[Anesthesiological acute pain therapy in Germany: telephone-based survey]. / Anästhesiologische Akutschmerztherapie in Deutschland: Telefonbasierte Umfrage.

INTRODUCTION: The last survey of anesthesiological acute pain therapy in Germany was conducted in 1999. Since then new organisational as well as therapeutic aspects have developed. Amongst others the operation and procedures key (OPS) figure 8-919 complex acute pain therapy has been introduced in the German medical billing system, with the restriction that it cannot currently be redeemed. There is an ongoing debate on the role of epidural analgesia in acute pain therapy and new oral medication concepts have been established. Therefore a survey of the present state of acute pain therapy in Germany was conducted. METHODS: Based on a list of all 1,356 hospitals in Germany a randomized list of 412 hospitals was generated. Out of these 412 hospitals those with anesthesiology departments (378 hospitals) were contacted via telephone and asked to participate in the survey. Out of the 378 hospitals 285 (75.4 %) agreed to take part. The survey consisted of a questionnaire containing closed and open questions regarding organisational and therapeutic aspects of acute pain therapy. The ethics committee of the University of Regensburg rated the survey as not being subject to approval due to the lack of personal patient data. RESULTS: Of the participating hospitals 183 (64.2 %) had an acute pain service (APS) and of these 107 (58.5 %) met the quality criteria of the OPS 8-919. This figure however, was only consistently documented by 40 (37 %) APSs. Epidural analgesia (EA) was offered by 275 (96.5 %) hospitals and patient-controlled intravenous analgesia (PCA) by 255 (89.5 %). Likewise, 255 (89.5 %) hospitals used controlled-released opioids in acute pain therapy. Concerning EA, the medications most used were sufentanil as an opioid and ropivacaine as a local anesthetic in255 (92.7 %) of the hospitals with EA for sufentanil and 253 (92 %] for ropivacaine. An EA was offered on regular wards in 240 (87.3 %) hospitals. Uncertainty existed about concrete limits for coagulation values before removal of an epidural catheter. The opioid most utilized in PCA was piritramide with some hospitals using morphine or oxycodone (92.2 %, 9.4 % and 9.4 %, respectively). Other opioids, such as hydromorphone and tramadol were rarely used and remifentanil was not used at all. Oral medication was widely used with metamizole being the non-opioid analgesic and oxycodone/naloxone the controlled-release opioid being prescribed the most. New antiepileptic drugs, such as gabapentin or pregabalin were rarely employed in acute pain therapy. CONCLUSIONS: Since 1999 the number of hospitals that have implemented an APS has risen from 36.1 % to 64.2 %. The lack of consistent documentation of the OPS 8-919 will probably not increase the likelihood that it will become redeemable in the near future. Certain therapy methods, such as EA and PCA were still well established with oral therapy gaining in significance. The uncertainty regarding limits for coagulation values before removal of an epidural catheter could perhaps be reduced by a statement from the German Society of Anesthesia and Intensive Care.

Reciprocal regulation of the nitric oxide synthase/arginase balance in mouse bone marrow-derived macrophages by TH1 and TH2 cytokines.

Activation with lipopolysaccharide induces macrophages to produce the enzymes arginase and nitric oxide (NO) synthase. Both enzymes use as a substrate the amino acid L-arginine, which can be either hydrolyzed by arginase to urea and ornithine or oxidized by NO synthase to NO and citrulline. NO is important in the bactericidal and cytotoxic activities of macrophages. An equivalent functional role of arginase and its products is not known. We tested the induction of arginase in bone marrow-derived macrophages by endogenous mediators that are known to induce NO synthase, such as interferon-gamma (IFN-gamma), or suppress the induction of this enzyme, such as interleukin (IL)-4, IL-10, and prostaglandin E2 (PGE2). We find that PGE2 and the TH2 cytokines IL-4 and IL-10 are potent inducers of arginase. In contrast, the TH1 cytokine IFN-gamma does not induce arginase. Simultaneous application of both types of mediators leads to reduced induction of both arginase and NO synthase. Exposure of macrophage cultures to inducers of NO synthase exhausts their ability to respond subsequently to inducers of arginase. Conversely, exposure of the cells to inducers of arginase exhausts their ability to respond subsequently to inducers of NO synthase. The results are consistent with a competition of both enzymes for their substrate, L-arginine, with a reciprocal inhibition in the induction of both enzymes, or a combination of both phenomena. The enzymes NO synthase and arginase appear to define two alternate functional states of macrophages, induced by TH1 and TH2 cytokines, respectively.

Differential modulation of the effects of lipopolysaccharide on macrophages by a major outer membrane protein of Proteus mirabilis.

We previously showed that a major protein isolated from purified cell walls of Proteus mirabilis (39-kDa protein) is a strong modulator of the specific immune responses to LPS from this bacterium in mice. When mixed with LPS before immunization, this protein enhances T cell-dependent, IgG antibody-producing cell responses specific for LPS. Furthermore, complexes of the 39-kDa protein with LPS drastically inhibit the production of oxygen radicals by murine macrophages activated with LPS, as measured in a chemiluminescence assay. In the present report, we have further investigated possible modulating effects of the protein at the level of LPS-macrophage interaction. When mixed with LPS, the 39-kDa protein inhibited IL-1 production by murine macrophages derived from bone marrow in a dose-dependent manner, as determined in an IL-2-dependent IL-1 assay. On the other hand, the protein had little effect on LPS-mediated suppression of MHC class II expression on the surface of macrophages induced with IFN-gamma. Some abrogation of suppression was observed, but the amounts of protein needed for this effect were quite large, in comparison with the amounts rendering inhibition of IL-1 production. In contrast, the 39-kDa protein enhanced the LPS-induced cytotoxicity of macrophages against L929 target cells, primarily as the result of production of TNF. These results show that the 39-kDa protein is a potent modulator of the interaction of LPS with macrophages, exerting its effects in a differential manner with respect to various parameters of LPS-induced activation of macrophages.

[Treatment of emergency situations in autoimmune diseases with plasma exchange]. / Behandlung von Notfallsituationen bei Autoimmunerkrankungen mit Plasmaaustausch.

Plasma exchange has been applied successfully to treat severely ill patients with autoimmune diseases in recent years. We report on 12 patients with systemic lupus erythematosus (SLE), myasthenia gravis (MG), and Goodpasturés syndrome (GS), that have been treated with membrane plasma separation. Two to three liters of plasma were exchanged per session. Three to nine treatments were done within 1--4 weeks. Human albumin solution was used for replacement of the discarded plasma. Improvement was seen in 3 out of 5 SLE patients, in all 5 myasthenic patients and in one of the two patients with GS. Plasma exchange in combination with immunosuppressive therapy is indicated in states of active autoimmune diseases, not controllable by routine immunosuppression. For long-term treatment, however, immunosuppressive medication should be used.