STUDIES CONCERNING THE NATURE OF THE SECRETORY ACTIVITY OF THE ISOLATED RINGER-PERFUSED FROG LIVER : II. THE INHIBITORY AND THE PROMOTING INFLUENCE OF ORGANIC ELECTROLYTES AND NON-ELECTROLYTES UPON THE SECRETION OF DYESTUFFS

The ability of the isolated Ringer-perfused frog liver, to concentrate dyestuffs in its secretion several hundred times, can be abolished entirely and reversibly by replacing in the Ringer solution about 1/8 of the NaCl by the isosmotic amount of a surface-inactive non-electrolyte (disaccharide, hexose, pentose, polyhydric alcohol, amino acid, acid amide) or electrolyte (salts of lower fatty acids, hydroxyl carboxylic, and dicarboxylic acids). This effect is not dependent upon changes in the perfusion rate. The opposite effect, promotion of secretory activity, can be brought about by polar-non-polar electrolytes (salts of higher fatty acids, bile acids, and other aromatic carboxylic acids, aromatic sulfonic acids) and surface-active non-electrolytes (anesthetics, alkaloids, digitonin). However, reversibility of this effect cannot be regularly observed, since cytolysis is frequently the end result. Suitable concentrations of inhibitory and promoting substances, simultaneously applied, counteract each other. Inhibitory and promoting substances, in general, exhibit opposite effects upon the dispersion of colloids (starch, lecithin, gelatin). The correlation between the physicochemical and the physiological action of the organic compounds is discussed.

Biomarkers of acute kidney injury in anesthesia, intensive care and major surgery: from the bench to clinical research to clinical practice

Acute kidney injury (AKI) is common after major surgery and reportedly occurs in approximately 36% of ICU patients (RIFLE Risk/Injury/ Failure categories). It is associated with increased mortality, greater cost, and prolonged Intensive Care Unit (ICU) and hospital stay, despite attempts to develop therapies to prevent or attenuate AKI, which have had limited success. One major reason for this lack of success may be the result of delayed implementation due to the inability to detect AKI early. Traditional biomarkers of AKI (creatinine and urea) do not detect injury early enough. Thus, it is a priority to find reliable, early biomarkers that predict subsequent AKI. Innovative technologies such as functional genomics and proteomics have facilitated detection of several promising early biomarkers of AKI, such as neutrophil gelatinase-associated lipocalin (NGAL), cystatin C (CyC), liver-type fatty acid binding protein (L-FABP), interleukin-18 (IL-18), and kidney injury molecule-1 (KIM-1). These biomarkers have many potential applications during anesthesia and in the ICU. They can be used to evaluate the effect of new techniques and therapies on kidney function, as safety markers to monitor toxicity and as measures of treatment effect. For example, NGAL and cystatin C have been used in a safety monitoring trial of hydroxyethylstarch therapy and to detect AKI early, during or immediately after cardiac surgery. Clinical use beyond research settings is rapidly expanding.

Reliability of rapid testing for hepatitis B in a region of high HIV endemicity

Hepatitis B (HBV) and HIV co-infection is common in resource-poor settings. A recent study from Malawi revealed poor correlation between hepatitis B surface antigen (HBsAg) point-of-care tests and reference tests in patients co-infected with HIV. We studied a cohort of 300 Malawian adults entering a treatment programme for HIV. Sera were tested for HBsAg first using the Determine rapid test and re-tested using a commercial enzyme immunoassay (EIA). All tests were done under optimal conditions in Liverpool, UK. Sera from all 25 patients positive for HBsAg using the rapid test and from 50 who were negative, were re-tested using the EIA, with complete concordance of results. The kappa correlation was 1, specificity 100% (93-100%) and sensitivity 100% (86-100%) compared to the reference test. Patients had advanced immune suppression (mean CD4=175 cells x 10(6)/l). In a non-field setting, the results of point-of-care Determine rapid hepatitis B tests appear reliable in patients with HIV-1 co-infection.

Prenatal alcohol exposure alters the patterns of facial asymmetry

Directional asymmetry, the systematic differences between the left and right body sides, is widespread in human populations. Changes in directional asymmetry are associated with various disorders that affect craniofacial development. Because facial dysmorphology is a key criterion for diagnosing fetal alcohol syndrome (FAS), the question arises whether in utero alcohol exposure alters directional asymmetry in the face. Data on the relative position of 17 morphologic landmarks were obtained from facial scans of children who were classified as either FAS or control. Shape data obtained from the landmarks were analyzed with the methods of geometric morphometrics. Our analyses showed significant directional asymmetry of facial shape, consisting primarily of a shift of midline landmarks to the right and a displacement of the landmarks around the eyes to the left. The asymmetry of FAS and control groups differed significantly and average directional asymmetry was increased in those individuals exposed to alcohol in utero. These results suggest that the developmental consequences of fetal alcohol exposure affect a wide range of craniofacial features in addition to those generally recognized and used for diagnosis of FAS.

Diabetes care in hospital--the impact of a dedicated inpatient care team

AIMS

At any given time, people with diabetes occupy approximately 5-10% of acute hospital beds. In addition, diabetes is associated with a greater length of stay (LOS). This is partially because of increased complexity of the cases but also because of unfamiliarity of dealing with the condition by other specialist teams.

METHODS

In 2002, with increasing pressure on acute hospital beds, a team was established to improve the care of inpatients with diabetes admitted to Derriford Hospital. The team consisted of five diabetes specialist nurses dedicated to inpatient care, supported by a consultant and specialist registrar diabetologist. A link nurse responsible for diabetes was appointed on every ward and each individual with a diagnosis of diabetes was identified on admission. We have compared LOS of all patients with diabetes admitted between January 2002 and December 2006.

RESULTS

LOS fell from a mean +/- se of 8.3 +/- 0.18 days in 2002 to 7.7 +/- 0.10 days in 2006 (P = 0.002). Significant falls were seen for emergency admissions (9.7 +/- 0.23 vs. 9.2 +/- 0.20, P < 0.001) but not elective admissions. The data show significant reductions in LOS for medical admissions (9.2 +/- 0.24 vs. 8.4 +/- 0.20, P < 0.001) but not surgical admissions. Over the same period, LOS for the total hospital population fell by 0.3 days (P < 0.001).

CONCLUSION

In conclusion, a team specifically employed to focus on inpatient diabetes care has a significant impact on LOS of this patient group.

A phase II study to determine if sensory neuropathy of nab-paclitaxel can be reduced by prolonging infusion in patients with non-small cell lung cancer (NSCLC)

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Background: We have previously reported that nab-paclitaxel (ABI-007; Abraxane) administered at 125 mg/m2 over 30 minutes on days 1, 8, and 15 every 28 days has a response rate (RR) of 30% and median survival of 11 months [Rizvi, Proc. ASCO 2006]. We also observed 15/40 (38%) patients developed grade 2/3 sensory neuropathy with a 30 minute infusion. We hypothesize that a longer infusion with nab-paclitaxel may reduce peak plasma levels and accordingly reduce sensory neuropathy. Methods: After enrollment of 40 patients at 125 mg/m2 over 30 minutes on days 1, 8, and 15 every 28 days, we amended the protocol to study an additional 25 patients with chemotherapy naïve stage IV NSCLC with a 2 hour infusion. The enrollment criteria and treatment schedule otherwise remained the same. Our goal was to detect 1 to 2 grade improvement of peripheral neuropathy with 80% power at the two sided p=0.10 significance level compared to the 40 patients treated with this dose given over 30 minutes. Results: To date, 22 of 25 planned patients have been treated with a 2 hour infusion. The mean number of doses administered was 11 for the initial 40 patients treated with a 30 minute infusion and 10 for the 22 patients treated with the 2 hour infusion. We observed 9/40 grade 2 and 6/40 grade 3 sensory neuropathy with the 30 minute infusion and 2/22 grade 2 and 1/22 grade 3 sensory neuropathy with the 2 hour infusion. The combined grade 2 and 3 toxicities were less with the 2 hour infusion (3/22, 14%) compared with the 30 minute infusion (15/40, 38%; p=0.078, Fisher’s exact test). Conclusions: Prolonging the infusion rate of nab-paclitaxel from 30 minutes to 2 hours is associated with a significant decrease in grade 2 and 3 sensory neuropathy. Efficacy data is presently being evaluated.

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Combined inhibition of mTOR and EGFR with everolimus (RAD001) and gefitinib in patients with non-small cell lung cancer who have smoked cigarettes: A phase II trial

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Background: Most non-small cell lung cancers (NSCLC) are primarily resistant to the EGFR tyrosine kinase inhibitor gefitinib. One strategy to overcome resistance is to block parallel or downstream effectors that maintain tumor growth and proliferation. Preclinical data supports this hypothesis as inhibition of the PIK3CA/Akt/mTOR pathway restores gefitinib sensitivity in resistant cells. In a phase I study, gefitinib (250 mg) and the mTOR inhibitor everolimus (5 mg) were safely administered orally once-a-day (Milton Proc ASCO 2005). This combination induced regressions in patients with NSCLC. To assess the efficacy of this regimen, we designed this phase II trial. Methods: Two cohorts of patients with measurable stage IIIB/IV NSCLC were entered: (1) untreated with chemotherapy and (2) previously treated with cisplatin or carboplatin and docetaxel. A Simon two-stage design proposed to enroll up to 31 patients in each cohort. Response was assessed after 1 month then every 2 months. Pretreatment tumor specimens were collected on all patients. Results: To date, 25 patients have entered, 11 untreated and 14 previously treated. The median age was 66 years and KPS 80%. 52% were women, 68% had adenocarcinoma, and all were current (n=1) or former smokers. Partial responses (RECIST) have been observed in 4 of 23 evaluable patients (17%, 95% CI 5 to 39%) One of these 4 tumors harbored a KRAS mutation and one an EGFR exon 19 deletion. Responses lasted 3, 4, 9+, and 16+ months. Responses were observed in 2 of 13 untreated and 2 of 10 previously treated individuals. Toxicities: Grade 2/3 diarrhea in 13%, Grade 2 pustular rash in 25%, and Grade 2 mucosal ulcerations in 38%. 8% had dose reductions. There were no Grade 4 toxicities or treatment-related deaths. Conclusions: The combination of everolimus and gefitinib produced a 17% partial response rate in smokers with NSCLC, a group less likely to benefit from gefitinib. Enough responses have been seen in both untreated and previously treated cohorts to complete enrollment according to the two stage design of this trial. We plan to correlate outcomes with the molecular profile of tumors. Supported by Novartis, USA

No significant financial relationships to disclose.

Nurse-led clinics reduce severity of childhood atopic eczema: a review of the literature

BACKGROUND

The increasing prevalence and impact of atopic eczema in children in Western countries such as Australia substantiate the need to evaluate the current management of this illness. It has been well documented that the most important aspects in the management of atopic eczema are to allow adequate time for education and demonstration of treatments. However, current models of healthcare funding restrict the opportunity for patient education during medical consultation times. The contribution of nursing to patient care through nurse-led clinics has significant potential in the management of many common chronic illnesses, although atopic eczema has received minimal attention by researchers to date.

OBJECTIVES

To discuss the current clinical management of atopic eczema, and to identify the evidence surrounding the benefits of nurse-led clinics in managing patients with chronic illnesses.

METHODS

Systematic searches were undertaken using the Cochrane Library, MedLine, PUBMed and CINAHL from 1995 to 2005. Manual searches of references of retrieved articles identified two additional key studies from 1990 and 1993 which were also included in the review.

RESULTS

In total, 22 relevant publications were identified. These included both primary research and descriptive studies that covered the medical management of eczema, patient education and improved patient outcomes. The evidence emerging from the literature indicates that the current management of eczema through doctor-led clinics could be improved, with doctors often lacking the time to offer sufficient patient education to manage chronic illnesses effectively. The literature supports the efficacy of nurse-led clinics in the management of chronic illnesses. The benefits of nurse-led clinics include increased patient satisfaction, longer consultations resulting in improved patient education and similar health outcomes when compared with care from a doctor. No studies were identified comparing nurse-led and doctor-led clinics in the management of eczema.

CONCLUSIONS

The most effective way to manage atopic eczema is to provide adequate time for education and demonstration of treatments, which the literature suggests can be achieved through nurse-led clinics. The literature review supports an investigation researching the outcomes of a nurse-led clinic on reducing the severity of eczema in children.

Prospective FDG-PET and CT assessment of discontinuation of erlotinib (E) or gefitinib (G) in patients with EGFR TKI sensitive non-small cell lung cancer (NSCLC) who subsequently progress radiographically on E or G (“acquired resistance”) followed by re-initiation of E or G and the subsequent addition of everolimus (RAD001)

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Background: About 10% of patients (pts) with NSCLC have a radiographic response to E or G. A dependence on signaling through the epidermal growth factor receptor (EGFR) is thought to underlie this response. Despite initial regression, these pts invariably develop acquired resistance to E or G. Optimal management of these patients is unknown. In patients with acquired resistance, we sought to evaluate changes in tumor metabolism by PET and size by CT after discontinuation of E or G, resumption of E or G, and then the addition of the mTOR inhibitor everolimus to E or G. Methods: Pts with stage IV NSCLC with exon 19 or 21 EGFR mutation or previous radiographic response after treatment with E or G and then radiographic progression after > 6 months of treatment were eligible. All pts had 4 FDG-PET/CT and helical CT scans: baseline, 3 weeks after discontinuation of E or G, 3 weeks after restarting E or G, and 3 weeks after combined treatment with everolimus (5 mg daily) and E or G. CT measurements were uni-dimensional. Results: To date, 9 pts (5 on G, 4 on E) have enrolled with 6 pts completing all 4 PET/CT and CT assessments. Within 3 weeks of discontinuation of E or G, 7 of 9 (77%, 95% CI 40–97%) developed symptomatic disease progression. Three of 6 pts had an increase in SUV of >50% and increase in CT measurements >15% 3 weeks after discontinuation of E or G. Three of 6 pts had decrease in SUV of >10% 3 weeks after resumption of E or G. Two of 6 pts had further reduction of SUV > 50% and >10% decrease in CT measurements 3 weeks after everolimus was added to E or G. Conclusions: In EGFR TKI-sensitive patients who develop acquired resistance: 1) Discontinuation of E or G results in rapid symptomatic progression and increases in SUV on PET of indicator lesions. 2) Both symptoms and SUV values improve on re-initiation of E or G, suggesting that some tumor cells remain sensitive to EGFR blockade. 3) We saw further improvement when everolimus was combined with E or G. Based on these data we now recommend continuing E or G in similar patients. Support: Novartis, CA05826, MSKCC “Steps for Breath.”

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Almost all five year disease free survivors are cured following rectal cancer surgery, but longer term follow-up detects some late local and systemic recurrences

BACKGROUND

The necessity, timing and benefits of follow-up after rectal cancer surgery remain controversial, with two years traditionally considered adequate to detect most local recurrences. This unit has a policy of lifetime follow-up, and this paper investigates, at 23 years, the value of prolonged surveillance.

METHOD

Six hundred and sixty consecutive patients undergoing surgery for rectal cancer were prospectively followed-up between 1978 and 2002, and local or systemic recurrence recorded. This analysis was performed on the 509/660 (76%) patients who underwent potentially curative surgery.

RESULTS

Total mesorectal excision (TME) was performed in 422/509 (83%) patients, mesorectal transection in 78 (15%), and local excision in 9 (2%). Follow-up ranged from 1 to 23 years (mean = 9.7). Seven (1.4%) patients had local recurrence alone, 11 (2.2%) local plus systemic, and 86 (17%) systemic recurrence alone. Of the local recurrences 3 (17%) became evident within 1 year, 9 (50%) within 2 years, 16 (89%) within 5 years, and 2 (11%) presented after 5 years, at 5.6 and 5.8 years. Of the systemic recurrences 26 (27%) became evident within 1 year, 57 (59%) within 2 years, 93 (96%) within 5 years, and 4 (4%) presented after 5 years at 5.3, 5.3, 5.4 and 7.9 years.

CONCLUSION

This long-term surveillance of patients undergoing curative surgery for rectal cancer demonstrates that most local and systemic recurrences occur within 5 years. Almost half occurred more than 2 years after surgery. However, those centres wishing to set standards of care, or evaluate current or new therapies in rectal cancer treatment, should be aware that unexpected late recurrences occasionally develop.

Metyrapone and cocaine: A double-blind, placebo-controlled drug interaction study

Pre-clinical research suggests that suppression of adrenocorticosteroid synthesis might decrease susceptibility to stress-induced relapse. Metyrapone effectively suppresses cortisol synthesis and thus might have promise as a cocaine dependence treatment. The present inpatient study evaluated the interaction of metyrapone and cocaine to assess the safety of conducting an outpatient trial. Twelve nontreatment-seeking cocaine-dependent individuals completed this double-blind, placebo-controlled, crossover study with two factors: medication (750 mg of metyrapone vs. placebo) and infusion (40 mg of cocaine vs. saline). Safety measures included vital signs, adverse events, and electrocardiogram. Efficacy measures included visual analog scale (VAS) ratings of craving and drug effect. Neuroendocrine measures included cortisol and ACTH. As predicted, metyrapone was well tolerated and did not exacerbate cocaine's physiological effects. Also as predicted, metyrapone did not significantly alter cocaine's subjective effects. The results of the present study suggest that metyrapone at the dose studied can likely be used safely in an outpatient study with active cocaine users.