Parálisis residual posoperatoria tras anestesia general sin monitorización neuromuscular objetiva: un estudio observacional en el Hospital Regional Docente de Cajamarca, Perú / Postoperative residual paralysis after general anesthesia without objective neuromuscular monitoring: An observational study at the Regional Cajamarca Hospital, Perú

Objetivo: Determinar la incidencia y severidad de la parálisis residual en pacientes sin monitorización neuromuscular intraoperatoria. Materiales y métodos: Se realizó un estudio prospectivo y observacional en 236 pacientes adultos ASA I-III intervenidos bajo anestesia general sin monitorización neuromuscular intraoperatoria. A su llegada a la Unidad de Cuidados Post-Anestesia (UCPA) se realizó la monitorización neuromuscular mediante aceleromiografía del músculo aductor del pulgar. La incidencia de parálisis residual con TOF ratio (TOFr) < 0,9 y TOFr < 0,7 fueron valorados. Resultados: La incidencia de parálisis residual en la UCPA con TOFr < 0,9 fue de 81,36% (IC 95%: 76,39-86,33) y con TOFr < 0,7 fue de 33,9% (IC 95%: 27,86-39,94). La neostigmina fue utilizada para revertir el bloqueo neuromuscular solamente en el 48,3% de los casos. La incidencia de parálisis residual con TOFr < 0,7 fue significativamente mayor entre los que no recibieron antagonistas del bloqueo neuromuscular y los que sí lo recibieron (42,62% vs. 24,56%, p=0.003). Conclusiones: La incidencia y severidad de la parálisis residual posoperatoria en pacientes sin monitorización neuromuscular fue elevada en nuestra institución, probablemente favorecida por una dosificación no guiada de los relajantes musculares, la escasa utilidad de los criterios subjetivos para valorar la recuperación de la función neuromuscular y la falta de reversión rutinaria del bloqueo neuromuscular.

Objective: To determine both the incidence and severity of residual paralysis in patients not undergoing intraoperative neuromuscular monitoring. Material and Methods: A prospective observational study was performed in 236 ASA I-III adult subjects who underwent surgery under general anesthesia without intraoperative neuromuscular monitoring. When patients were brought to the Post-Anesthesia Care Unit (PACU), neuromuscular monitoring was performed using acceleromiography of the adductor muscle of the thumb. The incidence of residual paralysis with TOF ratio (TOFr) values <0.9 and <0.7 was assessed. Results: The incidence of residual paralysis in the PACU with TOFr <0.9 was 81.36% (95% CI: 76.39%-86.33%) and with TOFr <0.7 was 33.9% (95% CI: 27.86%-39.94%). Neostigmine was used to revert neuromuscular blockade only in 48.3% of all cases. The incidence of residual paralysis with TOFr<0.7 was significantly higher in those subjects who did not receive neuromuscular blockade antagonists compared with those who did (42.62% vs. 24.56%, p= 0.03). Conclusions: Both the incidence and severity of residual postoperative paralysis in patients without neuromuscular monitoring was notoriously high in our institution, likely favored by a non-guided dosing of muscle relaxant agents, as well as due to low usefulness of subjective criteria for assessing recovery of neuromuscular function and the lack of routine reversion of neuromuscular blockade.

Complicación respiratoria en el postoperatorio tardío en un paciente con distrofia miotónica tipo I. Reporte de un caso / Respiratory complication in the late postoperative period in a patient with type I myotonic dystrophy. Case report

Myotonic dystrophy is an uncommon disease, characterised by disorders of the muscle membrane. Its clinical manifestations are muscle weakness, difficulty at initiating movements and delayed muscle relaxation. Carriers of this disease are very sensitive to anaesthetic drugs. Residual neuromuscular blockade is common among these patients, leaving them at risk of various postoperative complications. Proper neuromuscular blockade reversal is therefore crucial. We report the case of an 18-year-old male with myotonic dystrophy type I (Steinert's disease), who was admitted for a complicated hydatid cyst. He required a laparotomy, which was done under general anesthesia with no intraoperative incidents. He was extubated at the end of the procedure, with 94% response at the train-of-four (TOF) and adequate spontaneous ventilation. No reversal for neuromuscular blockade was given. The patient evolved favourably during the postoperative phase. However, in the later postoperatory period the patient presented severe respiratory complications. Proper anaesthetic management of these patients, as described in the literature, includes the use of non-depolarising muscle relaxants, monitoring of muscle relaxation and reversal of neuromuscular blockade. The combination of rocuronium and sugammadex appears to convey the optimum reversal required for these cases.

Las distrofias miotónicas son enfermedades poco comunes, caracterizadas por trastornos a nivel de la membrana muscular. Clínicamente se manifiestan por debilidad muscular progresiva, dificultad al iniciar movimientos y retardo en la relajación muscular. Los portadores de este grupo de enfermedades tienen una marcada sensibilidad a los fármacos anestésicos. Es habitual que presenten bloqueo neuromuscular residual, arriesgándose a sufrir diversas complicaciones postoperatorias. Por ello, es importante realizar una reversión adecuada de la relajación muscular en estos pacientes. Presentamos el caso de un paciente masculino de 18 años, con distrofia miotónica de Steinert tipo I, que ingresa para laparotomía por quiste hidatídico hepático complicado. Recibió anestesia general sin incidentes. Es extubado con una respuesta al tren-de-cuatro (TOF) de 94% y ventilación espontánea adecuada. No se realiza reversión del bloqueo neuromuscular y evoluciona favorablemente en el postoperatorio inmediato. Sin embargo, en el período postoperatorio tardío, presenta complicaciones respiratorias severas. El adecuado manejo de estos pacientes, según lo recomendado en la literatura, requiere el uso de relajantes no-depolarizantes, monitorización y reversión del bloqueo neuromuscular, siendo probablemente la combinación de rocuronio y sugammadex, la más adecuada para estos fines.

Immunotherapy in esophageal cancer / 国际肿瘤学杂志

Tumor progression is often associated with immune suppression or the ability of the tumors to avoid immune surveillance.Immunotherapy improves the ability of the immune system to recognize and clear tumor cells with a little influence on the normal tissues.Immunotherapy is a hot spot in the research of advanced esophageal cancer.Innnunotherapy of esophageal cancer includes immune checkpoint inhibitors,adoptive cellular immunotherapy,tumor vaccines and antibody therapy.At present,a large number of clinical trials are underway to evaluate the role of immunotherapy in esophageal cancer.Checkpoint inhibitors represented by Pembrolizumab and Nivolumab,has achieved initial success in the treatment of advanced esophageal cancer to improve the prognosis and life quality of esophageal cancer patients.In the future,further studies are needed to have a research on the effects of tumor heterogeneity,prediction of therapeutic targets,and immune tolerance.

Advances of immune checkpoint blockades in the treatment of digestive cancers / 国际肿瘤学杂志

Immune checkpoint blockade is a hot spot in treatment of cancers recently,and their effi-cacy in digestive cancer cannot been ignored.Nivolumab is superior to sorafenib in the terms of prolonging survival period for the patients with advanced live cancer.The effective rate of Pembrolizumab for advanced PD-L1 positive expression esophageal cancer can reach 30%.Nevertheless,Ipilumumab shows no significant efficacy in advanced pancreatic carcinoma.More researches are on the way,such as Avelumab in advanced gastric cancer,and Pembrolizumab in advanced esophageal squamous carcinoma.

Radiotherapy and immune checkpoint blockades: a snapshot in 2016

Immune checkpoint blockades including monoclonal antibodies (mAbs) of cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1), and programmed death-ligand 1 (PD-L1) have been emerged as a promising anticancer therapy. Several immune checkpoint blockades have been approved by US Food and Drug Administration (FDA), and have shown notable success in clinical trials for patients with advanced melanoma and non-small cell lung cancer. Radiotherapy is a promising combination partner of immune checkpoint blockades due to its potent pro-immune effect. This review will cover the current issue and the future perspectives for combined with radiotherapy and immune checkpoint blockades based upon the available preclinical and clinical data.

Advances in immunocheckpoint blockades in the treatment of non-small cell lung cancer / 中国肿瘤临床

In China, most patients with non-small cell lung cancer (NSCLC) were diagnosed with advanced or metastatic disease on first admission. These patients were treated by chemotherapy, radiotherapy, or targeted therapy. However, the 5-year overall survival rate is still low. Immunocheckpoint blockades adjust the immune function, dispatch immune escape, enhance T cell activation, and kill tumor cells. Immunocheckpoint blockade becomes one of the important methods of anti-tumor treatments. This approach may also change the model of NSCLC treatment because of its promising anti-tumor activity. This review summarizes the clinical trials on immu-nocheckpoint blockades in NSCLC and the possibility of combining this technique with other treatments.

Political Environment and Conditions of Protest: Manipur Experience.

The purpose of this paper is to initiate an exploration of various environmental factors associated with the incidence of collective social protest activities, which is directed mostly towards the state authority and its agencies in Manipur. Good governance is considered to be a requisite for the smooth functioning of the state machineries, which induces an ideal environment for the socio-economic development of the state as well as its citizens. The legitimacy of the state authority is dependent on the trust the people has on the authority. This legitimacy of authority and trust could be sustained by the conventional functioning of the state agencies such as the courts and the police. The courts and the police are the two main agencies of the state which is directly responsible for the rights, justice, equality and safety of its citizens. When these two agencies are unresponsive in a political setup, it gives rises to conditions of social protest activities.

Bloqueo radicular lumbar selectivo guiado por TAC Alternativa para diagnòstico y tratamiento de radiculopatìas originadas por hernias discales y/o artrosis facetarias / Selective lumbar radicular lock replacement for CT-guided diagnosis and treatment of radiculopathy caused by herniated discs and / or facet arthrosis

El presente estudio muestra experiencia en la realización de bloqueos facetarios periarticulares y radiculares lumbares guiados Por Toomografía Axial Computada (TAC), en pacientes con dolor lumbar, o lumbociático provocado por estenosis foraminales de diversas causas, especialmente las secundarias a hernias discales foraminales sin manifestaciones de déficit motor y artrosis facetarias, en estos casos, la causa del dolor se supone se debe ala isquemia que afecta directamente las raíces nerviosas y produce sìntomas. Se realizó la evaluaciòn de 55 pacientes a los que se les efectuó este procedimiento entre los años 2007-2010 con diagnóstico de radiculopatía lumbar provocados por estenosis foraminales secundarias a hernias discales foraminales sin manifestaciones de deficít motor y artrosis facetarias y que no mejorarón con tratamiento médico - kinésico en 4 a 6 semana. 40 Hombres y 15 mujeres con edades entre 35 y 84 años. se realizaron 45 bloqueos de raíces nerviosas, a 10 pacientes se le realizó en dos espacios simultáneo en forma homolateral, y 10 facetarios periarticulares, 8 en forma bilateral. el 90% de los pacientes y refirió mejoría inmediata después del procedimiento, con resultados variables a largo plazo. la duración de la mejoría del dolor fue variable y osciló en un rango de 15 días hasta en forma permanente en el 80% de los casos. Los procedimientos en su mayoría se realizaron con internación de 24 horas. No se presentaron complicaciones técnicas ni posteriores a la inyección. En nuestra experiencia los mejores resultados se encuentran en el dolor radicular con el diagnóstico de hernia discal foraminal. Se concluye con los bloqueos facetarios y radiculares constituyen un método diagnóstico y terapéutico que puede realizarse con mucha precisión y seguridad utilizando la ayuda de imágenes diagnósticas, especialmente la TAC siendo útiles para la localización del origen del dolor y para decidir un eventual tratamiento definitivo...

SUMMARY: The following study shows our experience doing TAC-guided lumbar facet periarticular and radicular blockades in patients with lumbar or lumbociatic pain caused by foraminal stenosis due to different causes, specially those secondary to foraminal disc herniantions without motor impairment and facetary arthrosis (in these cases, the cause of the pain is supposed to be due to ischemia affecting the nerve roots which causes the symptoms). We evaluated patients to whom the procedure was performed between 2007 and 2010, with diagnosis of lumbar radiculopathy caused by foraminal stenosis secondary to foraminal disc herniations without evidence of motor impairment and facetary arthrosis, whichdidn' t improve with kinesic medical treatment in 4 to 6 weeks. 55 patients were incluided, 40 men and 15 women, between 35 and 84 years. 45 nerve root blockades, in 10 patients it was done homolaterally in two space simultaneously, and 10 periarticular facetary blockades were performed, 8 bilateral, 90% of the patients refered immediate improvement of the symptoms after the procedure, with variable long-term results. The duration of the pain relief was variable and ranged from 15 days to permanent in 80% of the cases. In most of the cases the procedure was done with 24-hour hospital stay. There were no complications, neither technical nor following the injections. In our experience the best results are achieved in the treatment of radicular pain with the diagnosis of foraminal disc herniation. In conclusion, facetary and radicular blockades represent highly precise and safe, both therapeutic and diagnostic methods, that could be used with the aid of diagnostic images, specially TAC, to localize the origin of the pain as well as to decide an eventual definitive treatment.

Neuromuscular blockade and pharmacokinetic-pharmacodynamic modeling

A major goal in pharmacokinetic-pharmacodynamic (PK/PD) modeling of neuromuscular blockade (NMB) is to quantitatively estimate the dose-response relationship.Our PK/PD model consists of three submodels:PK, link kinetics, and PD.A virtual effect compartment in which the drug concentration is in equilibrium with the observed concentration is used to extract the kinetic component (keo) from the pharmacodynamic data alone.Parameters of this model are keo, Ce(50), and gamma.The underlying structural pharmacokinetics and pharmacodynamics for NMB have been well understood, and new novel PK/PD models have been substituted for the gold standard PK/PD model for NMB.The purpose of this review was to describe progress in the field of PK/PD modeling of NMB from the first model, a simultaneous PK/PD model developed by Sheiner et al in the 1970s, to some of the more complicated models.Specific PK/PD models, which accurately described the behaviors of rocuronium, mivacurium, atracurium, and cisatracurium, include the recirculatory model, the peripheral link model, the peripheral elimination model, and a nonparametric model for link kinetics.

Comparison of Different Analgesia Methods after Pediatric Half Inguinal Hernia Repair / 实用儿科临床杂志

ObjectiveTo compare the efficacy and side effects of ilioinguinal/iliohypogastric nerve blockades and rectal paracetamol after pediatric inguinal hernia repair.MethodsNinety children undergoing half inguinal hernia repair were randomly divided into 3 groups:nerve block group(n=30),paracetamol group(n=30) and control group(n=30).After basal anesthesia,ilioinguinal/iliohypogastric nerve blockades was administed in nerve block group,paracetamol group received rectal paracetamol,control group had not any medication.Every child was oberserved 1,3,6,8 h postoperatively for pain score,overall satisfaction were evaluated by parents,furthermore,evaluation of distress for children such as nausea,vomiting and delayed femoral nerve palsy was made.ResultsPain scores were significantly lower in nerve block group and paracetamol group during the postoperative follow-up 1,3 and 6 h.Overall satisfaction in nerve block group and paracetamol group were significantly higher than control group.The incidence of delayed femoral nerve palsy in nerve block group was higher than paracetamol group(F=4.22P

Role of Endogenous Histamine on the Pathogenesis in the Endotoxin-Induced Acute Lung Injury / 결핵

BACKGROUND: Histamine is widely distributed in the lung. It increases capillary permeability and the P-selectin expression on vascular endothelial cell surfaces. We studied the role of endogenous histamine on the pathogenesis of endotoxin-induced acute lung injury (ALI) in rats. METHODS: We instilled either normal saline (control group) or lipopolysaccharide (3 mg/Kg, LPS group) to tracheas of Sprague-Dawley rats. H1-receptor blocker (mepyramine, 10 mg/Kg, H1RB group), H2-receptor blocker (ranitidine, 10 mg/Kg, H2RB group), and H3-receptor blocker (thioperamide, 2 mg/Kg, H3RB group) were administered through vein or peritoneum along with intratracheal LPS administration. Statistical significance was accepted at p<0.05. RESULTS: LPS increases the histamine level in BAL fluid significantly at 2 h after the treatment compared with control group. LPS significantly increases protein concentration, PMN cell count in bronchoalveolar lavage (BAL) fluid, and myeloperoxidase (MPO) activity in the lung tissue at 6 h compared to control group. PMN cell count in BAL fluid and MPO activity in lung tissue were significantly lower in H2RB-group compared to LPS-group. However, protein concentration in BAL fluid showed no significant differences between the LPS alone and LPS with histamine receptor blockade. CONCLUSIONS: Endogenous histamine might be involved in the recruitment of PMNs in LPS-induced ALI via H2 receptor. However, its role in ALI would not be significant in this model.

Role of Endogenous Histamine on the Pathogenesis in the Endotoxin-Induced Acute Lung Injury / 결핵

BACKGROUND: Histamine is widely distributed in the lung. It increases capillary permeability and the P-selectin expression on vascular endothelial cell surfaces. We studied the role of endogenous histamine on the pathogenesis of endotoxin-induced acute lung injury (ALI) in rats. METHODS: We instilled either normal saline (control group) or lipopolysaccharide (3 mg/Kg, LPS group) to tracheas of Sprague-Dawley rats. H1-receptor blocker (mepyramine, 10 mg/Kg, H1RB group), H2-receptor blocker (ranitidine, 10 mg/Kg, H2RB group), and H3-receptor blocker (thioperamide, 2 mg/Kg, H3RB group) were administered through vein or peritoneum along with intratracheal LPS administration. Statistical significance was accepted at p<0.05. RESULTS: LPS increases the histamine level in BAL fluid significantly at 2 h after the treatment compared with control group. LPS significantly increases protein concentration, PMN cell count in bronchoalveolar lavage (BAL) fluid, and myeloperoxidase (MPO) activity in the lung tissue at 6 h compared to control group. PMN cell count in BAL fluid and MPO activity in lung tissue were significantly lower in H2RB-group compared to LPS-group. However, protein concentration in BAL fluid showed no significant differences between the LPS alone and LPS with histamine receptor blockade. CONCLUSIONS: Endogenous histamine might be involved in the recruitment of PMNs in LPS-induced ALI via H2 receptor. However, its role in ALI would not be significant in this model.