A national Israeli survey of neuraxial anesthesia for cesarean delivery: pre-operative block assessment and intra-operative pain management.

BACKGROUND: Neuraxial protocols for cesarean delivery differ among institutions, with various means of assessing the block prior to incision and managing breakthrough intra-operative pain. The different approaches used to deal with these issues in Israel have not been assessed. METHODS: Questionnaires were distributed to all anesthesiologists working in obstetric units in Israeli hospitals. The survey included several non-identifying respondent details intended to allow a description of the study population as a whole and multiple-choice questions addressing neuraxial techniques, method of pre-operative block assessment and medications used to treat intra-operative pain. RESULTS: Three hundred and sixty-one doctors completed the survey in 24 medical centers, an 81.1% response rate. Thirteen different protocols for spinal anesthesia and 20 different protocols for epidural anesthesia were described. Nine different protocols for assessment of the block prior to incision were identified, with significant inter-institutional differences (P <0.001). For treatment of intra-operative pain prior to delivery, 35.7% of spinals given and 40% of epidurals given were converted to general anesthesia whereas, after delivery, conversion of spinal to general anesthesia was 18% and epidural to general anesthesia was 18.6%. CONCLUSIONS: There were a variety of spinal and epidural regimens used as well as different methods for assessing the block and managing intra-operative pain. Further studies should be performed to identify optimal techniques for neuraxial anesthesia for pre-operative block assessment and for management of intra-operative pain.

[Evaluation of surgical repair of distal biceps tendon ruptures]. / Hodnocení operacní lécby rupt.

PURPOSE OF THE STUDY To present the results of surgical repair of ruptures of the distal tendon of the biceps brachii muscle and thus show the adequacy of this treatment. MATERIAL Between 1987 and 2006, 19 patients had surgery for distal biceps tendon rupture. Only one side was affected in each patient. All patients were men between 28 and 69 years (average age, 47.5 years) at the time of injury (surgery). When the patients were evaluated at the end of 2007, 18 patients were included, because one died a year after surgery. METHODS The surgical repair always included a single-incision anatomical reattachment into the radial tuberosity. In 11 patients, a modified Mac Reynolds method with screw and washer fixation was used; in seven patients the insertion was fixed with Mitek anchors and, in one, it was sutured to the adjacent soft tissues. The average follow-up was 7 years (range, 1 to 20.5 years). The patients were evaluated for the cause of injury, their physical activity, age, dominance of the injured arm, surgical procedure and complications. RESULTS In 18 patients surgical repair was done early and, in one, at 16 days after injury. In all of them the tendon was detached from its site of insertion, but never torn. The intra-operative complications included, in one patient, bleeding owing to iatrogenic damage to a branch of the brachial artery, and difficult separation of the tendon due to its previous healed injury in another patient. Early post-operative complications included superficial skin necrosis in one patient and transient neurological deficit of the dorsal brand of the radial nerve and of the lateral cutaneous nerve of the forearm in two and one patient, respectively. The late complications were heterotropic ossification in three patients and screw migration in the one treated by the Mac Reynolds method. Excellent results were recorded in 11 patients (61 %), and good outcomes with a slight restriction of motion or muscle strength not limiting the patient's physical activities were in six (33.5 %) patients; only one patient (5.5 %) experienced pain on moderate exercise and had recurrent heterotropic ossification. Apart from this condition, there was no difference in the frequency of complications associated with the method used. DISCUSSION Only sparse information on distal biceps tendon ruptures has been available in the relevant Czech literature and, if so, only small groups with short follow-ups have been involved. Conservative treatment or the methods of non-anatomical reattachment have poor functional outcomes. Much better results are achieved by anatomical reattachment. Based on our experience with the Mac Reynolds technique, an anterior single-incision approach using fixation with Mitek anchors can be recommended. CONCLUSIONS Early surgical repair involving anatomical reattachment from the anterior singleincision approach with two Mitek anchors is recommended when a rupture of the distal tendon insertion of the biceps brachii is diagnosed. Key words: biceps radii muscle, biceps tendon injury, tendon fixation, bone screw and washer use.

[Splenosis in the abdominal wall subcutis]. / Splenóza v podkozí brisni steny.

A case of subcutaneous splenosis in the abdominal wall of a 23-year-old oligophrenic man is reported. Further, the most important features of splenosis in various localisations are provided. The patient presented with a well-demarcated 8x7x5 cm subcutaneous tumour in the left inguinal area closely above the scar after a previous operation for hernia. The lesion simulated clinically a hernia or a tumour due to its large size and location. Additionally, no history could be taken from the patient due to his mental handicap. The diagnosis of splenosis was established histologically.

Blocking of the placental immune-modulatory ferritin activates Th1 type cytokines and affects placenta development, fetal growth and the pregnancy outcome.

BACKGROUND: Placenta immunomodulatory ferritin (PLIF) cDNA was recently cloned from the human placenta, where it is expressed in syncytiotrophoblast and decidual mononuclear cells. PLIF and its subcloned bioactive domain (C48), expressed in Escherichia coli, are immunosuppressive proteins and induce pronounced IL-10 production in vitro and in vivo. METHODS AND RESULTS: PLIF serum level, measured by enzyme-linked immunosorbent assay, was elevated in pregnant mice throughout gestation and declined towards delivery. Blocking of PLIF activity by vaccination of mice with C48 prior to mating inhibited pregnancy development. Passive transfer of anti-C48 immunoglobulin (Ig) starting at 3.5-12.5 days post coitum (dpc) resulted in high rate of embryo resorption. Furthermore, treatment with anti-C48 Ig resulted in placental and embryonal growth restriction. At gestation day 13.5, growth retardation was especially notable in the placentae, while at 16.5 dpc it was pronounced in the embryos. Histopathological examination revealed that experimental placentae were globally hypoplastic and the labyrinth was strikingly pale and contained less maternal blood compared with control. Immune-activated spleen cells harvested at 13.5 dpc from anti-C48 Ig-treated pregnant mice secreted in vitro increased level of Th1 cytokines (IL-2, TNF-alpha, IL-12) and decreased level of Th2 cytokines (IL-10, IL-4, IL-5, IL-6) as compared with the level of the respective cytokines secreted by spleen cells from control pregnant mice. CONCLUSION: This study provides the first in vivo evidence that PLIF plays a major role in placentation and embryonic growth.

[Liver metastasis in colorectal carcinoma]. / Jaterní metastázy kolorektálního karcinomu.

The authors describe the method and therapeutic results of liver metastases of colorectal carcinoma in a group of 14 patients followed up for 2 to 33 months. In these patients in five instances (35.7%) resection with subsequent intraarterial chemotherapy (HAI) was possible. In nine instances (64.3%) a chemoport was introduced, as resection was impossible due to the size of the lesion. For checking of the site and patency of the arterial chemoport, the authors recommend the use of port scintigraphy, a method which is accurate, accessible and simple.

[Enteral nutrition--nasojejunal tube or percutaneous jejunostomy?]. / Enterální výziva--nasojejunální sonda nebo punkcní jejunostomie?

As many as 60% patients develop malnutrition during the postoperative period. Enteral nutrition can prevent its development or at least mitigate its manifestations. The author mentions the advantages, disadvantages, indications and contraindications of enteral nutrition. He mentions tho advantages and disadvantages of two routes of establishment of enteral nutrition, i.e. by a nasoenteral tube and by puncture stomy. Of many possible procedures he describes experience with a nasojejunal tube and with puncture jejunostomy. He deals with complications he recorded with both methods and presents two case-histories of less common application of puncture jejunostomy. The author prefers the use of puncture jejunostomy to that of a nasojejunal tube and recommends its use after surgery of the upper GIT and in acute necrotizing pancreatitis.

Exclusive expression of the receptor tyrosine kinase MDK4 in skeletal muscle and the decidua.

Mouse developmental kinase 4 (MDK4), a novel receptor tyrosine kinase (RTK), was identified via degenerate primer screening of mouse embryo cDNA. The mRNA encoding this RTK was found only in skeletal muscle of mouse embryos and the maternal decidua. Northern blot analysis predicted an mRNA transcript size of 6.1 kb. The amino acid sequence is most closely related to Torpedo RTK. Analysis of mRNA and protein content of C2C12 cells at different stages of the differentiation process revealed increasing levels of MDK4 during this process. Immunofluorescence data indicated that MDK4 protein production begins with myoblasts elongation and is maintained throughout myotube formation. MDK4 transcripts were furthermore detected in the decidua tissue surrounding young embryos. Since decidua cells also form syncytia, it is possible that MDK4 is involved in the formation, regulation, and/or maintenance of the polynucleated state.

ERK6, a mitogen-activated protein kinase involved in C2C12 myoblast differentiation.

ERK6, a mitogen-activated protein (MAP) kinase-related serine/threonine kinase, is highly expressed in human skeletal muscle and appears to function as a signal transducer during differentiation of myoblasts to myotubes. In transfected 293 cells, activation of the 45-kDa enzyme results in tyrosine-phosphorylated 46- and 56-kDa forms, which phosphorylate myelin basic protein. Overexpression of wild-type ERK6 or the inactive mutant Y185F has no effect on fibroblast and myoblast proliferation, but it enhances or inhibits C2C12 cell differentiation to myotubes, respectively. Our findings suggest ERK6 to be a tissue-specific, differentiation signal-transducing factor that is connected to phosphotyrosine-mediated signaling pathways distinct from those activating other members of the MAP kinase family such as LRK1 and ERK2.

Lymph node (but not spleen) invasion by murine lymphoma is both CD44- and hyaluronate-dependent.

Similar to activated T cells, LB T cell lymphoma expresses the CD44 cell surface Ag. In addition, the vast majority of LB cells also express the beta 2 (CD18) and alpha L (CD11a) chains of LFA-1 integrin. In view of the finding that anti-CD18 mAb blocked spleen, but not lymph node invasion by LB cells inoculated s.c. into BALB/c mice, we tested the ability of anti-CD44 mAb (IM 7.8.1) to block the infiltration of LB cells into the lymph nodes. We found that, as opposed to anti-CD18 mAb, anti-CD44 mAb, as well as its F(ab')2 or Fab fragment, prevented lymph node infiltration but had no effect on spleen invasion. This conclusion was based on histologic examination and [3H]thymidine incorporation into proliferating LB cells invading the lymphoid organs. Histologic analysis further demonstrated that LB cells invade the lymph node via the afferent lymphatics. The surface expression of CD44 molecules on LB cells was enhanced after PMA activation. PMA activation also enabled in vitro binding of the lymphoma to hyaluronic acid (HA), a known ligand of CD44. Because anti-CD44 mAb, its F(ab')2 or Fab fragment, and hyaluronidase blocked this binding, we also tested the ability of the enzyme to inhibit lymph node invasion by LB cells. We established through histologic examination and [3H]thymidine incorporation that hyaluronidase protected the lymph node, but not the spleen, from invasion by the lymphoma.

Beta 2-integrin dependent aggregate formation between LB T cell lymphoma and spleen cells: assessment of correlation with spleen invasiveness.

LB is an aggressive T cell lymphoma which rapidly invades the spleen and lymph nodes of BALB/c mice after s.c. inoculation. We previously reported that mAb directed against the beta 2 chain of the leukocyte function-associated antigen-1 (LFA-1) adhesion molecule (CD18) blocked the invasion of LB cells into the spleen but not into the lymph nodes. The same antibody also blocked in vitro aggregate formation between normal spleen cells and LB cells. However, aggregate formation between normal lymph node cells and LB cells was not detected, regardless of ratio. In an attempt to evaluate the association between aggregate formation and tumor invasion of the lymphoid organs, we have now extended the study. Intravenous injection of anti-CD18 mAb, which blocked spleen invasion by LB cells, also blocked the formation of ex vivo aggregates, spontaneously generated in spleen, but not in lymph node, cell suspensions of BALB/c mice s.c. inoculated with LB cells. In contrast, mAbs unable to block spleen invasion were ineffective inhibitors of both in vitro and ex vivo aggregate formation between spleen and LB cells. Spleens of nude mice that did not provide a supportive environment for lymphoma invasion, were also deficient in target cells forming aggregates with LB cells. In line with this observation, enriched T cells formed more aggregates with LB cells than did enriched non-T cells, indicating the lymphoma's preferential binding to splenic T cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Blocking lymphoma invasiveness with a monoclonal antibody directed against the beta-chain of the leukocyte adhesion molecule (CD18).

The same integrin adhesion molecules used by normal leukocytes for traffic and localization in inflammation sites may be used by malignant cells for dissemination. Identifying the adhesion molecules and then blocking them with appropriate antibody may therefore prove useful for controlling tumor spread. This prediction was tested on a spontaneous murine T cell lymphoma (LB) that expresses LFA-1 adhesion molecules. The adhesion molecules were identified by fluorocytometry and immunoprecipitation with anti-CD18 mAb (M18/2). Subcutaneously inoculated LB lymphoma rapidly infiltrated the spleen and the lymph nodes, as indicated by histologic examination and [3H]thymidine incorporation assay of proliferating LB cells derived from the invaded organs. The normal organization of the lymphoid organs was totally effaced by the infiltrating LB cells. Intravenous injection of anti-CD18 mAb, protein G-purified anti-CD18 mAb, or its F(ab')2 fragments (but not irrelevant control mAb) blocked the invasion of the s.c. inoculated lymphoma into the spleen. Whereas i.v. injected anti-CD18 mAb could not block the infiltration of LB cells into the lymph nodes, local s.c. injection of this antibody near the lymph nodes partially inhibited lymphoma invasion into these organs. It was further found that LB cells form aggregates with spleen cells but not with lymph node cells. In addition, spleen-infiltrating LB cells invade both the spleen and the lymph nodes after s.c. injection. On the other hand, lymph node-infiltrating LB cells invade mainly the lymph nodes under similar circumstances.

[Ultrasonography as an aid in the detection of intestinal invagination]. / Ultrasonografie jako pomocná metoda pri odhalení invaginace strevní.

The authors demonstrate on two case-histories of intestinal invagination in children the effectiveness and aptness of ultrasonographic examination which contributes towards early diagnosis and therapy. They recommend this method therefore in case of obscure findings of the child abdomen as a routine examination.

Inflammatory response induced with an isolated syngeneic activation antigen shared by normal lymphoblasts and YAC lymphoma cells.

An immunogenic protein with an identical Mr (64 kDa) was isolated from syngeneic concanavalin A-induced lymphoblasts (syn-Con A-blasts) and YAC lymphoma cells, both derived from A mice. The 64-kDa protein was purified by a sequence of biochemical steps: Sephadex G-100 gel filtration, ion-exchange chromatography in a fast protein liquid chromatography system, Con A-Sepharose affinity chromatography, and preparative gel electrophoresis. The immunogenic fraction isolated in each step was moved to the next one, and so on. The immunogenicity of the separated fractions was measured by a lymph node proliferation (LNP) assay, which is indicative of a delayed-type hypersensitivity response. For instance, the final 64-kDa isolated protein of the syn-Con A-blasts induced an efficient LNP response in A mice which was detected after challenge with the final 64-kDa isolated protein of YAC cells. In addition to their identical molecular weight, both proteins were eluted at the same ionic strength and both expressed affinity to Con A-Sepharose beads, suggesting that they were glycosilated. Similar 64-kDa proteins were isolated by a different purification procedure, which was performed in the presence of protease inhibitors, excluding the possibility that the final antigen was an autodigested product. As the 64-kDa protein is immunogenic in the syngeneic host, it may be employed as a immunotherapeutic reagent against the original tumor and perhaps against other tumors expressing the same antigen.

[Postcholecystectomy syndromes]. / Postcholecystektomické syndromy.

The author analyzes postcholecystectomic complaints in 513 patients cholecystectomized in 1981-1985. He mentions the relationship between postcholecystectomic syndromes and preoperative complaints, the peroperative diagnosis and surgical operation. He recommends diagnostic investigations to elucidate the dyspepsia; the doctor must not be satisfied with the finding of cholecystolithiasis. The author also compares postcholecystectomic syndromes in patients with a biliodigestive anastomosis with papillosphincterotomy. The author analyzes in more detail the experience with treatment of nine patients, i.e. 1.75% patients with the finding of residual concrements.