 34 participants were needed in each group to detect a 50 ml or more difference in estimated blood loss between laparoscopic and robotic surgeries, MAIN RESULTS: Age, preoperative pelvic organ prolapse quantification (POPQ) staging, and concomitant medical disorders did not differ significantly by procedure type. For LSC and RSC, the mean estimated intraoperative blood loss was 206 ± 107 and 48 ± 55 ml, P < 0.0001; mean operative times were 176 (110-380 min) and 186 (105-345 min), P = 0.34; and mean length of hospital stay, 3.8 ± 1 and 2.4 ± 1 days, P < 0.0001, respectively. Adverse events were rare, not severe, and did not differ significantly by procedure type. CONCLUSIONS: RSC and LSC are feasible procedures with acceptable complication rates. RSC enables operating more anatomically with less bleeding.

N-acetyl-cysteine (NAC) attenuates LPS-induced maternal and amniotic fluid oxidative stress and inflammatory responses in the preterm gestation.

OBJECTIVE: Maternal infection is associated with oxidative stress and inflammation. We sought to determine whether N-acetyl-cysteine can decrease maternal oxidative stress and the inflammatory response in preterm gestation. STUDY DESIGN: Pregnant rats 16 days, were treated with (1) lipopolysaccharide, (2) N-acetyl-cysteine 120 minutes after lipopolysaccharide, or (3) saline solution (intraperitoneal). Six hours after lipopolysaccharide administration, serum lipid peroxide formation (LPO), tumor necrosis factor-α, interleukin-6, and interleukin-1ß levels in maternal serum and amniotic fluid were determined. RESULTS: Lipopolysaccharide significantly increased maternal serum lipid peroxide formation (24-118.5 nmol/mL; P < .05), and maternal serum and amniotic fluid tumor necrosis factor-α, interleukin-6, and interleukin-1ß. N-acetyl-cysteine treatment after lipopolysaccharide significantly attenuated lipid peroxide formation (47.5 nmol/mL) and proinflammatory cytokines response in maternal serum and amniotic fluid. CONCLUSION: Maternal and amniotic fluid oxidative stress and inflammatory stimulation are attenuated by N-acetyl-cysteine even when administered after lipopolysaccharide. These results suggest that N-acetyl-cysteine may protect the fetus from adverse sequelae associated with inflammatory stimulation.

Maternal lipopolysaccharide-induced inflammation during pregnancy programs impaired offspring innate immune responses.

OBJECTIVE: Because the fetal innate immune system is responsive, while still maturing during the preterm period, we hypothesized that the early activation of fetal inflammatory pathways may have an impact on the ultimate expression of immune competency. STUDY DESIGN: Pregnant Sprague Dawley rats (n = 7; Harlan Sprague Dawley Inc, Jerusalem, Israel) at 18 days gestation received intraperitoneal injections of saline solution or lipopolysaccharides (500 microg/kg). Pups were delivered spontaneously. At postnatal day 24, pups received intraperitoneal lipopolysaccharide (100 microg/kg), and plasma cytokine levels were measured before and 4 hours after lipopolysaccharide administration. RESULTS: In response to lipopolysaccharides, pups of the lipopolysaccharide-injected dams had significantly (P < .05) reduced interleukin-6 (median [25th,75th percentile], 229 [84,6086] vs 4745 [2765,6643] pg/mL), interleukin-1beta (median [25th,75th percentile], 820 [125,1196] vs 1682 [1515,2127] pg/mL), tumor necrosis factor-alpha (median [25th,75th percentile], 4.8 [1.2,91] vs 163 [46,205] pg/mL), and interleukin-10 responses, when compared with saline solution-injected dams. CONCLUSION: Maternal lipopolysaccharide exposure suppresses offspring innate immune response to inflammatory stimuli. These results suggest that maternal inflammatory exposures during pregnancy may impair newborn infant innate responses and increase susceptibility to infection.

Focused helical CT using rectal contrast material only as the preferred technique for the diagnosis of suspected acute appendicitis: a prospective, randomized, controlled study comparing three different techniques.

PURPOSE: Focused helical CT using rectal contrast material only has emerged recently as an accurate diagnostic tool for the evaluation of suspected acute appendicitis. This study was designed to prospectively compare the efficacy of rectal contrast CT to other commonly used contrast-enhanced and nonenhanced CT techniques for the detection of acute appendicitis. METHODS: A total of 232 patients with clinically suspected appendicitis were randomly assigned to one of three focused helical CT techniques: noncontrast enhanced CT, CT using rectal contrast material only, and dual-contrast CT using both oral and intravenous material. All scans were interpreted by the on-call residents and reported immediately to the surgeon. The sensitivity, specificity, predictive values, and overall accuracy rates were compared between the protocols. RESULTS: One hundred eleven patients (48 percent) had acute appendicitis. The sensitivity and specificity rates of rectal contrast CT were 93 and 95 percent, respectively, with overall accuracy of 94 percent. The sensitivity and specificity rates of dual-contrast CT were 100 and 89 percent, respectively, with overall accuracy of 94 percent. The sensitivity and specificity of noncontrast enhanced CT were 90 and 86 percent, respectively, but the overall accuracy was significantly lower (70 percent) compared with the other studies. CONCLUSIONS: Rectal contrast CT is as accurate, although less sensitive, compared with dual-contrast CT and significantly superior to noncontrast-enhanced CT for the diagnosis of acute appendicitis. Rectal contrast CT may be performed rapidly, saves resources, and may avoid the diagnostic delay and potential allergic reactions associated with oral and intravenous-enhanced studies, and, therefore, may be the preferred initial technique in the diagnostic workup of suspected acute appendicitis.

Structural and biochemical basis for novel mutations in homozygous Israeli maple syrup urine disease patients: a proposed mechanism for the thiamin-responsive phenotype.

Maple syrup urine disease (MSUD) results from mutations affecting different subunits of the mitochondrial branched-chain alpha-ketoacid dehydrogenase complex. In this study, we identified seven novel mutations in MSUD patients from Israel. These include C219W-alpha (TGC to TGG) in the E1alpha subunit; H156Y-beta (CAT to TAT), V69G-beta (GTT to GGT), IVS 9 del[-7:-4], and 1109 ins 8bp (exon 10) in the E1beta subunit; and H391R (CAC to CGC) and S133stop (TCA to TGA) affecting the E2 subunit of the branched-chain alpha-ketoacid dehydrogenase complex. Recombinant E1 proteins carrying the C219W-alpha or H156Y-beta mutation show no catalytic activity with defective subunit assembly and reduced binding affinity for cofactor thiamin diphosphate. The mutant E1 harboring the V69G-beta substitution cannot be expressed, suggesting aberrant folding caused by this mutation. These E1 mutations are ubiquitously associated with the classic phenotype in homozygous-affected patients. The H391R substitution in the E2 subunit abolishes the key catalytic residue that functions as a general base in the acyltransfer reaction, resulting in a completely inactive E2 component. However, wild-type E1 activity is enhanced by E1 binding to this full-length mutant E2 in vitro. We propose that the augmented E1 activity is responsible for robust thiamin responsiveness in homozygous patients carrying the H391R E2 mutation and that the presence of a full-length mutant E2 is diagnostic of this MSUD phenotype. The present results offer a structural and biochemical basis for these novel mutations and will facilitate DNA-based diagnosis for MSUD in the Israeli population.