Potential Airborne Asbestos Exposure and Risk Associated with the Historical Use of Cosmetic Talcum Powder Products

Over time, concerns have been raised regarding the potential for human exposure and risk from asbestos in cosmetic-talc-containing consumer products. In 1985, the U.S. Food and Drug Administration (FDA) conducted a risk assessment evaluating the potential inhalation asbestos exposure associated with the cosmetic talc consumer use scenario of powdering an infant during diapering, and found that risks were below levels associated with background asbestos exposures and risk. However, given the scope and age of the FDA's assessment, it was unknown whether the agency's conclusions remained relevant to current risk assessment practices, talc application scenarios, and exposure data. This analysis updates the previous FDA assessment by incorporating the current published exposure literature associated with consumer use of talcum powder and using the current U.S. Environmental Protection Agency's (EPA) nonoccupational asbestos risk assessment approach to estimate potential cumulative asbestos exposure and risk for four use scenarios: (1) infant exposure during diapering; (2) adult exposure from infant diapering; (3) adult exposure from face powdering; and (4) adult exposure from body powdering. The estimated range of cumulative asbestos exposure potential for all scenarios (assuming an asbestos content of 0.1%) ranged from 0.0000021 to 0.0096 f/cc-yr and resulted in risk estimates that were within or below EPA's acceptable target risk levels. Consistent with the original FDA findings, exposure and corresponding health risk in this range were orders of magnitude below upper-bound estimates of cumulative asbestos exposure and risk at ambient levels, which have not been associated with increased incidence of asbestos-related disease.

Seasonal changes in tissue-water relations for eight species of ferns during historic drought in California

PREMISE OF THE STUDY

California experienced severe drought between 2012 and 2016. During this period, we compared seasonal changes in tissue-water relations among eight fern species in the Santa Monica Mountains of southern California to elucidate differential mechanisms of drought survival and physiological performance during extreme water deficits.

METHODS

We monitored seasonal changes in water potential (Ψmd) and dark-adapted chlorophyll fluorescence (Fv/Fm), assessed tissue-water relations including osmotic potential at saturation and the turgor loss point (Ψπ, sat and Ψπ, tlp), and measured, for two evergreen species, xylem-specific and leaf-specific hydraulic conductivity (Ks and Kl) and vulnerability of stem xylem to water stress-induced embolism (water potential at 50% loss hydraulic conductivity, Ψ50).

KEY RESULTS

Species grew in either riparian or chaparral understory. The five chaparral species had a wider range of seasonal water potentials, root depths, and frond phenological traits, including one evergreen, two summer-deciduous, and two desiccation-tolerant (resurrection) species. Evergreen species were especially diverse, with an evergreen riparian species maintaining seasonal water potentials above -1.3 MPa, while an evergreen chaparral species had seasonal water potentials below -8 MPa. In those two species the Ψ50 values were -2.5 MPa and -4.3 MPa, respectively.

CONCLUSIONS

Observed differences in physiological performance among eight fern species reflected niche partitioning in water utilization and habitat preference associated with distinct phenological traits. We predict differential survival among fern species as future drought events in California intensify, with desiccation-tolerant resurrection ferns being the most resistant.

Occupational exposure to benzene at the ExxonMobil refinery in Baytown, TX (1978-2006)

Although occupational benzene exposure of refinery workers has been studied for decades, no extensive analysis of historical industrial hygiene data has been performed focusing on airborne concentrations at specific refineries and tasks. This study characterizes benzene exposures at the ExxonMobil Baytown, TX, refinery from 1978 to 2006 to understand the variability in workers' exposures over time and during different job tasks. Exposures were grouped by operational status, job title, and tasks. More than 9000 industrial hygiene air samples were evaluated; approximately 4000 non-task (> 3 h) and 1000 task-related (< 3 h) personal samples were considered. Each sample was assigned to one of 27 job titles, 29 work areas, and 16 task bins (when applicable). Process technicians were sampled most frequently, resulting in the following mean benzene concentrations by area: hydrofiner (n=245, mean=1.3 p.p.m.), oil movements (n=286, mean=0.23 p.p.m.), reformer (n=575, mean=0.10 p.p.m.), tank farm (n=9, mean=0.65 p.p.m.), waste treatment (n=446, mean=0.13 p.p.m.), and other areas (n=460, mean=0.062 p.p.m.). The most frequently sampled task was sample collection (n=218, mean=0.40 p.p.m.). Job title and area did not significantly impact task-related exposures. Airborne concentrations were significantly lower after 1990 than before 1990. Results of this task-focused study may be useful when analyzing benzene exposures at other refineries.

Benzene exposure in refinery workers: ExxonMobil Joliet, Illinois, USA (1977-2006)

While petroleum industry studies have indicated low benzene exposure potential for refinery workers, most provide limited data for assessing job or task-related benzene exposures. This study characterizes job and task-specific airborne benzene concentrations and variability over time for the ExxonMobil refinery in Joliet, Illinois from 1977 to 2006. A database of 2289 industrial hygiene air samples, including 1145 non-task (≥180 min) personal samples and 480 task-related (<180 min) personal samples, were analyzed. Samples were grouped by operational status, job, and task. Benzene concentrations were determined for each job category and task bin, with additional analyses conducted to determine whether benzene concentrations changed over time. The results indicate that the benzene concentrations for non-task and task samples were relatively low. For all non-task samples, the arithmetic mean benzene concentration was 0.12 part per million (ppm). The most frequently sampled workers (process technicians during routine operations) had an arithmetic mean benzene concentration of 0.038 ppm. The most frequently sampled task bin (blinding and breaking) had an arithmetic mean benzene concentration of 1.0 ppm. This study provides benzene air concentration data that can be used in combination with job histories to reconstruct historical benzene exposures for workers at the Joliet Refinery over the past 30 years.

The transverse occipital ligament: anatomy and potential functional significance

BACKGROUND

Knowledge of the anatomy of ligaments that bind the craniocervical junction is important for treating patients with lesions of this region. Although the anatomy and function of these ligaments have been well described, those of the transverse occipital ligament (TOL) have remained enigmatic.

OBJECTIVE

To describe the anatomy and functions of the transverse occipital ligament.

METHODS

Via a posterior approach, 9 cadaveric specimens underwent dissection of the craniocervical junction with special attention to the presence and anatomy of the TOL.

RESULTS

The TOL was identified in 77.8% of the specimens. The ligament was found to be rectangular with fibers running horizontally between the lateral aspects of the foramen magnum. The attachment of each ligament near the occipital condyle was consistent, and each ligament was found superior to the transverse portion of the cruciform ligament and inserted just posterior to the lateral attachment sites of the alar ligaments. The average width, length, and thickness of the TOL was 0.34, 1.94, and 0.13 cm, respectively. The TOL in some specimens also had connections to the alar and transverse ligaments.

CONCLUSION

The TOL was found in the majority of our specimens. The possible functions of this ligament when attached to the alar ligaments include providing additional support to these structures in stabilizing lateral bending, flexion, and axial rotation of the head. Knowledge of this ligament may aid in further understanding craniocervical stability and help in differentiating normal from pathology via imaging modalities.

Occupational exposure to benzene at the ExxonMobil refinery at Baton Rouge, Louisiana (1977-2005)

Because crude oil contains up to 3% benzene and there is an association between high chronic exposure to appreciable concentrations of benzene and acute myelogenous leukemia, exposure of refinery workers has been studied for many years. To date, no extensive industrial hygiene exposure analyses for historical benzene exposure have been performed, and none have focused on the airborne concentrations in the workplace at specific refineries or for specific tasks. In this study, the authors evaluated the airborne concentrations of benzene and their variability over time at the ExxonMobil refinery in Baton Rouge between 1977 and 2005. Refinery workers were categorized into 117 worker groups using company job descriptions. These 117 groups were further collapsed into 25 job categories based on similarity of measured exposure results. Results of 5289 personal air samples are included in this analysis; 3403 were considered nontask (>or= 180 min) personal samples, and 830 were considered task-related (< 180 min) personal samples; the remainder did not fit in either category. In general, nontask personal air samples indicated that exposures of the past 30 years were generally below the occupational exposure limit of 1 ppm, but there was only a small, decreasing temporal trend in the concentrations. The job sampled most frequently during routine operations was process technician and, as broken down by area, resulted in the following mean benzene concentrations: analyzers (mean = 0.12 ppm), coker (mean = 0.013 ppm), hydrofiner (mean = 0.0054 ppm), lube blending and storage (mean = 0.010 ppm), waste treatment (mean = 0.092 ppm), and all other areas (mean = 0.055 ppm). Task-based samples indicated that the highest exposures resulted from the sampling tasks, specifically from those performed on process materials; in general, though, even these tasks had concentrations well below the STEL of 5 ppm. The most frequently sampled task was gauging (mean = 0.12 ppm). Task-related exposures were also similar across job categories for a given task, with a few exceptions. This study thus provides a task-focused analysis for occupational exposure to benzene during refinery operations, which can be insightful for understanding exposures at this refinery and perhaps others operated since about 1975.

Anatomy of the reflected ligament of the inguinal region

BACKGROUND

There is a paucity in the literature regarding the reflected ligament. Therefore, the present study was performed in order to further elucidate this anatomy.

MATERIAL AND METHODS

Eighteen formalin-fixed adult cadavers (35 sides) underwent dissection of the medial inguinal region. The reflected ligament was observed for and when identified, its dimensions were measured.

RESULTS

83% of sides were found to have a reflected ligament. These were identified in 16 male and 13 female bodies. The size and shape for the reflected ligaments were variable but overall, triangular in nature. In general, the reflected ligament was found to extend from the lacunar and medial inguinal ligaments and extended obliquely toward the midline at an approximate 45 degrees angle to insert near the linea alba. Two ligaments (6.9 %) were identified that interdigitated with the contralateral reflected ligament. The medial and lateral lengths of the ligament had a mean measurement of 2.28 and 2.58 cm. The base of the reflected ligament had a mean of 2.52 cm and the height of this ligament was found to have a mean of 2.56 cm. The mean area of the reflected ligament was calculated as 2.93 cm(2). There was no statistically significant difference between right or left sides or between genders.

CONCLUSIONS

The reflected ligament was identified in the majority of our specimens and this structure usually contributed to the formation of the posteromedial wall of the external inguinal ring. Therefore, this fact should be included in future descriptions of this ligament.

Cyclooxygenase-2 inhibitor reduces simvastatin-induced bone morphogenetic protein-2 and bone formation in vivo

BACKGROUND AND OBJECTIVE

Simvastatin, a cholesterol-lowering drug, also stimulates oral bone growth when applied topically, without systemic side-effects. However, the mechanisms involved in vivo are not known. We hypothesized that bone morphogenetic protein-2, nitric oxide synthase, and cyclooxygenase-2 are involved, based on prior in vitro evidence.

MATERIAL AND METHODS

A rat bilateral mandible model, where 0.5 mg of simvastatin in methylcellulose gel was placed on one side and gel alone on the other, was used to quantify nitric oxide, cyclooxygenase-2 and bone morphogenetic protein-2 (via tissue extraction, enzyme activity or immunoassay), and to analyze the bone formation rate (via undecalcified histomorphometry). Cyclooxygenase-2 and nitric oxide synthase inhibitors (NS-398 and L-NAME, respectively) were administered intraperitoneally.

RESULTS

Simvastatin was found to stimulate local bone morphogenetic protein-2, nitric oxide and the regional bone formation rate (p < 0.05), whereas NS-398 inhibited bone morphogenetic protein-2 and reduced the bone formation rate (p < 0.05).

CONCLUSION

These data suggest an association between simvastatin-induced bone morphogenetic protein-2 and bone formation in the mandibular microenvironment, and the negative effect of cyclooxygenase-2 inhibitors on bone growth.

WY-14,643 induced cell proliferation and oxidative stress in mouse liver are independent of NADPH oxidase

Long-term exposure of rodents to peroxisome proliferators leads to increases in peroxisomes, hepatocellular proliferation, oxidative damage, suppressed apoptosis, and ultimately results in the development of hepatic adenomas and carcinomas. Peroxisome proliferators-activated receptor (PPAR)alpha was shown to be required for these pleiotropic responses; however, Kupffer cells, resident liver macrophages, were also identified as playing a role in peroxisome proliferators-induced effects, independently of PPARalpha. Previous studies showed that oxidants from NADPH (nicotinamide adenine dinucleotide phosphate, reduced) oxidase mediate acute effects of peroxisome proliferators in rodent liver. To determine if Kupffer cell oxidants are also involved in chronic effects, NADPH oxidase-deficient (p47(phox)-null) mice were fed 4-chloro-6-(2,3-xylidino)-2-pyrimidinylthio acetic acid (WY-14,643)-containing diet (0.1% wt/wt) for 1 week, 5 weeks, or 5 months along with Pparalpha-null and wild type mice. As expected, no change in liver size, cell replication rates, or other phenotypic effects of peroxisome proliferators were observed in Pparalpha-null mice. Through 5 months of treatment, the p47(phox)-null and wild type mice exhibited peroxisome proliferators-induced adverse liver effects, along with increased oxidative DNA damage and increased cell proliferation, a response that is potentially mediated through nuclear factor kappa B (NFkB). Suppressed apoptosis caused by WY-14,643 was dependent on both NADPH oxidase and PPARalpha. Collectively, these findings suggest that involvement of Kupffer cells in WY-14,643-induced parenchymal cell proliferation and oxidative stress in rodent liver is an acute phenomenon that is not relevant to long-term exposure, but they are still involved in chronic apoptotic responses. These results provide new insight for understanding the mode of hepatocarcinogenic action of peroxisome proliferators.

Sustained formation of alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone radical adducts in mouse liver by peroxisome proliferators is dependent upon peroxisome proliferator-activated receptor-alpha, but not NADPH oxidase

Reactive oxygen species are thought to be crucial for peroxisome proliferator-induced liver carcinogenesis. Free radicals have been shown to mediate the production of mitogenic cytokines by Kupffer cells and cause DNA damage in rodent liver. Previous in vivo experiments demonstrated that acute administration of the peroxisome proliferator di(2-ethylhexyl) phthalate (DEHP) led to an increase in production of alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone (POBN) radical adducts in liver, an event that was dependent on Kupffer cell NADPH oxidase, but not peroxisome proliferator-activated receptor (PPAR)alpha. Here, we hypothesized that continuous treatment with peroxisome proliferators will cause a sustained formation in POBN radical adducts in liver. Mice were fed diets containing either 4-chloro-6-(2,3-xylidino)-2-pyrimidinylthioacetic acid (WY-14,643, 0.05% w/w) or DEHP (0.6% w/w) for up to 3 weeks. Liver-derived radical production was assessed in bile samples by measuring POBN radical adducts using electron spin resonance. Our data indicate that WY-14,643 causes a sustained increase in POBN radical adducts in mouse liver and that this effect is greater than that of DEHP. To understand the molecular source of these radical species, NADPH oxidase-deficient (p47phox-null) and PPARalpha-null mice were examined after treatment with WY-14,643. No increase in radicals was observed in PPARalpha-null mice that were treated with WY-14,643 for 3 weeks, while the response in p47phox-nulls was similar to that of wild-type mice. These results show that PPARalpha, not NADPH oxidase, is critical for a sustained increase in POBN radical production caused by peroxisome proliferators in rodent liver. Therefore, peroxisome proliferator-induced POBN radical production in Kupffer cells may be limited to an acute response to these compounds in mouse liver.

Peroxisome proliferator-activated receptor-beta/delta inhibits epidermal cell proliferation by down-regulation of kinase activity

Recent work has shown that peroxisome proliferator-activated receptor beta (PPARbeta) attenuates cell proliferation and skin carcinogenesis, and this is due in part to regulation of ubiquitin C expression. In these studies, the role of PPARbeta in modulating ubiquitin-dependent protein kinase Calpha (PKCalpha) levels and phosphorylation signaling pathways was evaluated. Intracellular phosphorylation analysis showed that phosphorylated PKCalpha and other kinases were lower in wild-type mouse skin treated with 12-O-tetradecanoylphorbol-13-acetate (TPA) as compared with PPARbeta-null mouse skin. No differences in expression levels of other PKC isoforms present in skin were observed. Lower ubiquitination of PKCalpha was found in TPA-treated PPARbeta-null skin as compared with wild-type, and inhibition of ubiquitin-dependent proteasome degradation prevented TPA-induced down-regulation of PKCalpha. The activity of PKCalpha and downstream signaling kinases is enhanced, and expression of cyclooxygenase-2 (COX-2) is significantly greater, in PPARbeta-null mouse skin in response to TPA compared with wild-type mouse skin. Inhibition of PKCalpha or COX-2 reduced cell proliferation in TPA-treated PPARbeta-null keratinocytes in a dose-dependent manner, whereas it only slightly influenced cell proliferation in wild-type keratinocytes. Combined, these studies provide strong evidence that PPARbeta attenuates cell proliferation by modulating PKCalpha/Raf1/MEK/ERK activity that may be due in part to reduced ubiquitin-dependent turnover of PKCalpha.

Role of peroxisome proliferator-activated receptor-alpha (PPARalpha) in bezafibrate-induced hepatocarcinogenesis and cholestasis

Prolonged administration of peroxisome proliferators to rodents typically leads to hepatocarcinogenesis. Peroxisome proliferator-activated receptor-alpha (PPARalpha) is required to mediate alterations in PPARalpha target gene expression, repress apoptosis, enhance replicative DNA synthesis, oxidative stress to DNA and hepatocarcinogenesis induced by the relatively specific PPARalpha agonist, Wy-14,643. Interestingly, administration of the less specific PPARalpha agonist, bezafibrate, leads to a modest induction of PPARalpha target genes in the absence of PPARalpha expression. In these studies, the role of PPARalpha in modulating hepatocarcinogenesis induced by long-term feeding of 0.5% bezafibrate was examined in wild-type (+/+) and PPARalpha-null (-/-) mice. The average liver weight was significantly higher in (+/+) and (-/-) mice fed bezafibrate than controls, but this effect was considerably less in (-/-) mice as compared with similarly treated (+/+) mice. Increased levels of mRNA encoding cell cycle regulatory proteins and DNA repair enzymes were found in (+/+) mice fed bezafibrate, and this effect was not found in (-/-) mice. In mice fed bezafibrate for 1 year, preneoplastic foci, adenomas and a hepatocellular carcinoma were found in (+/+) mice, while only a single microscopic adenoma was found in one (-/-) mouse. This effect was observed in both Sv/129 and C57BL/6N strains of mice, although only preneoplastic foci were observed in the latter strain. Interestingly, hepatic cholestasis was observed in 100% of the bezafibrate-fed (-/-) mice, and this was accompanied by significantly elevated hepatic expression of mRNA encoding bile salt export pump and lower expression of mRNA encoding cytochrome P450 7A1, consistent with enhanced activation of the bile acid receptor, farnesoid X receptor. Results from these studies demonstrate that the PPARalpha is required to mediate hepatocarcinogenesis induced by bezafibrate, and that PPARalpha protects against potential cholestasis.

Peroxisome proliferator-activated receptor beta (delta)-dependent regulation of ubiquitin C expression contributes to attenuation of skin carcinogenesis

The role of peroxisome proliferator-activated receptor-beta (PPARbeta) in the molecular regulation of skin carcinogenesis was examined. Increased caspase-3 activity associated with apoptosis was found in the skin of wild-type mice after tumor promotion with 12-O-tetradecanoylphorbol-13-acetate, and this effect was diminished in PPARbeta-null mice. The onset of tumor formation, tumor size, and tumor multiplicity induced from a two-stage carcinogen bioassay (7,12-dimethylbenz[a]anthracene/12-O-tetradecanoylphorbol-13-acetate) were significantly enhanced in PPARbeta-null mice compared with wild-type mice. To begin to characterize the molecular changes underlying this PPARbeta-dependent phenotype, microarray analysis was performed and a number of differentially regulated gene products were identified including ubiquitin C. Subsequent promoter analysis, reporter gene assays, site-directed mutagenesis, and electrophoretic mobility shift assays provide evidence that PPARbeta regulates ubiquitin C expression, and that ubiquitination of proteins is influenced by PPARbeta. These results strongly suggest that activation of PPARbeta-dependent target genes provides a novel strategy to inhibit tumor promotion and carcinogenesis.

Bezafibrate is a dual ligand for PPARalpha and PPARbeta: studies using null mice

Bezafibrate is a known activator of peroxisome proliferator-activated receptors (PPARs) that can activate both PPARalpha and PPARbeta. To determine the role(s) of these receptors in mediating the biological effects of this chemical, the effect of bezafibrate was examined in PPARalpha-null and PPARbeta-null mice. Wild-type, PPARalpha-null, or PPARbeta-null mice were fed either a control diet or one containing 0.5% bezafibrate for 10 days. Bezafibrate feeding caused a significant increase in liver weight in wild-type and PPARbeta-null mice compared to controls, while liver weight was unchanged in bezafibrate-fed PPARalpha-null mice. Gonadal adipose stores were significantly smaller in wild-type and PPARbeta-null mice fed bezafibrate than in controls, and this effect was not found in similarly fed PPARalpha-null mice. Analysis of liver, white adipose tissue, and intestinal mRNAs showed that bezafibrate caused similar changes of mRNAs encoding lipid metabolizing enzymes in wild-type and PPARbeta-null mice compared to controls. Interestingly, in PPARalpha-null mice, bezafibrate also induced several mRNAs previously thought to be solely controlled by PPARalpha, showing that the effects of this drug are not exclusively modulated by this PPAR isoform. Western blot analysis of liver protein was consistent with changes in mRNA expression showing that the alterations in mRNA expression correlate with protein expression in this tissue. Results from these studies demonstrate that the effect of bezafibrate is mediated in large part by PPARalpha, although some changes in gene expression are dependent on PPARbeta. In contrast to other PPARalpha ligands such as WY-14,643, induction of some target genes by bezafibrate can also be modulated in the absence of a functional PPARalpha.

Bifurcations of periodic orbits in axisymmetric scalefree potentials

We study orbits in potentials with central cusps, emphasizing the spheroidal equidensity (SED) potentials generated by mass distributions with spheroidal equidensity surfaces. The most prominent bifurcations are those related to 1:1 and 4:3 resonances between radial motions and motions perpendicular to the central plane. We find that 1:1 resonances can cause the thin tube orbit, as well as the equatorial plane orbit, to become unstable. We concentrate on period-tripling bifurcations because they appear to be the least understood. We study them via a class of analytic maps. This study suggests that stable period-three orbits generally arise de novo in stable and unstable pairs via a turning-point bifurcation, and not through a bifurcation from the thin tube at a 120 degree rotation angle. The stable period-three orbits typically have only a short span of existence before becoming unstable to a period-doubling instability through a supercritical pitchfork bifurcation.

Profiles of time perspective and personality: developmental considerations

Time perspective is an important but subtle cognitive construct underlying personality, decision making, and goal setting. This study identified 3 temporal dimensions--temporal extension, temporal attitude, and temporal structure--and reviewed the associations among them. T. J. Cottle's (1969, 1977) work on temporal profiles was briefly reviewed; it suggested that 3 types of temporal profiles can be isolated and that 3 broad personality dimensions--human agency, mood, and temperament--from characteristic associations with each of the temporal profiles. The authors expected the profiles to reflect developmental sensitivities as a person moves from adolescence into early adulthood. Two samples (159 high school students and 236 university students) participated in the study. The results provided some limited support for the actualizer and atomist profiles; somewhat surprisingly, the role of temporal extension appeared to be insignificant. No evidence was found for a developmental transition of time perspective between middle adolescence (15-17 years) and early adulthood (18-25 years).

Time perspective: temporal extension, time estimation, and impulsivity

It has been proposed that time perspective is an important variable that can, in part, explain the differences between people in terms of the development of self-control. One corollary of this position is that time perspective is somehow related to systematic biases in the way people perceive the passage of time. Such a bias may or may not be augmented by an association between time perspective and impulsivity. Two studies were conducted using measures of temporal extension, time estimation, and impulsivity. In general, no consistent effects were found. Neither time perspective nor impulsivity was related to any characteristic pattern of errors. In the second study, time perspective (mediated by age) was associated with predicting very brief time estimation scores, but not longer time estimation periods. It was concluded that whatever the mechanism might be that underlies the purported effect between time perspective and self-control, it is not related to a differential ability to perceive time moving more or less quickly.

Effects of inotropes on human leucocyte numbers, neutrophil function and lymphocyte subtypes

We have investigated the effects of inotropes with different adrenergic receptor specificity on differential white cell count, lymphocyte subtypes and neutrophil function in healthy volunteers. Six healthy, male volunteers were enrolled into this randomized, placebo-controlled pilot study. Each volunteer was studied on four separate occasions during a 2-h infusion of various agents, and for 2 h after stopping the infusion. The agents investigated were adrenaline 0.1 microgram kg-1 min-1, dobutamine 5 micrograms kg-1 min-1, dopexamine 2 micrograms kg-1 min-1 and 5% glucose 0.5 ml kg-1 h-1. Venous blood was sampled at 0, 30, 120 and 240 min. Haemodynamic monitoring was continued throughout the study. Full blood count, white cell differential count and enumeration of lymphocyte subtypes were performed. Neutrophil function tests included chemoluminescence, and assessment of neutrophil chemotaxis, phagocytosis and adhesion. The Wilcoxon signed rank test was used to compare differences between placebo and active drugs at each time compared with baseline. There was a significant increase in white cell count, lymphocyte count and neutrophil count with adrenaline, and a small but significant decrease in these variables with dobutamine and dopexamine. These changes were also apparent for absolute CD3+, CD4+ and CD8+ lymphocyte counts. Neutrophil respiratory burst in response to f-methionyl-leucyl-phenylalanine increased significantly only with adrenaline at 30 min (P = 0.046). There were no other significant changes in tests of neutrophil function. Infusion of inotropes was associated with changes in white cell numbers, lymphocyte subtypes and neutrophil respiratory burst. In healthy volunteers, adrenaline had effects different from those of dobutamine and dopexamine. The clinical relevance of such effects requires further investigation in critically ill patients.

Creatinine and 51Cr-EDTA clearance after liver transplantation

We have compared glomerular filtration rate measured by creatinine clearance with that measured by 51Cr-EDTA clearance after liver transplantation. Fourteen pairs of values were obtained from seven patients on the first and second days after operation. There were wide discrepancies between the values for glomerular filtration rate measured by the two methods, with a regression co-efficient of 0.43 (p = 0.12). Both methods assume a steady state, with no change of extracellular fluid volume or in the rates of exchange between physiological compartments, that does not apply in the immediate period after operation. The results show the difficulties of using clearance techniques to assess renal function after major surgery. Since drug therapy may be based on these measurements, we suggest that in this group of patients isolated clearance values should not be used.

The use of sedative agents in critically ill patients

The main aim of sedation in the critically ill patient is to provide relief from anxiety and pain. The current, ideal level of sedation should leave a patient who is lightly asleep but easily roused. No single regimen is suitable for all patients. The level of sedation should be monitored, and the choice of agent, the dose and the route of administration adjusted appropriately. Midazolam is often used to provide sleep and anxiolysis. Alternatives include propofol and isoflurane. Propofol is easily titrated to achieve the desired level of sedation, and its effects rapidly end when the infusion is stopped. Isoflurane also appears promising, but special equipment is needed for its administration. Morphine is the standard analgesic agent. The principal metabolites, morphine-6-glucuronide, is also a potent opioid agonist and may accumulate in renal failure. Of the newer analgesic agents, alfentanil is an ideal agent for infusion, and may be the agent of choice in renal failure. Neuromuscular blocking agents are indicated only in specific circumstances, and used only once it is known patients are asleep and pain free. The actions of these agents are unpredictable in the critically ill patient. Alterations in drug effect and elimination may occur, especially in the patient with hepatic and renal failure. This may also apply to active metabolites of the parent drug. When planning sedation regimens, specific patient needs and staffing levels must be remembered. Attention to the environment is also important. Midazolam and morphine given by intermittent bolus or by infusion are the mainstay of most regimens. Propofol is ideal for short periods of care on the ICU, and during weaning when longer acting agents are being eliminated.

Prolonged action of enoximone in renal failure

Enoximone was administered on two separate occasions to a 37-year-old woman with renal failure secondary to thrombotic thrombocytopenic purpura. Plasma concentrations of enoximone and its principal metabolite, enoximone sulphoxide, were measured over a 9-day period. As renal function improved the rate of elimination of enoximone sulphoxide increased. The duration of effect of enoximone may be prolonged in patients with renal failure.

Serum acute phase proteins after orthotopic liver transplantation

Acute phase proteins were measured in six patients before liver transplantation and for 72 h after orthotopic liver transplantation. The ability of the donor liver to mount an acute phase response was demonstrated, although the response was less than that seen in other groups of patients in whom this has been studied. Because of the reduced response to stress, the value of these measurements as indicators of liver function in this group of patients is limited.

Caudal analgesia for pediatric day case surgery: assessment of motor function prior to discharge

The benefits of caudal analgesia are well recognized in the prevention of postoperative pain following pediatric surgery. The possibility of motor weakness may deter anesthetists from using this technique. This study investigates motor function prior to discharge in boys who, as day case patients, received caudal analgesia for pain relief following circumcision. Motor function was assessed using a simple and clinically relevant scale. Three different dosage regimens of bupivacaine were compared. No important motor weakness was demonstrated, and there was no difference with respect to motor block in the three groups. Caudal analgesia may be recommended as a suitable technique for day case patients.

Anaesthesia for patients with mitochondrial myopathy

The anaesthetic management for an infant with mitochondrial encephalomyopathy due to fumarase deficiency is described. Mitochondrial myopathies may produce skeletal and cardiac muscle abnormalities, central nervous system effects and metabolic problems. The solutions to the anaesthetic problems posed by these patients are discussed.

Anaesthetic management of caesarean section for a mother with pre-eclampsia, the Klippel-Feil syndrome and congenital hydrocephalus

A mother with the Klippel-Feil syndrome, congenital hydrocephalus and increased intracranial pressure presented for delivery by Caesarean section at 33 weeks because of pre-eclampsia. Anaesthetic management comprised awake intubation using the fibreoptic bronchoscope, followed by induction and maintenance of general anaesthesia for the delivery of a live male infant. This case report describes the problems arising under these circumstances and the relative merits of different anaesthetic techniques.