Stability of piritramide in patient-controlled analgesia (PCA) solutions

For patient controlled analgesia, syringes with solutions of 1.5 mg/ml piritramide in 0.9% aqueous sodium chloride are used. The physical and chemical stability for dilutions of the commercially available preparation of piritramide is limited up to 72 hours by the manufacturer. Since application duration for patient-controlled analgesia can exceed that limited time, stability was investigated by HPLC. Our results show that these solutions are chemically stable over a time period of 60 days.

Ligand-mediated regulation of peroxisome proliferator-activated receptor (PPAR) beta/delta: a comparative analysis of PPAR-selective agonists and all-trans retinoic acid

Peroxisome proliferator-activated receptors (PPARs) are members of the nuclear hormone receptor superfamily that modulate target gene expression in response to natural fatty acid ligands and synthetic agonists. It is noteworthy that all trans-retinoic acid (atRA) has recently been reported to act as a ligand for PPARbeta/delta, to activate its transcriptional activity, and, in contrast to the "classic" function of atRA, to stimulate cell proliferation (Schug et al., 2007). Here, we report that in contrast to synthetic PPARbeta/delta agonists, atRA failed to induce the transcriptional activity of PPARbeta/delta using different types of reporter gene assays. Likewise, atRA did not affect the expression of the bona fide PPARbeta/delta target genes ADRP and ANGPTL4 but strongly increased expression of the retinoic acid target gene CYP26A under the identical experimental conditions. Consistent with these observations, atRA did not compete with established PPARbeta/delta agonists in a ligand binding assay, and atRA did not enable the interaction of PPARbeta/delta with a coactivator peptide in a time-resolved fluorescence resonance energy transfer assay in vitro. These results are in sharp contrast to the effect of established PPARbeta/delta agonists in both in vitro assays. Taken as a whole, these data strongly suggest that atRA does not function as a ligand of PPARbeta/delta in any of the experimental systems tested and that the previously reported atRA effects are more likely to reflect an uncharacterized and less direct mechanism.

[Postoperative pain after ambulatory surgery]

BACKGROUND

Outpatient surgeons were surveyed about the quality of postoperative pain therapy after outpatient interventions.

PATIENTS AND METHODS

Of 2,317 outpatient surgeons who received a questionnaire by mail, 419 responded. The return rate was 18.1%. The questionnaire collected data on the operative procedures and methods of anesthesia from 2004 and the analgesics, which were applied in the immediate postoperative period and at home. Methods and contents of quality control were registered.

RESULTS

The respondents indicated that the person responsible for the pain therapy was the surgeon in 74% of the practices, the anesthesiologist in 16%, and both in 10%. The drugs used in the practice were: novaminsulfone (34%), NSAIDs (28%), and opioids (36%). The drugs used for at-home care were: NSAIDs (58%), opioids (43%), novaminsulfone (32%), and mixed analgesics (28%). No analgesics were given by 6%, and 21% prescribed a supplementary antiemetic. Routine pain measurement was performed with pain scales in only 11% of the practices; among the certified practices, 48% performed pain measurement for quality control. Ninety-five percent of the surgeons were satisfied with the pain therapy.

CONCLUSION

This survey shows that the guidelines for acute pain therapy (http://www.awmf.de ) are only partially implemented.

[Deep-brain stimulation of the internal pallidum in multiple system atrophy]

INTRODUCTION

The experience with deep-brain stimulation (DBS) in multiple-system atrophy (MSA) is sparse and generally disappointing. DBS is currently not recommended in MSA and its use is often related to a misdiagnosis.

OBSERVATION

We describe the outcome of bilateral DBS of the internal pallidum in a 46-year-old woman suffering from MSA that initially resembled Parkinson's disease with prominent levodopa-induced dyskinesias. DBS of the left internal pallidum was performed in 1998 after a ten-year clinical course and improved dyskinesias. Six months later, the right side was implanted. A few months after the second surgery, the patient progressively developed signs of cerebellar and dysautonomic impairment and MSA was diagnosed.

CONCLUSION

Our observation confirms the ineffectiveness of DBS of the internal pallidum in MSA and even suggests a harmful effect. DBS remains contra-indicated in atypical parkinsonism.

Expression level and agonist-binding affect the turnover, ubiquitination and complex formation of peroxisome proliferator activated receptor beta

Peroxisome proliferator-activated receptors (PPARs) are members of the nuclear hormone receptor superfamily that modulate target gene expression in response to fatty acid ligands. Their regulation by post-translational modifications has been reported but is poorly understood. In the present study, we investigated whether ligand binding affects the turnover and ubiquitination of the PPARbeta subtype (also known as PPARdelta). Our data show that the ubiquitination and degradation of PPARbeta is not significantly influenced by the synthetic agonist GW501516 under conditions of moderate PPARbeta expression. By contrast, the overexpression of PPARbeta dramatically enhanced its degradation concomitant with its polyubiquitination and the formation of high molecular mass complexes containing multiple, presumably oligomerized PPARbeta molecules that lacked stoichiometical amounts of the obligatory PPARbeta dimerization partner, retinoid X receptor. The formation of these apparently aberrant complexes, as well as the ubiquitination and destabilization of PPARbeta, were strongly inhibited by GW501516. Our findings suggest that PPARbeta is subject to complex post-translational regulatory mechanisms that partly may serve to safeguard the cell against deregulated PPARbeta expression. Furthermore, our data have important implications regarding the widespread use of overexpression systems to evaluate the function and regulation of PPARs.

Deregulation of tumor angiogenesis and blockade of tumor growth in PPARbeta-deficient mice

The peroxisome proliferator-activated receptor-beta (PPARbeta) has been implicated in tumorigenesis, but its precise role remains unclear. Here, we show that the growth of syngeneic Pparb wild-type tumors is impaired in Pparb(-/-) mice, concomitant with a diminished blood flow and an abundance of hyperplastic microvascular structures. Matrigel plugs containing pro-angiogenic growth factors harbor increased numbers of morphologically immature, proliferating endothelial cells in Pparb(-/-) mice, and retroviral transduction of Pparb triggers microvessel maturation. We have identified the Cdkn1c gene encoding the cell cycle inhibitor p57(Kip2) as a PPARbeta target gene and a mediator of the PPARbeta-mediated inhibition of cell proliferation, which provides a possible mechanistic explanation for the observed tumor endothelial hyperplasia and deregulation of tumor angiogenesis in Pparb(-/-) mice. Our data point to an unexpected essential role for PPARbeta in constraining tumor endothelial cell proliferation to allow for the formation of functional tumor microvessels.

Was ist Schmerztherapie im „German refined – diagnosis related groups-System“ wert?

The German refined diagnosis-related-groups (G-DRG) system was introduced on 1st January 2003, initially on a voluntary basis and on 1st January 2004 the use of a G-DRG costing for stationary hospital treatment became obligatory. The possibility of a description of acute and chronic pain therapy in the G-DRG system was initially rudimentary and not logically planned and also a fair allotment of proceeds according to resources was not possible. By further development of the G-DRG system, pain therapeutic treatment could be improved in some areas, but in others it still remains unsatisfactory. This article offers a summary of the underlying systematics of the G-DRG system and consideration of chronic and current pain therapy in the G-DRG system 2006. In addition to information on currently available possibilities of a pain therapeutical coding in conformation with the G-DRG system, the tasks which are still outstanding will be outlined.

Induction of PPARbeta and prostacyclin (PGI2) synthesis by Raf signaling: failure of PGI2 to activate PPARbeta

A role for the nuclear receptor peroxisome proliferator-activated receptor-beta (PPARbeta) in oncogenesis has been suggested by a number of observations but its precise role remains elusive. Prostaglandin I2 (PGI2, prostacyclin), a major arachidonic acid (AA) derived cyclooxygenase (Cox) product, has been proposed as a PPARbeta agonist. Here, we show that the 4-hydroxytamoxifen (4-OHT) mediated activation of a C-Raf-estrogen receptor fusion protein leads to the induction of both the PPARbeta and Cox-2 genes, concomitant with a dramatic increase in PGI2 synthesis. Surprisingly, however, 4-OHT failed to activate PPARbeta transcriptional activity, indicating that PGI2 is insufficient for PPARbeta activation. In agreement with this conclusion, the overexpression of ectopic Cox-2 and PGI2 synthase (PGIS) resulted in massive PGI2 synthesis but did not activate the transcriptional activity of PPARbeta. Conversely, inhibition of PGIS blocked PGI2 synthesis but did not affect the AA mediated activation of PPARbeta. Our data obtained with four different cell types and different experimental strategies do not support the prevailing opinion that PGI2 plays a significant role in the regulation of PPARbeta.

Benchmarking as a tool of continuous quality improvement in postoperative pain management

BACKGROUND AND OBJECTIVE

Quality of acute pain management is far from being satisfactory. These deficits are not caused by the complexity of the medical problem but by difficulties in organization and hospital structures, sand procedures. Continuous quality improvement is a recommended tool to overcome such difficulties and to increase quality in the long run. This study reports the implementation of benchmarking-based continuous quality improvement to improve postoperative pain management at a university hospital.

METHODS

A specialised pain nurse interviewed patients of three surgical departments on the first day after surgery, and continuously assessed process and outcome quality parameters. A multidisciplinary team of anaesthetists, surgeons, nurses and pharmacists implemented a regular procedure of data analysing and internal benchmarking. Results and suggested improvements were fed back to the healthcare teams.

RESULTS

From 1998 to 2002, 6,756 patients were assessed. Average pain on ambulation and maximal pain were 3.7 +/- 2.4 and 5.0 +/- 2.5 (mean +/- SD) on a 11-point numeric rating scale. Pain intensity at rest was 1.9 +/- 1.8. Over time, pain intensity on ambulation decreased (P = 0.022) whereas maximal pain and pain at rest remained unchanged. There was an increase in the number of patients who received non-opioid analgesia (P < 0.001).

CONCLUSIONS

A continuous quality improvement process could be established and is now successfully used in clinical routine. Cornerstones of this project were frequent assessments of process and outcome parameters, regular benchmarking and implementation of feedback mechanisms. Changes in organization of medical management and multidisciplinary teamwork seem to be more important than medical or technical aspects.

Coherent spike-wave oscillations in the cortex and subthalamic nucleus of the freely moving rat

The basal ganglia play a critical role in controlling seizures in animal models of idiopathic non-convulsive (absence) epilepsy. Inappropriate output from the substantia nigra pars reticulata (SNr) is known to exacerbate seizures, but the precise neuronal mechanisms underlying abnormal activity in SNr remain unclear. To test the hypothesis that cortical spike-wave oscillations, often considered indicative of absence seizures, propagate to the subthalamic nucleus, an important afferent of SNr, we simultaneously recorded local field potentials from the frontal cortex and subthalamic nucleus of freely moving rats. Spontaneous spike-wave oscillations in cortex (mean dominant frequency of 7.4 Hz) were associated with similar oscillations in the subthalamic nucleus (mean of 7.9 Hz). The power of oscillations at 5-9 Hz was significantly higher during spike-wave activity as compared with rest periods without this activity. Importantly, spike-wave oscillations in cortex and subthalamic nucleus were significantly coherent across a range of frequencies (3-40 Hz), and the dominant (7-8 Hz) oscillatory activity in the subthalamic nucleus typically followed that in cortex with a small time lag (mean of 2.7 ms). In conclusion, these data suggest that ensembles of subthalamic nucleus neurons are rapidly recruited into oscillations during cortical spike-wave activity, thus adding further weight to the importance of the subthalamic nucleus in absence epilepsy. An increase in synchronous oscillatory input from the subthalamic nucleus could thus partly underlie the expression of pathological activity in SNr that could, in turn, aggravate seizures. Finally, these findings also reiterate the importance of oscillations in these circuits in normal behaviour.

Der Einfluss von enteralem Naloxon auf die Inzidenz von Gastritis und Ösophagitis bei opioidbehandelten Intensivpatienten: Doppelblinde plazebokontrollierte Studie

BACKGROUND

Gastrtis and esophagitis are frequent and severe complications in intensive care patients, mainly caused by increased duodenogastral reflux. Opioids, commonly used in intensive care, are known to impair gastrointestinal (GI) motility which increases retrograd flow of gastric content. In a previous study, we showed that enteral administered naloxone reduces gastric reflux by selectively blocking GI opioid receptors. Therefore, in a subpopulation of these patients we studied the effect of enteral naloxone on the incidence of mucosal injury in opioid-treated, mechanically ventilated patients.

METHODS

After IRB approval, mechanically ventilated, fentanyl-treated patients without gastrointestinal surgery or diseases were assigned to receive 8 mg naloxone or placebo four times daily via a gastric tube. Additional inclusion criteria were opioid treatment for at least three days and endoscopy of the upper GI tract. Frequency of gastritis and esophagitis was quantified according to the Savary-Miller Score, and further parameter of GI motility (frequency of propulsive medication, amount of enteral feeding) were measured.

RESULTS

In four of seventeen patients of the naloxone group (24 %) and 14 of 22 patients of the placebo group (64 %; p = 0.02), esophageal or gastral mucosal injuries were detected. In the naloxone group, gastral reflux as well as need for propulsive medication were significantly lower. Volume of enteral feeding showed an increasing trend in the second half of the study.

CONCLUSION

Reduction of esophagogastral mucosal injury and reduced need for procinetic medication suggests an improvement of GI motility by enteral naloxone in fentanyl-treated, mechanically ventilated patients.

Transcription Factor (TF)-like Nuclear Regulator, the 250-kDa Form of Homo sapiens TFIIIB″, Is an Essential Component of Human TFIIIC1 Activity

The general human RNA polymerase III transcription factor (TF) IIIC1 has hitherto been ill defined with respect to the polypeptides required for reconstitution of its activity. Here we identify Homo sapiens TFIIIB" (HsBdp1) as an essential component of hTFIIIC1 and hTFIIIC1-like activities. Several forms of HsBdp1 are described. The 250-kDa form of HsBdp1, also designated the "transcription factor-like nuclear regulator," strictly co-eluted with TFIIIC1 activity over multiple chromatographic purification steps as revealed by Western blot with anti-HsBdp1 antibodies and by MALDI-TOF analysis. In addition, TFIIIC1 activity could be depleted from partially purified fractions with anti-HsBdp1 antibodies but not with control antibodies. Moreover, highly purified recombinant HsBdp1 could replace TFIIIC1 activity in reconstituted transcription of the VAI gene in vitro. Furthermore, smaller proteins of approximately 90-150 kDa that were recognized by anti-HsBdp1 antibodies co-eluted with TFIIIC1-like activity. Finally, cytoplasmic extracts from differentiated mouse F9 fibroblast cells that lacked TFIIIC1 activity could be made competent for transcription of the VA1 gene by the addition of TFIIIC1, TFIIIC1-like, or recombinant HsBdp1. These results suggest that HsBdp1 proteins represent essential components of TFIIIC1 and TFIIIC1-like activities.