Lignocaine plasma levels following topical gel application in laparoscopic and hysteroscopic procedures

The study aim was to determine plasma lignocaine concentrations resulting from topical application of a newly formulated, sterile two-pack lignocaine gel in laparoscopic and hysteroscopic procedures. This was an open label single-centre study in which six female patients underwent laparoscopy and six underwent hysteroscopy. One venous blood sample was extracted pre-gel application, followed by 10 samples over a 24 hour period following application. Samples were centrifuged, stored at -20°C and subsequently analysed for lignocaine and its metabolite, monoethyl-glycinexylidide. Application of gel in doses between 2.7 and 5.8 mg/kg of lignocaine resulted in a maximum plasma concentration in any patient of 1520 ng/ml lignocaine and 240 ng/ml monoethyl-glycinexylidide. These maximum concentrations were recorded in a patient undergoing a laparoscopic procedure and patients undergoing hysteroscopic procedures all recorded lower maximum concentrations compared with patients undergoing laparoscopy; the maximum observed concentrations in a patient having a hysteroscopy were 420 ng/ml lignocaine and 56 ng/ml of monoethyl-glycinexylidide.A new sterile two-pack topical lignocaine gel, applied at the end of laparoscopic and hysteroscopic procedures in doses up to 5.84 mg/kg, resulted in plasma lignocaine levels below those known to have the potential to cause central nervous system toxicity.

Short-term metabolic and cardiovascular effects of metformin in markedly obese adolescents with normal glucose tolerance

OBJECTIVE

Although metformin (MET) is an insulin sensitizer currently used as an adjunct to the treatment of some of the complications of childhood obesity besides type 2 diabetes mellitus, few studies have comprehensively examined its metabolic and clinical effects in obese children with normal glucose tolerance (NGT).

METHODS

We therefore conducted a 4-month double-blind clinical trial in 28 obese [mean body mass index (BMI): 40.3 +/- 5.7 kg/m(2)], insulin-resistant [homeostasis model assessment - insulin resistance: 7.6 +/- 2.8 and whole body insulin sensitivity index (WBISI): 1.5 +/- 0.7] adolescents (age 15.0 +/- 1.3 yr) randomized to MET (n = 15, dose 1500 mg daily) or placebo (n = 13).

RESULTS

The treatment with MET was well tolerated. MET treatment was associated with a decreased BMI (p = 0.02) as well as with a reduction in subcutaneous fat (p = 0.03), particularly the deep subcutaneous fat (p = 0.04) as assessed by magnetic resonance imaging. Postintervention, the MET group had a 35% improvement in insulin sensitivity (WBISI) compared with the placebo group (p = 0.008). However, significance was lost with adjustments for differences in baseline insulin sensitivity (p = 0.09). While there was no change in inflammatory cytokines or lipid parameters, cardiovascular function as assessed by heart rate recovery after exercise improved with MET and worsened in placebo (p = 0.03).

CONCLUSION

Short-term use of MET is well tolerated by obese children with NGT and has a beneficial effect on BMI and autonomic control of the heart as well as a trend toward improved insulin sensitivity. Thus, long-term treatment with MET may provide a means to ameliorate the cardio-metabolic consequences of adolescent obesity.

Selective corticosteroid and calcineurin-inhibitor withdrawal after pancreas-kidney transplantation utilizing thymoglobulin induction and sirolimus maintenance therapy

Of 25 simultaneous pancreas-kidney transplant (SPK) recipients treated with thymoglobulin induction, sirolimus and reduced-dose cyclosporine (CsA), 18 low-immune responders (non-African-Americans, PRA < 30%) were withdrawn from prednisone on post-transplant day 5, whereas seven high-immune responders continued on prednisone. Most high- and low-immune responder recipients were converted from CsA to mycophenolic acid (MPA) at six months post-transplantation. At a mean follow-up of 28 +/- 10 months, two pancreas grafts were lost to pancreatitis. There were no patient or kidney graft losses, but one acute rejection episode. At 28 +/- 11 months, all 18 low-responder recipients remain steroid-free. Twenty recipients (14 low and six high-immune responders) were converted from CsA to MPA. During conversion, immune response was monitored by Flow-PRA and T-cell stimulation (Cylex) assays. Nineteen of 20 recipients displayed a post-conversion PRA of 0%, whereas one highly sensitized patient expressed a post-conversion PRA of 67%. Fifty-eight percent of individual T-cell stimulation scores were in the hypo-responsive range. Twelve of 18 low-immune responders are both steroid and CsA-free at a mean follow-up of 17 +/- 13 months, whereas five of seven high-immune responders remain CsA-free at a mean follow-up of 11 +/- 10 months. These data suggest that thymoglobulin induction with combined sirolimus and CsA maintenance therapy permits immunosuppression minimization in selected SPK recipients.

An in vivo model for studying adherence of intestinal pathogens

A new method for preparing an isolated colonic loop in a living rabbit is described. The loop with its intact neurovascular supply can be used as as a "living test tube" to study the adherence of microorganisms to intestinal mucosa. Moreover, the clear colonic mucus produced by the loop can be used to study its physiochemical nature and protecting properties in health and disease.

The Importance of Correct Norms in Blood Volume Measurement

Accurate individual norms are required for blood volume measurement to be useful in a clinical setting. The primary physiological determinant of normal blood volume is body composition. Norms have been developed based on weight and body surface area, but these have systematic errors arising from variations in body composition or body size. The only norm that specifically estimates body composition uses deviation from ideal weight. A clinically useful norm must also include a normal range that is sufficiently sensitive and specific. The ultimate test of a norm's effectiveness is how it relates to known physiological factors or outcomes in a clinical or research setting. When tested in relation to outcome results from previously published clinical studies, norms utilizing deviation from ideal weight provide the most accurate categorization of blood volume status.

Racial/ethnic differences in adequacy of information and peer support for women with breast cancer

9085

Background: Existing disparities in quality of care for women with breast cancer suggest the need to explore the adequacy of information and care support provided to patients. This study investigated whether racial/ethnic variation existed in receipt and usefulness of cancer-related information and availability of peer support. Methods: 2,030 women diagnosed with non-metastatic breast cancer and reported to the Los Angeles County, Surveillance Epidemiologic and End Results registry between 8/05–5/06, were identified and mailed a survey shortly after initial treatment. Latina and African American (AA) women were oversampled. Outcomes included self-reported receipt and perceived usefulness of treatment-related (recovery from surgery, radiation, chemotherapy) and survivorship-related (sexual functioning, relationships, nutrition, anxiety) information and experiences with other women with breast cancer. We report results on a 50% respondent sample (N=742) that will be updated based on a final sample of 1,400 women (projected response rate, 72%). Results: More women received information and found it useful regarding treatment than survivorship issues. After adjusting for age and education, a higher percentage of Latina women, compared to white and AA women, desired more information on treatment-related issues and survivorship-related issues (p<.01). A higher percentage of Latina women also reported having no contact with other women with breast cancer, either through the health care system or a family/friend (p<.001), and reported a desire for more contact as compared to white or AA women (42%, vs. 15% and 29%, respectively). Overall, women rated the benefit of talking to other women high, particularly in helping with emotional issues and few endorsed potentially negative consequences. Conclusions: Women with breast cancer expressed the need for more useful information and care support, especially about managing survivorship concerns. Particular focus is warranted with Latina women to provide desired information and greater opportunities for peer contact.

No significant financial relationships to disclose.

The effect of diet on endothelial function

Endothelial dysfunction is an early precursor to atherosclerosis. Lifestyle interventions, including diet, have been shown to affect endothelial function. High-fat diets have been shown to impair endothelial function, and diets such as the Mediterranean diet have been associated with improved endothelial function. This review discusses the effects of diet, dietary supplements such as folic acid, polyphenols, and antioxidant vitamins on endothelial function. We provide a summary of the current data linking diet with endothelial function and explore controversies within this field.

Modulation of ERK 1/2 and p38 MAPK signaling pathways by ATP in osteoblasts: involvement of mechanical stress-activated calcium influx, PKC and Src activation

There is evidence that extracellular nucleotides, acting through multiple P2 receptors, may play an important role in the regulation of bone metabolism by activating intracellular signaling cascades. We have studied the modulation of mitogen-activated protein kinase (MAPK) signaling pathways and its relationship to changes in intracellular calcium concentration ([Ca(2+)](i)) induced by ATP in ROS-A 17/2.8 osteoblastic cells. ATP and UTP (10 microM) increased [Ca(2+)](i) by cation release from intracellular stores. We have found that when the cells are subsequently subjected to mechanical stress (medium perturbation), a transient calcium influx occurs. This mechanical stress-activated calcium influx (MSACI) was not observed after ADP stimulation, indicating that P2Y(2) receptor activation is required for MSACI. In addition, ERK 1/2 and p38 MAPK were activated by ATP in a dose- and time-dependent manner. This activation was almost completely blocked using neomycin (2.5mM), an inhibitor of phosphoinositide-phospholipase C (PI-PLC), Ro 318220 (1 microM), a protein kinase C (PKC) inhibitor, and PP1 (50 microM), a potent and selective inhibitor of the Src-family tyrosine kinases. Ca(2+)-free extracellular medium (containing 0.5mM EGTA) and the use of gadolinium (5 microM), which suppressed MSACI, prevented ERK 1/2 and p38 phosphorylation by ATP. Altogether, these results represent the first evidence to date suggesting that P2Y(2) receptor stimulation by ATP in osteoblasts sensitizes mechanical stress activated calcium channels leading to calcium influx and a fast activation of the ERK 1/2 and p38 MAPK pathways. This effect also involves upstream mediators such as PI-PLC, PKC and Src family kinases.

Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference)

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.

A Pilot Study of Immunosuppression Minimization After Pancreas-Kidney Transplantation Utilizing Thymoglobulin Induction and Sirolimus Maintenance Therapy

AIMS

To determine outcomes utilizing thymoglobulin and sirolimus immunosuppression, with early steroid withdrawal in low-immune responder pancreas-kidney (SPK) recipients, and conversion from cyclosporine (CsA) to mycophenolic acid (MPA) in all recipients at 6 months posttransplantation.

METHODS

SPK recipients received thymoglobulin, sirolimus, and reduced-dose CsA immunosuppression. Low immune responders (non-African-Americans with a pretransplant PRA < 30%) were withdrawn from prednisone on posttransplant day 5 and high immune responders were continued on prednisone. All recipients were converted from CsA to MPA at 6 months posttransplantation. During conversion, recipient immune response was monitored by flow PRA and a T-cell stimulation assay (Cylex).

RESULTS

With a mean follow-up of 9 +/- 4 months, one pancreas was lost to pancreatitis, with no patient or kidney losses and no acute rejection episodes. All eight low immune responder patients were steroid-free at 9 +/- 5 months posttransplantation. Seven patients (five low and two high immune responders) with at least 6-month follow-up were converted from CsA to MPA. One high immune responder with a pretransplant PRA of 43% remained with a PRA of 53% +/- 2% postconversion. The second high immune responder had a pretransplant PRA of 34% and a postconversion PRA of 0%. The five low immune responders had a mean pretransplant PRA of 16% +/- 15% and a postconversion PRA of 0% (P < .01). The Cylex assay resulted in 67% low responsiveness for both high and low immune responders.

CONCLUSION

Thymoglobulin induction with sirolimus maintenance therapy permitted immunosuppression minimization in selected pancreas transplant recipients. Posttransplant evaluation revealed a diminished (regulated) immune response in six of seven patients.