BackgroundIn critical care units, pupil examination is an important clinical parameter for patient monitoring. Current practice is to use a penlight to observe the pupillary light reflex. The result seems to be a subjective measurement, with low precision and reproducibility. Several quantitative pupillometer devices are now available, although their use is primarily restricted to the research setting. To assess whether adoption of these technologies would benefit the clinic, we compared automated quantitative pupillometry with the standard clinical pupillary examination currently used for brain-injured patients.MethodsIn order to determine inter-observer agreement of the device, we performed repetitive measurements in 200 healthy volunteers ranging in age from 21 to 58 years, providing a total of 400 paired (alternative right eye, left eye) measurements under a wide variety of ambient light condition with NeuroLight Algiscan pupillometer. During another period, we conducted a prospective, observational, double-blinded study in two neurocritical care units. Patients admitted to these units after an acute brain injury were included. Initially, nursing staff measured pupil size, anisocoria and pupillary light reflex. A blinded physician subsequently performed measurement using an automated pupillometer.ResultsIn 200 healthy volunteers, intra-class correlation coefficient for maximum resting pupil size was 0.95 (IC: 0.93-0.97) and for minimum pupil size after light stimulation 0.87 (0.83–0.89). We found only 3-pupil asymmetry (≥1 mm) in these volunteers (1.5 % of the population) with a clear pupil asymmetry during clinical inspection. The mean pupil light reactivity was 40 ± 7 %. In 59 patients, 406 pupillary measurements were prospectively performed. Concordance between measurements for pupil size collected using the pupillometer, versus subjective assessment, was poor (Spearmen's rho = 0.75, IC: 0.70-0.79; P < 0.001). Nursing staff failed to diagnose half of the cases (15/30) of anisocoria detected using the pupillometer device. A global rate of discordance of 18 % (72/406) was found between the two techniques when assessing the pupillary light reflex. For measurements with small pupils (diameters <2 mm) the error rate was 39 % (24/61).ConclusionStandard practice in pupillary monitoring yields inaccurate data. Automated quantitative pupillometry is a more reliable method with which to collect pupillary measurements at the bedside.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1239-z) contains supplementary material, which is available to authorized users.

Endothelial progenitor cells (EPCs) seem to be a promising option to treat patients with ischemic diseases. Here, we investigated the effects of late outgrowth EPCs, or endothelial colony-forming cells (ECFCs), a recently defined homogeneous subtype of EPCs, in a rat model of transient middle cerebral artery occlusion (MCAO). Either vehicle or 4.10(6) ECFCs, isolated from human cord blood, were intravenously injected 24 h after 1 h MCAO in rats assigned to control and transplanted groups respectively. (111)In-oxine-labeled ECFCs specifically homed to ischemic hemisphere and CM-Dil prelabeled ECFCs preferentially settled in the inner boundary of the core area of transplanted animals. Although incorporation of cells into neovessels was hardly detectable, ECFCs transplantation was associated with a reduction in apoptotic cell number, an increase in capillary density and a stimulation of neurogenesis at the site of injury. These effects were associated with an increase in growth factors expression in homogenates from ischemic area and may be related to the secretion by ECFCs of soluble factors that could affect apoptosis, vascular growth and neurogenesis. Microscopic examination of the ischemic hemisphere showed that ECFCs transplantation was also associated with a reduction in reactive astrogliosis. In conclusion, we demonstrated that ECFCs injected 24 h after MCAO settled in the injured area and improved functional recovery. The neurological benefits may be linked to a reduction in ischemia-induced apoptosis and a stimulation of ischemia-induced angiogenesis and neurogenesis. These findings raise perspectives for the use of ECFCs as a well-characterized cell therapy product for optimal therapeutic outcome after stroke.

Summary.  Background:  Endothelial colony‐forming cells (ECFCs) are promising candidates for cell therapy of ischemic diseases. Erythropoietin (EPO) is a cytokine that promotes angiogenesis after ischemic injury. EPO receptors (EPORs) classically include two EPOR subunits, but may also associate with the β‐common chain (CD131) in a newly identified receptor involved in EPO cytoprotective effects. Objective:  The aim was to take advantage of the proangiogenic properties of EPO to enhance ECFC graft efficiency. We postulated that priming ECFCs by adding epoietin α in culture medium prior to experiments might increase their angiogenic properties. We also explored the role of the CD131 subunit in EPO priming of ECFCs. Methods and Results:  By western blotting on cord blood ECFC lysates, we showed that EPOR and CD131 expression increased significantly after EPO priming. These proteins coimmunoprecipitated and colocalized, suggesting that they are covalently bound in ECFCs. EPO at 5 IU mL−1 significantly stimulated proliferation, wound healing, migration and tube formation of ECFCs. EPO priming also increased ECFC resistance to H2O2‐induced apoptosis and survival in vivo. Similarly, in vivo studies showed that, as compared with non‐primed ECFC injection, 5 IU mL−1 EPO‐primed ECFCs, injected intravenously 24 h after hindlimb ischemia in athymic nude mice, increased the ischemic/non‐ischemic ratios of hindlimb blood flow and capillary density. These effects were all prevented by CD131 small interfering RNA transfection, and involved the phosphoinositide 3‐kinase–Akt pathway. Conclusion:  These results highlight the potential role of EPO‐primed ECFCs for cell‐based therapy in hindlimb ischemia, and underline the critical role of CD131 as an EPO coreceptor.

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Six hours of sevoflurane anesthesia in newborn rats induces significant long-term cognitive impairment. A single administration of rh-EPO immediately after postnatal exposure to sevoflurane reduces both early activation of apoptotic phenomenon and late onset of neurologic disorders.

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Endothelial colony-forming cells (ECFCs) are promising candidates for cell therapy of ischemic diseases, as less than 10% of patients with an ischemic stroke are eligible for thrombolysis. We previously reported that erythropoietin priming of ECFCs increased their in vitro and in vivo angiogenic properties in mice with hindlimb ischemia. The present study used SPECT/CT to evaluate whether priming of ECFCs with erythropoietin could enhance their homing to the ischemic site after transient middle cerebral artery occlusion (MCAO) followed by reperfusion in rats and potentiate their protective or regenerative effect on blood-brain barrier (BBB) disruption, cerebral apoptosis, and cerebral blood flow (CBF). Methods: Rats underwent a 1-h MCAO followed by reperfusion and then 1 d after MCAO received an intravenous injection of either PBS (control, n 5 10), PBS-primed ECFCs (ECFC PBS , n 5 13), or erythropoietinprimed ECFCs (ECFC EPO , n 5 10). ECFC homing and the effect on BBB disruption, cerebral apoptosis, and CBF were evaluated by SPECT/CT up to 14 d after MCAO. The results were expressed as median 6 interquartile range for ipsilateral-to-contralateral ratio of the activity in middle cerebral artery-vascularized territories in each hemisphere. Histologic evaluation of neuronal survival and astrocytic proliferation was performed on day 14. Results: Erythropoietin priming increased homing of ECFCs to the ischemic hemisphere (ECFC PBS , 111.0% 6 16.0%; ECFC EPO , 146.5% 6 13.3%). BBB disruption was significantly reduced (control, 387% 6 153%; ECFC PBS , 151% 6 46% [P , 0.05]; ECFC EPO , 112% 6 9% [P , 0.001]) and correlated negatively with ECFC homing (Pearson r 5 20.6930, P 5 0.0002). Cerebral apoptosis was significantly reduced (control, 161% 6 10%; ECFC PBS , 141% 6 9% [P , 0.05]; ECFC EPO ,118% 6 5% [P , 0.001]) and correlated negatively with ECFC homing (r 5 20.7251, P , 0.0001). CBF was significantly restored with ECFCs and almost totally so with erythropoietin priming (control, 72% 6 2%; ECFC PBS , 90% 6 4% [P , 0.01]; ECFC EPO , 99% 6 4% [P , 0.001]) and correlated positively with ECFC homing (r 5 0.7348, P , 0.0001). Immunoblocking against the CD146 receptor on ECFCs highlighted its notable role in ECFC homing with erythropoietin priming (ECFC EPO , 147% 6 14%, n 5 4; ECFC EPO with antibody against CD146, 101% 6 12%, n 5 4 [P , 0.05]). Conclusion: Priming with erythropoietin before cell transplantation is an efficient strategy to amplify the migratory and engraftment capacities of ECFCs and their beneficial impact on BBB disruption, apoptosis, and CBF.

The purpose of this prospective study was to determine concomittant lesions of glenohumeral dislocation and their correlation with the outcome, to determine the influence of various stabilizing operation techniques on the outcome. 106 shoulders [104 patients, 81 men, 23 women, mean age 36 (16-83) years] operated because of shoulder instability after at minimum one shoulder luxation between 1988 to 1995 were evaluated 3 years (0.8-8 years) postoperatively using Constant score. Preoperative arthroscopy was performed to document intraarticular lesions. There were 7 reluxations (5 because of a new accident), mostly after Putti-Platt procedures. The average modified Constant Score was 66 (10-85) points (maximum 85). 29 patients (27%) had less than 60 points, mostly because of pain and restriction of function, and were evaluated as poor. Lesions of rotator cuff, long biceps tendon and subscapularis tendon had a bad prognosis. The severity of arthroscopically found lesions correlated with the outcome. Operations with shortening of subscapularis tendon or using a bone graft gave bad results. Anatomic reconstruction of the labrum-ligament complex in combination with a plasty of the extended capsule gave best results. Preoperative arthroscopy can determine the extent of different lesions after shoulder luxation which influence the outcome and is useful to select the optimal operation technique.