[Impact of intrathecal morphine on the tolerance of early feeding after cesarean section]

INTRODUCTION

Early feeding is well tolerated in patients undergoing caesarean section under general or regional anaesthesia. Intrathecal morphine is effective for postoperative analgesia but can induce nausea and vomiting which may hamper feeding. This study assessed prospectively the effects of intrathecal morphine on early feeding in patients undergoing caesarean section.

METHODOLOGY

After ethical committee approval, 66 consenting women scheduled for caesarean section were randomized to receive intrathecal morphine 0.1 mg (group M, n=32) or not ("control group", group C, n=34) at the time of intrathecal anaesthesia performed with a 3 ml mixture containing 8.6 mg bupivacaine, 64 microg clonidine and 4.3 microg sufentanil. Standard antiemetic prophylaxis (5 mg dexamethasone + 2 mg tropisetron) was administered intravenously in all patients after umbilical cord clamping. Standardized multimodal analgesia was initiated postoperatively with 1 g of paracetamol and 30 mg of ketorolac given every 6 hours. Analgesia was evaluated by a numeric rating scale (NRS) at 4 hours intervals and 10 mg of oral morphine was administered if the NRS score exceeded 3. All patients received a protein enriched solution, 8 hours after caesarean section and were allowed to eat solid food on postoperative day 1. Nausea and vomiting episodes, gas and/or stools emission, itching, NRS score and morphine consumption were recorded on the first, second and fourth postoperative hour and then every 4 hours during 48 hours.

RESULTS

Nausea was significantly more frequent and persisted longer in group M. Vomiting occurred equally in both groups and stopped after feeding. Gas and/or stools emission appeared within 48 hours postoperatively in 72 and 77 % of patients in group M and group C respectively. Oral morphine consumption was significantly lower in group M (1.9+/-4 vs 6.5+/-7.3mg, p=0.006). When compared to group C, NRS were also lower in group M from the second to the 20th postoperative hour. Itching was observed more frequently and persisted longer in group M.

DISCUSSION AND CONCLUSION

A small dose of intrathecal morphine provided adequate and prolonged pain relief after caesarean section but increased the incidence of nausea and vomiting despite anti-emetic prophylaxis. Oral food intake was not hampered by intrathecal morphine.

Identification of key water quality characteristics affecting the filterability of biologically treated effluent in low-pressure membrane filtration

There are many water quality characteristics which could influence the filterability of biologically treated effluent from Melbourne's Western Treatment Plant (WTP). Statistical correlation was used to identify the key water characteristics affecting the microfiltration (MF) and ultrafiltration (UF) filterability in terms of permeate volume of the treated effluent. The models developed showed that turbidity, dissolved organic carbon (DOC) and total suspended solids (TSS) were the key factors which influenced the MF and UF filterability. Turbidity was the dominant factor affecting the accuracy of the model for MF filterability while DOC was the major factor affecting the accuracy of the model for UF filterability. A prediction accuracy of 85% was obtained for MF and 86% for UF filterability of the WTP effluent. The characteristics of the organic components of the wastewater were demonstrated by EEM spectra to have seasonal variation which would have reduced the prediction accuracy. As turbidity, DOC and TSS can be determined on-line, the models would be useful for rapid prediction of the filterability of WTP effluent and this may assist the control of low-pressure membrane filtration processes.

The role of intravascular ultrasound to guide drug-eluting stents implantation

Serial IVUS has demonstrated significant differences in intimal hyperplasia (IH) volume between drug-eluting stent (DES) and bare metal stents (BMS) in recent clinical trials. It has also been reported that IVUS is a useful tool in determining optimal DES implantation, especially for diabetes mellitus (DM) patients. Recent data have also suggested a critical role for, IVUS guidance in reduction of risk for DES thrombosis. IVUS has been invaluable in the elucidation of DES effects on the arterial wall, offering insight into the potential mechanisms of DES failure. Therefore, in this current manuscript, we review the potential benefits of intravascular ultrasound (IVUS) during drug eluting stent (DES) implantation.

A high affinity pyruvate decarboxylase is present in cottonwood leaf veins and petioles: a second source of leaf acetaldehyde emission?

Considerable evidence indicates that acetaldehyde is released from the leaves of a variety of plants. The conventional explanation for this is that ethanol formed in the roots is transported to the leaves where it is converted to acetaldehyde by the alcohol dehydrogenase (ADH) found in the leaves. It is possible that acetaldehyde could also be formed in leaves by action of pyruvate decarboxylase (PDC), an enzyme with an uncertain metabolic role, which has been detected, but not characterized, in cottonwood leaves. We have found that leaf PDC is present in leaf veins and petioles, as well as in non-vein tissues. Veins and petioles contained measurable pyruvate concentrations in the range of 2mM. The leaf vein form of the enzyme was purified approximately 143-fold, and, at the optimum pH of 5.6, the K(m) value for pyruvate was 42 microM. This K(m) is lower than the typical millimolar range seen for PDCs from other sources. The purified leaf PDC also decarboxylates 2-ketobutyric acid (K(m)=2.2mM). We conclude that there are several possible sources of acetaldehyde production in cottonwood leaves: the well-characterized root-derived ethanol oxidation by ADH in leaves, and the decarboxylation of pyruvate by PDC in leaf veins, petioles, and other leaf tissues. Significantly, the leaf vein form of PDC with its high affinity for pyruvate, could function to shunt pyruvate carbon to the pyruvate dehydrogenase by-pass and thus protect the metabolically active vascular bundle cells from the effects of oxygen deprivation.

Improving the quality of suicide risk assessments in the psychiatric emergency setting: physician documentation of process indicators

CONTEXT

Suicide risk assessment in the emergency department is a challenging task for psychiatrists and is further complicated when patients are admitted involuntarily.

OBJECTIVE

To evaluate the quality of suicide risk assessments in the psychiatric emergency setting by reviewing physician documentation of process indicators.

METHODS

A retrospective review of medical records for patients who were admitted involuntarily to the Kern Medical Center Psychiatric Emergency Service in Bakersfield, Calif. All patients were deemed a "danger to self" as defined by California Law and were admitted for evaluation in June 2006. Medical records were reviewed for 19 process indicators, which were identified from risk factors and treatment guidelines described in the literature. Documentation that a process indicator was not met by a patient was included in the data. Patients were then separated into two study groups: those who were admitted to the inpatient psychiatric unit, and those who were released. Data were analyzed using t tests for continuous variables and chi(2) tests for categorical variables.

RESULTS

The medical records of 145 patients were reviewed. None of the suicide risk assessments documented all 19 process indicators. The three most commonly documented process indicators were access to firearms (75.9%), recent stressful life events (75.2%), and "contract for safety" (74.5%). According to medical records, patients admitted to the inpatient unit were more likely than patients released to home care to have been assessed for command auditory hallucinations (P=.02) or prior psychiatric diagnoses (P=.001). Discharged patients were more likely to have been assessed for a family history of suicide (P=.001) or symptoms of major depressive disorder (P=.02).

CONCLUSION

Many important risk factors for suicide were not documented in emergency department assessments, suggesting that overall quality of psychiatric risk assessments was not optimal. This lack of documentation has important implications from a treatment and medicolegal perspective.

Meta-analysis and imputation identifies a 109 kb risk haplotype spanning TNFAIP3 associated with lupus nephritis and hematologic manifestations

TNFAIP3 encodes the ubiquitin-modifying enzyme, A20, a key regulator of inflammatory signaling pathways. We previously reported association between TNFAIP3 variants and systemic lupus erythematosus (SLE). To further localize the risk variant(s), we performed a meta-analysis using genetic data available from two Caucasian case-control datasets (1453 total cases, 3381 total control subjects) and 713 SLE trio families. The best result was found at rs5029939 (P=1.67 x 10(-14), odds ratio=2.09, 95% confidence interval 1.68-2.60). We then imputed single nucleotide polymorphisms (SNPs) from the CEU Phase II HapMap using genotypes from 431 SLE cases and 2155 control subjects. Imputation identified 11 SNPs in addition to three observed SNPs, which together, defined a 109 kb SLE risk segment surrounding TNFAIP3. When evaluating whether the rs5029939 risk allele was associated with SLE clinical manifestations, we observed that heterozygous carriers of the TNFAIP3 risk allele at rs5029939 have a twofold increased risk of developing renal or hematologic manifestations compared to homozygous non-risk subjects. In summary, our study strengthens the genetic evidence that variants in the region of TNFAIP3 influence risk for SLE, particularly in patients with renal and hematologic manifestations, and narrows the risk effect to a 109 kb DNA segment that spans the TNFAIP3 gene.

Fellow eye changes in optic neuritis correlate with the risk of multiple sclerosis

BACKGROUND

Recent studies demonstrate early diffuse central nervous system (CNS) inflammation in patients with multiple sclerosis (MS). The clinically unaffected (fellow) eye of patients with unilateral optic neuritis (ON) may reflect the status of normal-appearing white matter in the CNS, which can be assessed electrophysiologically.

OBJECTIVE

To study the relationship between electrophysiological parameters in the fellow eye of ON patients, and risk of conversion to MS.

METHODS

Forty-eight consecutive patients with acute unilateral ON were examined 12 months after ON of which 14 had MS, 19 remained high risk (HR) for MS, and 15 had low risk (LR) for MS according to McDonald's criteria. Twenty-five age-matched controls were also tested. Amplitude and latency of multifocal visual evoked potential (mfVEP) in the fellow eyes of patients at 12 months were analyzed and compared with controls.

RESULTS

Average mfVEP amplitude was 240 +/- 35, 232 +/- 36, 181 +/- 38, and 169 +/- 48 nV for controls, LR, HR, and MS groups respectively. Average mfVEP latency for controls, LR, HR, and MS patients was 139.7 +/- 5.5, 141.7 +/- 3.6, 145.9 +/- 8.9, and 152.0 +/- 9.9 ms respectively.

CONCLUSIONS

The magnitude of latency prolongation and amplitude decline 12 months after the initial episode was proportional to the risk of MS. The prognostic significance of these changes as predictors of subsequent MS should be investigated longitudinally.

Ixabepilone and lapatinib for HER2-positive advanced breast cancer: Preclinical rationale and phase I trial

2582

Trastuzumab with or without taxanes are the cytotoxic therapies of choice for advanced Her-2 positive breast cancer. Ixabepilone and lapatinib have demonstrated clinical efficacy in advanced breast cancer that is resistant to taxanes and trastuzumab. We have compared the therapeutic potential of ixabepilone, lapatinib, paclitaxel and trastuzumab, in vitro, prior to commencing a phase I clinical trial. Three different breast cancer cell lines SK-BR3, BT-474 and MCF-7 (control; non-Her-2 amplified), were seeded 96-well plates, cultured for 24 hours and different concentrations of ixabepilone or paclitaxel and trastuzumab or lapatinib were added. Experiments were performed in triplicate. A MTT viability assay was used to measure the activity of live cells after 0, 3, 24, 48 and 120 hours. The cells and vehicle control wells were averaged and normalized to 100% for comparison to the average value of the 6 replicate wells graphed over time for each cell line, drug concentration and cell density. Student-t test was used to determine the level of significance comparing the 0 hour time point in a pair-wise, pooled variance manner to each other time point. Paclitaxel + trastuzumab significantly reduced proliferation p < 0.001 at 120 hrs; Paclitaxel + lapatinib significantly reduced proliferation p < 0.001 at 120 hrs; Ixabepilone + trastuzumab significantly reduced proliferation p < 0.001 at 120 hrs; Ixabepilone + lapatinib significantly reduced proliferation p < 0.001 at 120 hrs; Dose response curves were clearly evident for all combinations. Of note proliferation was reduced earlier and at lower drug concentrations with lapatinib combinations than with trastuzumab combinations. The drugs whose efficacy was proven in MCF-7 cells were studied in detail on the xCELLigence cell analysis system. These data recapitulated the MTT data and provided in depth detail of the rate of drug action. An international multicentre phase I trial of Ixabepilone with lapatinib ± capecitabine has commenced in patients with Her-2 positive taxane and trastuzumab resistant advanced breast cancer. Toxicity has been as previously described with fatigue, arthralgias, onycholysis and rash occurring. No DLTs have occurred. RECIST responses have been confirmed in 2 of the first 3 patients enrolled.

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Combination products regulation at the FDA

The US Food and Drug Administration (FDA) is responsible for protecting the public health by assuring the safety, efficacy, and security of drugs, biological products, and medical devices. As single-entity products, drugs are generally regulated by the Center for Drug Evaluation and Research (CDER), devices by the Center for Devices and Radiological Health (CDRH), and biologics by the Center for Biologics Evaluation and Research (CBER). In recent years, technological advances have led to a blurring of the historical lines of separation between the centers.