Alternative pathway activation of complement in laparoscopic and open rectal surgery.

The study was designed to investigate whether complement is activated in patients subject to rectal surgery and whether the choice of surgical technique (open or laparoscopic) has any impact on the activation of complement. Our hypothesis is that laparoscopic surgery leads to a lower-level activation of complement than open surgery. Patients (n = 24) subject to rectal surgery owing to rectal cancer were included. The study was prospective and randomized. The patients were randomized to either laparoscopic surgery (n = 12) or open surgery (n = 12). Blood samples for determination of complement activation (C4d, Bb, C3bc and the terminal C5b-9 complex TCC) were drawn before start of surgery (T0) and at the following time-points after start of surgery: 180 min (T1), 360 min (T2), 24 h (T3) and 3-5 days (T4). A significant increase in the alternative pathway activation product Bb and in the terminal pathway activation product TCC was seen over time in both groups (P < 0.001). Bb peaked early (T1) and returned to baseline levels post-operatively, whereas TCC increased steadily with maximum values in the late post-operative period. The plasma concentrations of C4d and C3bc decreased significantly in both groups at T1 and T2 and returned to baseline levels at T4. There was no significant difference between the groups. Rectal surgery causes activation of the complement system. Complement is activated through the alternative pathway. Results mostly showed no significant differences between laparoscopic and open rectal surgery apart from lower levels of factor Bb in the former group in the perioperative period.

Complement activation and interleukin response in major abdominal surgery.

The objective of this study was to evaluate whether major abdominal surgery leads to complement activation and interleukin response and whether the kind of anaesthesia influence complement activation and the release of inflammatory interleukins. The study design was prospective and randomised. Fifty patients undergoing open major colorectal surgery due to cancer disease or inflammatory bowel disease were studied. Twenty-five patients were given total intravenous anaesthesia (TIVA) with propofol and remifentanil, and 25 patients were given inhalational anaesthesia with sevoflurane and fentanyl. To determine complement activation (C3a and SC5b-9) and the release of pro- and anti-inflammatory interleukins (tumour necrosis factor-a (TNF-a)), interleukin-1b (IL-1b), IL-6, IL-8, IL-4 and IL-10), blood samples were drawn preoperatively, 60 minutes after start of surgery, 30 minutes after end of surgery and 24 hours postoperatively. Complement was activated and pro-inflammatory interleukins (IL-6 and IL-8) and anti-inflammatory interleukins (IL-10) were released during major colorectal surgery. There was no significant difference between TIVA and inhalational anaesthesia regarding complement activation and cytokine release. Major colorectal surgery leads to activation of the complement cascade and the release of both pro-inflammatory and anti-inflammatory cytokines. There are no significant differences between total intravenous anaesthesia (TIVA) with propofol and remifentanil and inhalational anaesthesia with sevoflurane and fentanyl regarding complement activation and the release of pro- and anti-inflammatory interleukins.

Inflammatory response in patients undergoing colorectal cancer surgery: the effect of two different anesthetic techniques.

BACKGROUND: Anesthesia during surgery often induces an inflammatory response. The aim of this study was to establish and compare differences in inflammatory response among colorectal cancer surgery patients receiving either total intravenous anesthesia (TIVA) with propofol and remifentanil or inhalational anesthesia (INHAL) with sevoflurane and fentanyl. METHODS: After randomization, we included fifty consecutive patients undergoing colorectal cancer surgery in our study. TIVA patients received total intravenous anesthesia with propofol and remifentanil, while INHAL patients received inhalation anesthesia with sevoflurane in O2/air and fentanyl. Plasma concentrations of IL-8, IL-17, MPO, ICAM-1, V-CAM and L-selectin were quantified. Blood loss, body temperature and blood glucose levels were measured in patients both before and after surgery. RESULTS: In both groups, levels of IL-8, MPO, ICAM-1 and L-selectin decreased 60 min after the start of surgery (P<0.05, P<0.01, respectively) and 30 min post-surgery (P<0.05 for both groups). In the INHAL group, V-CAM levels were significantly lower 60 min after the start of surgery (P<0.01) and 30 min post-surgery (P<0.05). At 24 h post-surgery, V-CAM levels were significantly higher in both groups (P<0.01), while IL-17 levels significantly increased only in the INHAL group (P<0.05). Higher blood glucose levels were also observed in the INHAL group compared to that in the TIVA group (P<0.01). CONCLUSION: TIVA with propofol and remifentanil and INHAL with sevoflurane and fentanyl induced similar inflammatory responses during colorectal cancer surgery. We found that IL-17 cytokine levels were higher in patients anesthetized with sevoflurane and fentanyl.

Complement split products and proinflammatory cytokines in intraoperatively salvaged unwashed blood during hip replacement: comparison between heparin-coated and non-heparin-coated autotransfusion systems.

BACKGROUND AND OBJECTIVES: The aim of the present study was to investigate the quality of shed blood collected in a new intraoperative autotransfusion system (Sangvia, AstraTech, Sweden) and to study whether heparin-coated surfaces in the device reduce the production of inflammatory mediators. MATERIAL AND METHODS: The study was randomized and prospective. Twelve total hip arthroplasty patients whose blood was collected with a device having a heparin-coated surface and 12 patients whose blood was collected with a device having a non-heparin-coated surface were included. Venous blood was drawn from the patients preoperatively. Intraoperatively 200 ml salvaged blood was collected and samples were also withdrawn; samples were obtained from the blood bag. RESULTS: Compared to venous blood, elevated concentrations of interleukin 6 (IL-6), IL-8, C3a and polymorphonuclear elastase were found in collected blood. No significant differences in inflammatory mediators were found between the heparin-coated and the non-heparin-coated groups. The median haemoglobin concentration in the salvaged blood was 74 g/l in both groups. Plasma haemoglobin and potassium concentrations were also elevated. There were no significant differences between the groups. CONCLUSION: The present study indicates that the blood salvaged intraoperatively contains elevated levels of complement split product and proinflammatory cytokines and that heparin-coated surfaces of the salvage device do not significantly influence the formation of inflammatory mediators.

The analgesic effect of intravenous ketamine and lidocaine on pain after spinal cord injury.

BACKGROUND: Pain following spinal cord injury (SCI) is a therapeutic challenge. Only a few treatments have been assessed in randomized, controlled trials. The primary objective of the present study was to examine the analgesic effect of ketamine and lidocaine in a group of patients with neuropathic pain below the level of spinal cord injury. We also wanted to assess sensory abnormalities to see if this could help us to identify responders and if treatments resulted in changes of sensibility. METHODS: Ten patients with spinal cord injury and neuropathic pain below the level of injury were included. The analgesic effect of ketamine 0.4 mg kg(-1) and lidocaine 2.5 mg kg(-1) was investigated. Saline was used as placebo. The drugs were infused over 40 min. A randomized, double-blind, three-period, three-treatment, cross-over design was used. Systemic plasma concentrations of ketamine and lidocaine were assessed. Pain rating was performed using a visual analogue scale (VAS). Sensory function was assessed with a combination of traditional sensory tests and quantitative measurement of temperature thresholds. RESULTS: Response to treatment, defined as 50% reduction in VAS-score during infusion, was recorded in 5/10 in the ketamine, 1/10 in the lidocaine and 0/10 in the placebo groups. Neither ketamine nor lidocaine changed temperature thresholds or assessments of mechanical; dynamic and static sensibility. Nor could these sensory assessments predict response to treatment in this setting. Lidocaine and particularly ketamine were associated with frequent side-effects. CONCLUSION: Ketamine but not lidocaine showed a significant analgesic effect in patients with neuropathic pain after spinal cord injury. The pain relief was not associated with altered temperature thresholds or other changes of sensory function.

The effectiveness of intravenous ketamine and lidocaine on peripheral neuropathic pain.

BACKGROUND: Neuropathic pain is often severe and resistant to pharmacological treatment. The aims of the present study were to assess the analgesic effect of ketamine and lidocaine and to investigate if measurement of different variables of sensibility could be used to identify responders. We also wanted to study if treatment resulted in changes of sensibility. METHODS: Twelve patients with long-lasting peripheral neuropathic pain of traumatic origin were included. The effects of ketamine hydrochloride (Ketalar, Parke Davis) 0.4 mg/kg and lidocaine hydrochloride (Xylocain, Astra) 2.5 mg/kg were investigated. Saline was used as placebo. The intensity of continuous pain was measured by a visual analogue scale (VAS). Warm and cold perception as well as heat and cold pain thresholds were assessed. Sensibility to touch was also tested. Systemic plasma concentrations of lidocaine and ketamine were assessed. RESULTS: The mean reduction in VAS-scores was 55%, 34% and 22% for ketamine, lidocaine and placebo, respectively. A significant difference was registered between ketamine and placebo (P = 0.009). Response to treatment (50% reduction in VAS-score during infusion) was recorded in 7/12 in the ketamine, 4/12 in the lidocaine and 2/12 in the placebo group. Quantitative sensory testing (QST) of thermal sensitivity and sensory tests for mechanical stimuli could not separate responders from non-responders and neither were the results from these assessments changed by the infusion of the drugs. Lidocaine and particularly ketamine were associated with frequent side-effects, the most common being somnolence and dizziness. CONCLUSION: Ketamine showed a significant analgesic effect. The clinical usefulness is, however, limited by disturbing side-effects.

Peripheral neuropathic pain--a multidimensional burden for patients.

The present study was undertaken to assess the health-related quality of life (HRQoL) and burden of illness due to pain and its treatment for patients with peripheral neuropathic pain (PNP). It is the first step in finding reliable instruments/targets to evaluate treatment outcome in this patient population. Study population consisted of 126 patients suffering from neuropathic pain due to a peripheral nerve or root lesion, recruited from two multidisciplinary pain clinics. HRQoL was examined using Short Form 36 (SF-36) Health Survey and Nottingham Health Profile (NHP). Pain intensity in four categories (at rest and evoked by movement, touch and cold) was rated on a visual analogue scale (VAS). Degree of discomfort from pain and 25 symptoms related to pain and side-effects was also assessed. Reduction in workload due to pain was recorded, as was the pain relief from previous and current treatments and the reasons for discontinuing previous treatments. All dimensions in SF-36 and NHP were significantly impaired. SF-36 was a valid instrument for describing the impact of pain on the HRQoL of patients with PNP. NHP had a lower reliability but has other advantages that might be of importance. Many patients experienced poor pain relief from ongoing pain treatments. Most previous treatments were discontinued owing to lack of efficacy and/or severe side-effects. Many patients experienced a high intensity of at least one type of pain; median VAS for the highest pain intensity score of each patient (any type of pain) was 74/100. Besides pain, patients were most bothered by difficulty in sleeping, lack of energy, drowsiness, difficulty in concentrating and dry mouth. Employment status was reduced owing to pain in 52% of the patients. The intense pain, other troublesome symptoms, limited efficacy and tolerability of available treatments, together with the impaired health and reduced work status, amount to a substantial burden for patients with PNP.

A comparison of the SF-36 and Nottingham Health Profile in patients with chronic neuropathic pain.

The aim of this study was to evaluate and compare the psychometric properties of two generic health-related quality of life (HRQoL) instruments, the Short Form Health Survey (SF-36) and the Nottingham Health Profile (NHP) in a group of patients with chronic peripheral neuropathic pain (PNP). The sample consisted of 126 adults (56 men and 70 women) with PNP following a lesion of a peripheral nerve, spinal nerve or nerve root or patients with post-herpetic neuralgia. The battery of tests included visual analogue scales (VASs) for pain assessment and global rating of health and verbal rating scales of pain and other symptoms, as well as patient descriptors. The SF-36 had higher internal consistency reliability coefficients (alpha=0.79, range 0.70-0.90) than the NHP (alpha=0.68, range 0.49-0.79). Correlations between comparable dimensions of the two instruments were significant (range from -0.79 for the physical and mental dimensions to -0.29 for the social dimension) indicating a moderate degree of convergent validity. The study population had significantly worse scores on all dimensions of the two instruments when compared with the general population. Subjects with high VAS scores for pain on movement and those with low global health ratings had poorer scores on the both instruments. Overall, the SF-36 performed somewhat better on psychometric testing than did the NHP. However, the NHP contains dimensions such as sleep and more pain items which might be of particular importance in the PNP population. Since the instruments are short, both could be retained for continued testing in outcome studies of this population.

Detection of Staphylococcus aureus infection by enzyme-linked immunosorbent assay and immunoblotting, using high molecular weight staphylococcal proteins.

Two high molecular weight staphylococcal proteins, fibronectin-binding protein and a Mr 200,000 protein, were investigated as antigens for serodiagnosis of staphylococcal infections. Sera from patients with staphylococcal infections and from controls were subjected to immunoblot analysis with staphylococcal lysate proteins to identify staphylococcal antigens to which patients with staphylococcal infections specifically exhibited antibodies. One such protein was found in the Mr 200,000 region. This protein was purified and used as antigen in ELISA and compared with other antigens, namely fibronectin-binding protein(s) (FNBP, Mr 185,000), alpha-toxin and teichoic acid. Sera from patients with staphylococcal infections contained antibodies to the high molecular weight proteins in higher titers than sera from patients with non-staphylococcal infections or healthy subjects. Based on their amino-acid compositions and different abilities to bind fibronectin it was concluded that the Mr 200,000 protein and FNBP were not identical.