Midazolam plasma concentration after anesthesia premedication in clinical routine - an observational study : Midazolam plasma concentration after anesthesia premedication

BACKGROUND

Midazolam is commonly used as a pre-anesthesia anxiolytic. It`s elimination may not be fast enough for short procedures. In orally premedicated patients we obtained midazolam plasma concentrations at the end of surgical procedures and compared those to concentrations at anesthesia induction.

METHODS

The study was conducted prospectively with consent of the local ethics committee (Ethikkomission Kanton Thurgau, Switzerland) and carried out with written informed consent of each patient. Female patients aged 20 to 60 years undergoing elective procedures with general anesthesia were included, and were divided in two groups according to the planned surgical time: group S (<30 min) and group L (90-120 min), respectively. All patients received 7.5 mg Midazolam po as premedication. Blood samples were drawn at anesthesia induction, and at the end of surgery. Data were compared with t-test (independent samples; significance level p <0.05).

RESULTS

Twenty-five patients per group were included. Four patients were excluded from analysis, since midazolam was not detectable in any samples. Time of premedication to the 1st blood sample was not statistically different between groups, neither were Midazolam plasma levels at this time point (p = 0.94). None of the patients from group L (n = 24), but five patients in group S (n = 22) did have a higher plasma level of Midazolam at the end of the case compared to the beginning.

CONCLUSIONS

The elimination half-life of oral Midazolam can lead to higher plasma levels at the end of a short procedure compared to those at induction of anesthesia.

TRIAL REGISTRATION

German Clinical Trials Register (Deutsches Register Klinischer Studien), DRKS00005429 ; date of registration 3^rd January 2014.

Low dose DTIC is effective and safe in pretreated patients with well differentiated neuroendocrine tumors

Background

Streptozocin (STZ) based chemotherapy is recommended for patients with metastatic pancreatic neuroendocrine tumors (pNET). Temozolomide as mono- or combination therapy has been suggested to be a promising alternative. However, the treatment is costly and not approved for the treatment of pNETs. Dacarbazine (DTIC) shares the active metabolite with temozolomide and is broadly available at a low cost. The aim of this study was a retrospective evaluation of the efficacy and tolerability of a lower dose DTIC-regimen in patients with progressive advanced NETs.

Methods

We retrospectively analyzed 75 patients with NETs predominantly of pancreatic origin treated at our center between 1998 and 2013. 650 mg/m² of DTIC were administered intravenously over 60 min every 4 weeks. Morphological response was assessed according to RECIST1.1 criteria. The median progression free survival (PFS) was calculated using Kaplan-Meier and Cox regression methods, respectively. Univariate analyses of possible prognostic markers were performed.

Results

The objective response rate (ORR) was 27 % for the entire cohort and 32 % in 50 pNET patients, respectively. Stable disease (SD) was documented in 29 patients (39 %). Median PFS (mPFS) in patients receiving DTIC was 7 months (3.9–10; 95 % confidence interval). Radiological and biochemical response were the only significant prognostic markers for longer PFS in univariate analysis. Treatment was well tolerated. Nausea was the most common side effect (31 %), only one case (1.3 %) of grade 3 toxicity (vomiting) occurred.

Conclusion

Low dose DTIC chemotherapy is an effective and well-tolerated treatment option in patients with progressive well differentiated neuroendocrine neoplasms, especially of pancreatic origin.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2642-1) contains supplementary material, which is available to authorized users.

Migraine With Isolated Facial Pain: A Diagnostic Challenge

We present a series of seven migraine patients with typical features of a migraine attack without aura, but atypical pain localization in the face in one or both of the lower two distributions of the trigeminal nerve (V2 and V3). All of them responded well to triptans. Three patients responded to preventive treatment for migraine with β-blockers ( n = 2) or valproic acid ( n = 1). These cases underline the heterogenic clinical presentation of migraine, which is sometimes difficult to diagnose even for headache specialists, and broaden the pathophysiological understanding of trigeminal nociceptive processing in migraine in the light of neuronal plasticity.

Patient reported outcomes in randomized controlled cancer trials in advanced disease: a structured literature review

INTRODUCTION

In advanced cancer quality of life (QoL) is the most important goal of care. It is measured by patient-reported-outcomes (PRO). This structured review evaluated how randomized controlled trials (RCTs) on anti-cancer therapy in advanced cancer reported PRO.

METHODS

Search was performed in MEDLINE via PubMed for RCTs with median patient survival of ≤2 years. Reporting was rated with the Consolidated Standards of Reporting Trials (CONSORT) PRO extension.

RESULTS

Of 370 retrieved publications, 117 were eligible, but only 30/117 (26%) reported PRO. QoL was most frequently measured (29/30). On average, 4.4 (SD 2.5) of the 14 CONSORT items were met.

CONCLUSION

PRO are insufficiently reported in advanced cancer trials. Yet, this is paramount to enable an informed and patient-oriented decision making process.

Abstract P3-09-03: Combined effects of soy isoflavones and a high fat diet on the mammary gland in an animal model of diet-induced obesity

Scope: Obesity is a major risk factor for the development of breast cancer whereas isoflavone (ISO) exposure is discussed to reduce this risk. Aim of this study was to investigate effects of dietary soy ISO intake on proliferation and estrogenicity of ISO in the mammary gland of obese female Wistar rats.

Methods: Female Wistar rats (5 – 7 rats / group) grew up on low fat ISO-depleted diet (LF IDD) or ISO-rich diet enriched with a soy based commercial extract (LF IRD; ISO: 467 mg / kg diet). Starting postnatal day 83, ovariectomized (OVX) and intact animals received high fat diet for 12 weeks to induce obesity in the absence (HF IDD) or presence of ISO (HF IRD, ISO: 431 mg / kg diet). A special diet switch group (HF IRD switch OVX), grew up on LF IDD but switched to HF IRD after ovariectomy. This mimics the short term exposure to ISO in postmenopausal Western women who take ISO supplements. Two groups receiving LF diet either with or without ISO (LF IRD, LF IDD) lifelong served as control. From ablactation until the end of the experiment body weight and food consumption were monitored twice a week. After 12 weeks of HF diet animals were sacrificed. Body weight, visceral fat mass, and serum leptin were measured, and breast tissue was excised. Protein expression of proliferating cell nuclear antigen (PCNA) and progesterone receptor (PR) in breast tissue was analyzed by both immunohistochemistry (IHC) and Western Blot as markers for proliferation and estrogenicity of ISO, respectively.

Results: Analysis of ISO plasma levels revealed 1400 nM in LF IRD group and

300 – 700 nM in HF IRD groups. HF diet increased body weight, visceral fat mass and serum leptin levels compared to LF diet. In the mammary gland HF increased expression of proliferation marker PCNA and PR as compared to LF groups. Lifelong but not short term (HF IRD switch OVX) ISO exposure reduced body weight, visceral fat mass and leptin levels in HF OVX rats. In the mammary gland lifelong ISO exposure reduced PCNA expression in both LF and HF intact animals whereas in HF OVX animals lifelong ISO exposure increased PCNA expression compared to short term ISO exposure. PR expression increased in HF IRD OVX compared to HF IDD OVX.

Conclusion: The ISO plasma levels of the rats are comparable to the average ISO plasma levels as found in Asian population. Our results show that lifelong ISO intake reduces the risk to develop obesity in female rats. In the mammary gland lifelong ISO exposure decreases cell proliferation and shows estrogenicity by increasing PR expression. Effects of short term ISO exposure are less strong compared to lifelong ISO exposure. This supports the hypothesis that only lifelong but not short term ISO exposure can reduce the risk to develop breast cancer.

Citation Format: Kurrat A, Diel P, Blei T, Kluxen F, Mueller D, Pichotta M, Soukup S, Kulling S, Oden C. Combined effects of soy isoflavones and a high fat diet on the mammary gland in an animal model of diet-induced obesity. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-09-03.

Radiation Dose Reduction in Computed Tomography-Guided Lung Interventions using an Iterative Reconstruction Technique

PURPOSE

To compare the radiation doses and image qualities of computed tomography (CT)-guided interventions using a standard-dose CT (SDCT) protocol with filtered back projection and a low-dose CT (LDCT) protocol with both filtered back projection and iterative reconstruction.

MATERIALS AND METHODS

Image quality and radiation doses (dose-length product and CT dose index) were retrospectively reviewed for 130 patients who underwent CT-guided lung interventions. SDCT at 120 kVp and automatic mA modulation and LDCT at 100 kVp and a fixed exposure were each performed for 65 patients. Image quality was objectively evaluated as the contrast-to-noise ratio and subjectively by two radiologists for noise impression, sharpness, artifacts and diagnostic acceptability on a four-point scale.

RESULTS

The groups did not significantly differ in terms of diagnostic acceptability and complication rate. LDCT yielded a median 68.6% reduction in the radiation dose relative to SDCT. In the LDCT group, iterative reconstruction was superior to filtered back projection in terms of noise reduction and subjective image quality. The groups did not differ in terms of beam hardening artifacts.

CONCLUSION

LDCT was feasible for all procedures and yielded a more than two-thirds reduction in radiation exposure while maintaining overall diagnostic acceptability, safety and precision. The iterative reconstruction algorithm is preferable according to the objective and subjective image quality analyses.

KEY POINTS

Implementation of a low-dose computed tomography (LDCT) protocol for lung interventions is feasible and safe. LDCT protocols yield a significant reduction (more than 2/3) in radiation exposure. Iterative reconstruction algorithms considerably improve the image quality in LDCT protocols.

Magnetic diagnostics for equilibrium reconstruction and realtime plasma control in NSTX-Upgrade

This paper describes aspects of magnetic diagnostics for realtime control in National Spherical Torus Experiment-Upgrade (NSTX-U). The sensor arrangement on the upgraded center column is described. New analog and digital circuitry for processing the plasma current Rogowski data are presented. An improved algorithm for estimating the plasma vertical velocity for feedback control is presented.

In situ measurement of low-Z material coating thickness on high Z substrate for tokamaks

Rutherford backscattering of energetic particles can be used to determine the thickness of a coating of a low-Z material over a heavier substrate. Simulations indicate that 5 MeV alpha particles from an (241)Am source can be used to measure the thickness of a Li coating on Mo tiles between 0.5 and 15 μm thick. Using a 0.1 mCi source, a thickness measurement can be accomplished in 2 h of counting. This technique could be used to measure any thin, low-Z material coating (up to 1 mg/cm(2) thick) on a high-Z substrate, such as Be on W, B on Mo, or Li on Mo. By inserting a source and detector on a moveable probe, this technique could be used to provide an in situ measurement of the thickness of Li coating on NSTX-U Mo tiles. A test stand with an alpha source and an annular solid-state detector was used to investigate the measurable range of low-Z material thicknesses on Mo tiles.

Management of a metastasized high grade insulinoma (G3) with refractory hypoglycemia: case report and review of the literature

Insulinomas represent the most common functional neuroendocrine tumor of the pancreas. They are usually solitary, benign, well differentiated (G1/G2) and curable by surgery. We describe the case of a 45 year old male Caucasian with a unique malignant, metastasized pancreatic insulinoma (Ki 67 of 70%, G3). To control excessive insulin production emanating in refractory hypoglycemia and growth of the highly proliferating tumor a multimodal therapeutic approach including the consecutive use of tumor debulking surgery, chemotherapy, TACE, SIRT, PRRT as well as a drug therapy with diazoxide, somatostatin analogs and everolimus was employed. Chemotherapy with carboplatin/etoposide plus everolimus provided the longest normoglycemic period. After progress chemotherapy with dacarbazine had the most positive effect, while debulking approaches such as surgery and liver directed therapies, as well as PRRT were less efficient with only transient success.

A Coordinated Effort to Manage Soybean Rust in North America: A Success Story in Soybean Disease Monitoring

Existing crop monitoring programs determine the incidence and distribution of plant diseases and pathogens and assess the damage caused within a crop production region. These programs have traditionally used observed or predicted disease and pathogen data and environmental information to prescribe management practices that minimize crop loss. Monitoring programs are especially important for crops with broad geographic distribution or for diseases that can cause rapid and great economic losses. Successful monitoring programs have been developed for several plant diseases, including downy mildew of cucurbits, Fusarium head blight of wheat, potato late blight, and rusts of cereal crops. A recent example of a successful disease-monitoring program for an economically important crop is the soybean rust (SBR) monitoring effort within North America. SBR, caused by the fungus Phakopsora pachyrhizi, was first identified in the continental United States in November 2004. SBR causes moderate to severe yield losses globally. The fungus produces foliar lesions on soybean (Glycine max) and other legume hosts. P. pachyrhizi diverts nutrients from the host to its own growth and reproduction. The lesions also reduce photosynthetic area. Uredinia rupture the host epidermis and diminish stomatal regulation of transpiration to cause tissue desiccation and premature defoliation. Severe soybean yield losses can occur if plants defoliate during the mid-reproductive growth stages. The rapid response to the threat of SBR in North America resulted in an unprecedented amount of information dissemination and the development of a real-time, publicly available monitoring and prediction system known as the Soybean Rust-Pest Information Platform for Extension and Education (SBR-PIPE). The objectives of this article are (i) to highlight the successful response effort to SBR in North America, and (ii) to introduce researchers to the quantity and type of data generated by SBR-PIPE. Data from this system may now be used to answer questions about the biology, ecology, and epidemiology of an important pathogen and disease of soybean.

In vitro chipping behaviour of all-ceramic crowns with a zirconia framework and feldspathic veneering: comparison of CAD/CAM-produced veneer with manually layered veneer

The purpose of this in vitro study was to assess the breaking load of zirconia-based crowns veneered with either CAD/CAM-produced or manually layered feldspathic ceramic. Thirty-two identical zirconia frameworks (Sirona inCoris ZI, mono L F1), 0·6 mm thick with an anatomically shaped occlusal area, were constructed (Sirona inLab 3.80). Sixteen of the crowns were then veneered by the use of CAD/CAM-fabricated feldspathic ceramic (CEREC Bloc, Sirona) and 16 by the use of hand-layered ceramic. The CAD/CAM-manufactured veneer was attached to the frameworks by the use of Panavia 2.0 (Kuraray). Half of the specimens were loaded until failure without artificial ageing; the other half of the specimens underwent thermal cycling and cyclic loading (1·2 million chewing cycles, force magnitude F(max) = 108 N) before the assessment of the ultimate load. To investigate the new technique further, finite element (FE) computations were conducted on the basis of the original geometry. Statistical assessment was made by the use of non-parametric tests. Initial breaking load was significantly higher in the hand-layered group than in the CAD/CAM group (mean: 1165·86 N versus 395·45 N). During chewing simulation, however, 87·5% (7/8) of the crowns in the hand-layered group failed, whereas no crown in the CAD/CAM group failed. The CAD/CAM-produced veneer was significantly less sensitive to ageing than the hand-layered veneer.

First Report of Soybean Vein Necrosis Disease Caused by Soybean vein necrosis-associated virus in Wisconsin and Iowa

Several viral diseases of soybean (Glycine max) have been identified in the north-central U.S. soybean production area, which includes Wisconsin and Iowa (2). Previously, Soybean vein necrosis disease (SVND) caused by Soybean vein necrosis-associated virus was reported in Arkansas, Tennessee, and other southern states (4). In September 2012, soybean plants with symptoms similar to those reported for SVND (4) were observed in fields across Wisconsin and Iowa. Symptoms included leaf-vein and leaf chlorosis, followed by necrosis of the leaf veins and eventually necrosis of the entire leaf. Six samples with symptoms indicative of SVNaV were collected from research plots located at the West Madison Agricultural Research Station located in Madison, WI. An additional three samples were collected from three locations in central Iowa. Total RNA extracted from each sample using the Trizol Plus RNA purification kit (Invitrogen, Carlsbad, CA) was used to generate complementary DNA (cDNA) using the iScript cDNA synthesis kit (Bio-Rad Laboratories, Hercules, CA) following the manufacturers' suggested protocols. The resulting cDNA was used as template in a PCR with SVNaV-specific primers, SVNaV-f1 and SVNaV-r1 (3). PCRs of two of the six Wisconsin samples and two Iowa samples were positive. Amplification products were not detected in the other five samples. The amplification products from the four strongly positive samples were purified using the Wizard SV Gel and PCR Purification Kit (Promega, Madison, WI) following the manufacturer's suggested protocol and were subjected to automated sequencing (University of Wisconsin Biotechnology Center or Iowa State University, DNA Sequencing Facilities). BLASTn (1) alignments of the 915-bp consensus sequence revealed 98% and >99% identity of the Wisconsin and Iowa samples, respectively, with the 'S' segment of the SVNaV 'TN' isolate (GenBank Accession No. GU722319.1). Samples from the same leaf tissue used above, were subjected to serological tests for SVNaV using antigen coated-indirect ELISA (3). Asymptomatic soybeans grown in the greenhouse were used as a source of leaves for negative controls. These tests confirmed the presence of SVNaV in eight symptomatic soybean leaflets collected in Wisconsin and Iowa. The asymptomatic control and one Iowa sample, which was also PCR-negative, were also negative by serological testing. Six additional samples from soybean fields in as many Wisconsin counties (Fond Du Lac, Grant, Green, Juneau, Richland, Rock) tested positive for SVNaV using specific primers that amplify the 'L' segment (4). The sequenced amplification products (297-bp) showed 99 to 100% homology to the L segment of the TN isolate (GU722317.1). To our knowledge, this is the first report of SVNaV associated with soybean and the first report of SVND in Wisconsin and Iowa. Considering that little is known about SVNaV, it is assumed that it is like other Tospoviruses and can cause significant yield loss (4). Soybean is a major cash crop for Wisconsin and Iowa, and infection by SVNaV could result in potential yield loss in years where epidemics begin early and at a high initial inoculum level. References: (1) S. F. Altschul et al. J. Mol. Biol. 215:403, 1990. (2) G. L. Hartman et al. Compendium of Soybean Diseases, 4th ed, 1999. (3) B. Khatabi et al. Eur. J. Plant Pathol. 133:783, 2012. (4) J. Zhou et al. Virus Genes 43:289, 2011.

Fourier transform infrared spectroscopy (FTIR) and multivariate analysis for identification of different vegetable oils used in biodiesel production

The main objective of this study was to use infrared spectroscopy to identify vegetable oils used as raw material for biodiesel production and apply multivariate analysis to the data. Six different vegetable oil sources—canola, cotton, corn, palm, sunflower and soybeans—were used to produce biodiesel batches. The spectra were acquired by Fourier transform infrared spectroscopy using a universal attenuated total reflectance sensor (FTIR-UATR). For the multivariate analysis principal component analysis (PCA), hierarchical cluster analysis (HCA), interval principal component analysis (iPCA) and soft independent modeling of class analogy (SIMCA) were used. The results indicate that is possible to develop a methodology to identify vegetable oils used as raw material in the production of biodiesel by FTIR-UATR applying multivariate analysis. It was also observed that the iPCA found the best spectral range for separation of biodiesel batches using FTIR-UATR data, and with this result, the SIMCA method classified 100% of the soybean biodiesel samples.

[Clinical application of pain-related evoked potentials]

Pain-related evoked potentials (PREPs) represent a novel method for the evaluation of peripheral and central nociceptive pathways, e.g. in the diagnosis of small fiber neuropathy (SFN) or after therapeutic interventions for headache. Compared to contact heat-evoked and laser-evoked potentials, recording of PREPs is less stressful for the subjects and technically less demanding. The clinical usefulness of PREPs has been described for SFN associated with diabetes, HIV and hepatitis C infections as well as in headache and facial pain disorders. They have also been evaluated after interventional methods, such as direct current stimulation (tDCS). The article reviews and discusses the advantages and pitfalls of this technique in the context of recent clinical studies as compared to other paradigms of peripheral electrical stimulation and delineates perspectives and possible indications.

Intracranial aneurysms: optimized diagnostic tools call for thorough interdisciplinary treatment strategies

OBJECTIVE

Intracranial aneurysms (IAs) require deliberately selected treatment strategies as they are incrementally found prior to rupture and deleterious subarachnoid haemorrhage (SAH). Multiple and recurrent aneurysms necessitate both neurointerventionalists and neurosurgeons to optimize aneurysmal occlusion in an interdisciplinary effort. The present study was conducted to condense essential strategies from a single neurovascular centre with regard to the lessons learned.

METHOD

Medical charts of 321 consecutive patients treated for IAs at our centre from September 2008 until December 2010 were retrospectively analysed for clinical presentation of the aneurysms, multiplicity and treatment pathways. In addition, a selective Medline search was performed.

RESULTS

A total of 321 patients with 492 aneurysms underwent occlusion of their symptomatic aneurysm: 132 (41.1%) individuals were treated surgically, 189 (58.2%) interventionally; 138 patients presented with a SAH, of these 44.2% were clipped and 55.8% were coiled. Aneurysms of the middle cerebral artery were primarily occluded surgically (88), whereas most of the aneurysms of the internal carotid artery and anterior communicating artery (114) were treated endovascularly. Multiple aneurysms (range 2-5 aneurysms/individual) were diagnosed in 98 patients (30.2%). During the study period 12 patients with recurrent aneurysms were allocated to another treatment modality (previously clip to coil and vice versa).

CONCLUSIONS

Our data show that successful interdisciplinary occlusion of IAs is based on both neurosurgical and neurointerventional therapy. In particular, multiple and recurrent aneurysms require tailored individual approaches to aneurysmal occlusion. This is achieved by a consequent interdisciplinary pondering of the optimal strategy to occlude IAs in order to prevent SAH.