Effect of controlled-release delivery on the pharmacokinetics of oxybutynin at different dosages: severity-dependent treatment of the overactive bladder

OBJECTIVE

To assess the pharmacokinetics of a controlled-release formulation of oxybutynin (OROS-O, ALZA Corp., Mountain View, CA) at different dosages, compared with immediate-release oxybutynin (IR-O), and to determine the pharmacodynamic properties in the severity-dependent reduction of urge urinary incontinence (UUI).

PATIENTS AND METHODS

In all, 105 patients were enrolled in this multicentre, randomized, double-blind study. Individual dose titration was used to assess the minimum effective, maximum tolerated or maximum allowed dose of either OROS-O or IR-O. Blood samples were collected during maintenance therapy with frequent sampling to analyse for R-oxybutynin and R-desethyloxybutynin concentrations. Pre-dose plasma levels before dosing were obtained as the minimum concentrations achieved at steady state during the dosing regimen. In parallel, UUI episodes were assessed at baseline and during maintenance therapy at the final dose level.

RESULTS

For both IR-O and OROS-O, initial R-oxybutynin plasma concentrations increased in a dose-dependent fashion. For comparable dosages pre-dose plasma levels were higher for OROS-O than IR-O. After one dose of IR-O plasma concentrations peaked at approximately 27-fold after 1 h and decreased to baseline levels within 4-8 h. In contrast, plasma concentrations of R-oxybutynin remained constant for up to 24 h after taking OROS-O at all doses. The overall percentage reduction in weekly UUI episodes was 84% (to 4.8 episodes) and 88% (to 3.1 episodes) for OROS-O and IR-O, respectively (P < 0.05). Patients who titrated to final dose levels of 10, 15 and 20 mg OROS-O differed in their weekly UUI episodes at baseline (14.5, 30.3 and 42.0). Because of individual dose titration, UUI episodes/week were profoundly reduced at all applied doses (1.9-2.0, respectively). Fewer patients reported moderate to severe dry mouth with OROS-O than with IR-O (25% vs 46%, P < 0.05).

CONCLUSION

The pharmacokinetics of OROS-O are proportional to dose, with minimal fluctuations between peak and trough concentrations, as associated with IR-O. In clinical practice OROS-O may thus facilitate the highly effective severity-dependent treatment of UUI with flexible dose adaptations based on the patients' needs.

Modulation of fluorouracil by leucovorin in patients with advanced colorectal cancer: an updated meta-analysis

PURPOSE

The modulation of fluorouracil (FU) by folinic acid (leucovorin [LV]) has been shown to be effective in terms of tumor response rate in patients with advanced colorectal cancer, but a meta-analysis of nine trials previously published by our group failed to demonstrate a statistically significant survival difference between FU and FU-LV. We present an update of the meta-analysis, with a longer follow-up and the inclusion of 10 newer trials.

PATIENTS AND METHODS

Analyses are based on individual data from 3,300 patients randomized in 19 trials on an intent-to-treat basis. Two trials had multiple comparisons, leading to a total of 21 pair-wise comparisons. FU doses were similar in both arms in 10 pair-wise comparisons, 15% to 33% higher in the FU-alone arm in six comparisons, and more than 66% higher in five comparisons.

RESULTS

Overall analysis showed a two-fold increase in tumor response rates (11% for FU-LV v 21% for FU-LV v 11% for FU [corrected] alone; odds ratio, 0.53; 95% CI, 0.44 to 0.63; P <.0001) and a small but statistically significant overall survival benefit for FU-LV over FU alone (median survival, 11.7 v 10.5 months, respectively; hazards ratio, 0.90; 95% CI, 0.87 to 0.94; P =.004), which were primarily seen in the first year. We observed a significant interaction between treatment benefit and dose of FU, with tumor response and overall survival advantages of FU-LV over FU-alone being restricted to trials in which a similar dose of FU was prescribed in both arms.

CONCLUSION

This updated analysis demonstrates, on a large data set, that FU-LV improves both response rate and overall survival compared with FU alone and that this benefit is consistent across various prognostic factors.

An algorithm to predict pregnancy in assisted reproduction

BACKGROUND

Male fertility potential cannot be measured by conventional parameters for the assisted reproduction technique; ICSI. This study determines the relationship between testicular and ejaculated sperm mitochondrial (mt) DNA deletions, nuclear (n) DNA fragmentation, and fertilization and pregnancy rates in ICSI.

METHODS

Ejaculated sperm were obtained from 77 men and testicular sperm from 28 men with obstructive azoospermia undergoing ICSI. Testicular sperm were retrieved using a Trucut needle. mtDNA was analysed using a long PCR. The alkaline Comet assay determined nDNA fragmentation.

RESULTS

Of subjects who achieved a pregnancy (50%) using testicular sperm, only 26% had partners' sperm with wild-type (WT) mtDNA. Of pregnant subjects (38%) using ejaculated sperm, only 8% had partner sperm with WT mtDNA. In each, the successful group had less mtDNA deletions and less nDNA fragmentation. There were inverse relationships between pregnancy and mtDNA deletion numbers, size and nDNA fragmentation for both testicular and ejaculated sperm. No relationships were observed with fertilization rates. An algorithm for the prediction of pregnancy is presented based on the quality of sperm nDNA and mtDNA.

CONCLUSION

In both testicular and ejaculated sperm, mtDNA deletions and nDNA fragmentation are closely associated with pregnancy in ICSI.

A cluster of leptospirosis cases in canoeists following a competition on the River Liffey

On 6 November 2001, a possible case of leptospirosis was notified in a canoeist following a white-water event on the River Liffey. It emerged that a second race participant was also a possible case. An outbreak control team coordinated the epidemiological investigation, laboratory investigation, environmental assessment, communication and control measures. A cluster of six laboratory-confirmed cases of leptospirosis, serologically Leptospira interrogans serogroup Icterohaemorrhagiae was found. The attack rate was 9.2% (6/65). Fever, chills, red eyes and shortness of breath were significantly associated with being a confirmed case. Five cases were hospitalized. Swallowing more than one mouthful of water was associated with an increased risk of developing leptospirosis. Increased rainfall and release of hydroelectric water may have contributed to this outbreak. A multidisciplinary approach and use of the Internet and e-mail facilitated rapid and effective communication.

The natural history of the periacetabular fragment following Ganz osteotomy

The vascularity of the acetabular free fragment in Ganz osteotomies has remained a concern. This study aims to assess the role of MR imaging in the postoperative evaluation of Ganz osteotomies. Twenty patients (19 females, 1 male), average age 24 years (range, 12-36 years), had sequential magnetic resonance imaging studies of the pelvis at 6 weeks and 6 months following Ganz osteotomies. Normal healing with no evidence of periosteotomy edema was seen in 17 patients at 6 weeks. Three patients showed evidence of reduced vascularity. In two of these, there were focal changes suggestive of subclinical ischemia. The other had gross signal changes in the osteotomy fragment suggestive of diffuse ischemia. The patients with focal changes were asymptomatic and had normal 6-month scans. The patient with diffuse changes complained of persistent groin pain, which resolved after 4 months. The 6-month scan showed some persistent vascular changes. The scan at 1 year showed complete resolution. The study suggests that Ganz osteotomy has minimal effect on the vascularity of the acetabular free fragment.

MRI of Failed Total Hip Replacement Caused by Abductor Muscle Avulsion

OBJECTIVE

Our purpose is to describe the use of MRI and associated metal artifact reduction techniques to detect abductor muscle avulsion from the greater trochanter, a complication unusual to the anterolateral approach for total hip replacement.

CONCLUSION

MRI facilitates the detection of abductor muscle avulsion in patients who have undergone the anterolateral approach during total hip replacement. MRI is considered a valuable diagnostic tool when this condition is suspected.

Sacral pseudotumor complicating iliac bone harvest: radiographic, CT and MRI appearances

We present the imaging appearances of a lytic pseudotumor in the right sacral ala presenting with referred pain to the right thigh. Subsequent imaging revealed the presence of a cystic lesion arising at the site of previous bone graft harvest; CT-guided aspiration yielded synovial fluid presumed to arise from the contiguous sacroiliac joint.

Sacral pseudotumor complicating iliac bone harvest: radiographic, CT and MRI appearances

We present the imaging appearances of a lytic pseudotumor in the right sacral ala presenting with referred pain to the right thigh. Subsequent imaging revealed the presence of a cystic lesion arising at the site of previous bone graft harvest; CT-guided aspiration yielded synovial fluid presumed to arise from the contiguous sacroiliac joint.

Analysis of surgical salvage after failure of primary therapy in rectal cancer: results from Intergroup Study 0114

PURPOSE

Intergroup Study 0114 was designed to study the effect of various chemotherapy regimens delivered after potentially curative surgical resection of T3, T4, and/or node-positive rectal cancer. A subset analysis was undertaken to investigate the prevalence and influence of salvage therapy among patients with recurrent disease.

PATIENTS AND METHODS

Adjuvant therapy consisted of two cycles of fluorouracil (FU)-based chemotherapy followed by pelvic irradiation with chemotherapy and two more cycles of chemotherapy after radiation therapy. A total of 1,792 patients were entered onto the study and 1,696 were assessable. After a median of 8.9 years of follow-up, 715 patients (42%) had disease recurrence, and an additional 10% died without evidence of disease. Five hundred patients with follow-up information available had a single organ or single site of first recurrence (73.5% of all recurrences).

RESULTS

A total of 171 patients (34% of those with a single organ or single site of recurrence) had a potentially curative resection of the metastatic or locally recurrent disease. Single-site first recurrences in the liver, lung, or pelvis occurred in 448 patients (90% of the single-site recurrences), with 159 (35%) of these undergoing surgical resection for attempted cure. Overall survival differed significantly between the resected and nonresected groups (P <.0001), with overall 5-year probabilities of.27 and.06, respectively. Controlling for worst performance status at the time of recurrence does not alter this relationship. Patients who underwent salvage surgery had significantly increased survival (P <.001) for each site.

CONCLUSION

Attempted surgical salvage of rectal cancer recurrence is performed commonly in the United States. The chance of a long-term cure with such intervention is approximately 27%.

AnthracnoseTracer: A Spatiotemporal Model for Simulating the Spread of Anthracnose in a Lupin Field

ABSTRACT A spatiotemporal model has been developed to simulate the spread of anthracnose, initiated by infected seed, in a lupin field. The model quantifies the loss of healthy growing points of lupin in all 1-m(2) subunits of a field throughout a growing season. The development of growing points is modeled as a function of temperature using a 1-day time step, and disease-induced compensatory growth is accounted for. Dispersal of spores is simulated explicitly using Monte Carlo techniques. Spread of spores occurs during rainfall events on a 1-h time step. The distance traveled by spores is partially dependent on wind speed and is generated by adding the values selected from half-Cauchy distributions. The direction of travel of the spores is influenced by wind direction. The model has been employed to produce a theoretical assessment of damage from disease in two environments at five levels of seed infection. It was calculated that in a susceptible lupin cultivar with a 0.01% initial seed infection, anthracnose would cause approximately 15% loss of healthy growing points in a high rainfall environment in Western Australia. In a low rainfall environment, similar damage would be unlikely even with a much higher (1%) level of seed infection.

A comparison of mitochondrial and nuclear DNA status in testicular sperm from fertile men and those with obstructive azoospermia

BACKGROUND

Mitochondria are vital to sperm as their motility powerhouses. They are also the only animal organelles with their own unique genome; encoding subunits for the complexes required for the electron transfer chain.

METHODS

A modified long PCR technique was used to study mitochondrial DNA (mtDNA) in ejaculated and testicular sperm samples from fertile men undergoing vasectomy (n = 11) and testicular sperm from men with obstructive azoospermia (n = 25). Nuclear DNA (nDNA) fragmentation was measured by an alkaline gel electrophoresis (comet) assay.

RESULTS

Wild-type mtDNA was detected in only 60% of fertile men's testicular sperm, 50% of their ejaculated sperm and 46% of testicular sperm from men with obstructive azoospermia. The incidence of mitochondrial deletions in testicular sperm of fertile and infertile men was not significantly different, but the mean size of the deletions was significantly less in testicular sperm from fertile men compared with men with obstructive azoospermia (P < 0.02). NDNA fragmentation in testicular sperm from fertile men and men with obstructive azoospermia was not significantly different.

CONCLUSION

Multiple mtDNA deletions are common in testicular and ejaculated sperm from both fertile and infertile men. However, in males with obstructive azoospermia, the mtDNA deletions in testicular sperm are of a larger scale.

Mitochondrial DNA deletions and nuclear DNA fragmentation in testicular and epididymal human sperm

BACKGROUND

There are still concerns about the safety of intracytoplasmic sperm injection (ICSI) due to its brief clinical record and lack of animal testing. Testicular and epididymal sperm are now used routinely for ICSI in patients with obstructive azoospermia. The use of such immature sperm compounds fears, since little is known of their mitochondrial and nuclear DNA quality.

METHODS

A modified long polymerase chain reaction (LPCR) was employed to study mitochondrial DNA (mtDNA) and a modified alkaline Comet assay to determine nuclear DNA (nDNA) fragmentation in testicular and epididymal sperm from men with obstructive azoospermia (n = 25) attending the Regional Fertility Centre.

RESULTS

Testicular sperm displayed significantly more wild-type mtDNA (45% of patients) than epididymal sperm (16% of patients). They also had a lower incidence of multiple deletions and smaller mtDNA fragments. Epididymal sperm harboured more large-scale deletions (P < 0.05). There was a strong correlation between nuclear DNA fragmentation, the number of mtDNA deletions (r = 0.48, r = 0.50, P < 0.001) and their size (r = 0.58, r = 0.60, P < 0.001) in both epididymal and testicular sperm.

CONCLUSION

This study suggests that mtDNA and nDNA of testicular sperm have fewer mutations and fragmentation than epididymal sperm and should be used in preference for ICSI in clinical treatment.

Issues in adolescent health: a challenge for nursing

The young people of today are the greatest investment we as adults have in our future. The care and nurturing we afford the adolescent is just as important as that which we afford to children or the elderly. Although most adolescents have a preoccupation with their bodies, they do not always engage in activities that will protect and develop them. Adolescents are often exposed to peer pressure, the effects of which may impact negatively on their behaviour and their health. Many adolescent health and behavioural issues evolve from developmental changes and can manifest in a confrontational attitude toward society, parents and others. They are hormonally 'fully charged', and their adolescent sexuality can have enormous effects on their future physical, psychosocial, moral and sexual development. Nurses have a pivotal role to play in ensuring children and adolescents learn the facts relating to the consequences of engaging in unhealthy behaviour and lifestyle. Nurses must also encourage parents to model and reinforce good health practices, such as serving balanced and nutritious meals at regular times and planning positive family activities. In this paper we review some of the salient issues in adolescent health today.

Adjuvant therapy in rectal cancer: analysis of stage, sex, and local control--final report of intergroup 0114

PURPOSE

The gastrointestinal Intergroup studied postoperative adjuvant chemotherapy and radiation therapy in patients with T3/4 and N+ rectal cancer after potentially curative surgery to try to improve chemotherapy and to determine the risk of systemic and local failure.

PATIENTS AND METHODS

All patients had a potentially curative surgical resection and were treated with two cycles of chemotherapy followed by chemoradiation therapy and two additional cycles of chemotherapy. Chemotherapy regimens were bolus fluorouracil (5-FU), 5-FU and leucovorin, 5-FU and levamisole, and 5-FU, leucovorin, and levamisole. Pelvic irradiation was given to a dose of 45 Gy to the whole pelvis and a boost to 50.4 to 54 Gy.

RESULTS

One thousand six hundred ninety-five patients were entered and fully assessable, with a median follow-up of 7.4 years. There was no difference in overall survival (OS) or disease-free survival (DFS) by drug regimen. DFS and OS decreased between years 5 and 7 (from 54% to 50% and 64% to 56%, respectively), although recurrence-free rates had only a small decrease. The local recurrence rate was 14% (9% in low-risk [T1 to N2+] and 18% in high-risk patients [T3N+, T4N]). Overall, 7-year survival rates were 70% and 45% for the low-risk and high-risk groups, respectively. Males had a poorer overall survival rate than females.

CONCLUSION

There is no advantage to leucovorin- or levamisole-containing regimens over bolus 5-FU alone in the adjuvant treatment of rectal cancer when combined with irradiation. Local and distant recurrence rates are still high, especially in T3N+ and T4 patients, even with full adjuvant chemoradiation therapy.

The effects of cryopreservation on sperm morphology, motility and mitochondrial function

BACKGROUND

The effects of cryoinjury were determined simultaneously on the mitochondrial function, motility, morphology and viability of ejaculated human sperm.

METHOD

Rhodamine 123 (R123) uptake (% of sperm) and stain intensity were used to determine sperm mitochondrial activity before and after cryopreservation from the semen of 50 men attending for infertility investigation. Morphology was assessed using Tygerberg's strict criteria and viability was assessed by eosin Y. Sperm motility was measured using computer-assisted semen analysis (CASA).

RESULTS

Freeze-thawing caused a 37% (P = 0.001) reduction in normal morphological forms of sperm. All CASA sperm motility parameters except amplitude of lateral head displacement were similarly reduced. R123 uptake and intensity within sperm mitochondria decreased by 36 and 47% respectively (both P = 0.001). In addition, there was a similar significant decrease (31%, P = 0.001) in the viability of the sperm.

CONCLUSIONS

Sperm morphology, motility, mitochondrial activities and viability are equally susceptible to cryopreservation-induced damage. R123 intensity is a novel and robust indicator of mitochondrial function before and after such trauma.

Atraumatic medial collateral ligament oedema in medial compartment knee osteoarthritis

OBJECTIVE

To describe and determine the prevalence of atraumatic medial collateral oedema identified in patients with medial compartment osteoarthritis.

DESIGN AND PATIENTS

Sixty patients, 30 patients with medial compartment knee osteoarthritis (Kellgren and Lawrence grade 2 to 4) and 30 age-matched patients with atraumatic knee pain without osteoarthritis, referred for MR imaging over a 2 year period were included in the study. In each case, severity of osteoarthritis was recorded on radiographs and correlated with the presence or absence of medial collateral ligament oedema at MR imaging.

RESULTS

Medial collateral oedema was identified in 27 of the 30 patients with osteoarthritis, of whom 14 had grade 1 oedema and 13 had grade 2 oedema compared with the presence of medial collateral ligament oedema (grade 1) in only two of the 30 control patients without osteoarthritis ( P<<0.0001).

CONCLUSION

Medial collateral oedema is common in patients with osteoarthritis in the absence of trauma. When identified, medial collateral ligament oedema should be considered to be a feature of osteoarthritis and should not be incorrectly attributed to an acute traumatic injury.

Establishing a Mutual Reality

Nursing stories are a vehicle for sharing the uniqueness of the nurse-patient relationship. In this article, a nurse-patient engagement within an acute mental health inpatient unit is described and viewed through various lenses. Consideration is given to literature on reflective thinking. Each lens lends itself to exploring the reflective thinking that occurred for the author. The author's personal perspective on an ethic of care is presented.