Stress response in infants undergoing cardiac surgery: a randomized study of fentanyl bolus, fentanyl infusion, and fentanyl-midazolam infusion

There have been significant changes in the management of neonates and infants undergoing cardiac surgery in the past decade. We have evaluated in this prospective, randomized, double-blinded study the effect of large-dose fentanyl anesthesia, with or without midazolam, on stress responses and outcome. Forty-five patients < 6 mo of age received bolus fentanyl (Group 1), fentanyl by continuous infusion (Group 2), or fentanyl-midazolam infusion (Group 3). Epinephrine, norepinephrine, cortisol, adrenocortical hormone, glucose, and lactate were measured after the induction (T1), after sternotomy (T2), 15 min after initiating cardiopulmonary bypass (T3), at the end of surgery (T4), and after 24 h in the intensive care unit (T5). Plasma fentanyl concentrations were obtained at all time points except at T5. Within each group epinephrine, norepinephrine, cortisol, glucose and lactate levels were significantly larger at T4 (P values < 0.01), but there were no differences among groups. Within groups, fentanyl levels were significantly larger in Groups 2 and 3 (P < 0.001) at T4, and among groups, the fentanyl level was larger only at T2 in Group 1 compared with Groups 2 and 3 (P < 0.006). There were no deaths or postoperative complications, and no significant differences in duration of mechanical ventilation or intensive care unit or hospital stay. Fentanyl dosing strategies, with or without midazolam, do not prevent a hormonal or metabolic stress response in infants undergoing cardiac surgery.

IMPLICATIONS

We demonstrated a significant endocrine stress response in infants with well compensated congenital cardiac disease undergoing cardiac surgery, but without adverse postoperative outcome. The use of large-dose fentanyl, with or without midazolam, with the intention of providing "stress free" anesthesia, does not appear to be an important determinant of early postoperative outcome.

Recovering filter-based microarray data for pathways analysis using a multipoint alignment strategy

The use of commercial microarrays is rapidly becoming the method of choice for profiling gene expression and assessing various disease states. Research Genetics has provided a series of biological and software tools to the research community for these analyses. The fidelity of data analysis using these tools is dependent on a series of well-defined reference control points in the array. During the course of our investigations, it became apparent that in some instances the reference control points that are required for analysis became lost in background noise. This effectively halted the analysis and the recovery of any information contained within that experiment. To recover this data and to increase analytical veracity, the simple strategy of superimposing a template of reference control points onto the experimental array was developed. The utility of this tool is established in this communication.

Extraosseous osteosarcoma of the penis

Osteosarcomas have been reported as arising in a number of extraosseous primary sites, most commonly in the retroperitoneum and the muscles of the thighs and limb girdles, but also in a variety of other organs. We present a case arising in the penis, which we believe to be only the fifth reported in the literature and the only documented long-term survivor. Careful histopathological analysis and surgical management remain of key importance in the management of all sarcomas arising in soft tissue.

Structured exercise improves physical functioning in women with stages I and II breast cancer: results of a randomized controlled trial

PURPOSE

Self-directed and supervised exercise were compared with usual care in a clinical trial designed to evaluate the effect of structured exercise on physical functioning and other dimensions of health-related quality of life in women with stages I and II breast cancer.

PATIENTS AND METHODS

One hundred twenty-three women with stages I and II breast cancer completed baseline evaluations of generic and disease- and site-specific health-related quality of life, aerobic capacity, and body weight. Participants were randomly allocated to one of three intervention groups: usual care (control group), self-directed exercise, or supervised exercise. Quality of life, aerobic capacity, and body weight measures were repeated at 26 weeks. The primary outcome was the change in the Short Form-36 physical functioning scale between baseline and 26 weeks.

RESULTS

Physical functioning in the control group decreased by 4.1 points, whereas it increased by 5.7 points and 2.2 points in the self-directed and supervised exercise groups, respectively (P =.04). Post hoc analysis showed a moderately large (and clinically important) difference between the self-directed and control groups (9.8 points; P =.01) and a more modest difference between the supervised and control groups (6.3 points; P =.09). No significant differences between groups were observed for changes in quality of life scores. In a secondary analysis of participants stratified by type of adjuvant therapy, supervised exercise improved aerobic capacity (+3.5 mL/kg/min; P =.01) and reduced body weight (-4.8 kg; P <.05) compared with usual care only in participants not receiving chemotherapy.

CONCLUSION

Physical exercise can blunt some of the negative side effects of breast cancer treatment, including reduced physical functioning. Self-directed exercise is an effective way to improve physical functioning compared with usual care. In participants not receiving chemotherapy, supervised exercise may increase aerobic capacity and reduce body weight compared with usual care.

Sarcoma arising adjacent to a total hip arthroplasty

We present the case of a 79-year-old woman who developed a high grade spindle cell sarcoma adjacent to total hip arthroplasty 13 years after the index operation. MRI scan appeared to show a direct communication between the tumour and intra medullary canal through a breach in the femoral cortex.

Spatial trypanosomosis management: from data-layers to decision making

The use of geographical information systems (GIS) in the management of African animal trypanosomosis in sub-Saharan Africa offers potential in assisting decisions on allocation of resources, prioritization of control areas, and planning and management of field operations. Here, Guy Hendrickx and colleagues review approaches being used to develop reliable data-layers and to incorporate these data into GIS models. They argue that techniques should be further refined to produce more-detailed data layers and to include a dynamic element, a problem rarely addressed until now.

Toward elimination of Haemophilus influenzae type B carriage and disease among high-risk American Indian children

OBJECTIVES

This report describes the epidemiology of Haemophilus influenzae type b (Hib) invasive disease and oropharyngeal colonization among Navajo and White Mountain Apache children younger than 7 years in an era of widespread immunization.

METHODS

We conducted active surveillance for invasive H influenzae disease from 1992 to 1999 and an oropharyngeal carriage study from 1997 to 1999. The predominant vaccine used was PedvaxHib.

RESULTS

The average annual incidence of invasive Hib disease among children younger than 24 months was 22 cases per 100,000. Of 381 children younger than 7 years, only 1 (0.3%; 95% confidence interval = 0.0%, 1.3%) was colonized with Hib; 370 (97%) had received 2 or more doses of Hib conjugate vaccine.

CONCLUSIONS

Among Navajo and White Mountain Apache children, Hib conjugate vaccines have led to a sustained reduction in invasive Hib disease and a reduction in oropharyngeal Hib carriage. The disease incidence among children younger than 24 months remains 20 times higher than in the general US population. Hib elimination will require additional characterization of colonization and disease in these high-risk populations.

Estimation of the indirect effect of Haemophilus influenzae type b conjugate vaccine in an American Indian population

BACKGROUND

Oropharyngeal carriage studies of Haemophilus influenzae type b (Hib) and the rapid drop in Hib invasive disease in countries with widespread Hib conjugate vaccine immunization programmes for infants have indicated there may be significant indirect effects (herd immunity) associated with these vaccines. Our goal was to quantify the magnitude of these effects in an American Indian population during its early years of Hib immunization.

METHODS

In a synthetic case-cohort study, we combined data from an efficacy trial, an immunization uptake records survey, and ongoing surveillance for Hib disease on the Navajo Nation from 1988 to 1992. Decline in the incidence of invasive Hib disease among children <2 years old was estimated via proportional hazards survival models as a function of individual immunization status and the proportion of immunized children in a community.

RESULTS

The predominant vaccine during the study period was Hib-OMPC (92% of immunizations). The effectiveness of receipt of at least one dose was 97.2%. Compared to communities with 0-20% coverage with at least one dose, residence in communities with 20-40% and 40-60% coverage was associated with risk reductions of 56.5% and 73.2%, respectively.

CONCLUSIONS

The results indicate substantial indirect effects of Hib-OMPC immunization may occur even at relatively low levels of immunization coverage. Countries that implement Hib immunization programmes may receive greater benefits at the community level than those due to the direct protection conferred to the individual through vaccination.

Estimation of body fat from anthropometry and bioelectrical impedance in Native American children

OBJECTIVE

Obesity, as measured by body mass index, is highly prevalent in Native American children, yet there are no valid equations to estimate total body fatness for this population. This study was designed to develop equations to estimate percentage body fat from anthropometry and bioelectrical impedance as a critical part of Pathways, a multi-site study of primary prevention of obesity in Native American children.

DESIGN

Percentage fat was estimated from deuterium oxide dilution in 98 Native American children (Pima/Maricopa, Tohono O'odham and White Mountain Apache tribes) between 8 and 11 y of age. The mean fat content (38.4%+/-8. 1%) was calculated assuming the water content of the fat-free body was 76%. Initial independent variables were height, weight, waist circumference, six skinfolds and whole-body resistance and reactance from bioelectrical impedance (BIA).

RESULTS

Using all-possible-subsets regressions with the Mallows C (p) criterion, and with age and sex included in each regression model, waist circumference, calf and biceps skinfolds contributed least to the multiple regression analysis. The combination of weight, two skinfolds (any two out of the four best: triceps, suprailiac, subscapular and abdomen) and bioelectrical impedance variables provided excellent predictability. Equations without BIA variables yielded r2 almost as high as those with BIA variables. The recommended equation predicts percentage fat with a root mean square error=3.2% fat and an adjusted r2=0.840.

CONCLUSION

The combination of anthropometry and BIA variables can be used to estimate total body fat in field studies of Native American children. The derived equation yields considerably higher percentage fat values than other skinfold equations in children.

Immunogenicity of a heptavalent pneumococcal conjugate vaccine in Apache and Navajo Indian, Alaska native, and non-native American children aged <2 years

High rates of invasive pneumococcal disease have been described among infants living in various Native American communities. In this study, we evaluated the immunogenicity of a 7-valent pneumococcal vaccine consisting of serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F covalently linked to the outer membrane protein complex of Neisseria meningitidis in Apache and Navajo Indian, Alaska Native, and non-Native American children. The vaccine was administered at ages 2, 4, and 6 months; a booster dose was given at age 15 months. Levels of serotype-specific immunoglobulin G (IgG) were measured by a standardized enzyme-linked immunosorbent assay. The responses after 3 primary doses of vaccine were similar in all 3 groups of children, except for those to serotypes 14 and 23F. One month after the booster dose, geometric mean concentrations (GMCs) of serotype-specific IgG antibodies increased significantly in all 3 groups of children, compared with GMCs of IgG antibodies to pneumococcal serotypes before the booster dose.

Impact of duration in a cardiac rehabilitation program on coronary risk profile and health-related quality of life outcomes

BACKGROUND

Optimal cardiac rehabilitation (CR) program length and the time course of changes in relevant outcomes are unknown. The purpose of this study was to assess changes in coronary risk factors and health-related quality of life (HRQoL) after 3 months and 6 months of cardiac rehabilitation.

METHODS

This is an observational study of a cohort of 126 consecutive cardiac rehabilitation patients who completed baseline, 3-month, and 6-month evaluations of coronary risk factors and HRQoL. The coronary risk factors included lipid profile, blood pressure, body mass index (BMI), and physical activity level. HRQoL was assessed using the Short Form-36 questionnaire (SF-36) comprising eight health concepts and two component scales (physical [PCS] and mental [MCS]).

RESULTS

There was significant improvement in all coronary risk factors and HRQoL measures, except BMI, over the 6-month period (P < 0.001). Significant changes in blood pressure, physical activity, PCS, and high-density lipoprotein cholesterol (HDL-C) were apparent at 3 months, and no additional significant changes in these variables occurred between 3 and 6 months. For total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and MCS, significant change was achieved between 3 and 6 months but not between baseline and 3 months.

CONCLUSIONS

Secondary prevention and HRQoL outcomes improved at variable rates. Physical activity and physical function peaked at 3 months and were maintained at program completion. Significant improvements occurred in mental health recovery beyond the traditional 12-week CR program length. Outcomes furthest from normative values showed the most rapid improvement. Optimal duration of participation may vary according to the outcome of interest.

A phase II trial of gallium nitrate in patients with androgen-metastatic prostate cancer

INTRODUCTION

Due to in vitro data suggesting antitumor activity with gallium nitrate, we sought to evaluate the safety and activity in patients with androgen-independent prostate cancer.

METHOD

Patients were eligible for this study if they had an ECOG performance status of < or = 2, stage D2 metastatic prostate cancer that was progressing following combined androgen ablation (medical or surgical castration plus antiandrogen) and had failed antiandrogen withdrawal. Therapy consisted of gallium nitrate (200 mg/m(2)/day) as a continuous infusion for 7 days, administered every 21 days, with hydration (100 ml/m(2)/h). Individuals that had previously received suramin were treated at a dose of 150 mg/m(2)/day of gallium nitrate.

RESULTS

Eight patients were enrolled: 4 patients at the 200 mg/m(2)/day dose level and 4 patients at the lower dosage (150 mg/m(2)/day). One of 8 patients had a >75% decline in prostate-specific antigen (PSA), 3 patients had stable PSA values for 17, 18 and 22 weeks, and 4 patients had progression by PSA (>50% increase over baseline). Anemia requiring transfusion occurred in 5 of 8 patients (63%). Two patients (25%) developed grade 4 toxicity: 1 patient developed complete blindness with partial reversal over 12 months, and another patient had pulmonary infiltrates, hypoxemia, and fever. Serious adverse events were not correlated to prior suramin exposure, or gallium plasma concentrations (total or free), but appeared to be related to cumulative cycles of gallium nitrate. Remaining adverse events were grade 1 or 2. No patients developed renal or neurological toxicity.

CONCLUSION

This trial was prematurely terminated because repeated administration of gallium nitrate was poorly tolerated in an elderly population with androgen-independent prostate cancer. Gallium had modest clinical activity in this disease.

Prosthetic reconstruction of the femur for primary bone sarcoma

The survival of patients and implants, complications and functional outcome were reviewed in 25 consecutive femoral endoprosthetic reconstructions for treatment of primary bone sarcoma. The diagnosis was chondrosarcoma in 11, osteosarcoma in 10, MFH in 3 and Ewing's tumour in 1. Median follow up was 64 months (34 to 219) and median age at operation was 29 years (10 to 70). Twelve remained disease free at review. One had amputation for local recurrence and another was alive with metastases. 11 patients died at a median of 13 months (5 to 128); 8 from metastatic disease and 3 from other causes. Four implants were revised, at a median of 95 months (53 to 136); two for fractures of the stem and two for aseptic loosening. Three implants had radiological evidence of loosening at a median of 43 months (34 to 49). Fourteen patients had significant complications. The median functional score using the Musculoskeletal Tumour Society system was 68%. In our experience, prosthetic reconstruction of the femur does not compromise survival, although there is a significant complication rate.

Preferential pulmonary retention of (S)-albuterol after inhalation of racemic albuterol

The (R)-enantiomer of racemic albuterol produces bronchodilation, whereas the (S)-enantiomer may increase airway reactivity. After oral or intravenous administration of racemic albuterol, the (R)- enantiomer is metabolized several times faster than the (S)-enantiomer; however, enantiomer disposition after inhaling racemic albuterol with a metered-dose inhaler (MDI) is not known. Accordingly, 10 healthy subjects inhaled racemic albuterol with a MDI alone and with a MDI and holding chamber. We measured plasma levels of unchanged (R)- and (S)-albuterol before and up to 4 h after inhalation of racemic albuterol, and determined the unchanged R/S ratio in urine before and at 0.5, 4, 8, and 24 h later. The disposition of albuterol's enantiomers with a MDI and holding chamber was similar to that with a MDI alone. The area under the curve (AUC) of the plasma levels over time was significantly lower for the (S)- than for the (R)-enantiomer-395.5 +/- 141.0 (SE) versus 882.7 +/- 126.4 ng. ml(-)(1). min (p < 0.05)-indicating preferential retention of (S)-albuterol in the lung. The R/S ratio in urine at 0. 5 h after albuterol was > 1, reflecting the higher plasma level of the (R)-enantiomer. In conclusion, preferential retention of the (S)- compared with the (R)-enantiomer in the lung could lead to accumulation of the (S)-enantiomer after long-term use of racemic albuterol.

Radionuclides in seals and porpoises in the coastal waters around the UK

It has been suggested that marine predators be assessed for biologically relevant contamination levels because of their trophic position. Accordingly, in studying radioactive contamination in the marine environment around the UK, tissues from seals and porpoises have been chosen. Liver and muscle tissue from dead seals and porpoises found stranded around the UK coast have been analysed for the following radionuclides: 134Cs, 137Cs, 238Pu, 239Pu + 240Pu. Multifactor analysis of variance indicated that, for radiocaesium, there was no significant difference for harbour seals, grey seals or porpoises in terms of species or gender; however, the tissue activity concentration increased with body weight and decreased with distance from Sellafield, the major nuclear reprocessing plant in the UK. The levels of radiocaesium in muscle were higher than those in liver, while there appeared to be a concentration factor of approximately 3-4 for muscle radiocaesium when compared to radiocaesium levels reported for fish, the main food source of the marine mammals under study. Approximate radiation dose calculations indicated that the average dose from radiocaesium was less than 10% of the dose from the naturally occurring radioisotope of potassium, 40K. The highest tissue activity concentration for plutonium of 0.037 Bq/kg (239Pu + 240Pu) was detected in a grey seal stranded at Rathlin Island in Northern Ireland. Calculation of approximate radiation doses from plutonium contamination showed that, as with radiocaesium, the average dose was small compared with that from 40K. In summary, the radiocaesium contamination in seals and porpoises decreased with distance from Sellafield indicating that the BNF plc processing plant was the major source of the contamination. The marine mammals concentrated radiocaesium from their environment by a factor of 300 relative to the concentration in seawater indicating the value of using marine mammal tissue to measure radiocaesium contamination in the marine environment. The maximum radiation dose to the marine mammals from radiocaesium was higher than doses previously assessed for critical groups of humans living near Sellafield, while the maximum dose from plutonium was comparable to the doses for humans.

Oncology Rehabilitation Program at the Ottawa Regional Cancer Centre: program description

The Ottawa Regional Cancer Centre offers an Oncology Rehabilitation Program to patients with cancer. Between January 1997 and December 1998, 254 patients with cancer participated in the program. This paper describes the program and its participants. The program's strengths, limitations and future directions are also discussed.

Exposition of a family of RNA m(5)C methyltransferases from searching genomic and proteomic sequences

The Escherichia coli fmu gene product has recently been determined to be the 16S rRNA m(5)C 967 methyltransferase. As such, Fmu represents the first protein identified as an S -adenosyl-L-methionine (AdoMet)- dependent RNA m(5)C methyltransferase whose amino acid sequence is known. Using the amino acid sequence of Fmu as an initial probe in an iterative search of completed DNA sequence databases, 27 homologous ORF products were identified as probable RNA m(5)C methyltransferases. Further analysis of sequences in undeposited genomic sequencing data and EST databases yielded more than 30 additional homologs. These putative RNA m(5)C methyltransferases are grouped into eight subfamilies, some of which are predicted to consist of direct genetic counterparts, or orthologs. The enzymes proposed to be RNA m(5)C methyltransferases have sequence motifs closely related to signature sequences found in the well-studied DNA m(5)C methyltransferases and other AdoMet-dependent methyltransferases. Structure-function correlates in the known AdoMet methyltransferases support the assignment of this family as RNA m(5)C methyltransferases.

Postoperative ionizing radiation in the management of heterotopic bone formation in the temporomandibular joint

PURPOSE

The purpose of this study was to evaluate the effectiveness and possible morbidity of postoperative low-dose ionizing radiation in the treatment of recurrent temporomandibular joint ankylosis.

PATIENTS AND METHODS

From 1987 to 1996, 14 patients with a history of multiple surgeries and recurrent temporomandibular joint ankylosis were treated postsurgically with radiation therapy. The treatment regimen initially selected was a postoperative dose of 2,000 rads in 10 fractions. Subsequently, 1,000 rads was found to be as effective. The success of therapy was assessed by means of serial radiographic studies and clinical examination, with the longest follow-up being 9 years.

RESULTS

Thirteen of 14 patients (93%) showed radiographic evidence of decreased heterotopic bone formation. No patient redeveloped ankylosis. A transient xerostomia appeared to be the only significant complication.

CONCLUSION

Low-dose ionizing radiation therapy, consisting of 1,000 rads given in five fractionated doses soon after surgical treatment, reduces recurrent heterotopic bone formation and appears to be a useful adjunct to the surgical management of temporomandibular joint ankylosis.

The measurement of premenstrual mood symptoms

INTRODUCTION

To aid in the diagnosis and management of premenstrual syndromes, dozens of symptom measurement instruments have been created and several methods for classifying clinically important change in symptoms have been defined. While the diagnosis of premenstrual dysphoric disorder (PMDD) has become standardized through the application of research criteria, consensus amongst investigators as to the instruments best able to confirm the diagnosis and measure treatment effects has yet to be reached.

OBJECTIVE

To determine the performance and inter-correlations of three prospective symptom rating scales used to establish severity of premenstrual mood symptoms and measure efficacy during a treatment trial for premenstrual dysphoria.

METHODS

Single item visual analogue scales (VASs) for irritability, tension, depression and mood swings were used in combination with the Premenstrual Tension Syndrome Observer (PMTS-O) and Self-Rating (PMTS-SR) scales to measure the severity of premenstrual mood symptoms at baseline and during treatment.

RESULTS

Premenstrual mood symptoms as measured by VASs significantly correlated with PMTS-0 and PMTS-SR scale scores (range 0.70 to 0.82, P < 0.001). All scales were sensitive to premenstrual symptom worsening (which is a required characteristic of this disorder) and revealed differences in effects of treatment on premenstrual mood symptoms (P < 0.001).

CONCLUSIONS

VASs in combination with the PMTS-O are low in burden to the client, reliable, valid and sensitive to change. In light of the current debates regarding instruments most appropriate for the classification and measurement of treatment effects in women diagnosed with premenstrual dysphoria, further refinement of these scales is warranted.