Anesthesia in endovascular treatment of aortic aneurysm. Results and perioperative risks

Surgical treatment of aortic aneurysms carries significant cardiovascular risks. Transvascular insertion of endoluminal prostheses is a new, minimally invasive treatment for aortic aneurysms. The pathophysiology of this novel procedure, risks and benefits of different anaesthetic techniques, and typical complications need to be defined. METHODS: With their informed, written consent, 19 male patients aged 48-83 years of ASA physical status III and IV with infrarenal (n = 18) or thoracic (n = 1) aortic aneurysms underwent 23 stenting procedures under general endotracheal (n = 9), epidural (n = 8), or local anaesthesia with sedation (n = 6). Intra-anaesthetic haemodynamics, indicators of postoperative (p.o.) oxygenation and systemic inflammatory response, and perioperative complications were analysed retrospectively and compared between anaesthetic regimens. RESULTS: Groups were well matched with regard to morphometry and preoperative risk profiles (Table I). The use of pulmonary artery pressure monitoring, incidence of intraoperative hypotensive episodes, and p.o. intensive care was more frequent with general anaesthesia. Groups did not differ in total duration of anaesthesia care, incidence and duration of intraoperative hypertensive, brady-, or tachycardic periods, incidence of arterial oxygen desaturation, use of vasopressors, colloid volume replacements, or antihypertensives (Table 2). Postoperatively, all groups showed a similar, significant systemic inflammatory response, i.e., rapidly spiking temperature (p.o. evening: mean peak 38.5 +/- 1.0 degrees C). leucocytosis, and rise of acute-phase proteins without bacteraernia (Table 3). During this period, despite supplemental oxygen, pulse oximetry revealed temporary arterial desaturation in 13 of 18 patients (70%) (Table 3). In 3 patients, hyperpyrexia was associated with intermittent tachyarrhythmias (n = 3) and angina pectoris (n = 1). There was no conversion to open aortic surgery, perioperative myocardial infarction, or death. CONCLUSIONS: Regional and local anaesthesia with sedation are feasible alternatives to general endotracheal anaesthesia for minimally invasive treatment of aortic aneurysms by endovascular stenting. However, invasive monitoring and close postoperative monitoring are strongly recommended with either method. Specific perioperative risks in patients with limited cardiovascular or pulmonary reserve are introduced by the abacterial systemic inflammatory response to aortic stent implantation. Hyperpyrexia increases myocardial and whole-body oxygen consumption, and can precipitate tachyarrhythmias. Hyperfibrino-genaemia may increase the risk of postoperative arterial and venous thromboses. Close monitoring of vital parameters and prophylactic measures, including oxygen supplementation, low-dose anticoagulation, antipyretics, and fluid replacement are warranted until this syndrome resolves.     

Exercise and cellular innate immune function

PURPOSE: To determine, in three-dimensions, the difference between prostate delineation in magnetic resonance (MR) and computer tomography (CT) images for radiotherapy treatment planning. PATIENTS AND METHODS: Three radiation oncologists, considered experts in the field, outlined the prostate without seminal vesicles both on CT, and axial, coronal, and sagittal MR images for 18 patients. To compare the resulting delineated prostates, the CT and MR scans were matched in three-dimensions using chamfer matching on bony structures. The volumes were measured and the interscan and interobserver variation was determined. The spatial difference between delineation in CT and MR (interscan variation) as well as the interobserver variation were quantified and mapped three-dimensionally (3D) using polar coordinates. A urethrogram was performed and the location of the tip of the dye column was compared with the apex delineated in CT and MR images. RESULTS: Interscan variation: CT volumes were larger than the axial MR volumes in 52 of 54 delineations. The average ratio between the CT and MR volumes was 1.4 (standard error of mean, SE: 0.04) which was significantly different from 1 (p < 0.005). Only small differences were observed between the volumes outlined in the various MR scans, although the coronal MR volumes were smallest. The CT derived prostate was 8 mm (standard deviation, SD: 6 mm) larger at the base of the seminal vesicles and 6 mm (SD 4 mm) larger at the apex of the prostate than the axial MRI. Similar figures were obtained for the CT and the other MRI scans. Interobserver variation: The average ratio between the volume derived by one observer for a particular scan and patient and the average volume was 0.95, 0.97, and 1.08 (SE 0.01) for the three observers, respectively. The 3D pattern of the overall observer variation (1 SD) for CT and axial MRI was similar and equal to 3.5 to 2.8 mm at the base of the seminal vesicles and 3 mm at the apex. CONCLUSION: CT-derived prostate volumes are larger than MR derived volumes, especially toward the seminal vesicles and the apex of the prostate. This interscan variation was found to be larger than the interobserver variation. Using MRI for delineation of the prostate reduces the amount of irradiated rectal wall, and could reduce rectal and urological complications.     

Stress and immune function in diabetes mellitus

Type I diabetic men were found to have a greater number of stresses, more perceived stress per episode, greater anxiety, poorer immune function, and less metabolic control than Type II diabetic men. Degree of family support and compliance with the medical regimen did not differ. Correlation of perceived stress with immune function and metabolic control showed that Type I had more correlates than Type II, with more perceived stress associated with more depressed immune responses.     

Effect of pentachlorophenol on immune function

The organochlorine compound, pentachlorophenol, was evaluated for effects on immune system function in male Fisher 344 rats. Pentachlorophenol was prepared in an olive oil vehicle and was administered by oral gavage twice weekly for 28 days at a dose of 2.0 mg/kg per treatment. Exposure to pentachlorophenol increased body weight gains (P=0.024) during the treatment period. Liver (P=0.034) and kidney (P=0.012) body weight ratios were also increased. Pentachlorophenol exposure enhanced T-lymphocyte blastogenesis induced by concanavalin A (Con A)(P=0.0001) and phytohemagglutinin (PHA)(P=0.048) evaluated using stimulation indices. Corresponding B-lymphocyte blastogenesis induced by lipopolysaccharide/dextran (LPS/dex)(P=0.0034) was also enhanced by pentachlorophenol exposure. Pentachlorophenol suppressed the antibody response against sheep red blood cells (SRBCs) by 39% when the response was expressed per viable spleen cell (P=0.006). This suppression was not evident when the response was expressed per spleen (P=0.22), suggesting that a compensatory mechanism or extramedullary splenic hemopoiesis was occurring minimizing the overall impact on humoral immunity. The enhanced B- and T-lymphocyte blastogenesis may also reflect compensatory or hemopoietic activity. Pentachlorophenol exposure had no effect on peritoneal macrophage phagocytosis (P=0.31) or lymphocyte cell surface antigen expression. The observed alterations in lymphocyte blastogenesis and humoral immunity subsequent to pentachlorophenol exposure do not appear to be associated with phagocytosis or lymphocyte cell surface antigen expression.     

Exercise and physical health: cancer and immune function

Over the last decade, there has been accumulating epidemiological data suggesting that exercise may decrease the risk of cancer, particularly colon cancer. However, exercise appears unrelated to rectal cancer risk. With regard to other cancers, because physical activity can alter levels of reproductive hormones, investigators have hypothesized that active individuals should experience decreased incidence of breast or prostate cancer. The better conducted studies suggest that exercise may reduce the risk of developing breast cancer. However, the epidemiological data on prostate cancer have been inconsistent. Meanwhile, data on other site-specific cancers have been sparse. An exciting and emerging body of research has suggested that exercise, at least in moderate amounts, can enhance the human immune system. Theoretically, then, this provides a further biological basis for expecting an inverse relationship between physical activity and cancer risk. However, the changes seen in immune function tend to be transient in nature; thus, the physiological significance with respect to cancer development is uncertain. Preliminary data also suggest that exercise may be beneficial for cancer patients by improving the quality of life and enhancing immune function. Although promising, this needs more careful research. Again, it is unclear whether the enhanced immune function is of any clinical significance in retarding the spread of cancer that has already developed. Finally, with regard to URTIs, moderate exercise appears to decrease the risk of this infection, although high-endurance exercise may increase the risk. This finding parallels the changes seen in the immune system in response to exercise and comes as no surprise, as the immune system also regulates susceptibility to infections.     

Human vaginal mucosal immune system: characterization and function

The analysis of 49 fatal cases of venous thromboembolism--VTE (15% of total ambulatory patients number during long observation was performed. The advanced age of patients, multiple risk factors, underlying circulatory and respiratory tract diseases, malignancies, previous episodes of VTE especially with secondary pulmonary hypertension were the most important factors determining fatal prognoses in those patients.     

Stress, emotion, and human immune function.

This article provides a review of empirical evidence linking emotional processes to immune function in humans. Acute stressors have produced mixed effects on immunity, presumably through differential activation of physiological stress systems. Chronic stress has been associated with suppression of immune function, and there is evidence that the immune system may not adapt over time. Effects of stress accompanying social disruption and psychological depression, when demonstrated, have been consistently adverse. Certain personality styles may enhance or degrade immune response. Relationships between psychosocial factors and immunity have been identified for several diseases, including cancer, acquired immune deficiency syndrome (AIDS), and autoimmune diseases; psychosocial interventions have been tested with variable results. Theoretical and methodological considerations are summarized and directions for future research suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychoneuroimmunology: Psychological influences on immune function and health.

This review focuses on human psychoneuroimmunology studies published in the past decade. Issues discussed include the routes through which psychological factors influence immune function, how a stressor's duration may influence the changes observed, individual difference variables, the ability of interventions to modulate immune function, and the health consequences of psychosocially mediated immune dysregulation. The importance of negative affect and supportive personal relationships are highlighted. Recent data suggest that immune dysregulation may be one core mechanism for a spectrum of conditions associated with aging, including cardiovascular disease, osteoporosis, arthritis, Type 2 diabetes, certain cancers, and frailty and functional decline; production of proinflammatory cytokines that influence these and other conditions can be stimulated directly by negative emotions and indirectly by prolonged infection. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Glutamine, exercise and immune function. Links and possible mechanisms

Annexin VI, a member of a family of Ca(2+)-dependent phospholipid- and membrane-binding proteins, interacts with the Ca(2+)-regulated EF-hand proteins, S100A1 and S100B, and blocks the ability of these two proteins to inhibit the assembly of desmin and glial fibrillary acidic protein (GFAP) into intermediate filaments in a Ca(2+)- and dose-dependent manner. S100A1 and S100B each possess one annexin VI binding site, characterized by an affinity for annexin VI in the submicromolar range. Binding of annexin VI to either S100 protein occurs at a site that appears to differ in some parts from that recognizing desmin and GFAP. As S100A1 and S100B exist in solution as homodimers in which the two monomers are related by a 2-fold symmetry axis, each of the above S100 homodimers likely crosslinks two annexin VI molecules, a situation that appears typical of all the annexin-S100 protein complexes described thus far. However, whereas in the cases of other annexin-S100 complexes the C-terminal extension of the S100 molecule appears indispensable for annexin binding, the annexin VI binding site cannot be restricted to the S100A1 and S100B C-terminal extension. We speculate that the annexin VI site on S100A1/B may only partially overlap to the desmin/GFAP site. In contrast, no effects of annexin V on the ability of S100A1 or S100B to affect the desmin and GFAP assemblies could be documented, although binding of annexin V to S100A1 and S100B could be detected at relatively high Ca2+ concentrations. The present data suggest that annexin VI might regulate S100A1 and S100B activities and vice versa.     

Social support and immune function among spouses of cancer patients.

This study investigated whether social support was related to immune function among spouses of cancer patients. Effects of depression and negative life events were examined as potential mediators. Results showed evidence of greater immunocompetence on 2 of 3 dynamic measures: natural killer cytotoxicity and proliferation response to phytohemaglutinin among spouses who reported high levels of social support. All six components of social support assessed by the Social Provisions Scale (C. E. Cutrona and D. W. Russell, 1987) were strongly related to these indices of immune function. No evidence was found for mediation by either life events or depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stress, reactivity, and immune function in healthy men.

Examined the effects of acute psychological stress on lymphocyte proliferation and circulating levels of interleukin-1 and -2. 20 healthy men were exposed to 2 viewings of a gruesome surgery film and were asked to recall details of the film twice during a 20-min period. These Ss were compared to a nonstress control group of 9 Ss. Lymphocyte proliferation to the mitogen concanavalin-A was decreased during and after exposure to the stressor when compared to the control group. This decrease was more pronounced in Ss exhibiting greater blood pressure reactivity while viewing the film than in Ss showing smaller blood pressure responses. None of the other immunological measures was significantly affected by the stressor. Cortisol was not correlated with lymphocyte responsiveness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Endocrine regulation of the immune response. Prolactin and its function

Traditionally the immune system has been considered as autonomous. However, recent evidence has showed that there are bidirectionally communications between the neuroendocrine and immune system. It has been seen influences of gonadal, thyroid, suprarrenal and pituitary hormones. Of this, prolactin has emerged like a potential target to modify the immune response in some states of disease.     

Leishmaniasis: principles of the immune response and function of nitric oxide

Leishmania are flagellated protozoa, which are transmitted to mammals by sand flies. Depending on the parasite species and the host immune system, infection with Leishmania can lead to simple self-healing ulcers (e.g., oriental sore), progressive mucocutaneous lesions, or to visceral disease involving spleen, liver and bone marrow (kala azar). The control of the parasites is critically dependent on type 1 CD4+ T helper cells, which evolve in the presence of interleukin-12 and activate the macrophages for the killing of the intracellular, amastigote Leishmania stage through the production of interferon-gamma. The killing process involves reactive oxygen and nitrogen intermediates (e.g., NO). Anti-Leishmania antibodies are generated during the infection, but do not confer protection. In this article, the main components of immune response against Leishmania and the role of nitrogen monoxide (nitric oxide, NO) in the Leishmania major mouse model will be reviewed.     

Anesthesia and delivery]

Close collaboration of an informed anaesthetist with the obstetrician, and respect of the security protocols in every anaesthesia must guarantee the well-being of pregnant women. The development of loco-regional anaesthesia for use in labour analgesia and caesarean section has reduced the indications and the mortality related to general anaesthesia. In the last 30 years, analgesia and control of loco-regional anaesthesia effects have been greatly improved. Loco-regional anaesthesia protocols are now safe for the mother and various. Epidural anaesthesia using low concentrations of local anaesthetics allows parturient ambulation. Intrathecal anaesthesia, with combined spinal-epidural technique, is mostly used for caesarean-section and for the early and late labour.