Initial management of closed fracture-dislocations of the ankle

BACKGROUND

Immediate management of closed fracture-dislocations of the ankle requires urgent reduction and immobilisation of the ankle prior to definitive surgery.

METHODS

The management of 23 patients attending the accident and emergency department of a district general hospital with this type of injury were reviewed retrospectively.

RESULTS

Paramedic reduction was attempted in 1 of the 22 patients brought by ambulance. Triage categorisation was inappropriate in 14 patients. Unnecessary pre-reduction radiographs were obtained in 8 patients. Reduction was initially inadequate in 2 patients, and no post-reduction splintage was applied in a further 2 patients. Recording of skin and neurovascular status was inadequate in the majority of the patient's notes.

CONCLUSIONS

The necessary urgent reduction and splintage is being delayed in some cases because of inadequate injury recognition, inappropriate triage categorisation and unnecessary radiographs.

Echolocation clicks of two free-ranging, oceanic delphinids with different food preferences: false killer whales Pseudorca crassidensand Risso's dolphins Grampus griseus

Toothed whales (Odontoceti, Cetacea) navigate and locate prey by means of active echolocation. Studies on captive animals have accumulated a large body of knowledge concerning the production, reception and processing of sound in odontocete biosonars, but there is little information about the properties and use of biosonar clicks of free-ranging animals in offshore habitats. This study presents the first source parameter estimates of biosonar clicks from two free-ranging oceanic delphinids, the opportunistically foraging Pseudorca crassidens and the cephalopod eating Grampus griseus. Pseudorca produces short duration (30 μs), broadband(Q=2–3) signals with peak frequencies around 40 kHz, centroid frequencies of 30–70 kHz, and source levels between 201–225 dB re. 1 μPa (peak to peak, pp). Grampus also produces short (40 μs),broadband (Q=2–3) signals with peak frequencies around 50 kHz,centroid frequencies of 60–90 kHz, and source levels between 202 and 222 dB re. 1 μPa (pp). On-axis clicks from both species had centroid frequencies in the frequency range of most sensitive hearing, and lower peak frequencies and higher source levels than reported from captive animals. It is demonstrated that sound production in these two free-ranging echolocators is dynamic, and that free-ranging animals may not always employ biosonar signals comparable to the extreme signal properties reported from captive animals in long-range detection tasks. Similarities in source parameters suggest that evolutionary factors other than prey type determine the properties of biosonar signals of the two species. Modelling shows that interspecific detection ranges of prey types differ from 80 to 300 m for Grampus and Pseudorca, respectively.

Effect of physiotherapy attendance on outcome after anterior cruciate ligament reconstruction: a pilot study

BACKGROUND

In many centres patients are routinely referred for physiotherapy after anterior cruciate ligament (ACL) reconstruction. However, to date the role and amount of supervised physiotherapy required has not been clearly established.

OBJECTIVE

To establish whether there was any difference in outcome between a group of patients who attended physiotherapy regularly after ACL reconstruction and a group who attended only infrequently.

METHODS

Ten patients who had attended physiotherapy infrequently (mean 1.9 visits) during the first six months after ACL reconstructive surgery were matched for age, sex, graft type, and activity level and occupation before injury with 10 patients who had attended physiotherapy regularly (mean 26.5 visits). Outcome was assessed at 12 months using the Cincinnati knee rating system and the IKDC form.

RESULTS

Compared with the regular physiotherapy group, patients in the minimal physiotherapy group had fewer symptoms (mean Cincinnati symptom score 46.2 v 43.4, p = 0.045). There was also a trend towards higher overall Cincinnati knee scores in the minimal physiotherapy group (mean 93.7 v 87.3, p = 0.06) but no difference in IKDC ratings.

CONCLUSION

These preliminary results indicate that some patients who choose to attend physiotherapy on a very limited basis after ACL reconstruction can achieve satisfactory, if not better, outcomes than patients who attend physiotherapy regularly.

2-Aminoethoxydiphenyl borate inhibits phototransduction and blocks voltage-gated potassium channels in Limulus ventral photoreceptors

2-Aminoethoxydiphenyl borate (2-APB) is a membrane-permeable modulator that inhibits the activation of inositol (1,4,5) trisphosphate (InsP(3)) receptors, store operated channels (SOCs) and TRP channels in cells that utilize the phosphoinositide cascade for cellular signaling. In Limulus ventral photoreceptors, light-induced calcium release via the phosphoinositide cascade is thought to activate the photocurrent. Injection of either exogenous InsP(3) or calcium ions can therefore mimic excitation by light. One hundred micromolar 2-APB reversibly inhibited the photocurrent of ventral photoreceptors in a concentration-dependent manner, acting on at least two processes thought to mediate the visual cascade. 2-APB reversibly inhibited both light and InsP(3)-induced calcium release, consistent with its role as an inhibitor of the InsP(3) receptor. In addition, 2-APB reversibly inhibited the activation of depolarizing current flow through the plasma membrane caused by pulsed pressure injection of calcium ions into the light-sensitive lobe of the photoreceptor. We also found that 100 micro M 2-APB reversibly inhibited both transient and sustained voltage-activated potassium current during depolarizing steps. 2-APB has previously been shown to block phototransduction in Drosophila photoreceptors. The lack of specificity of the action of 2-APB in Limulus indicates that this blockade need not necessarily arise from inhibition of InsP(3)-induced calcium release.

Sperm whale sound production studied with ultrasound time/depth-recording tags

Delphinoids (Delphinidae, Odontoceti) produce tonal sounds and clicks by forcing pressurized air past phonic lips in the nasal complex. It has been proposed that homologous, hypertrophied nasal structures in the deep-diving sperm whale (Physeter macrocephalus) (Physeteridae, Odontoceti) are dedicated to the production of clicks. However, air volumes in diving mammals are reduced with increasing ambient pressure, which seems likely to influence pneumatic sound production at depth. To study sperm whale sound production at depth, we attached ultrasound time/depth-recording tags to sperm whales by means of a pole and suction cup. We demonstrate that sperm whale click production in terms of output and frequency content is unaffected by hydrostatic reduction in available air volume down to less than 2% of the initial air volume in the nasal complex. We present evidence suggesting that the sound-generating mechanism has a bimodal function, allowing for the production of clicks suited for biosonar and clicks more suited for communication. Shared click features suggest that sound production in sperm whales is based on the same fundamental biomechanics as in smaller odontocetes and that the nasal complexes are therefore not only anatomically but also functionally homologous in generating the initial sound pulse.

A sensitive assay for ZD1839 (Iressa) in human plasma by liquid-liquid extraction and high performance liquid chromatography with mass spectrometric detection: validation and use in Phase I clinical trials

A specific and sensitive high performance liquid chromatography method for the quantitative determination of ZD1839 ('Iressa') concentrations in treated healthy volunteers and patients with cancer has been developed and validated. Plasma samples (0.5 ml) were extracted, at basic pH, with methyl-t-butyl ether using deuterated ZD1839 as an internal standard. The extracts were chromatographed on an Inertsil ODS3 column eluted with acetonitrile/ammonium acetate and ZD1839 and the internal standard quantified by mass spectrometric detection. The method was validated with respect to linearity, selectivity, precision, accuracy, limit of quantification (LOQ), recovery and stability. The precision and accuracy of the assay were good and the LOQ was 0.5 ng/ml. The assay has been successfully applied to a number of clinical and pharmacokinetic studies and been shown to be robust and reliable during routine use.

A safe and effective method for converting cancer patients from intravenous to transdermal fentanyl

BACKGROUND

Therapeutic fentanyl blood levels are reached approximately 12-16 hours after the initial application of transdermal fentanyl patches. For this reason, fentanyl patches should not be used to treat acute exacerbations of cancer pain. Acute cancer-related pain can be treated with fentanyl administered by continuous intravenous infusion (CII) in combination with patient-controlled analgesia (PCA). Patients then can be switched from intravenous (IV) to transdermal fentanyl once stable pain relief has been achieved. The objective of the current case series was to evaluate and describe the safety and effectiveness of a method for converting hospitalized patients with cancer-related pain from IV to transdermal fentanyl.

METHODS

The authors prospectively evaluated 15 consecutive cancer patients during the conversion from IV to transdermal fentanyl. In all patients, a transdermal patch delivering fentanyl at a rate equivalent to that of the final continuous IV infusion was applied. The CII rate was decreased by 50% 6 hours after application of the fentanyl patch and then discontinued after another 6 hours. Demand boluses of IV fentanyl equivalent in dosage to 50-100% of the final CII rate remained available via PCA during the 24 hours after patch application. Pain intensity (on a scale of 0-10), sedation (on a scale of 0-3), and hourly PCA administration (microg/hr) were assessed and recorded immediately prior to application of the fentanyl patch and 6, 12, 18, and 24 hours thereafter.

RESULTS

Pain intensity, sedation, and hourly PCA administration appeared to remain stable throughout the transition from IV to transdermal fentanyl.

CONCLUSIONS

The results of the current study demonstrate that the conversion from IV to transdermal fentanyl can be accomplished safely and effectively using a 1:1 (IV:transdermal) conversion ratio and a two-step taper of the CII over 12 hours.

Intravenous methadone in the management of chronic cancer pain: safe and effective starting doses when substituting methadone for fentanyl

BACKGROUND

Patients often are rotated from other opioids to methadone when side effects occur before satisfactory analgesia is achieved. Various strategies have been proposed to estimate safe and effective starting doses of methadone when rotating from morphine and hydromorphone; however, there are no guidelines for estimating safe and effective starting doses of methadone when rotating from fentanyl.

METHODS

The authors prospectively observed 18 consecutive patients experiencing chronic pain from cancer who underwent opioid rotation from intravenous patient-controlled analgesia (PCA) with fentanyl to intravenous PCA with methadone. Patients were switched from fentanyl to methadone because of uncontrolled pain associated with sedation or confusion. A conversion ratio of 25 microg/hour of fentanyl to 0.1 mg/hour of methadone was used to calculate the initial dose of methadone in all patients.

RESULTS

Mean pain scores decreased from 8.1 to 4.8 on Day 1 after the switch and to 3.22 on Day 4 after the switch. Mean sedation scores were 1.5 before the switch and 0.44 and 0.16 on Days 1 and 4, respectively. Among the 6 patients who experienced confusion while on fentanyl before the switch, 5 improved within 2 days of the switch. None of the patients experienced toxicity from methadone.

CONCLUSIONS

On the basis of this preliminary study, the authors suggest that when switching from intravenous fentanyl to methadone a conversion ratio of 25 microg/hour of fentanyl to 0.1 mg/hour of methadone may be safe and effective.

Palliative care and rehabilitation

Disability in patients with advanced cancer often results from bed rest, deconditioning, and neurologic and musculoskeletal complications of cancer or cancer treatment. Terminally ill patients have a high prevalence of weakness, pain, fatigue, and dyspnea in addition to other symptoms. Rehabilitation and palliative care have emerged as two important parts of comprehensive medical care for patients with advanced disease; this article discusses the relationship between the two and the possible role of rehabilitation interventions in the care of terminally ill patients. Palliative care and rehabilitation share common goals and therapeutic approaches. Both disciplines have a multidisciplinary model of care, which aims to improve patients' levels of function and comfort. There is scarce evidence that rehabilitation interventions can impact function and symptom management in terminally ill patients. However, clinical experience suggests that the application of the fundamental principles of rehabilitation medicine is likely to improve their care. Physical function and independence should be maintained as long as possible to improve patients' quality of life and reduce the burden of care for the caregivers. Future research on the rehabilitation of terminally ill patients should focus on better understanding the role of rehabilitation and defining appropriate interventions. The development of an evidence-based body of knowledge will ensure that these patients receive appropriate rehabilitation interventions.

A cGMP-gated channel subunit in Limulus photoreceptors

The phototransduction cascade in invertebrate photoreceptors has not been fully elucidated. It has been proposed that in Limulus ventral photoreceptor cGMP is the intracellular second messenger that directly controls the gating of the light-dependent channels (Johnson et al., 1986: Bacigalupo et al., 1991). Recently, a putative cGMP-gated channel cDNA, Lcng1, has been cloned from Limulus and shown to be expressed in the brain and the ventral eye (Chen et al., 1999). In this study, we sought to more specifically localize the LCNG1 transcript and protein. In situ hybridization was used to determine whether the gene is expressed in glia or photoreceptor cells in the ventral eye. The results clearly demonstrated that Lcngl mRNA is transcribed in the ventral photoreceptors. On Western blots probed with a polyclonal antibody raised against the C-terminus of LCNGI, a 100-kDa band and an 80-kDa band was labeled in the membrane protein preparations from brain and ventral eye, respectively. The labeling of these bands was blocked by preabsorption of the antibody with the antigen, indicating the labeling specificity. Immunocytochemistry and confocal microscopy were applied to investigate the subcellular localization of this antigen. Immunolabeling was highly localized in the transducing lobes of ventral eye photoreceptors and lateral eye photoreceptors. In both cases, the labeling was associated with membrane regions specialized for phototransduction, but the exact pattern appeared to be somewhat different in the two eyes. Preabsorption of the antiserum with antigen abolished the labeling, confirming specificity. The results lend support to the hypothesis that a cGMP-gated channel is directly involved in the phototransduction process.

Long-term safety of oral transmucosal fentanyl citrate for breakthrough cancer pain

This open-label study evaluated the long-term safety and tolerability of oral transmucosal fentanyl citrate (OTFC) in ambulatory cancer patients with breakthrough pain undergoing cancer care at 32 university- or community-based practices. Patients had participated in a previous short-term titration trial of OTFC, were experiencing at least one episode per day of breakthrough pain, and had achieved relief of their breakthrough pain with an opioid. Patients received OTFC units at a starting dosage strength determined in the short-term trial (200-1600 microg). Outcome measures included number of successfully treated breakthrough pains, global satisfaction rating (0 = poor through 4 = excellent), and side effects. In total, 41,766 units of OTFC were used to treat 38,595 episodes of breakthrough pain in 155 patients. Number of treatment days ranged from 1 to 423 (mean, 91 days). Patients averaged 2.9 breakthrough pain episodes per day. About 92% of episodes were successfully treated with OTFC and there was no trend toward decreased effectiveness over time. Most patients (61%) did not require dose escalation during treatment. Global satisfaction ratings were consistently above 3, indicating very good to excellent relief. Common adverse events associated with OTFC were somnolence (9%), constipation (8%), nausea (8%), dizziness (8%), and vomiting (5%). Six patients (4%) discontinued therapy due to an OTFC-related adverse event. There were no reports of abuse and no concerns about the safety of the drug raised by patients or families. OTFC was used safely and effectively during long-term treatment of breakthrough pain in cancer patients at home.

Immunocytochemical localization of opsin, visual arrestin, myosin III, and calmodulin in Limulus lateral eye retinular cells and ventral photoreceptors

The photoreceptors of the horseshoe crab Limulus polyphemus are classical preparations for studies of the photoresponse and its modulation by circadian clocks. An extensive literature details their physiology and ultrastructure, but relatively little is known about their biochemical organization largely because of a lack of antibodies specific for Limulus photoreceptor proteins. We developed antibodies directed against Limulus opsin, visual arrestin, and myosin III, and we have used them to examine the distributions of these proteins in the Limulus visual system. We also used a commercial antibody to examine the distribution of calmodulin in Limulus photoreceptors. Fixed frozen sections of lateral eye were examined with conventional fluorescence microscopy; ventral photoreceptors were studied with confocal microscopy. Opsin, visual arrestin, myosin III, and calmodulin are all concentrated at the photosensitive rhabdomeral membrane, which is consistent with their participation in the photoresponse. Opsin and visual arrestin, but not myosin III or calmodulin, are also concentrated in extra-rhabdomeral vesicles thought to contain internalized rhabdomeral membrane. In addition, visual arrestin and myosin III were found widely distributed in the cytosol of photoreceptors, suggesting that they have functions in addition to their roles in phototransduction. Our results both clarify and raise new questions about the functions of opsin, visual arrestin, myosin III, and calmodulin in photoreceptors and set the stage for future studies of the impact of light and clock signals on the structure and function of photoreceptors.

Methadone analgesia in cancer pain patients on chronic methadone maintenance therapy

Methadone is currently best known for its use as the maintenance drug in opioid addiction. The main concern when using methadone for the treatment of pain is its long and unpredictable half-life, which is associated with the risk of delayed toxicity. This may result in side effects such as sedation and respiratory depression if careful titration and close observation of individual patient responses are not performed. For this reason, methadone is often viewed as a second line opioid, after other opioids with a more predictable dose-response have been tried. We report six patients with long-term exposure to methadone as a treatment for heroin dependency, who were also treated with methadone for cancer pain. The first five patients were at least partially refractory to the analgesic effects of opioids other than methadone. All six patients achieved analgesia without sedation or respiratory depression from aggressive upward methadone titration. Methadone analgesia can be considered early in the course of treatment of patients with chronic exposure to methadone who develop new or worsening pain requiring opioid therapy.

Reversible Spastic Paraparesis Induced by High-Dose Intravenous Methadone

High doses of parenteral opioids can cause multifocal myoclonus and seizures. Spasticity has been reported in patients receiving intraspinal opioids. In this article, we describe a patient who developed reversible spastic paraparesis with prominent extensor spasms in the legs while receiving an infusion of intravenous methadone at 100 mg/hr. We discuss clinical presentation and possible pathophysiologic mechanisms of opioid side effects on the somatic motor system.

Current management of opioid-related side effects

The optimal management of opioid-related side effects is hampered by a lack of comparative studies of management strategies. The prevalence of such side effects is influenced by the extent of disease, the patient's age, the presence of coexistent renal and hepatic disease, pulmonary disease, and cognitive dysfunction, a prior opioid history, use of polypharmacy, dose of opioid drug being administered, and the route of administration. The most common opioid-related side effects are constipation, sedation, nausea, vomiting, and cognitive disturbance. Less frequent side effects include urinary retention, perceptual distortion, respiratory depression, and myoclonus. In an era emphasizing quality of life in cancer care, clinicians need to be aware of (1) factors that influence the prevalence of opioid-related side effects, (2) effective management strategies, and (3) how to recognize when symptoms are opioid related as opposed to caused by other etiologies, such as the patient's disease process or treatment approaches. The use of validated instruments and repeated assessment enhances such an evaluation and subsequent treatment. This article delineates the current optimal management of opioid-related nausea and vomiting, constipation, cognitive side effects, myoclonus, and respiratory depression.

NCCN Practice Guidelines for Cancer Pain

The overall approach to pain management encompassed in these guidelines is comprehensive. It is based on objective pain assessments, utilizes both pharmacologic and nonpharmacologic interventions, and requires continual reevaluation of the patient. The NCCN Cancer Pain Practice Guidelines Panel believes that cancer pain can be well controlled in the vast majority of patients if the algorithms presented are systematically applied, carefully monitored, and tailored to the needs of the individual patient.

World-wide genetic differentiation of Eubalaena: questioning the number of right whale species

Few studies have examined systematic relationships of right whales (Eubalaena spp.) since the original species descriptions, even though they are one of the most endangered large whales. Little morphological evidence exists to support the current species designations for Eubalaena glacialis in the northern hemisphere and E. australis in the southern hemisphere. Differences in migratory behaviour or antitropical distribution between right whales in each hemisphere are considered a barrier to gene flow and maintain the current species distinctions and geographical populations. However, these distinctions between populations have remained controversial and no study has included an analysis of all right whales from the three major ocean basins. To address issues of genetic differentiation and relationships among right whales, we have compiled a database of mitochondrial DNA control region sequences from right whales representing populations in all three ocean basins that consist of: western North Atlantic E. glacialis, multiple geographically distributed populations of E. australis and the first molecular analysis of historical and recent samples of E. glacialis from the western and eastern North Pacific Ocean. Diagnostic characters, as well as phylogenetic and phylogeographic analyses, support the possibility that three distinct maternal lineages exist in right whales, with North Pacific E. glacialis being more closely related to E. australis than to North Atlantic E. glacialis. Our genetic results provide unequivocal character support for the two usually recognized species and a third distinct genetic lineage in the North Pacific under the Phylogenetic Species Concept, as well as levels of genetic diversity among right whales world-wide.

Sumatriptan for headache caused by head and neck cancer

The use of sumatriptan for the treatment of migraine and cluster headache is well established. Sumatriptan has also been reported to be effective for the treatment of postdural puncture headache, postictal headache, and headache related to intravenous immunoglobulin infusion. We report two patients with headache caused by locally invasive head and neck cancer relieved by oral sumatriptan.

Limitations of NSAIDs for pain management: Toxicity or lack of efficacy?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in the management of arthritis and acute and chronic pain of many etiologies, including cancer-related pain. These drugs are indicated for use as single agents in mild to moderate pain and in combination with opioid analgesics or adjuvant analgesic drugs in severe pain. NSAIDs, which nonselectively inhibit the cyclooxygenase enzymes (isoenzymes 1 and 2), pose a potentially serious risk of gastrointestinal toxicity with acute and chronic use, hematologic toxicity with acute use, and nephrotoxicity with chronic use. Patients experiencing acute and chronic pain associated with serious and even life-threatening medical illness such as cancer and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) fall into a high-risk group with respect to the use of NSAIDs. This is so because the occurrence of gastrointestinal bleeding and the masking of opportunistic infections related to the antipyretic effects of NSAIDs pose particular risk and might even cause lethal complications in patients who are neutropenic, thrombocytopenic, or otherwise immuno-compromised.

Outcome of cancer pain consultations

BACKGROUND

All major cancer centers in the United States are equipped with pain management consultation services. We report on the outcome of such consultations within 24 hours from the intervention.

METHODS

All consecutive patients referred to the pain management service of a tertiary care cancer center were assessed before and 14-24 hours after the intervention.

RESULTS

A total of 45 patients completed the study. The mean current pain intensity score was 5.2 on the Visual Analogue Scale before the consultation and 2.7 after the consultation (P < 0.05). The pain was described as excruciating on the Categorical Scale by three patients before the consultation and by no patients after the consultation.

CONCLUSIONS

In hospitalized cancer patients with difficult to control pain, cancer pain consultations result in a measurable effect within 24 hours of the pharmacologic intervention. To avoid unnecessary suffering, timeliness is of the utmost importance when requesting and delivering cancer pain consultations.

Timing of Ca(2+) release from intracellular stores and the electrical response of Limulus ventral photoreceptors to dim flashes

Light-induced release of Ca(2+) from stores in Limulus ventral photoreceptors was studied using confocal fluorescence microscopy and the Ca(2+) indicator dyes, Oregon green-5N and fluo-4. Fluorescence was collected from a spot within 4 microm of the microvillar membrane. A dual-flash protocol was used to reconstruct transient elevations of intracellular free calcium ion concentration (Ca(i)) after flashes delivering between 10 and 5 x 10(5) effective photons. Peak Ca(i) increased with flash intensity to 138 +/- 76 microM after flashes delivering approximately 10(4) effective photons, while the latent period of the elevation of Ca(i) fell from approximately 140 to 21 ms. The onset of the light-induced elevation of Ca(i) was always highly correlated with that of the receptor potential. The time for Ca(i) to exceed 2 microM was approximately equal to that for the receptor potential to exceed 8 mV (mean difference; 2.2 +/- 6.4 ms). Ca(i) was also measured during steps of light delivering approximately 10(5) effective photons/s to photoreceptors that had been bleached with hydroxylamine so as to reduce their quantum efficiency. Elevations of Ca(i) were detected at the earliest times of the electrical response to the steps of light, when a significant receptor potential had yet to develop. Successive responses exhibited stochastic variation in their latency of up to 20 ms, but the elevation of Ca(i) and the receptor potential still rose at approximately the same time, indicating a shared process generating the latent period. Light-induced elevations of Ca(i) resulted from Ca(2+) release from intracellular stores, being abolished by cyclopiazonic acid (CPA), an inhibitor of endoplasmic reticulum Ca(2+) pumps, but not by removal of extracellular Ca(2+) ions. CPA also greatly diminished and slowed the receptor potential elicited by dim flashes. The results demonstrate a rapid release of Ca(2+) ions that appears necessary for a highly amplified electrical response to dim flashes.

An alternative algorithm for dosing transdermal fentanyl for cancer-related pain

Many cancer patients are undermedicated and inappropriately managed for pain, leading to a diminished quality of life. Patients with moderate to severe pain often require opioid analgesics. Recently published guidelines emphasize individualization of opioid treatment to provide the drug and route of administration that meet the needs of the particular patient. Intolerable side effects, ineffective pain relief, or a change in the patient's clinical status can dictate the need for a new pain management regimen. Physicians must be able to readily quantify relative analgesic potency when converting from one opioid to another or from one route of administration to another. Transdermal fentanyl (Duragesic) is an opioid agonist that has been shown to be safe and effective for the treatment of cancer pain. However, clinicians should realize that the manufacturer's recommendations for equianalgesic dosing of transdermal fentanyl may result in initial doses that are too low in some patients, and in a titration period that is too long. Under these circumstances, the patient is likely to experience unrelieved pain. An alternative dosing algorithm that considers both a review of the literature and our combined clinical experience with transdermal fentanyl should help clinicians individualize the treatment of pain.

Minority cancer patients and their providers: pain management attitudes and practice

BACKGROUND

The goals of the current studies were: 1) to determine the pain treatment needs of socioeconomically disadvantaged African-American and Hispanic patients with recurrent or metastatic cancer and 2) to assess the attitudes of health care professionals who treat them.

METHODS

In the first study 108 African-American and Hispanic patients with metastatic or recurrent cancer and pain completed a survey about their pain intensity, pain interference, and attitudes toward analgesic medications. Physicians also rated their patients' pain and the adequacy of the patients' current analgesic prescriptions was assessed. In the second study 55 physicians and nurses who treat these patients completed a questionnaire regarding cancer pain and its management in their practice settings.

RESULTS

Approximately 28% of the Hispanic and 31% of the African-American patients received analgesics of insufficient strength to manage their pain. Although the majority of patients received appropriate analgesics, 65% reported severe pain. Physicians underestimated pain severity for 64% of the Hispanic and 74% of the African-American patients. Physicians were more likely to underestimate the pain severity of female patients than male patients. Inadequate pain assessment, patient reluctance to report pain, and lack of staff time were perceived as barriers to pain management.

CONCLUSIONS

Although the data suggest recent improvements in analgesic prescribing practices for African-American and Hispanic cancer patients, the majority of patients reported high levels of pain and limited pain relief from analgesic medications. Inadequate pain assessment remains a major barrier to optimal cancer pain treatment.

Multidisciplinary care of the terminally ill patient

This article discusses sedation, the assessment and management of physical symptoms, and symptom-assessment scales for the terminally ill patient. The evaluation of the ability of the family or community to care for a terminally ill patient in pain also is discussed.

Axial and total-body bone densitometry using a narrow-angle fan-beam

We assessed a new dual-energy bone densitometer, the PRODIGY, that uses a narrow-angle fan-beam (4.5 degrees) oriented parallel to the longitudinal axis of the body (i.e., perpendicular to the usual orientation). High-resolution scans across the body can be stepped at 17 mm intervals. The energy-sensitive array detector uses cadmium zinc telluride, which allowed rapid photon counting. Spine and femur scans required 30 s, and total-body scans required 4-5 min; the dose was only 3.7 mrem and 0.04 mrem respectively, or about 5 to 10 times lower than conventional fan-beam densitometry. We found only a small influence of soft-tissue thickness on bone mineral density (BMD) results. There was also a small (+/- 1%) influence of height above the tabletop on BMD results. A software correction for object height allowed a first-order correction for the large magnification effects of position on bone mineral content (BMC) and area. Consequently, the results for BMC and area, as well as BMD, with PRODIGY corresponded closely to those obtained using the predecessor DPX densitometer, both in vitro and in vivo; there was a generally high correlation (r = 0.98-0.99) for BMD values. Spine and femur values for BMC, area and BMD averaged within 0.5% in vivo (n = 122), as did total-body BMC and BMD (n = 46). PRODIGY values for total-body lean tissue and fat also corresponded within 1% to DPX values. Regional and total-body BMD were measured with 0.5% precision in vitro and 1% precision in vivo. The new PRODIGY densitometer appears to combine the low dose and high accuracy of pencil-beam densitometry with the speed of fan-beam densitometers.

Chronic pain: challenges in the assessment and management of cancer pain

Assessing and managing pain while caring for the whole patient is a challenge for physicians. Barriers to pain management include clinician-, patient-, and health system-related issues. The traditional model of care is focused on disease-specific treatments. If these treatments fail, the focus shifts to palliation. A new model of care integrates disease-specific treatments with palliative care and rehabilitation. This model includes prevention and treatment of suffering. An essential element of this model is evaluation of the patient's concerns about the future and fear. Treating patient pain with quality pain management and palliative care involves a holistic pain assessment and management strategy.

Protein kinase C activators inhibit the visual cascade in Limulus ventral photoreceptors at an early stage

The phosphoinositide cascade mediates visual transduction in invertebrate photoreceptors. Phospholipase C (PLC) catalyzes the hydrolysis of phosphatidylinositol bisphosphate, producing inositol trisphosphate (InsP(3)) and diacylglycerol (DAG). Protein kinase C (PKC) is a major target of DAG in many cell types. We have used PKC activators to investigate the function of the kinase in the phototransduction cascade in Limulus polyphemus ventral photoreceptors. Extracellular application of (-)-indolactam V (0. 03-30 microM) or phorbol-12,13-dibutyrate (10 microM) reversibly reduced the sensitivity of the electrical response of the photoreceptors to light by up to 1000-fold. The inert stereoisomer (+)-indolactam V and 4alpha-phorbol had no effect. The effect of (-)-indolactam V was antagonized by the PKC inhibitors bisindolylmaleimide I and Gö 6976. Coapplication of bisindolylmaleimide V, used as a negative control compound for PKC inhibition, did not reduce the effectiveness of (-)-indolactam V. These findings are consistent with (-)-indolactam V activating PKC and desensitizing the light response. Furthermore, our pharmacological results indicate that PKC activation does not appear to play a role in light adaptation. We localized the position of the target of PKC in the visual cascade. We chemically excited the cascade at various stages to determine the kinase's target. PKC activation by (-)-indolactam V decreased the light-induced elevation of intracellular calcium but had no effect on the photoreceptor's excitatory response to intracellular injection of InsP(3). However, the PKC activator greatly reduced the excitation caused by GTP-gamma-S injection. We propose that PKC inhibits the visual transduction cascade at the G-protein and/or PLC stage.

Dorsal skin color patterns among southern right whales (Eubalaena australis): genetic basis and evolutionary significance

Distribution and inheritance of dorsal skin color markings among two populations of southern right whales (Eubalaena australis) suggest that two genes influence dorsal skin color. The grey-morph and partial-grey-morph phenotypes (previously known as partial albino and grey-blaze, respectively) appear to be controlled by an X-linked gene, whereas the white blaze appears controlled by an autosomal gene (recessive phenotype). Calving intervals, calf size, and length of sighting history data suggest that partial-grey-morph, white-blaze, and black cows experience similar levels of reproductive success. Grey-morph cows (XgXg) are rare or absent in the two populations, but this was not unexpected given observed population frequencies of grey-morph males (XgY) and partial-grey-morph females (XGXg). The proportion of partial-grey-morph calves produced by black cows (XGXG) suggests that the reproductive success of grey-morph males was equal to that of black males, however, larger sample sizes are required to determine whether grey-morph males tend to have shorter sighting histories. The reproductive success of white-blaze males appeared similar to that of black males among whales off Argentina. There were significantly fewer white-blaze calves than expected off South Africa, which could be due to white-blaze males experiencing reduced reproductive success or to sighting blases that result in white-marked calves being misidentified as black calves. The relative frequencies of both types of dorsal color markings varied between the South African and Argentinian right whale populations, suggesting limited nuclear gene flow between these populations; analyses using other nuclear markers are under way to confirm the extent of gene flow.

Oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough pain in cancer patients: a controlled dose titration study

Oral transmucosal fentanyl citrate (OTFC) is a novel opioid formulation in which the potent synthetic mu-agonist fentanyl is embedded in a sweetened matrix that is dissolved in the mouth. It is undergoing investigation as a treatment for cancer-related breakthrough pain, a prevalent phenomenon defined as a transitory flare of moderate to severe pain that interrupts otherwise controlled persistent pain. There have been no controlled trials of other treatments for this condition. To evaluate the safety and efficacy of ascending doses of OTFC, a novel controlled dose titration methodology was developed that applied blinding and randomization procedures to the evaluation of recurrent pains in the home environment. The study was a multicenter, randomized, double-blind dose titration study in ambulatory cancer patients. The sample comprised adult patients receiving a scheduled oral opioid regimen equivalent to 60-1000 mg oral morphine per day, who were experiencing at least one episode per day of breakthrough pain and had achieved at least partial relief of this pain by use of an oral opioid rescue dose. After collection of 2 days of baseline data concerning the efficacy of the usual rescue drug, patients were randomly treated with either 200 or 400 microg OTFC unit doses in double-blind fashion. Up to two breakthrough pains each day could be treated with up to four OTFC unit doses per pain. OTFC in unit doses containing 200, 400, 600, 800, 1200 or 1600 microg of fentanyl citrate were available for the study. The unit dose was titrated upward in steps until the patient had 2 consecutive days on which breakthrough pain could be treated with the single unit dose, titration was ineffective at a 1600 microg unit dose, or 20 days elapsed. To maintain the double-blind, orders to titrate up were ignored one-third of the time according to a pre-defined randomization schedule accessible only to an unblinded study pharmacist. Main outcome measures included, numeric or categorical measures of pain intensity, pain relief, and global assessment of drug performance. Dose response relationships were found suggesting that the methodology was sensitive to opioid effects. Seventy-four percent of patients were successfully titrated. There was no relationship between the total daily dose of the fixed schedule opioid regimen and the dose of OTFC required to manage the breakthrough pain. Although the study was not designed to provide a definitive comparison between OTFC and the usual rescue drug, exploratory analyses found that OTFC provided significantly greater analgesic effect at 15, 30 and 60 min, and a more rapid onset of effect, than the usual rescue drug. Adverse effects of the OTFC were typically opioid-related, specifically somnolence, nausea and dizziness. Very few adverse events were severe or serious. This study demonstrated the feasibility of controlled trial methodology in studies of breakthrough pain. OTFC appears to be a safe and effective therapy for breakthrough pain, and dose titration can usually identify a unit dose capable of providing adequate analgesia. If the lack of a relationship between the effective OTFC dose and fixed schedule opioid regimen is confirmed, dose titration may be needed in the clinical use of this formulation. Further investigation of OTFC as a specific treatment for breakthrough pain is warranted.

Molecular cloning of a putative cyclic nucleotide-gated ion channel cDNA from Limulus polyphemus

Cyclic nucleotide-gated channels have been proposed to mediate the electrical response to light in the ventral photoreceptor cells of the horseshoe crab, Limulus polyphemus. However, a cyclic nucleotide-gated channel has not been identified from Limulus. We have cloned a putative full-length cyclic nucleotide-gated channel cDNA by screening cDNA libraries constructed from Limulus brain using a probe developed from Limulus ventral eye nerves. The putative full-length cDNA was derived from two overlapping partial cDNA clones. The open reading frame encodes 905 amino acids; the sequence shows 44% identity to that of the alpha subunit of the bovine rod cyclic GMP-gated channel over the region containing the transmembrane domains and the cyclic nucleotide binding domain. This Limulus channel has a novel C-terminal region of approximately 200 amino acids, containing three putative Src homology domain 3 binding motifs and a putative coiled-coil domain. The possibility that this cloned channel is the same as that detected previously in excised patches from the photoreceptive membrane of Limulus ventral photoreceptors is discussed in terms of its sequence and its expression in the ventral eye nerves.

Practice guidelines for cancer pain therapy. Issues pertinent to the revision of national guidelines

The high prevalence of pain in cancer patients has been appreciated for a long time. However, despite release of cancer pain management guidelines by the Agency for Health Care Policy and Research (AHCPR) in 1994, pain is still undertreated. Recent reports in the literature have identified multiple factors that influence analgesic response and pain management, such as the ethnicity, gender, and age of the patient. Recognition of these factors, and the availability of new drugs, alternative delivery methods, and an enhanced understanding of pain mechanisms and receptor pharmacology compel a revision of the existing cancer pain management guidelines. Assessment and management of pain and other symptoms in cancer patients that influence the quality of survival are increasingly being incorporated into randomized-controlled clinical trials. Strategies should be developed by the National Comprehensive Cancer Network (NCCN) to develop and implement extant and revised pain management guidelines into clinical practice and test new hypotheses regarding pain management treatments in clinical trials.

Presenting symptoms in patients referred to a multidisciplinary clinic for bone metastases

Symptom control is the goal of palliative irradiation. Approximately 1 month is required before symptomatic relief is accomplished with radiotherapy. However, many patients with cancer-related pain do not receive adequate analgesics, and opioids are often not prescribed until patients fail to respond to palliative irradiation. The presenting symptoms of 108 patients who were referred to a multidisciplinary clinic for bone metastases were evaluated with the Wisconsin Brief Pain Inventory (BPI). This validated instrument evaluates the severity of pain using a 0-10 scale; 10 represents the worst pain imaginable. The population comprised 65 men (60%) and 43 women whose ages ranged from 33 years to 81 years; median age was 55 years, and 69% of patients were less than 65 years of age. Despite the presence of metastatic disease, 21% of patients were working full-time outside the home, and 6% were employed part-time outside the home; 13% were homemakers. Only 17 patients (16%) were unemployed. The time since diagnosis ranged from 2 weeks to 23 years; the median time since diagnosis was 22 months, and 30% of patients had been diagnosed with the past 6 months. Pain was a presenting symptom in 74% (N = 80) of patients at diagnosis. At its worst, the pain was rated as severe (levels 7-10) by 78% and intolerable (level 10) in 22% of the patients in the 24 hr prior to the clinic appointment. On average, the pain was rated moderate to severe (levels 4-10) in 79% and severe in 23% of patients. Only 45% of patients experienced good relief from the prescribed analgesics, and 23% of patients indicated that the prescribed analgesics were ineffective. This survey demonstrates that bone metastases incur significant pain that is often undertreated with analgesics before antineoplastic therapy is administered.

Putative inositol 1,4,5-trisphosphate receptor localized to endoplasmic reticulum in Limulus photoreceptors

Invertebrate microvillar photoreceptors utilize the phosphoinositide cascade to transduce light stimuli and inositol 1,4,5-trisphosphate is thought to be one of the messengers that triggers the electrical response by mobilizing intracellular stored calcium. To further characterize the role of the phosphoinositide signaling pathway in invertebrate phototransduction, we have examined the distribution of inositol 1,4,5-trisphosphate receptors in Limulus lateral eye and ventral nerve photoreceptors using an immunohistochemical approach combined with confocal microphotolysis of caged inositol 1,4,5-trisphosphate. We have localized the inositol 1,4,5-trisphosphate receptor using an antibody raised against a highly conserved region of the N-terminal of the protein. In lateral eye photoreceptors, the antibody intensely stains cytoplasm directly beneath the photoreceptive microvilli, containing subrhabdomeral cisternae of endoplasmic reticulum. In ventral nerve photoreceptors, the distribution of immunostaining was more homogeneous than within the lateral eye photoreceptors. Simultaneous confocal microphotolysis of caged inositol 1,4,5-trisphosphate and Ca2+ measurements using the fluorescent indicator Calcium Green 5N were performed to estimate inositol 1,4,5-trisphosphate-induced Ca2+ release in functionally distinct areas of the ventral nerve photoreceptors. This is the first direct demonstration of the localization of putative inositol 1,4,5-trisphosphate receptor in invertebrate visual cells. The inositol 1,4,5-trisphosphate receptor appears to be localized predominantly to endoplasmic reticulum and taken in conjunction with earlier physiological data from other workers, our result supports a central role for the phosphoinositide pathway in visual transduction in Limulus photoreceptors.

Light-induced Mn2+ influx in Limulus ventral photoreceptors

In contrast to insect species, light-activated influx of divalent ions into Limulus ventral photoreceptors has proven difficult to demonstrate. We used the quench of the fluorescent indicator dye, fura-2, to measure Mn2+ influx. Limulus ventral photoreceptors were injected with fura-2 and excited at 360 nm. When the photoreceptors were bathed in 1 mmol.l-1 Mn2+, an approximately 1% per 10 s decline in the fura-2 fluorescence during intervals between 50-ms flashes was taken as a measure of Mn2+ entry in darkness. Fluorescence decline during 10-s flashes was used to monitor Mn2+ entry during the photoresponse. During the 10-s flashes we observed a small rapid decline of the fura-2 fluorescence even in the absence of Mn2+. This reflected a contamination of the fluorescence signal arising from light-induced release of intracellular calcium stores. A subsequent slower decline in fluorescence during the 10-s flash, amounting to approximately 9% per 10 s, was only observed in the presence of extracellular Mn2+ and was attributed to Mn2+ influx. This light-activated influx was not through voltage-gated calcium channels since it persisted under voltage clamp, was not stimulated by depolarizing current injections, nor blocked by NiCl2. Depletion of internal calcium stores by cyclopiazonic acid treatment did not accelerate Mn2+ influx.

Factors influencing quality of life in cancer patients: the role of transdermal fentanyl in the management of pain

A transdermal fentanyl patch for the treatment of chronic cancer-related pain is available in four dosages (25, 50, 75, and 100 microg/hr). Fentanyl is released from a 72-hour reservoir by diffusion through a controlled-release membrane to the skin, through which it is absorbed into the microcirculation. The pharmacokinetics of fentanyl differ markedly as a function of the route of administration. Unlike intravenous administration, in which peak plasma levels occur within minutes and the plasma elimination half-life is 2 to 3 hours, after initial transdermal fentanyl patch application, peak levels occur within 14 hours and the elimination half-life exceeds 24 hours. When compared with oral morphine at doses effecting the same degree of pain relief, fewer gastrointestinal disturbances (nausea, vomiting, and constipation) and better alertness and sleep quality have been reported in two studies. The transdermal fentanyl patch is as effective as oral opioids in relieving cancer-related pain, with a safety and side effect profile equal to or better than that of oral opioids. The convenient, once-every-72 hours dosing regimen is easily adjusted to the individual's need for around-the-clock pain control, and provides stable and predictable therapeutic drug plasma concentrations. Patient acceptability is high and the cost is lower than other methods required to deliver parenteral opioids. The recent development of an oral transmucosal fentanyl citrate delivery system for the treatment of breakthrough pain will further expand the use of transdermal fentanyl patches for the treatment of chronic pain.

Quality of life and cancer pain: satisfaction and side effects with transdermal fentanyl versus oral morphine

PURPOSE

To compare pain-related treatment satisfaction, patient-perceived side effects, functioning, and well-being in patients with advanced cancer who were receiving either transdermal fentanyl (Duragesic, Janssen Pharmaceuticals, Titusville, NJ) or sustained-release oral forms of morphine (MS Contin, Perdue Frederick Co, Norwalk, CT, or Oramorph SR, Roxanne Laboratories, Columbus, OH).

PATIENTS AND METHODS

A total of 504 assessable cancer patients participated in this cross-sectional, quality-of-life study. Relevant elements of four validated scales were used--the Functional Assessment of Cancer Therapy-General (FACT-G) scale, the Brief Pain Inventory (BPI), the Medical Outcomes Study (MOS) questionnaire, and the Memorial Symptom Assessment Scale (MSAS)--as well as original scales that were developed and validated for this study.

RESULTS

The majority of patients in both treatment groups had late-stage (IV/D) cancer. Patients who received transdermal fentanyl were more satisfied overall with their pain medication than those who received sustained-release oral forms of morphine (P = .035). Fentanyl patients also experienced a significantly lower frequency (P < .002) and impact (P < .001) of pain medication side effects. These results occurred despite the fact that cancer patients who received fentanyl were significantly older (P < .001) and had significantly lower functioning and well-being scores (P = .001). Measures of pain intensity, sleep adequacy, and symptoms demonstrated no significant differences between treatment groups.

CONCLUSION

These data suggest that patients are more satisfied with transdermal fentanyl compared with sustained-release oral forms of morphine. A lower frequency and reduced impact of side effects with transdermal fentanyl may be one reason cancer patients who receive fentanyl are more satisfied with their pain management.