Effect of a Simple Dose-Escalation Schedule on Tramadol Tolerability

OBJECTIVE

To assess the effect of a very simple dose-escalation schedule on tramadol tolerability in clinical practice. This schedule consists of starting treatment with sustained-release tramadol 50mg twice daily, and escalating the dose around 7 days later to 100mg twice daily.

METHODS

Data from 1925 outpatients with non-malignant chronic pain were collected in this multicentre, prospective, comparative, non-randomised, open, observational study.

RESULTS

A total of 1071 patients (55.6%) were included in the dose-escalation group (50mg group) and 854 patients (44.4%) in the control group (sustained-release tramadol 100mg twice daily; 100mg group). The proportion of patients who interrupted tramadol treatment due to the occurrence of adverse reactions was significantly lower in the 50mg group (5.6%) than in the 100mg group (12.6%) [p = 0.001]. In line with this, the proportion of patients who experienced at least one adverse reaction was significantly lower in the 50mg group (18.4%) than in the 100mg group (30.4%) [p = 0.001] and, interestingly, the two most frequently reported adverse reactions, nausea and dizziness, were found with a significantly lower frequency in the 50mg group (p < 0.001). Multivariate analysis showed that the risk of safety-related treatment cessations was 2.3 times higher in the 100mg group than in the 50mg group, and 2.2 times higher in females than in males. The two treatments were equally effective in reducing pain intensity (p = 0.121), measured as a reduction in pain score obtained by means of a visual analogue scale.

CONCLUSION

The instauration of tramadol treatment, starting with sustained-release 50mg capsules twice daily and escalating the dose some days later to 100mg twice daily, was shown to be an effective and easy way to improve tramadol tolerability in clinical practice, whilst maintaining its analgesic efficacy.

Lercanidipine in patients with chronic renal failure: the ZAFRA study

OBJECTIVE

The objective was primary to evaluate the safe use of a new calcium channel blocker, lercanidipine, in patients with chronic renal failure (CRF). The secondary objective was to study the protective effect of calcium channel blocker on renal function in CRF patients previously treated with ACE inhibitors or angiotensin receptor blockers.

DESIGN AND METHODS

The study recruited 203 CRF patients (creatinine >1.4 mg/dL for males, creatinine > 1.2 mg/dL for females, or creatinine clearance <70 mL/min). All patients were receiving ACE inhibitors (63.4%) or angiotensin II antagonist (36.6%) therapy, but they had higher blood pressure than recommended for CRF (130/85 mmHg). No patients were under diuretic treatment. Patients were clinically evaluated 1, 3, and 6 months after starting treatment with lercanidipine. Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to the treatment, excluding diuretics. Creatinine clearance was measured using 24 h urine collection.

RESULTS

175 patients rendered valuable for the study (age 63.9+/-11.9 years, 52.9% males and 47.1% females). Blood pressure (BP) significantly decreased from 162+/-17/93+/-8.3 mmHg to 132+/-12/78+/-6 mmHg. 89.2% of patients showed a significant BP reduction, and 58.1% achieved optimal BP control (<130/85 mmHg). Seven patients (3.4%) showed untoward effects. Not one case of edema was detected, and the prevalence of adverse effects related to vasodilatation was extremely low (three patients, 1.48%). Plasmatic creatinine did not change (1.9+/-0.5 baseline versus 1.9+/-0.6 mg/dL), but creatinine clearance increased at the end visit (41.8+/-16.0 baseline versus 45.8+/-18.0 mL/min, p=0.019). Plasmatic cholesterol also decreased from 221+/-46 to 211+/-35 mg/dL (p=0.001).

CONCLUSIONS

Lercanidipine showed a high antihypertensive effect in CRF patients. It has a good tolerability profile and showed an interesting effect on plasmatic lipids. An improvement in renal function, measured through creatine clearance, was detected.

[The role of laparoscopy in emergency abdominal surgery]

Abdominal emergencies can also be operated on through the laparoscopic approach: the approach can be diagnostic laparoscopy, surgery assisted by laparoscopy or laparotomy directed according to the findings of the laparoscopy. The general contraindications refer above all to the state of haemodynamic instability of the patient and to seriously ill patients (ASA IV). In the absence of any specific counter-indications for the specific laparoscopic procedure to be carried out, many abdominal diseases requiring emergency surgery can be performed with the laparoscopic approach. The most frequent indications are appendicitis, acute colecistitis, gastroduodenal perforation, occlusion of the small intestine, and some abdominal traumas. With a correct selection of patients and the appropriate experience of the surgeon, the results are excellent and better than open surgery (less infection of the wound, complications, hospital stay and postoperative pain). A detailed explanation is given of the basic aspects of the surgical technique in the most frequent procedures of emergency laparoscopy.

Evolution of endogenous hormone concentration in embryogenic cultures of carrot during early expression of somatic embryogenesis

Embryogenic callus and suspension cultures of carrot (Daucus carota L., cv. Nantaise), growing on/in medium including 1 mg/l 2,4-dichlorophenoxy acetic acid (2,4-D), were transferred to medium with or without this plant growth regulator, to impair or induce, respectively, further development of somatic embryos. The endogenous hormone levels of the cultures were determined over 7 days by means of radio-immunoassay, to characterize their evolution in the initial stages of embryo development. In general, levels of indoleacetic acid (IAA) and abscisic acid (ABA) showed only short-lived differences among treatments during this time in both types of tissue analyzed (i.e., a peak of IAA in callus cultures in the absence of 2,4-D, 48 h after medium change, and higher ABA contents 144 h after subculture of suspension cultures in the presence of 2,4-D). Gibberellins (1, 3 and 20) were detected only in suspension cultures devoid of 2,4-D, starting 24 h after subculture. Concerning the evaluated cytokinins-zeatin/zeatin riboside and N6(Delta2-isopentenyl) adenine/N6(Delta2-isopentenyl) adenosine-the most remarkable observation is that high levels of the former generally coincided with low concentrations of the latter, indicating a shift from precursor to the active form, and vice versa.

[Comments on Cogan's syndrome (congenital oculomotor apraxia) based on a case]

CASE

A 4-month-old girl was seen by a paediatrician for psychomotor delay and defective visual fixation. In order to shift gaze direction, she had to jerk her head in order to drag her eyes in the direction she wanted to look. She also showed non-specific pyramidal impairment. Herpes human virus type 6 (HHV-6) was amplified by PCR. No other findings could explain her troubles with fixation. She was diagnosed with congenital ocular motor apraxia (C.O.M.A.).

DISCUSSION

When C.O.M.A. is suspected, other causes of defective fixation and abnormal cephalic movements must be ruled out through the use of physical examination, electrophysiology and neuroimaging: troubles with ocular motility, poor vision or neurological processes. There have been cases associated with neurological misdevelopment, systemic diseases, metabolic deficits and chromosomic abnormalities.

[Lercanidipine in diabetic patients with renal failure]

OBJECTIVE

To evaluate the safe use of a new calcium channel blocker, lercanidipine, in diabetic chronic renal failure (CRF) patients.

DESIGN AND METHODS

The study recruited 42 diabetic CRF patients (creatinine > 1.4 mg/dl for males, creatinine > 1.2 mg/dl for females, or creatinine clearance < 70 ml/min). Mean age was 68.2 +/- 9.1 years. 53.8% were males and 46.2% females. Three patients were type 1 diabetics and 39 ones were type II. All patients were receiving ACE inhibitors (67.4%) or angiotensin II antagonist (32.6%) therapy but they had higher blood pressure than recommended for CRF patients (130/85 mmHg). No patients were under diuretic treatment. Patients were clinically evaluated 1, 3 and 6 months after starting treatment with lercanidipine. Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to treatment, excluding diuretics. Creatinine clearance was measured using 24 h urine collection.

RESULTS

BP significantly decrease from 163 +/- 18/90 +/- 8 mmHg to 134 +/- 12/77 +/- 9 mmHg. One half of patients showed significant reduction of blood pressure, 26.7% reached the target blood pressure (< 130/85 mmHg) and 20.0% gets optimal BP control (< 130/85 mmHg). No one patient showed untoward effects. No edema was detected nor adverse effects related to vasodilatation were found. Plasmatic creatinine did not change (1.9 +/- 0.5 baseline vs 1.8 +/- 0.5 mg/dl) and creatinine clearance increased at the end visit (40.1 +/- 14.5 baseline vs 45.4 +/- 18.2 ml/min) but the difference was not significant. Proteinuria was unchanged.

CONCLUSIONS

Lercanidipine showed a good antihypertensive effect in diabetics CRF patients. It has a good tolerability profile and showed neutral effect on plasmatic lipids. Neither impairment of renal function nor increment in proteinuria were detected.

[Present state of the surgical treatment of hepatic metastasis of colorectal origin: a practical view]

Hepatic resection is the only real possibility of cure for a selected group of patients with hepatic metastasis of colorectal cancer. Survival obtained in these patients is of some 30-40% after 5 years and some 20-25% after ten years following surgery; no other treatment approaches these results. The key for obtaining these results is the treatment of these patients by a multidisciplinary team, a team that must include the participation of surgeons specially trained in the techniques of hepatic resection. The present review describes: the pre-operational staging of hepatic metastasis of colorectal origin by diagnostic imaging techniques, the selection criteria for surgery, the standards of the surgical technique and the adjuvant treatment that forms part of the Protocol of the Hepatobiliary Surgery Section of the Hospital of Navarra, based on our experience in 150 hepatectomies and on the best scientifically available evidence.

Expression of lectin receptors on the membrane surface of sperm of fertile and subfertile boars by flow cytometry

Studies suggest that carbohydrates are important in different stages of fertilization. Plasma membrane changes accompanying in vitro capacitation and acrosome reaction (AR), such as removal or appearance of specific glycoproteins, have been studied using lectins that bind specifically to carbohydrate residues. In specialized artificial insemination farms and semen production centers, identification of boars with decreased fertilization ability (subfertility) is a newborn necessity. This investigation is a sequential study to determine the kinetics of surface carbohydrates turnover during in vitro capacitation and AR in fertile and subfertile boar sperm. Flow cytometry determinations of the binding of three FITC-labeled lectins were assessed. WGA binding was significantly lower in fresh, capacitated, and acrosome-reacted sperm of subfertile boars than in fertile boars. Con-A binding was not significantly different in fresh sperm of fertile and subfertile boars. However. Con-A labeling in capacitated, and acrosome-reacted sperm differed significantly in both groups. UEA binding increased only in capacitated sperm of subfertile boars. These findings could be used as indicators of capacitation and AR and may also be a good indicator of sperm fertilizing ability in boars.

Acrosome reaction in fertile and subfertile boar sperm

The main purpose of sperm evaluation is to predict its fertilizing ability. However, basic sperm test results show a low correlation with fertilizing ability. The purpose of this study was to determine whether there is an association between acrosome reaction (AR) and the incidence of subfertility of normal sperm boar. The production records of 22 farms were analyzed to identify boars with low fertility and/or prolificity, classified as subfertile. Twenty-two subfertile boar semen samples were analyzed and compared with 51 samples of fertile boars. Sperm were capacitated during 4 h at 39 degrees C. viability was determined by bisbenzimide (Hoechst-33258) staining. Acrosome reaction was assessed with fluorescein isothiocyanate conjugated Pisum sativum agglutinin. The percentage of spontaneous acrosome reaction (SAR) was not significantly different in fertile (4.5%) and subfertile boars (4.75%) (p > .05). Nevertheless, the percentage of progesterone-induced acrosome reaction (IAR) was significantly lower in subfertile boars (5.75%) as compared with fertile boars (10%) (p < .01). These results suggest that assessment of IAR in vitro may be a useful parameter to identify subfertility in boars.

Physical activity in first-degree relatives of breast cancer patients

This study sought to evaluate physical activity in women at moderate risk for breast cancer, the correlates of engaging in regular physical activity, and whether physical activity relates to psychological well-being. The results revealed that 55% of women were regularly active. Logistic regression models indicated that positive affect was associated with increased and negative affect was associated with decreased overall and leisure activity. Older, married, and employed women were more likely to engage in household/occupational activity, whereas women who perceived their risk for breast cancer as high were less likely. More educated women and those with higher perceived risk were more likely to engage in leisure activity, and married women were less likely. These results suggest a need to increase activity levels in women at moderate risk for breast cancer, provide variables upon which interventions can be tailored to promote activity, and point to psychological benefits of activity in this population.

Changes in symptoms, lipid and hormone levels after the administration of a cream with phytoestrogens in the Climacteric--preliminary report

OBJECTIVE

To establish the changes in lipid and hormone levels, as well as in symptoms, after topical application of a cream with phytoestrogens in postmenopausal women.

METHODS

30 postmenopausal women were studied. At baseline and 1 month after the beginning of treatment, levels of FSH, estradiol, estrone, testosterone, androstenedione, dehydroepiandrosterone, total cholesterol, HDL-C, LDL-C, and triglycerides were measured. Climacteric symptoms were evaluated with a modified Kupperman's index (KI). The subjects received a cream with phytoestrogens (n = 15) or placebo (cold cream) (n = 15) in a randomized, double-blind manner. Statistically significant differences were determined by Student's t test.

RESULTS

No differences were found in hormones, lipids, or in KI between the groups. When comparing each group separately, only a significant decrease in KI was found, in both groups, at the end of the treatment.

CONCLUSIONS

This cream with phytoestrogens had an effect only in climacteric symptoms, but similar to the placebo. The lack of effect in the other variables was probably due to the administration route, or to a lack of effect of this product.

Trypanosoma cruzi: data supporting clonality in Mexican stocks

To further study genetic heterogeneity of Mexican stocks of Trypanosoma cruzi, genomic Southern analyses from 54 Mexican isolates and 5 South American reference stocks were carried out. The membranes were hybridized with a homologous cDNA clone from the ribosomal protein S4 that identifies allelic bands from a single gene type locus. These allelic bands were sequentially numbered depending on their relative size. Mexican T. cruzi stocks were quite homogeneous: 31 cases (57%) showed a homozygous genotype 3/3, and 21 isolates (38%) exhibited the heterozygote genotype 2/3. Just 2 Mexican stocks (3%) showed a different genotype 2/5, but the potential parental homozygous 2/2 was never observed. Being that T. cruzi is a diploid organism, the apparent absence of the presumptive parental homozygous genotype 2/2 argues against sexual reproduction within the population, at least as a common event. Therefore, these data support a clonal population structure of T. cruzi in Mexico.

Embryonic-derived glial-restricted precursor cells (GRP cells) can differentiate into astrocytes and oligodendrocytes in vivo

We have isolated and characterized a unique glial-restricted precursor cell (GRP) from the embryonic spinal cord. Clonal analysis demonstrated that these cells are able to generate oligodendrocytes and two distinct type of astrocytes (type 1 and type 2) when exposed to appropriate signals in vitro. We now show that many aspects of these cells are retained in vivo. GRP cells are restricted to the glial lineage in vivo as they seem to be unable to generate neuronal phenotypes in an in vivo neurogenic environment. GRP cells survive and migrate in the neonatal and adult brain. Transplanted GRP cells differentiate into myelin-forming oligodendrocytes in a myelin-deficient background and also generate immature oligodendrocytes in the normal neonatal brain. In addition, GRP cells also consistently generated glial fibrillary protein-expressing cells in the neonatal and adult brain, a property not consistently expressed by other glial precursor cells like the O-2A/OPC cells. We suggest that the lineage restriction of GRP cells and their ability to generate both oligodendrocytes and astrocytes in vivo together with their embryonic character that allows for extensive in vitro expansion of the population makes the cell useful for clinical application.

Preservation of the recipient inferior vena cava in liver transplantation

Twenty piggy-back (PB) liver transplantations (LT) were compared with 20 LT performed by the standard technique in order to evaluate whether or not the theoretical haemodynamic advantages of the preservation of the inferior vena cava (IVC) have any impact on the final results of the LT. Statistically significant differences were observed in the duration of the hepatectomy, which was longer for PB LT (192 min vs. 146 min), and in the duration of the anhepatic phase, which was shorter in that group (52 min vs. 76 min). There were no differences in the duration of the complete surgical procedure, consumption of blood products, incidence of postoperative acute renal failure, number of reoperations or survival.