Increasing the tolerance of DCD hearts to warm ischemia by pharmacological postconditioning

Donation after circulatory death (DCD) offers a potential additional source of cardiac allografts. We used a porcine asphyxia model to evaluate viability of DCD hearts subjected to warm ischemic times (WIT) of 20–40 min prior to flushing with Celsior (C) solution. We then assessed potential benefits of supplementing C with erythropoietin, glyceryl trinitrate and zoniporide (Cs), a combination that we have shown previously to activate ischemic postconditioning pathways. Hearts flushed with C/Cs were assessed for functional, biochemical and metabolic recovery on an ex vivo working heart apparatus. Hearts exposed to 20-min WIT showed full recovery of functional and metabolic profiles compared with control hearts (no WIT). Hearts subjected to 30- or 40-min WIT prior to C solution showed partial and no recovery, respectively. Hearts exposed to 30-min WIT and Cs solution displayed complete recovery, while hearts exposed to 40-min WIT and Cs solution demonstrated partial recovery. We conclude that DCD hearts flushed with C solution demonstrate complete recovery up to 20-min WIT after which there is rapid loss of viability. Cs extends the limit of WIT tolerability to 30 min. DCD hearts with ≤30-min WIT may be suitable for transplantation and warrant assessment in a transplant model.

Catatonia in systemic lupus erythematosus: a case report and review of literature

Although, neuropsychiatric morbidity is quite high in patients with systemic lupus erythematosus (SLE), catatonia has been rarely reported. We report a case of a 22-year-old female who presented with catatonic symptoms at the time of relapse of SLE and have discussed the presentation in the context of existing literature with regard to phenomenology of catatonia, psychiatric co-morbidity and treatment of catatonia in patients with SLE.

Profile of blood donors and reasons for deferral in coastal South India

BACKGROUND

A blood transfusion is a life-saving procedure in many instances. An adequate supply of safe blood is ensured by exercising donor deferral criteria and screening for Transfusion Transmitted Infections (TTI). The aim of this paper is to study the profile of blood donors and reasons for donor deferral in coastal South India.

METHOD

The study was conducted at a tertiary care hospital in Mangalore. All those who donated between 1 January 2008 and 31 December 2008 were included in the study. Data was collected using a pre-tested semi-structured proforma and analysed using SPSS version 11.5.

RESULTS

Most of the donors were under the age of 25 (42.92%). Donors were predominantly male (95.20%). In terms of occupation, most subjects were students (28.01%) followed by businessmen (18.61%). Slightly more than three-quarters of the donors (77.20%) were replacement donors. The main reasons for deferral were consumption of medication in the past 72 hours (15.15%), hypertension (13.18%), a low haemoglobin level (12.34%) and alcohol intake in the past 72 hours (12.20%). Among the TTIs identified, most samples were positive for Hepatitis B surface Antigen - HBsAg (0.87%) or tested positive for Anti-Hepatitis C (HCV antibodies (0.36%).

CONCLUSION

From the study it was concluded that the majority of the donor population was young and educated. The reason for donation was mainly replacement rather than voluntary. This issue needs to be addressed by exercising proactive measures to increase the number of voluntary, nonremunerated, low-risk donors.

Toxicity of alpha-ketoglutarate following 14-days repeated oral administration in Wistar rats

Oral treatment of alpha-ketoglutarate (A-KG) is known to antagonise experimental cyanide poisoning in rodents. Maximum protective efficacy of A-KG has been observed at a dose of 2.0 g kg-1 body weight but no acute toxicity has been observed at this dose level. As a pre-clinical regulatory requirement, sub-acute toxicity of A-KG has to be determined in two different animal species, following repeated exposure by the intended route of use. The present study reports the toxicity and No Observed Adverse Effect Level (NOAEL) of A-KG following 14 days repeated oral administration at low (1.0 g kg-1), middle (2.0 g kg-1) and high (4.0 g kg-1) doses of A-KG in Wistar rats. After termination of the exposure, animals were further observed for 7 days to assess the recovery pattern and residual effects. Clinical signs included diarrhoea at 4.0 g kg-1 in both the sexes and decrease in mean body weight in males. This dose also caused anaemia in females which resolved after withdrawal of treatment. In males, significant increase in absolute and relative weights of organs (adrenal, liver and kidneys) and haematological changes were observed at the end of recovery period, suggesting delayed toxic manifestations at 2.0 and 4.0 g kg-1 dose. However, these observations were not accompanied by any histological changes to suggest any toxicity of A-KG of clinical significance. The NOAEL of A-KG was determined as 1.0 g kg-1 body weight. Although A-KG is intended to treat acute cyanide poisoning, caution on dosage should be observed during its repeated administration.

Absence of Wip1 partially rescues Atm deficiency phenotypes in mice

Wild-type p53-induced phosphatase 1 (WIP1) is a serine/threonine phosphatase that dephosphorylates proteins in the ataxia telangiectasia mutated (ATM)-initiated DNA damage response pathway. WIP1 may have a homeostatic role in ATM signaling by returning the cell to a normal pre-stress state following completion of DNA repair. To better understand the effects of WIP1 on ATM signaling, we crossed Atm-deficient mice to Wip1-deficient mice and characterized phenotypes of the double knockout progeny. We hypothesized that the absence of Wip1 might rescue Atm deficiency phenotypes. Atm null mice, like ATM-deficient humans with the inherited syndrome ataxia telangiectasia, exhibit radiation sensitivity, fertility defects, and are T-cell lymphoma prone. Most double knockout mice were largely protected from lymphoma development and had a greatly extended lifespan compared with Atm null mice. Double knockout mice had increased p53 and H2AX phosphorylation and p21 expression compared with their Atm null counterparts, indicating enhanced p53 and DNA damage responses. Additionally, double knockout splenocytes displayed reduced chromosomal instability compared with Atm null mice. Finally, doubly null mice were partially rescued from gametogenesis defects observed in Atm null mice. These results indicate that inhibition of WIP1 may represent a useful strategy for cancer treatment in general and A-T patients in particular.

Average daily dose, medication adherence, and healthcare costs among commercially-insured patients with fibromyalgia treated with duloxetine

OBJECTIVE

What is the relationship between average daily dose (ADD) of duloxetine, adherence to therapy, and healthcare costs among patients with fibromyalgia?

METHODS

Employing a retrospective cohort design, this study assessed administrative claims data for commercially-insured fibromyalgia patients who initiated duloxetine in 2006. Initiation was defined as a 90-day clean period without access to duloxetine. Five study cohorts were constructed based on the ADD of duloxetine, calculated from all prescriptions dispensed over the 12-month follow-up period: <30 mg, 30 mg, 31-59 mg, 60 mg, and >60 mg (duloxetine starting dose: 30 mg/day; target dose: 60 mg/day). Medication possession ration (MPR) was used to assess duloxetine adherence, with MPR ≥0.8 as 'high' adherence. Multivariate regressions were applied to examine the association between ADD, duloxetine adherence, and healthcare costs (total, inpatient, outpatient, and pharmacy), adjusting for differences in demographic and clinical characteristics between cohorts.

RESULTS

Of the 4869 patients with fibromyalgia, 3% had an ADD of <30 mg, 12% had 30 mg, 21% had 31-59 mg, 46% had 60 mg, and 18% had >60 mg. High adherence to duloxetine ranged from 16% to 41% across cohorts. Controlling for demographic and clinical characteristics, patients with an ADD of 31-59 mg or >60 mg were more likely to adhere to duloxetine therapy than those in the 60 mg cohort, while patients in the <30 mg cohort were less likely to adhere to duloxetine (all p < 0.05). Total costs were significantly higher for individuals in the 31-59 mg or >60 mg ADD cohorts ($1834 and $5766) than those maintaining an ADD of 60 mg, as were outpatient ($1167 and $2275) and pharmacy costs ($502 and $2983) (all p < 0.05). Patients with an ADD of 30 mg had significantly lower total (-$1770), inpatient (-$1524), and pharmacy (-$827) costs (all p < 0.05) than those with an ADD of 60 mg.

LIMITATIONS

This study is subject to selection bias because some confounders might be unobserved in the administrative claims database. Indirect costs or over-the-counter medication costs were also not available.

CONCLUSIONS

Fibromyalgia patients with an ADD of 60 mg of duloxetine had better adherence than patients with an ADD ≤30 mg. Duloxetine patients with an ADD of 30 mg (31-59 or >60 mg) had significantly lower (higher) healthcare costs than those maintaining an ADD of 60 mg.

A British Society of Paediatric Gastroenterology, Hepatology and Nutrition survey of the effectiveness and safety of adalimumab in children with inflammatory bowel disease

BACKGROUND

Adalimumab is efficacious therapy for adults with Crohn's disease (CD).

AIM

To summarise the United Kingdom and Republic of Ireland paediatric adalimumab experience.

METHODS

British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) members with Inflammatory Bowel Disease (IBD) patients <18 years old commencing adalimumab with at least 4 weeks follow-up. Patient demographics and details of treatment were then collected. Response and remission was assessed using the Paediatric Crohn's Disease Activity Index (PCDAI)/Physicians Global Assessment (PGA).

RESULTS

Seventy-two patients [70 CD, 1 ulcerative colitis (UC), 1 IBD unclassified (IBDU)] from 19 paediatric-centres received adalimumab at a median age of 14.8 (IQR 3.1, range 6.1-17.8) years; 66/70 CD (94%) had previously received infliximab. A dose of 80 mg then 40 mg was used for induction in 41(59%) and 40 mg fortnightly for maintenance in 61 (90%). Remission rates were 24%, 58% and 41% at 1, 6 and 12 months, respectively. Overall 43 (61%) went into remission at some point, with 24 (35%) requiring escalation of therapy. Remission rates were higher in those on concomitant immunosuppression cf. those not on immunosuppression [34/46 (74%) vs. 9/24 (37%), respectively, (χ(2) 8.8, P=0.003)]. There were 15 adverse events (21%) including four (6%) serious adverse events with two sepsis related deaths in patients who were also on immunosuppression and home parenteral nutrition (3% mortality rate).

CONCLUSIONS

Adalimumab is useful in treatment of refractory paediatric patients with a remission rate of 61%. This treatment benefit should be balanced against side effects, including in this study a 3% mortality rate.