Continuous intestinal infusion of levodopa/carbidopa in advanced Parkinson's disease: efficacy, safety and patient selection

Long-term oral therapy with levodopa is associated with the development of motor fluctuations and dyskinesia in a large percentage of patients with Parkinson's disease (PD). Motor complications are associated with a number of non-motor symptoms and have a negative impact on disability and quality of life. There are three therapeutic options available for the management of patients at this advanced stage: high frequency deep brain stimulation, continuous subcutaneous infusion of apomorphine, and continuous intestinal infusion of levodopa/carbidopa. On the basis of published data and in consideration of the risk-benefit profile of current therapeutic strategies, we here propose an algorithm to help clinicians select the most suitable treatment option for patients with advanced PD.

Contribution of infectious disease consultation toward the care of inpatients being considered for community-based parenteral anti-infective therapy

BACKGROUND

In the acute care setting in a multidisciplinary healthcare environment, the contribution of infectious disease (ID) specialists to overall patient care is difficult to measure. This study attempts to quantify the contribution of ID specialists when consulted for an activity specific to ID practice, community-based parenteral anti-infective therapy (CoPAT).

METHODS

In February 2010, an electronic form for requesting ID consultations was introduced in the computerized provider order entry (CPOE) system at the Cleveland Clinic. This allowed for easy identification of ID consultations for CoPAT. Hospital records for all patients with CoPAT consultation requests between February 11, 2010 and May 15, 2010 were reviewed for specific defined contributions in the domains of optimization of antimicrobial therapy, significant change in patient assessment, and additional medical care contribution.

RESULTS

Over a 3-month period, there were 263 CoPAT consultation requests via CPOE, of which 172 were initial consultations and 91 reconsultations. Antimicrobial treatment was optimized in 84%, a significant change in patient assessment made in 52%, and additional medical care contribution provided in 71% of consultations. In 33% of consultations, there was contribution in all 3 domains. CoPAT was deemed not to be necessary in 27%. For patients requiring CoPAT, effective care transition from the inpatient to outpatient setting was assured at least 86% of the time.

CONCLUSION

Infectious disease consultation before discharge on parenteral antibiotics adds value by contributing substantially to inpatient care, and providing antimicrobial stewardship and continuity of care at a critical patient care transition point.

Amnioinfusion for preterm premature rupture of membranes

BACKGROUND

Preterm premature rupture of membranes (PPROM) is a leading cause of perinatal morbidity and mortality. Amnioinfusion aims to restore amniotic fluid volume by infusing a solution into the uterine cavity.

OBJECTIVES

The objective of this review was to assess the effects of amnioinfusion for PPROM on perinatal and maternal morbidity and mortality.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011).

SELECTION CRITERIA

Randomised trials of amnioinfusion compared to no amnioinfusion in women with PPROM.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy.

MAIN RESULTS

We included five trials but we only analysed data from four studies (with a total of 241 participants). One trial did not contribute any data to the review.Transcervical amnioinfusion improved fetal umbilical artery pH at delivery (mean difference 0.11; 95% confidence interval (CI) 0.08 to 0.14; one trial, 61 participants) and reduced persistent variable decelerations during labour (risk ratio (RR) 0.52; 95% CI 0.30 to 0.91; one trial, 86 participants).Transabdominal amnioinfusion was associated with a reduction in neonatal death (RR 0.30; 95% CI 0.14 to 0.66; two trials, 94 participants), neonatal sepsis (RR 0.26, 95% CI 0.11 to 0.61; one trial, 60 participants), pulmonary hypoplasia (RR 0.22; 95% CI 0.06 to 0.88; one trial, 34 participants) and puerperal sepsis (RR 0.20; 95% CI 0.05 to 0.84; one trial, 60 participants). Women in the amnioinfusion group were also less likely to deliver within seven days of membrane rupture (RR 0.18; 95% CI 0.05 to 0.70; one trial, 34 participants). These results should be treated with circumspection as the positive findings were mainly due to one trial with unclear allocation concealment.

AUTHORS' CONCLUSIONS

These results are encouraging but are limited by the sparse data and unclear methodological robustness, therefore further evidence is required before amnioinfusion for PPROM can be recommended for routine clinical practice.

[Chronic osteomyelitis due to Pseudomonas aeruginosa: treatment with elastomeric infusor in an outpatient setting]

Chronic bacterial osteomyelitis requires long-term antibiotic treatment (at least 6-8 weeks). After in-hospital management, patients are usually discharged and treated in outpatient settings. However, when the aetiology is represented by Gram-negative microorganisms, outpatient treatment could be difficult. Beta-lactam administration by means of an elastomeric infusor may represent an attractive approach. We report two cases of osteomyelitis due to Pseudomonas aeruginosa successfully treated with continuous ceftazidime administration via an elastomeric infusor in outpatient settings. In both cases the patients were free from clinical and laboratory signs of osteomyelitis at the end of treatment and after 12 months follow-up.

Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer

BACKGROUND

Ovarian cancer tends to be chemosensitive and confine itself to the surface of the peritoneal cavity for much of its natural history. These features have made it an obvious target for intraperitoneal (IP) chemotherapy. Chemotherapy for ovarian cancer is usually given as an intravenous (IV) infusion repeatedly over five to eight cycles. Intraperitoneal chemotherapy is given by infusion of the chemotherapeutic agent directly into the peritoneal cavity. There are biological reasons why this might increase the anticancer effect and reduce some systemic adverse effects in comparison to IV therapy.

OBJECTIVES

To determine if adding a component of the chemotherapy regime into the peritoneal cavity affects overall survival, progression-free survival, quality of life (QOL) and toxicity in the primary treatment of epithelial ovarian cancer.

SEARCH METHODS

We searched the Gynaecological Cancer Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2011, MEDLINE (1951 to May 2011) and EMBASE (1974 to May 2011). We updated these searches in February 2007, August 2010 and May 2011. In addition, we handsearched and cascade searched the major gynaecological oncology journals.

SELECTION CRITERIA

The analysis was restricted to randomised controlled trials (RCTs) assessing women with a new diagnosis of primary epithelial ovarian cancer, of any FIGO stage, following primary cytoreductive surgery. Standard IV chemotherapy was compared with chemotherapy that included a component of IP administration.

DATA COLLECTION AND ANALYSIS

We extracted data on overall survival, disease-free survival, adverse events and QOL and performed meta-analyses of hazard ratios (HR) for time-to-event variables and relative risks (RR) for dichotomous outcomes using RevMan software.

MAIN RESULTS

Nine randomised trials studied 2119 women receiving primary treatment for ovarian cancer. We considered six trials to be of high quality. Women were less likely to die if they received an IP component to chemotherapy (eight studies, 2026 women; HR = 0.81; 95% confidence interval (CI): 0.72 to 0.90). Intraperitoneal component chemotherapy prolonged the disease-free interval (five studies, 1311 women; HR = 0.78; 95% CI: 0.70 to 0.86). There was greater serious toxicity with regard to gastrointestinal effects, pain, fever and infection but less ototoxicity with the IP than the IV route.

AUTHORS' CONCLUSIONS

Intraperitoneal chemotherapy increases overall survival and progression-free survival from advanced ovarian cancer. The results of this meta-analysis provide the most reliable estimates of the relative survival benefits of IP over IV therapy and should be used as part of the decision making process. However, the potential for catheter related complications and toxicity needs to be considered when deciding on the most appropriate treatment for each individual woman. The optimal dose, timing and mechanism of administration cannot be addressed from this meta-analysis. This needs to be addressed in the next phase of clinical trials.

[Tactics of preoperative infusion therapy in obturation jaundice]

The influence of the infusion therapy content on a hepatic function of bile outflow (HFBO), a bilirubin content and the enzymes activity in obturation jaundice in 139 patients was studied up. In 54 patients (the first group) a Ringer solution and 10% solution of glucose in 1:1 ratio were applied; in 37 patients (the second group) - a sterofundin-G-5 solution; in 48 patients (the third group) - remaxol in a dose of 800 ml/day. Application of sterofundin-G-5 and remaxol as a component of infusion therapy have promoted a bile outflow intensity enhancement in early postoperative period in comparison with such while Ringer solution and 10% solution of glucose application. Remaxol more effectively have eliminated a hyperbilirubinemia, enzymemia and a HFBO disorder, than sterofundin-G-5.

Probiotics for prevention of necrotizing enterocolitis in preterm infants

BACKGROUND

Necrotizing enterocolitis (NEC) and nosocomial sepsis are associated with increased morbidity and mortality in preterm infants. Through prevention of bacterial migration across the mucosa, competitive exclusion of pathogenic bacteria, and enhancing the immune responses of the host, prophylactic enteral probiotics (live microbial supplements) may play a role in reducing NEC and associated morbidity.

OBJECTIVES

To compare the efficacy and safety of prophylactic enteral probiotics administration versus placebo or no treatment in the prevention of severe NEC and/or sepsis in preterm infants.

SEARCH STRATEGY

For this update, searches were made of MEDLINE (1966 to October 2010), EMBASE (1980 to October 2010), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2010), and abstracts of annual meetings of the Society for Pediatric Research (1995 to 2010).

SELECTION CRITERIA

Only randomized or quasi-randomized controlled trials that enrolled preterm infants < 37 weeks gestational age and/or < 2500 g birth weight were considered. Trials were included if they involved enteral administration of any live microbial supplement (probiotics) and measured at least one prespecified clinical outcome.

DATA COLLECTION AND ANALYSIS

Standard methods of the Cochrane Collaboration and its Neonatal Group were used to assess the methodologic quality of the trials, data collection and analysis.

MAIN RESULTS

Sixteen eligible trials randomizing 2842 infants were included. Included trials were highly variable with regard to enrollment criteria (i.e. birth weight and gestational age), baseline risk of NEC in the control groups, timing, dose, formulation of the probiotics, and feeding regimens. Data regarding extremely low birth weight infants (ELBW) could not be extrapolated. In a meta-analysis of trial data, enteral probiotics supplementation significantly reduced the incidence of severe NEC (stage II or more) (typical RR 0.35, 95% CI 0.24 to 0.52) and mortality (typical RR 0.40, 95% CI 0.27 to 0.60). There was no evidence of significant reduction of nosocomial sepsis (typical RR 0.90, 95% CI 0.76 to 1.07). The included trials reported no systemic infection with the probiotics supplemental organism. The statistical test of heterogeneity for NEC, mortality and sepsis was insignificant.

AUTHORS' CONCLUSIONS

Enteral supplementation of probiotics prevents severe NEC and all cause mortality in preterm infants. Our updated review of available evidence supports a change in practice. More studies are needed to assess efficacy in ELBW infants and assess the most effective formulation and dose to be utilized.

Transitioning antimicrobial stewardship beyond the hospital: the Cleveland Clinic's community-based parenteral anti-infective therapy (CoPAT) program

One of the tenets of value-based health care is a focus on providing benefits to patients, as measured by better health outcomes per dollar spent rather than minimizing costs. In fact, proponents of value-based health care argue that the best way to reduce health care costs is through a focused approach to improving health outcomes. Associated with this approach is the need to measure outcomes over the full cycle of care, not simply for services rendered while an inpatient. This article examines the community-based parenteral anti-infective therapy program at the Cleveland Clinic as a model for antimicrobial stewardship for patients requiring parenteral antimicrobial therapy at the time of discharge from the inpatient setting. The program is a patient needs-focused, coordinated team effort that mandates inpatient infectious disease consultation for patients requiring community-based parenteral anti-infective therapy. An examination of some of the features of the Cleveland Clinic program should provide guidance for other institutions seeking to improve the care of their patients requiring parenteral anti-infectives when transitioning care from the acute setting.

Parenteral delivery of HPβCD: effects on drug-HSA binding

It is thought that cyclodextrins, such as 2-hydroxypropyl-β-cyclodextrin (HPβCD), will at high concentration affect pharmacokinetics of drugs through competitive binding with plasma proteins. Albumin is the major component of plasma proteins responsible for plasma protein binding. The purpose of this study was to evaluate in vitro the competitive binding of drugs between human serum albumin (HSA) and HPβCD in isotonic pH 7.4 phosphate buffer saline solution (PBS) at ambient temperature. Eight model drugs were selected based on their physicochemical properties and ability to form complexes with HSA and HPβCD. The drug/HPβCD stability constants (K(1:1)) were determined by the phase-solubility method and HSA/HPβCD competitive binding determined by an equilibrium dialysis method. Protein binding of drugs that are both strongly protein bound and have high affinity to HPβCD (i.e., have high K(1:1) value) is most likely to be affected by parenterally administered HPβCD. However, this in vitro study indicates that even for those drugs single parenteral dose of HPβCD has to be as high as 70 g to have detectable effect on their protein binding. Weakly protein bound drugs and drugs with low affinity towards HPβCD are insensitive to the cyclodextrin presence regardless their lipophilic properties.

Curative treatment of colorectal peritoneal carcinomatosis: current status and future trends

A new therapeutic approach to treat colorectal peritoneal carcinomatosis (PC) is becoming increasingly popular. Its main principle is to treat the macroscopic (visible) malignant peritoneal disease with complete cytoreductive surgery and, immediately after, to treat the remaining microscopic (non visible) malignant peritoneal disease with hyperthermic intraperitoneal chemotherapy (HIPEC). This combined treatment has become the gold standard approach when feasible. It is associated with good oncologic results, considering a 5-year survival rate close to 40% when complete cytoreductive surgery is achieved, and acceptable surgical results, considering a postoperative mortality rate ranging from 3 to 5% and a postoperative morbidity rate ranging from 30 to 50%. The exact effects of each steps of this combined treatment are currently unknown; therefore a randomized controlled trial is on going evaluating the real impact of HIPEC by itself (randomization with or without HIPEC after a complete cytoreductive surgery). One of the future indications of this combined approach might be its use in the very early development of PC. Indeed, early PC is currently only detectable and treatable during a second-look surgery, as recently demonstrated in high-risk patients. A trial is currently comparing the oncologic benefits of this second-look approach with HIPEC to the usual simple survey in patients with a high risk to develop PC.

[Perioperative infusion therapy in children]

A volume replacement therapy compensates a reduced intravascular volume to stabilize and maintain hemodynamics and vital signs. For this therapy, a physiologically-based solution comprising both, osmotic and colloid osmotic components, should be administered. The basic requirement for a sufficient fluid replacement and volume resuscitation therapy in children are the profound and special knowledge of the physiological and pathophysiological interactions in water balance and electrolyte metabolism in childhood, the pharmacology of the applied solutions and the adequate monitoring of this fluid and volume replacement therapy. Wrong dosages and side effects are reasons for a negative postoperative outcome in children.

Drug delivery systems in domestic animal species

Delivery of biologically active agents to animals is often perceived to be the poor relation of human drug delivery. Yet this field has a long and successful history of species-specific device and formulation development, ranging from simple approaches and devices used in production animals to more sophisticated formulations and approaches for a wide range of species. While several technologies using biodegradable polymers have been successfully marketed in a range of veterinary and human products, the transfer of delivery technologies has not been similarly applied across species. This may be due to a combination of specific technical requirements for use of devices in different species, inter-species pharmacokinetic, pharmacodynamic and physiological differences, and distinct market drivers for drug classes used in companion and food-producing animals. This chapter reviews selected commercialised and research-based parenteral and non-parenteral veterinary drug delivery technologies in selected domestic species. Emphasis is also placed on the impact of endogenous drug transporters on drug distribution characteristics in different species. In vitro models used to investigate carrier-dependent transport are reviewed. Species-specific expression of transporters in several tissues can account for inter-animal or inter-species pharmacokinetic variability, lack of predictability of drug efficacy, and potential drug-drug interactions.

Upfront intraperitoneal chemotherapy for patients with epithelial ovarian cancer: long-term follow-up of a previously published trial

OBJECTIVE

To update previously published work on the long-term survivorship of patients with surgically debulked epithelial ovarian cancer who were treated with intraperitoneal cisplatin-based chemotherapy after initial debulking surgery during the pretaxane era.

METHODS

The records of 15 ovarian cancer patients treated with i.p. cisplatin (CDDP) and either i.v. doxorubicin or i.v. cyclophosphamide from 1985-1993 were reviewed. Data on long-term survivorship, toxicity and ultimate cause of death were updated.

RESULTS

Recurrence-free survival rates for all subjects were 67% at two years, 47% at five years and 40% at 10 years. Five of the 15 (33%) original patients are alive with no evidence of disease (NED) at 180, 183, 205, 228 and 228 months respectively with a median of 205 months since last treatment. Toxicity was present yet posed no long-term threat.

CONCLUSION

As presented in the original paper, i.p. chemotherapy can be safely utilized in a community hospital setting. Long-term survival is possible even with suboptimal regimens of chemotherapy as compared with today's standard treatments.

Treatment of ovarian cancer with intraperitoneal chemotherapy

In early 2006, the National Cancer Institute (NCI) issued a Clinical Announcement suggesting that intraperitoneal (IP) chemotherapy should become the standard of care for patients with newly diagnosed stage III optimally debulked epithelial ovarian cancer. IP chemotherapy, the administration of chemotherapy or biologic therapy via catheter into the peritoneal space, is new to many healthcare providers (physicians, nurses, and pharmacists). The goals of this article are to address the rationale for IP chemotherapy, present the data supporting its use, and describe the nursing management of patients undergoing this treatment. Education of patients and staff regarding IP therapy is essential for successful patient outcomes.

Efficacy of early use of intrathecal baclofen therapy for treating spastic hypertonia due to acquired brain injury

OBJECTIVE

To determine the efficacy and safety of early (<1 year post-disease onset) use of intrathecal baclofen (ITB).

DESIGN

Consecutive case series of 14 individuals with spastic hypertonia due to trauma (5), anoxia (6) and stroke (3).

MAIN OUTCOME MEASURES

Modified Ashworth (MAS) and Disability Rating (DRS) scales.

INTERVENTIONS

ITB pump placement within 1 year of onset, after inadequate response to other previous treatment modalities.

RESULTS

At follow-up after ITB pump implantation (mean = 13.9 months; mean daily dose = 591.5 microg per day), mean MAS scores improved from baseline by 1.0 and 2.1 points in the upper and lower limbs, respectively. DRS scores did not change significantly. Functional gains included decreased pain and improved gait speed and motor skills. The only complication was spinal leak in one subject.

CONCLUSIONS

ITB therapy within 1 year of onset of acquired brain injury appears effective and safe in decreasing spastic hypertonia and does not appear to adversely affect recovery.

Advanced cancer of the ovary: intraperitoneal chemotherapy as a new therapeutical option

Intraperitoneal (IP) chemotherapy has been used in patients presenting different stages of ovarian cancer. We performed a critical review of the available literature on IP as first-line treatment in advanced ovarian cancer to consider if this new option should be incorporated into the commonly applied guidelines for treatment of ovarian cancer. We concluded that without further data, it would not be ethically correct to administer chemotherapy intraperitoneally. Outside of planned clinical trials, patients should not be exposed to this treatment modality and its associated toxicity. The present international guidelines are still valid and recommended chemotherapy in advanced ovarian cancer remains treatment with paclitaxel and carboplatin. Further studies on this topic are, however, warranted.

[Difficulties encountered during formulation of a parenteral dosage form containing a poorly soluble drug]

Poor water solubility and consequently the difficulties in formulating a liquid dosage form is a great concern in pharmaceutical development. The importance of this issue is underlined by the fact that 10-30% of marketed drugs and 60-70% of drugs coming from early development stage have solubility problems. In this paper we summarize the existing solubility enhancing techniques that are applicable in parenteral dosage forms for overcoming the issue. We address the problem of choosing the most adequate solubility enhancing technique and present the considerations that should be kept in mind during formulating the solvent systems. Such questions are for example the possible haemolysing effect of the excipients, pH of the composition and its compatibility with various sterilizing methods. We also focus on the probable technological issues, which may arise in each solubility enhancing method, we present examples for every one of them and where possible the solution to the problem is also proposed.

[Application of enteral and "individual" parenteral nutrition therapies in pediatric patients]

In long-standing stress situation, in malabsorption syndromes we cannot provide the adequate protein and energy intake with enteral nutrition, so we often have to add complementary parenteral feeding. Using combined enteral and "individualised" parenteral nutrition the quality of life improves, the time of hospital stay decreases. The parenteral nutrition of neonates and infants implies a great challenge for health care supplier; there is no available "All-in-One" mixture infusion below 2 years of age. We developed a new chart for parenteral nutrition, which can be modified easily according to the patient's age, body weight, need. This chart was introduced to the "Guidelines of the Infant and Pediatric Board" in 2003 and accepted by the Health Ministry in 2006. The Central Pharmacy of the Semmelweis University prepares the "individualised" parenteral mixture in laminar air-flow box, in aseptic condition. Further advantage of the Infusion Mixture, that 4-day portion can be prepared. We review the usefulness and the development of combined enteral and "individualised" parenteral nutrition. Altogether we had 30 patients needing total parenteral nutrition (TPN) in the last 5 years: 46% short bowel syndrome, 18% oesophageal disorders, 15% oncology patients, 21 % septicaemia and other disorders. Beside the "individualised" parenteral nutrition the use of enteral formulas increased, too. Our goal is the optimal combination of parenteral and enteral nutrition in order to diminish the hospital stay and to improve the quality of life of our patients.

Age-dependent response of the acid-base parameters (Henderson-Hasselbalch, Stewart) in healthy calves with experimentally induced metabolic acidosis

The intensity of the response to acid-base parameters in relation to the age after a defined acid load was studied in calves. 32 clinically healthy calves (age: 4-104 days) were infused with 5M NH4Cl solution (dose: 1.0 ml/kg) through a permanent intravenous catheter. Before (0 hrs) and after starting the infusion (2, 4, 6, 8 and 24 hrs) venous blood samples were collected for the determination of the various acid-base parameters. The intensity of the response of the acid-base parameters was estimated by using the "area under curve (AUC)" procedure. By 2-6 hrs after the infusion of the NH4Cl solution, the Henderson-Hasselbalch parameters decreased significantly (decrease pH, decrease [HCO3-]) as did Stewart's variables (decrease [Strong ion difference=SID3], decrease [Acid total = A(tot) or A-]). A transient moderate hyperchloraemic acidosis with a slight hypoproteinaemic alkalosis was observed in all calves in association with a respiratory compensation (decrease PCO2). The younger calves (1st-3rd week) showed a similar pattern of response to the same dose per kg 0.75 acid load with significantly greater acid-base parameters response (higher AUC values) than the older animals. The calculated pH was determined by using the three Stewart variables PvCO2, serum-[SID3] and serum-[A(tot)]. The mean difference was -0.03 to -0.09 compared with the measured pH (7.32-7.40).

CONCLUSION

The Stewart model appears to be more successful in providing a comprehensive evaluation of acid-base status compared with the traditional Henderson-Hasselbalch model. The younger calves during the first week of life reacted more sensitively to an equal acidotic condition than the older animals.

[Correction of protein metabolism violations in patients with malabsorption syndrome]

It is established that a heightened nitrogen balance is defined by a dysabsorbtion syndrom. Proved that the optimal quota of protein at albuminous insufficiency is about 135 g/day. Parenteral introduction of aminoacidic mixes (Infesol) led to clinical improvement, normalization of an aminoacidic spectrum of blood. Use of mixes for an enteral nutrition (Nutridrink) provides a reduction of symptoms of albuminous deficiency.