High-Dose Methotrexate-Leucovorin Rescue Therapy: Selected Application in Non-Hodgkin's Lymphoma

Methotrexate with leucovorin rescue (HDMTX-LV rescue), has been used to treat solid tumors and non-Hodgkin's lymphomas (NHL). We studied the use of HDMTX-LV rescue in patients with widespread NHL with histologic diagnosis of diffuse poorly differentiated lymphocytic and diffuse histiocytic including involvement of the central nervous system (CNS) and/or bone marrow. The prognosis with conventional chemotherapy is extremely poor. Three patients have bone marrow involvement, 2 patients CNS, and 2 both. These patients were unresponsive to conventional chemotherapy and had a rapid progression of their disease. Therapy with HDMTX-LV rescue induced responses in 5 patients: 2 patients achieved a complete remission and three a partial remission. Regression of CNS involvement was observed in 3 patients; bone marrow toxicity was not observed. Only 1 patient failed to respond. These data suggest that HDMTX-LV rescue may be useful as primary therapy in lymphoma patients with CNS and/or bone marrow involvement.

An audit of patient-controlled analgesia after appendicectomy in children

BACKGROUND

Patient-controlled analgesia (PCA) is commonly used after appendicectomy in children.

AIM

The aim of this study was to characterize the analgesic use of children prescribed PCA after appendicetomy, in order to rationalize future use of this modality.

METHODS

We retrospectively audited all cases of acute appendicitis over a 4-year period in a single pediatric hospital, recording demographics, surgical approach, pathology, analgesia use, pain scores, and duration of PCA. We preplanned subgroup analyses for surgical approach, pathology, and intraoperative nonsteroidal anti-inflammatory drug (NSAID) administration. We subsequently identified a patient subgroup who were unlikely to require PCA and conducted a (2 months) prospective audit of such patients (uncomplicated appendicitis with intraoperative NSAID) having non-PCA (oral) analgesia.

RESULTS

Of the 649 patients undergoing appendicectomy for acute appendicitis, 85% were prescribed an opioid PCA, 8% received an opioid infusion (younger patients), and 7% received neither PCA nor infusion. Of the 541 bolus only PCA patients, 49% had laparoscopic surgery, 36% had complicated appendicitis, and 49% received intraoperative NSAID (diclofenac). Mean (SD) duration of PCA was shorter with uncomplicated vs complicated appendicitis (21.9 ± 10.7 vs 32.8 ± 21.1 h, P < 0.001, difference in means [95% CI]: 10.9 [7.7-14.1]), and with intraoperative NSAID (23.2 ± 14.4 vs 28.4 ± 17.4 h, P < 0.001, difference in means [95% CI]: 5.2 [2.5-7.9]). There was no difference in the time to PCA cessation between laparoscopic and open approach. Morphine consumption and pain scores were lower in the early postoperative period for those patients receiving intraoperative NSAID. In the prospective audit, 44 of 69 patients had uncomplicated appendicitis. Thirty-eight of these were prescribed oral analgesia and none required any parenteral opioid or acute pain service intervention postoperatively. Parental satisfaction level was high (>90%) with oral analgesia.

CONCLUSIONS

It is feasible that children with uncomplicated appendicitis given intraoperative NSAID can be successfully managed without PCA.

Transition to propofol after sevoflurane anesthesia to prevent emergence agitation: a randomized controlled trial

BACKGROUND

Emergence agitation (EA) is a common behavioral disturbance after sevoflurane anesthesia in children. Propofol 1 mg · kg(-1) bolus at the end of sevoflurane anesthesia has had mixed results in reducing the incidence of EA, whereas propofol infusion throughout anesthesia maintenance seems effective but is more complex to administer. If a simple, short transition to propofol anesthesia was found to be effective in reducing EA, this could enhance the recovery of children following sevoflurane anesthesia. We therefore aimed to determine whether transition to propofol over 3 min at the end of sevoflurane anesthesia reduces the incidence of EA in children.

METHODS

In this prospective randomized controlled trial, 230 children aged 1-12 years, undergoing magnetic resonance imaging (MRI) scans under sevoflurane anesthesia were randomized to receive either propofol 3 mg · kg(-1) over 3 min (propofol group), or no propofol (control group), at the end of sevoflurane anesthesia. EA was assessed by a blinded assessor using the Pediatric Emergence Anesthesia Delirium (PAED) scale and the Watcha scale until 30 min after emergence. EA on the PAED scale was defined as a PAED score >12. EA on the Watcha scale was defined as a score ≥ 3. Times to emergence, postanesthesia care unit (PACU) discharge, and discharge home were also recorded.

RESULTS

Data were analyzed for 218 children. The incidence of EA was lower in the propofol group on both PAED (29% vs 7%; relative risk = 0.25; 95% confidence interval 0.12-0.52; P < 0.001) and Watcha (39% vs 15%; relative risk = 0.37; 95% confidence interval 0.22-0.62; P < 0.001) scales. Duration and severity of EA were also reduced in the propofol group. Preplanned subgroup analyses for midazolam premedication, preexisting cognitive or behavioral disturbance, and age group did not alter our findings. Emergence time and time in PACU were both increased by a mean of 8 min in the propofol group (P < 0.001) with no difference in time to discharge home.

CONCLUSIONS

Transition to propofol at the end of sevoflurane anesthesia reduces the incidence of EA and improves the quality of emergence. There is a small increase in recovery time, but no delay in discharge home.

Effects of sevoflurane versus other general anaesthesia on emergence agitation in children

BACKGROUND

Sevoflurane is an inhaled volatile anaesthetic that is widely used in paediatric anaesthetic practice. Since its introduction, postoperative behavioural disturbance known as emergence agitation (EA) or emergence delirium (ED) has been recognized as a problem that may occur during recovery from sevoflurane anaesthesia. For the purpose of this systematic review, EA has been used to describe this clinical entity. A child with EA may be restless, may cause self-injury or may disrupt the dressing, surgical site or indwelling devices, leading to the potential for parents to be dissatisfied with their child's anaesthetic. To prevent such outcomes, the child may require pharmacological or physical restraint. Sevoflurane may be a major contributing factor in the development of EA. Therefore, an evidence-based understanding of the risk/benefit profile regarding sevoflurane compared with other general anaesthetic agents and adjuncts would facilitate its rational and optimal use.

OBJECTIVES

To compare sevoflurane with other general anaesthetic (GA) agents, with or without pharmacological or non-pharmacological adjuncts, with regard to risk of EA in children during emergence from anaesthesia. The primary outcome was risk of EA; secondary outcome was agitation score.

SEARCH METHODS

We searched the following databases from the date of inception to 19 January 2013: CENTRAL, Ovid MEDLINE, Ovid EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost), Evidence-Based Medicine Reviews (EBMR) and the Web of Science, as well as the reference lists of other relevant articles and online trial registers.

SELECTION CRITERIA

We included all randomized (or quasi-randomized) controlled trials investigating children < 18 years of age presenting for general anaesthesia with or without surgical intervention. We included any study in which a sevoflurane anaesthetic was compared with any other GA, and any study in which researchers investigated adjuncts (pharmacological or non-pharmacological) to sevoflurane anaesthesia compared with no adjunct or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the databases, decided on inclusion eligibility of publications, ascertained study quality and extracted data. They then resolved differences between their results by discussion. Data were entered into RevMan 5.2 for analyses and presentation. Comparisons of the risk of EA were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Sevoflurane is treated as the control anaesthesia in this review. Sensitivity analyses were performed as appropriate, to exclude studies with a high risk of bias and to investigate heterogeneity.

MAIN RESULTS

We included 158 studies involving 14,045 children. Interventions to prevent EA fell into two broad groups. First, alternative GA compared with sevoflurane anaesthesia (69 studies), and second, use of an adjunct with sevoflurane anaesthesia versus sevoflurane without an adjunct (100 studies). The overall risk of bias in included studies was low. The overall Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) assessment of the quality of the evidence was moderate to high. A wide range of EA scales were used, as were different levels of cutoff, to determine the presence or absence of EA. Some studies involved children receiving potentially inadequate or no analgesia intraoperatively during painful procedures.Halothane (RR 0.51, 95% CI 0.41 to 0.63, 3534 participants, high quality of evidence) and propofol anaesthesia were associated with a lower risk of EA than sevoflurane anaesthesia. Propofol was effective when used throughout anaesthesia (RR 0.35, 95% CI 0.25 to 0.51, 1098 participants, high quality of evidence) and when used only during the maintenance phase of anaesthesia after sevoflurane induction (RR 0.59, 95% CI 0.46 to 0.76, 738 participants, high quality of evidence). No clear evidence was found of an effect on risk of EA of desflurane (RR 1.46, 95% CI 0.92 to 2.31, 408 participants, moderate quality of evidence) or isoflurane (RR 0.76, 95% CI 0.46 to 1.23, 379 participants, moderate quality of evidence) versus sevoflurane.Compared with no adjunct, effective adjuncts for reducing the risk of EA during sevoflurane anaesthesia included dexmedetomidine (RR 0.37, 95% CI 0.29 to 0.47, 851 participants, high quality of evidence), clonidine (RR 0.45, 95% CI 0.31 to 0.66, 739 participants, high quality of evidence), opioids, in particular fentanyl (RR 0.37, 95% CI 0.27 to 0.50, 1247 participants, high quality of evidence) and a bolus of propofol (RR 0.58, 95% CI 0.38 to 0.89, 394 participants, moderate quality of evidence), ketamine (RR 0.30, 95% CI 0.13 to 0.69, 231 participants, moderate quality of evidence) or midazolam (RR 0.57, 95% CI 0.41 to 0.81, 116 participants, moderate quality of evidence) at the end of anaesthesia. Midazolam oral premedication (RR 0.81, 95% CI 0.59 to 1.12, 370 participants, moderate quality of evidence) and parental presence at emergence (RR 0.91, 95% CI 0.51 to 1.60, 180 participants, moderate quality of evidence) did not reduce the risk of EA.One or more factors designated as high risk of bias were noted in less than 10% of the included studies. Sensitivity analyses of these studies showed no clinically relevant changes in the risk of EA. Heterogeneity was significant with respect to these comparisons: halothane; clonidine; fentanyl; midazolam premedication; propofol 1 mg/kg bolus at end; and ketamine 0.25 mg/kg bolus at end of anaesthesia. With investigation of heterogeneity, the only clinically relevant changes to findings were seen in the context of potential pain, namely, the setting of adenoidectomy/adenotonsillectomy (propofol bolus; midazolam premedication) and the absence of a regional block (clonidine).

AUTHORS' CONCLUSIONS

Propofol, halothane, alpha-2 agonists (dexmedetomidine, clonidine), opioids (e.g. fentanyl) and ketamine reduce the risk of EA compared with sevoflurane anaesthesia, whereas no clear evidence shows an effect for desflurane, isoflurane, midazolam premedication and parental presence at emergence. Therefore anaesthetists can consider several effective strategies to reduce the risk of EA in their clinical practice. Future studies should ensure adequate analgesia in the control group, for which pain may be a contributing or confounding factor in the diagnosis of EA. Regardless of the EA scale used, it would be helpful for study authors to report the risk of EA, so that this might be included in future meta-analyses. Researchers should also consider combining effective interventions as a multi-modal approach to further reduce the risk of EA.

Anesthesia for Treacher Collins syndrome: a review of airway management in 240 pediatric cases

OBJECTIVES

To review airway management with anesthesia for children with Treacher Collins syndrome (TCS) and determine whether intubation was more difficult with increasing age.

BACKGROUND

Treacher Collins syndrome is a rare disorder of craniofacial development characterized by maxillary, zygomatic, and mandibular dysplasia. TCS is associated with difficult intubation, but reports of airway management are limited to case reports and small cases series. Children with TCS may require multiple general anesthetics, and it has been suggested that intubation becomes more difficult with increasing age.

METHODS

A retrospective case note review of children with TCS from birth to 18 years undergoing anesthesia from 1971 to 2011 in a single center was performed. Demographic data, procedure type, anesthesia type, method of airway management, modified Cormack-Lehane (MCL) grade of laryngoscopic view, and any other descriptions of airway difficulty or complications were collated.

RESULTS

Of 59 patients with TCS, 35 children underwent a total of 240 anesthetics, most commonly for craniofacial surgery. Final airway management consisted of face mask 17%, laryngeal mask airway 16%, endotracheal intubation 49%, and 18% had a preexisting tracheostomy. The laryngeal mask airway provided an adequate airway in all cases when it was used. MCL grade was recorded in 97 cases involving 28 patients: 7% grade 1, 9% grade 2a, 31% grade 2b, 26% grade 3, and 27% grade 4. Fifteen (54%) patients were MCL grade 4 on at least one occasion. Failed intubation occurred in 6 (5%) of 123 cases of planned intubation. The procedure was canceled in two cases (0.8%) because of failure to intubate. Intubation techniques other than conventional direct laryngoscopy were used in 41% of cases. MCL grade increased with increasing age (P = 0.007).

CONCLUSIONS

Most children with TCS have difficult laryngoscopic views with many requiring specialized intubation techniques. Direct laryngoscopy becomes more difficult with increasing age. The laryngeal mask airway is a good choice of airway when endotracheal intubation is not required.

Intraoperative and postoperative hyponatremia with craniosynostosis surgery

BACKGROUND

  An alarming incidence of significant intraoperative hyponatremia during major pediatric craniofacial surgery has recently been reported, the mechanism of which is unclear.

AIMS

  To establish the incidence and severity of hyponatremia occurring during and after major craniofacial surgery for craniosynostosis in our institution and identify any associated risk factors.

METHODS

  Retrospective review of case notes and blood test results for all cases of major craniofacial surgery for craniosynostosis in children under 10 years of age from January 2007 to May 2011. Hyponatremia was classified as: mild 131-134 mmol·l(-1) ; moderate 126-130 mmol·l(-1) ; and, severe ≤125 mmol·l(-1) . Analyses were performed to look for factors associated with hyponatremia including gender, weight, syndromic or not, duration of procedure, and volumes of crystalloid, colloid and blood administered.

RESULTS

  One hundred and two consecutive cases were identified. Mild intraoperative hyponatremia occurred in five (5%) of children. There were no cases of moderate or severe intraoperative hyponatremia. All five had normal sodium values within two hours of their single low readings of 134 mmol.l(-1) and none had any subsequent episodes of hyponatremia in the postoperative period. Intraoperative hyponatremia was associated with lower body weight (P = 0.002). Mild postoperative hyponatremia on the day of surgery (POD0) occurred in three other children (3%) with no identifiable associations. There were no cases of moderate or severe postoperative hyponatremia on POD0. Hyponatremia on the first postoperative day (POD1) was mild in 23 children (24%) and moderate in one child (1%). There were no cases of severe postoperative hyponatremia on POD1. Hyponatraemia on POD1 was associated with male gender (P = 0.042).

CONCLUSIONS

  Clinically significant intraoperative hyponatremia was not a feature of major craniofacial surgery in our institution. Mild postoperative hyponatremia was relatively common on POD1.

An audit of anesthetic management and complications of tracheo-esophageal fistula and esophageal atresia repair

BACKGROUND

Many different anesthetic techniques have been suggested for the management of tracheo-oesophageal fistula/oesophageal atresia (TOF/OA) although the incidence of ventilation difficulty is not well known and it is unclear which technique is best in managing this. The aim of our audit was to determine the incidence of ventilation difficulty during repair of TOF/OA. We also recorded the current practice for anesthesia and analgesia in these children as well as the incidence of comorbidities and surgical complications.

METHODS

We retrospectively audited cases of TOF/OA repair over a 3-year period in four hospitals, recording demographics, comorbidities, surgical data, postoperative complications, and anesthetic technique, including ventilation difficulty and management strategy.

RESULTS

A total of 111 patients were identified with TOF/OA, and 106 patient notes and 101 anesthetic records were found. 42% of patients were premature, and 57.5% had significant comorbidities. Death was most likely in infants with low birth weight and low gestational age at birth and in those with major cardiac comorbidity. A range of techniques were used for induction, maintenance, extubation, and pain control. There were ventilation difficulties recorded at induction in seven patients, and significant desaturations were recorded in 15 patients intraoperatively.

CONCLUSIONS

This audit adds to the data already published about incidences of complications and comorbidities associated with TOF/OA repair. Defining anesthetic practice with regard to ventilation and analgesic strategies is important in comparing the adequacy and risk of techniques used. Our audit shows that a range of differing anesthetic techniques are still employed by different anesthetists and institutions and details some of the techniques being used for managing difficult ventilation.

Use of invasive placebos in research on local anaesthetic interventions

Placebos play a vital role in clinical research, but their invasive use in the context of local anaesthetic blocks is controversial. We assessed whether recently published randomised controlled trials of local anaesthetic blocks risked harming control group patients in contravention of the Declaration of Helsinki. We developed the 'SHAM' (Serious Harm and Morbidity) scale to assess risk: grade 0 = no risk (no intervention); grade 1 = minimal risk (for example, skin allergy to dressing); grade 2 = minor risk (for example, subcutaneous haematoma, infection); grade 3 = moderate risk (with or without placebo injection) (for example, neuropraxia); and grade 4 = major risk (such as blindness, pneumothorax, or liver laceration). Placebo interventions of the 59 included trials were given a SHAM grade. Nine hundred and nineteen patients in 31 studies, including six studies with 183 children, received an invasive placebo assessed as SHAM grade ≥ 3. A high level of agreement (78%, κ = 0.80, p < 0.001) for SHAM grades 0-4 increased to 100% following discussion between assessors. More than half of the randomised controlled study designs subjected patients in control groups to risks of serious or irreversible harm. A debate on whether it is justifiable to expose control group patients to risks of serious harm is overdue.

A comparison of emergence delirium scales following general anesthesia in children

BACKGROUND

Emergence delirium (ED) is of increasing interest since the introduction of short-acting volatiles such as sevoflurane.

METHODS

We compared the Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales for assessing the presence of ED in 117 of 118 consecutive children <18 years recovering from general anesthesia. The primary measure was the worst score for ED as assessed on each scale and for each patient during their PACU stay. An experienced anesthetist observer also made a subjective assessment of the presence of ED.

RESULTS

A PAED score of > or =10 detected ED in 37 children (32%), while the Watcha detected 30 (26%) and Cravero 41 (35%). Twenty-five patients (21%) fulfilled criteria for ED in all three scales as did all eight patients assessed by the experienced pediatric anesthetist observer. Median PAED scores (interquartile ranges) for patients assessed as having ED or not respectively were for Watcha, 12 (11,14), 7 (4,8); for Cravero, 11 (9,13), 7 (4,8); and for the experienced anesthetist observer, 14.5 (13.5,16.5), 7 (6,10).

CONCLUSIONS

All three scales correlated reasonably well with each other but have individual limitations in their potential to assess whether ED is present. In the absence of developing an improved research tool to assess ED, a PAED score >12 appears to provide greater sensitivity and specificity than a PAED score > or =10. However, the Watcha scale is a simpler tool to use in clinical practice and may have a higher overall sensitivity and specificity than the other scales.

VISPA's group (evaluation of the implementation Strategies of the Measurements Instruments Adopted in the Italian nursing Practice)

An innovative teaching strategy focused on problem based approach rather than theorical aiming to facilitate the learning of the research methodology in advanced nursing student has been introduced. Through out a qualitative evaluation of the diary kept by the student nurses involved, advantages and disadvantages of this innovative approach have been evaluated. This paper reports a synthesis of the teaching strategy and its impact on the competences in the research methodology as it has been perceived by the students participants.

[VISPA's group (evaluation of the implementation strategies of the measurements instruments adopted in the Italian nursing practice)]

An innovative teaching strategy focused on problem based approach rather than theorical aiming to facilitate the learning of the research methodology in advanced nursing student has been introduced. Through out a qualitative evaluation of the diary kept by the student nurses involved, advantages and disadvantages of this innovative approach have been evaluated. This paper reports a synthesis of the teaching strategy and its impact on the competences in the research methodology as it has been perceived by the students participants.

General anesthesia in an infant with X-linked myotubular myopathy

We present a 20-week-old infant with the X-linked form of myotubular myopathy who required anesthesia for a Nissen fundoplication procedure where the response to nondepolarizing neuromuscular blockade was evaluated.

Biochemical and ultrasound tests for early diagnosis of active neuro-osteoarthropathy (NOA) of the diabetic foot

OBJECTIVES

To test the effectiveness of a combined approach to an early diagnosis of neuro-osteoarthropathy (NOA) of the diabetic foot, we studied a group of outpatients with active NOA, presenting for the first time to our Diabetic Foot Clinic in 1998, by means of an integrated approach designed to assess bone turnover.

PATIENTS AND METHODS

Fifteen consecutive diabetic patients (five Type 1 and ten Type 2 diabetic individuals, age 61.9+/-12.2 years, diabetes duration 18.7+/-8.9 years, HbA(1c) 8.4+/-1.5%) with active NOA (Group 1) were compared to nine diabetic patients with chronic stable NOA (Group 2), 14 neuropathic diabetic patients without NOA (Group 3), 13 non-neuropathic diabetic patients (Group 4) and 15 healthy controls (Group 5). Determination of serum carboxy-terminal collagen telopeptide (ICTP), bone alkaline phosphatase isoenzyme (B-ALP), osteocalcin (BGP) concentrations, as well as urinary excretion of deoxypyridinoline (DPD) were obtained in all individuals for assessment of bone reabsorption and new bone formation. Moreover in all individuals quantitative ultrasound (QUS) of the calcaneal bone was performed and mass density of lumbar spine and femur bone was determined by dual-energy X-ray absorptiometry (DEXA).

RESULTS

QUS was significantly lower in the active NOA patients as compared with other groups (P<0.01), while ICTP was higher in both NOA groups (P<0.01). Urinary DPD was higher in the neuropathic non-NOA group (P<0.01) than the other groups, and osteocalcin was higher in healthy controls compared to diabetic patients without NOA. QUS and ICTP were inversely correlated (r=0.44, P=0.000). QUS in the active NOA group was significantly (P<0.01) lower in the affected compared to the unaffected foot.

CONCLUSION

Our results indicate a possible role for an integrated approach to the diagnosis and monitoring of NOA involving the diabetic foot. DPD may identify patients at-risk for NOA, ICTP could be tested as a marker for NOA in asymptomatic cases. Finally, QUS of the calcaneal bone may be useful in discriminating active versus quiescent phases.

Importance of bioavailable calcium drinking water for the maintenance of bone mass in post-menopausal women

The aim of this research was to establish the importance of calcium intake through mineral water on vertebral bone density in women. To this purpose, we examined 255 women divided into two groups: those regularly drinking a high calcium content mineral water (group A; no.=175) and those using different type of water with a lower calcium content (group B; no.=80). Their dietary daily calcium intake was determined by means of a validated questionnaire (N.I.H. Consensus statement) and vertebral bone density was measured by Dual-Energy X-ray absorptiometry (Unigamma-plus ACN densitometer). Women in group A ingested a significantly higher quantity of calcium in water than women in group B (mean difference 258 mg; 95% confidence limits: 147-370 mg). The average bone density values were slightly but significantly higher in group A as compared to group B (mean+/-SD: 1.044+0,15 vs 1.002+0,14; p=0.03). In addition to age, BMI and menopausal status, calcium intake was a significant predictor of spinal BMD. These 4 variables explained about 35% of the spinal BMD variance. When the analysis was repeated separately for pre- and post-menopausal subjects, calcium remained a significant predictor in post-menopausal women (t=2.28; p=0.02), but not in premenopausal women. These results underline the importance of a lifelong daily calcium intake, resulting by the regular drinking of high bioavailable calcium water, in order to maintain bone mass after the menopause, in comparison to the use of a lower content calcium water.

In vitro characterisation of intramural neural pathways between the duodenum and the sphincter of Oddi of the brush-tailed possum

The aims of this study were to determine if neural pathways between the duodenum and sphincter of Oddi are intramural, activated by duodenal electrical field stimulation (EFS) in vitro, and contain capsaicin-sensitive primary afferents. The possible involvement of cholinergic (muscarinic and/or nicotinic) and adrenergic receptors in these pathways were also investigated. Duodenal EFS (5-60 Hz, 70 V, 0.5 ms duration, 10 s train) at sites 2 cm oral and 2 cm anal to the sphincter of Oddi-duodenal junction produced frequency-dependent excitatory responses in the sphincter of Oddi, measured by manometry (n = 3). Excitatory responses from duodenal circular muscle were also evident. Tetrodotoxin (1 microM; n = 7) pretreatment abolished both sphincter of Oddi and duodenal responses to duodenal EFS. Crushing the duodenum between the site of stimulation and the sphincter of Oddi-duodenal junction also abolished sphincter of Oddi response. The sphincter of Oddi responses to duodenal EFS at the oral and anal sites were reduced by pretreatment with (i) atropine (100 nM: n = 7) to 19 +/- 6% (P < 0.05) and 22 +/- 8% (P < 0.05) of control respectively. (ii) hexamethonium (100 microM: n = 9) to 10 +/- 2% (P < 0.01) and 6.0 + 2.5% (P < 0.01) of control respectively and (iii) guanethidine (1 microM; n = 6) to 75 +/- 6% (P < 0.05) and 78 +/- 10% (P < 0.05) of control, respectively. Combined pretreatment with phentolamine and propranolol (both 1 microM; n = 7) was without effect, as was capsaicin (1 microM; n = 12) pretreatment. Excitatory intramural pathways between the sphincter of Oddi and the duodenum are primarily cholinergic in nature and contain an adrenergic component. Capsaicin-sensitive primary afferents are not involved.

Effects of chronic heroin abuse on bone and mineral metabolism

Though the chronic use of opiates can modify several body functions, only a few data are available on the effects of opioid drugs on mineral metabolism. We have examined the possible consequences of chronic opiate abuse on bone mass, bone turnover and calcium metabolism in 13 male chronic heroin users, examined 1-2 days after the last administration of the drug (group A), 14 former male heroin addicts, examined 4-24 months after drug discontinuation (group B), and 22 healthy, age- and sex-matched control subjects. In group A, the vertebral bone mineral density (measured by Dual-Photon Absorptiometry) was significantly lower (p < 0.05) than in the control subjects, despite similar values of total body bone mineral, lean body and fat mass. Blood-ionised calcium and urinary calcium and hydroxyproline were significantly increased (p < 0.01), whereas parathyroid hormone was lower than in controls (p < 0.01). Bone alkaline phosphatase and osteocalcin, however, were not significantly different from the control values. LH and testosterone levels were low (p < 0.01 vs controls). In contrast, group B subjects did not show significant differences from the control group. The chronic abuse of opioid drugs may be associated with altered bone metabolism and reduced trabecular bone mass, attributable, at least in part, to gonadal deficiency. These alterations seem reversible after drug discontinuation.

Effect of ipriflavone on bone mass in elderly osteoporotic women

A study in elderly osteoporotic women was performed to assess the effect of one year treatment with ipriflavone (IP) on bone mass and bone biomarkers. Twenty-eight women aged over 65, with diagnosis of osteoporosis and X-ray evidence of at least one vertebral fracture, were treated with IP tablets (600 mg/day) or placebo (PL), according to a randomized, double-blind, parallel-group design. One g/day calcium supplementation was given to all patients. After 12 months a significant increase (+6%, P < 0.05) of bone mineral density (BMD) at the distal radius (DPA) was obtained in the IP-group. Serum osteocalcin (BGP) and urinary HO-proline/creatinine (HOP/Cr) values were reduced in the same group. BMD values did not change (-0.3%) in the placebo group. One woman of the PL-group was withdrawn from treatment because of worsening of pain, due to new vertebral crushes. Side effects (mainly gastrointestinal) arose in 8 IP- and in 5 PL-treated women. The compliance to the oral administration was good.

Longitudinal study of bone loss after thyroidectomy and suppressive thyroxine therapy in premenopausal women

The effects of suppressive doses of L-thyroxine on the appendicular and axial bone mineral content were followed for 12-36 months after total or subtotal thyroidectomy in 15 premenopausal women. Compared to age-matched controls, these patients had a more marked bone loss of the spinal bone mineral content (2.6 +/- 1.9% vs 0.2 +/- 1.2% per year). The changes in radial cortical bone density were not significantly different from the control group. We conclude that when a suppressive therapy with L-thyroxine is necessary the rate of bone loss should be monitored at regular intervals.

Motilin and erythromycin enhance the in vitro contractile activity of the sphincter of Oddi of the Australian brush-tailed possum

Erythromycin has been shown to interact with gastrointestinal smooth muscle in a similar manner to motilin, and has been postulated as a motilin receptor agonist. We report that in isolated preparations from the biliary tract of thirty one Australian Brush-tailed Possums (Trichosurus vulpecula) erythromycin acts in a similar manner to motilin. In all muscle strips from the sphincter of Oddi, prepared in both the circular and longitudinal orientation, both synthetic porcine motilin (10(-10) M-10(-6) M) and erythromycin (lactobionate) (10(-8) M-10(-4) M) stimulated contractile activity in a concentration dependent manner, via a direct effect on the smooth muscle (the response was unaffected by tetrodotoxin, omega conotoxin GVIA or atropine). In strips prepared from the gallbladder neither agonist affected the contractile activity in 7 of 8 animals. Motilin was approximately 1000 fold more potent in stimulating contractile activity than erythromycin in both sphincter of Oddi circular strips [pD2 for peak response to motilin 8.67 (mean) +/- 0.06 (SEM) compared with erythromycin 5.67 +/- 0.09] and sphincter of Oddi longitudinal strips [pD2 for peak response to motilin 8.64 (mean) +/- 0.28 (SEM) compared with erythromycin 5.45 +/- 0.23]. The concentration response curves for motilin and erythromycin were similar and both agonists required the presence of extracellular calcium to elicit responses (responses were diminished by verapamil and abolished in calcium free Krebs solution). Our results support the hypothesis that erythromycin mimics the action of motilin in stimulating the sphincter of Oddi in vitro.

Intermittent treatment with intravenous 4-amino-1-hydroxybutylidene-1,1-bisphosphonate (AHBuBP) in the therapy of postmenopausal osteoporosis

Since data on the efficacy of 4-amino-2-hydroxybutylidene-1,1-bisphosphonate (AHBuBP) in the therapy of osteoporosis are not yet available, we have examined in an open, randomized study, the effects of an intravenous intermittent treatment with this drug on the vertebral and radial bone mass in postmenopausal osteoporosis. Forty postmenopausal osteoporotic women were randomly assigned to one of two groups, one treated with AHBuBP (5 mg/day on two consecutive days every 3 months for one year; n = 20), the other with oral calcium (n = 20). The bone mineral density (BMD) of the spine increased significantly in women receiving AHBuBP, whereas it tended to decrease in patients given calcium. The differences in the vertebral BMD changes between groups was highly significant (P less than 0.01). Radial BMD tended to increase in patients treated with AHBuBP, and to decrease in patients receiving calcium. The difference in the linear trends was statistically significant (P less than 0.05). The side effects of AHBuBP (a transient acute phase reaction in 3 out of 20 subjects) were slight and well-tolerated. A good effect of AHBuBP was observed also on back pain (P less than 0.05). We conclude that intermittent treatment with AHBuBP is capable of increasing spinal BMD and conserving radial BMD in postmenopausal osteoporosis and may represent a convenient therapeutic choice in this condition.

[Effects of alpha-calcidiol (1 alpha-hydroxy-cholecalciferol) on the serum levels of osteocalcin in involutional osteoporosis]

We have examined the effects of 1 alpha-hydroxycolecalciferol (1 alpha) (1.5 micrograms for 5 days) on serum osteocalcin (OC) and other parameters of bone and mineral metabolism in 20 osteoporotic women and 11 age-matched normal women. After 1 alpha administration, a statistically significant (p less than 0.01) increase of serum OC, calcium and phosphate and urinary calcium and hydroxyproline was observed. In contrast, alkaline phosphatase was unchanged. There was no significant difference between normal and osteoporotic women in the changes of any of the parameters we monitored. In particular, OC increased in a comparable way in both groups. Thus, by means of an index that reflects the global activity of the skeleton, we could not find any apparent defect of osteoblastic responsiveness to the drug in osteoporotic subjects.